consider seismic and other natural disasters as safety. in the case of sandy, for example, we have a facility near the battery, near battery park in lower manhattan. the entire first floor was water. we are now building a wall that can help us keep out higher levels of water should another storm occur. safety is number one. i don't have the specific facts on the facility in long island. we can get together and go through that. >> thank you so much, mr. secretary. >> thank you, mr. chairman. >> thank you, secretary ville zach -- vilsack.

i want to commend dr. wenstrup for bringing up the cost of care and that's something i'm very concerned about and i wanted to ask a few more questions about when you think you are going to have an idea or is this independent review of the va system, is that going to help look at that number because i know i'm very concerned about it and continuing to implement access to care locally and can you elaborate on that a little bit? >> sure. in addition to the external independent assessments which we anticipate will be here around august or before then we are commissioning internal work, internal contracts and so forth from some of the leaders in the industry to figure out how do we get to some of the questions you raised in your recent hearing when he presented and so forth. one of the issues we struggle with in terms of cost is this reliance factor for some veterans use va for some of their needs but they go outside for others. my uncle recently told me he got

his hearing aid but by and large given where he lives it does not go to va for most of his care. he goes closer to home so that's part of the issue that we have got to work through as well as this issue of fixed and variable costs and again i think this is why the secretary raising this issue of costs that are a drag on the budget in terms of getting to the issues of access and veteran experience are so important. >> i think that is what dr. westrich was talking about come the cost of these half billion dollar hospital overruns, that all adds to the cost of taking care of the patient walking into a clinic and i just want to make sure that all these costs are included in that because we are supporting a bureaucracy. are we supporting way too much of a bureaucracy for the care we are getting out of it? that's my concern. >> it's a fair question. >> let me ask another question

here and this is something else we have talked about in our subcommittee as well is the management of pain within the va because i know it's been over a year since we have talked about this in my subcommittee and is opioid medication and the high doses and a number of prescriptions written and then this recent incident with aig [indiscernible] what has been going on in the va recently to try to address pain management? is there a better pain management system? is there a referral to pain management specialist? tell me what's happening more recently and how are we going to put an end to the practice of using opioids on a chronic basis for people with chronic pain? >> we take this opioid use very

seriously and we track it very closely. one of the things i'm most proud of that we do in the va that i don't see as much of in the private sector is we use a lot of alternative approaches and alternative medicines. we use acupuncture. we use yoga. we have used electronic devices that have been shown to be effective amongst some of our veterans. anything we can do to get that veteran off of opioids is something we want to do and we are developing quite a broad array of tools that we can use that allow us to reduce the opioid use. >> well i mean that sounds great mr. secretary but i think if you look at the numbers of people on the alternate treatment versus the opioids you would find there are a lot of people on opioids compared to the number of people on alternate therapies. it's great you mentioned those

things but it seems to me there should be a lot more people having access to pain management specialist than are being treated by their family physician or other primary care physician. -- physician with narcotics. >> we track opioid use perp facility. we have seen a trend line go down which is a good thing but we are also looking at the prescribing patterns of individual physicians to see, to make sure an overall positive trend that is going down isn't masking some practices that we would consider suboptimal. we are supporting a lot of research in this area as well because for some patients the combination of nsaids and so forth -- >> apparently the situation

contradicts what you are saying here today and i just want to be sure that we maintain the high vigilance on this problem. i'm out of time but i appreciate your efforts. >> thank you. >> mr. brown has one final question. >> >> thank you mr. secretary. thank you for your service. i have one question. just a few minutes ago the congressional order came out and i don't know whether you have seen the article va health care and i guess they do this order every two years. seems like they were rehashing a lot of the stuff that is going on. i appreciate you going on television and we need to respond. in our town hall meetings we see 7 million people a year that once they get into the system they are happy with the service. can you speak to the article that is just coming out today and whether or not you would be willing to do an op-ed piece

to "usa today" because i think it's important that veterans are not sidetracked -- we are definitely headed in the right direction. >> yes maam. i actually met with the comptroller general and we were talking about whether or not he should put va on the high-risk list. i encouraged him to and the reason i did that as we are a health care system and we are going through a large amount of change right now. during that time and the organization goes through a large amount of change we need to make sure that we have the appropriate oversight, the leadership as well as those responsible for it so while i think the va system is absolutely essential to american medicine we trained 70% of u.s. doctors. we have developed innovations that are critical for american medicine, the first liver transplant, the first implantable pacemaker, nicotine

patch and a bar code to connect patients with medicine. we have to make sure we have a robust va and so is because the -- as we go to this change i am thankful that you and your oversight role and others will be helping us get through this change and develop this robust system that this country and our veterans need. thank you. >> i want to again thank you all for your service. >> mr. secretary and everybody at the table thank you for being here today. you are excused. [applause] >> representatives from several veterans organizations also testified. they offered recommendations on how the v.a. could improve the service it provides the veterans. >> i invite the second panel to the table and welcome mr. carl blake the associate executive director of the

government relations paralyzed veterans of america who is going to be testifying to the committee on behalf of the co-authors of the independent budget. accompanying mr. blake is mr. joe vilante director of dav. mr. ray kelley director of national legislative service veterans of foreign wars, ms. diane zumatto national legislative director of amvets. we are also going to be having testimony from mr. en's de planque legislative director of the american legion. mr. blake you are now recognized for five minutes. >> thank you mr. chairman and members of the committee. on behalf of the co-authors of the independent budget seated at the table, i would like to thank you for the opportunity to testify on the 2016/2017 budget.

we ask that our report of independent budget for the department of veterans affairs for fiscal year 2016 and 2017 be admitted into the official hearing record. >> without objection. >> thank you mr. chairman. let me begin by saying we believe this is probably the best va budget we have seen in my years being up here on the hill. that being said recent media reports have pointed out that va's have hundreds of millions of dollars in resources carried over in recent years. the va has done a questionable job of managing resources that have been given in the past that we believe the axis problems in the long waiting lists identified over the last year clearly affirmed that point. however we also believe the va prior to this year has continuously requested and -- insufficient funds to adequately provide health care and benefits services to veterans. congress has given the administration virtually everything it has requested yearly but that certainly does not mean the va has requested what it truly needs. perhaps the office of management and budget would have something to say about this. this does not mean the va should not be properly scrutinized for

for what it spends or does not spend. we wholeheartedly support this notion but it should be screwed -- grounded in facts. the independent budget recommendation represents our view of the actual resource needs of the va to provide services across the entire spectrum of programs. despite the closeness of our recommendations come at independent assessment of the budget requirements released before the administration even release the most recent budget request. it is not bloated with unnecessary resources. i'll call your attention to the clear differences between our recommendations for budget line items and i.t. to affirm that point. our recommendations focus on areas for services medical services major and minor construction to veterans benefits administration national

cemetery administration and other key areas. the couple of those areas were identified in our policy agenda we released in january. those include women veterans programs and caregiver support programs and we appreciate the emphasis the committee is put on these two areas. we appreciate the fact that the committee held a hearing back in december to review the caregiver support program. it's a high priority for many of our members. those issues are particularly critical issues in this years budget. clearly they are wide-ranging opinions about how the va manages it's capital infrastructure. we have no doubt the va construction contract management has been a disaster. the only people to suffer the consequences of these failures are veterans seeking care particularly in the denver area. none of this changes the fact that the v.a. has a huge backlog of valid building projects at various stages from initial planning to near completion. nevertheless we believe the va has not shown the level or degree of commitment in its request for resources to get all of these projects moving in the

right direction or to complete them. we stand with the committee to resolve these construction management problems and we hope that will be done quickly. lastly i would like to comment on a couple of pointed and raised here. -- points raised here. with regards to the question about costs for care we are certainly not expert but i would suggest in all of the briefings i've received about the bees -- va projection model, if one wanted to know how much it cost to do a particular procedure in any region of the u.s. at that model would produce number. -- produce a number. that is what we have been told over the years when we have been briefed on this so what i would expect the committee would want to know how much to do a colonoscopy came up in the cost for care hearing that the va can produce a number. we appreciate the fact that the va is committed to providing better information with regards to cost for care and we look forward to having the opportunities to review that information and lastly the question about choice program which the va has brought out into light of day.

i think independent budget probably agrees with the principle the secretary is laid out that it should be obligated -- shouldn't be obligated to spend the money you have been given for one singular purpose. i thought the secretary's analogy that he used about gas versus food is a perfect way to describe the need to shift money around. that being said i'm not sure we agree with taking money from a program that is clearly in its infant stage. the program has to be given time to flush itself out and see what occurs. three months is not enough time to do a thorough evaluation of the utilization of the program. until there has been more time to fully evaluate what would happen i'm not sure we support what the administration has requested. with that mr. chairman i would like to thank you for the opportunity to testify. i would be happy to answer any questions you or members of the committee may have. >> thank you. mr. de planque. >> i would like to thank

secretary mcdonald and his staff for their words today. i'm very fortunate to sit here and speak on behalf of the american legion for a national commander and the 2.4 million members throughout the country who make up the backbone of the world, nations largest wartime service organization. we are focused on getting things right, not just for members, but 20 million members who are veterans. this is a team sport. we can't do it by ourselves. i think everyone agrees the country owes a great service to the veterans. i spent two of the last four weekends at various grassroots in nebraska and kansas with blue cappers like myself who were

there out there wanting to go out and go into the va hospitals and help out whatever way they can. we had over 7000 legionnaires donating almost 1 million hours of volunteer service to va. this only works if we are all on the same page and ranking member brown, you mentioned you wished hr 16 was the law of the land. i think we agreed and in a legislative hearing there was a lot of agreement on both sides of the aisle about that. we have to be able to look back and forth to compare these things. i was speaking with a colleague of mine about strategic capital investment plans and whether or not they are putting enough money into these things. american legion four years ago was talking about looking at the v.a.'s construction figures. it was going to take them 60 years to complete the 10 year

plan if they went forward with those numbers for trying to compare the figures together you are pulling up a budget from one year and try to hold the next to another. having it all laid out there where all the stakeholders can participate in that. chairman miller when that bill was up in the legislative hearing you spoke about the transparency and we need to have that same kind of transparency planning for the va budget so we can maximize the resources that everyone is putting into this. we have a lot of great organizations. we have a lot of great veterans out there trying to make this a better system. we believe in the va system. we believe the choices are important because we have to get access to care for veterans but we want to make sure the veteran still have access to that system. it is there because -- secretary

mcdonald talked about the demand expanding beyond v.a.'s capability. the va that we want to be the leader in pioneering medicine that is the utmost expert in so many conditions. you look at traumatic brain injury, post-traumatic stress disorder. you look at amputation injuries. there is no reason the va should not be the world's leading authority on that and we need to make that happen. that comes from everybody working together and everyone being on the same page. american legion is devoted to that. the va's request for an additional 770 full-time employees who work on the claims backlog it's important and it's a good point they have been given more staff and were supposed to have been increasing their productivity. you can't deny the fact that they have been on mandatory overtime for four years. go through four weeks of mandatory overtime so you might have a bit of a problem.

four years on mandatory overtime you might not have enough people to do that. we don't know how many people we need and that is why we need to be able to look these at these figures on the same page together. working together we can do that and we are very committed to being a major partner in that in helping to drive that. we want the system to be the best it can be for veterans. i think the committee has been generous in giving budgets to the va to work with and we need to keep working on the same page we can accomplish that. thank you for having the american legion here to speak on us and thank you to all the veterans and i look forward to for questions. >> i would like to ask either of you if you would the critical components and probably one of the toughest things to secretary -- the secretary is having to be confronted with is closing outdated substandard or underutilized facilities. it's not easy politically.

it's not easy as the secretary have already alluded but i would like to know if you feel like that's an important step that that the secretary has to look at. course i will refer to my colleague. >> mr. chairman, if v.a. is falling property that is underutilized, they need to find out how to get rid of that property. in the process of figuring out how to get rid of it, they also need to have that conversation with the community to ensure that those veterans understand that there will be services there. that is the fear in the community. my hospital is going away therefore my services are going away. they need to understand that that full continuum of care will be in the community. there's no need to spend three

dollars per square foot to maintain a building that is no longer being used. >> if i could dovetail onto that. the subject that comes to mind is hot springs. that community wants to keep their medical center. i can understand if you have an unutilized building that's not serving veterans in the community. there are probably regions where it's not effective, but we have to make sure those veterans are included as a part of that learning process. i know there has been a tremendous amount of frustration in hot springs. the community is adamant vehement, and it has been organized to try to organize its opinion. this is serving the veterans in this area. there are very concerned that that is not being heard. yes, i think it's important to be able to open up to some possibility, but let's making

sure that were still serving veterans. >> any other comments? >> i would only add that one thing we would caution as they make a determinations of where facilities are underused, that they be innovative. we've talked for years about using some of this space for the homeless veterans issue. one of the challenges of homelessness is having supportive housing that allows them to transition to finding a job, being able to become -- facility serve a purpose. that doesn't mean some facilities should be close especially if they're sitting empty. >> mr. blake, where specifically do you think the administrative costs within the a could be reduced and work of those funds be reallocated specifically we are talking about page three in

your testimony. >> i would suggest that from the perspective of the recommendations we have made, we have stuck to the same principle , that we directed most of our recommendations at the medical services line where the rubber meets the road for providing health care. there's been some discussion about blessing of staff and administration lines. we've also had some conversations with the committee staff on the vha side on the administered costs that exist. the very layers that exist within vha. we are interested to see the plan to seemingly transition the regional framework of the v.a. what we would hate to say is that we transition to a five region alignment to five regions

that are just those people shifted into an original alignment, and you did not streamline your administered supported all. >> if i could, the secretary asked mr. kaufman to ask the question since mr. kaufman is not here, i will ask a question on behalf of the secretary, have you seen a difference in the a? -- in the v.a.? >> i think we have all been impressed with what he and debit or he gives an have done in the short time they have been here. i would say that, yes, we appreciate what he's doing and what he's trying to do and hope that we will work with him to make sure that these changes happen. >> we see a difference in spots. there's going to be areas that are slower to change than other areas, but we are seeing pockets

of improvement. just solving the problem in west l.a., land management issue, and a very short time, something that's been around for years. it is an indication that he is hands-on. he will get things done. it's people at all levels to do the same thing. >> my time is expired, but can i give yes or no. >> i will give a yes. yes. they are starting to own problems to come which is a big change. >> i agree with my politics -- colleagues. >> i agree there is a difference. i would say that hr 216 is special -- scheduled to be marked up tomorrow. we would expect to see that pass very quickly. ms. brown. >> thank you. i would like to associate myself with the remarks from the german

for florida. i think it is a change in the v.a. and headed in a positive direction. when you talk about v.a., i remember going to l.a., and we had four brand-new units sitting for over two years. we have built those units, 400 units, four separate buildings that are still vacant for two years because we build them, but the state of california did not have the money to operate it. we have to make sure that does not happen in the future. i am pleased that he was able to go in and resolve those issues. can you give me a response as to how you feel about how this is going to help the a move forward?

i just want to hear from all three. i would say that we offered our support of the legislative hearing. >> he hit on an important point. this was allow for more transparency. i would also suggest that -- what i appreciate seeing is that i believe this is the first time i've seen the v.a. take serious this requirement as part of the advanced appropriations process. for the last several years since his was passed one of our chief complaints has been that the congress passes an advanced appropriation as requested by the v.a., then the next year there is no consideration given to how that should be adjusted. this is certainly the first year that i can remember where a substantial analysis review and re-estimate has taken place. we appreciate the fact that this leadership team in particular has taken this requirement far

more seriously than in the past. >> the forward funding, you're not going to have veterans who are worried about not getting if there is some sort of friction between the congress and they can't get a pass. that's an important guarantee for them down the road. i'll so think of that planning component that's going along with your legislation is a critical handshake with that bill. the ability to plan is critical as our forward funding things. to be overlooked down the road and see the anticipated results beyond that. they are hand-in-hand with each other and very helpful. >> let me mention that when i first came here, we were going through a process, and we support closing some of the v.a. facilities, but keep in mind that as long as you don't close any in florida. that's the mentality of the

members of congress. as we work to it, we have to keep in mind that it is a team effort. those communities need to have input and involvement as we evolve as to what we want it to look like. we are sitting up here saying that this is the right thing this is the best thing for the country, but when we go to similar places in hot springs and that community feel that they are going to be disenfranchised. the question is, how do we have these other communities and everybody involved in those decisions. don't think that politics doesn't play a part, because we do get ready to close it, when the sentences way in and some senators say we don't do that what is best for the country that is not always the case.

i want to thank you all for your service and for your presentation. i have 30 seconds. >> it has been nice to see that some folks is our -- are willing to do with us on an open basis. since the cost for care hearing two weeks ago, prior to that, the last meeting we had with the v.a. employees on health care model back in 2009. they are clearly more in tune with the concerns of the committee, the concerns we raise, trying to get us more involved in the discussion so that we know what we are doing whether we necessarily wholly supported, at least we have a better idea were going and what they're doing. >> i feel the same way could have been over there four times critical in the morning i would get the entire community over there to review the town hall and this discussion so that we have a better feel as to what is going on over there because i

think it is very exciting to have the employees involved in what were doing and is not some top-down, but it's the input of the employees as well. thank you, mr. chairman. i yield back the balance of my time. >> thank you very much. dr. abraham. >> i am honored to be here. i was a practicing physician or to see veterans in my clinic. i am jumping up and down with joy for this choice program. are you getting feedback on the implementation of the choice. is it working? is it seamless? where does it stand from your perspectives?

>> the commission to survey to our membership to get feedback. we are doing a two-part survey. we cut it off at the beginning of this month. for a two-month. a good portion of veterans who called for an appointment to the v.a., when they interacted with the a to get an appointment were not told that they had a choice, but now that where an the second phase of this survey we are finding more those veterans understand they have a choice. v.a. employees are being educated to provide that choice. we are seeing that trend of access go up. at the same time, early on, the perception of choice was very positive. this seems to be a trend that now that it has got more people in it that there is a slight downtick in people's opinion of

it. it's something we will continue to monitor. we will have a report very soon. >> i wanted to touch on that. i just recently talked to a number of people. there's a lot of confusion over whether or not people are eligible. there was a lot of confusion among the access. we get calls all the time about this as well. we've been working hard. i know v.a. has been working hard as well to educate better about that. the 40 mile straight line, when you're in a rural area where the roads are that accessible, the -- i'm close to a clinic but the clinic does not offer the services i need. when you're driving 340 miles to get something so there's a lot of concern about that. we've heard feedback from the members. as far as whether they want to use the choice program or whether they want to use the v.a., it's a mixed. we have some people that have

been very happy with the care that they got it to the a, they could not get access to his bid they were frustrated by committee will get back in the v.a. great on the other hand, is of the border excited about the options of looking at it. we're continuing to monitor that. the biggest part we've noticed early on has been the confusion about eligibility, particularly with that sort of 40 mile circle and how that interacted with facilities that did not treat the condition they had. >> i think the playing field is unlevel in trying to valuate it. when you consider that the the a dozen have the capacity to meet all the demand as we see it. i the same time, we don't know for sure that the private sector truly has the capacity to meet the demand that might come from the choice program. that is a great unknown. we forget that private health care is a business. they maximize their revenue for their business by not operating with excess capacity. it would stand a reason that when people try to access the private health care system they

might find challenges. we find challenges using private insurance now. i try to get an appointment for special be carried george washington university hospital in town it would be six months. there are challenges. the field is not level on the v.a. sutter the private sector side. until we have more time to let the program itself even out allow the v.a. to get its footprint more from implanted by expanding his capacity, i'm not sure we can do a real thorough analysis. >> from dav sampling, we are getting ready to go out with the survey of our members to see what they're hearing. we are not hearing complaints greater is some confusion as has been said about travel. that's because of the way the law was written. early on, our people were more concerned of being forced out of the system, thinking that if they live more than 40 miles away or had to wait longer than 30 days, that they would not be evident come into v.a..

that concern them greatly. >> certainly. that misinformation has hopefully been disproven. i hope that the veteran when he needs primary care, he can go to a choice dr. p certainly him if he needs specialty, he can go to the v.a. facility he wants. we wanted this to be seamless for the veteran. are we slowly obtaining that goal? >> i think right now it is a little early. in terms of making analysis about what utilization is, i understand that the secretary stated before that it wasn't so much about what the utilization was right now. they were trying to give a warning light. for us, it's a little bit early to make decisions about that. people are just starting to get their feet wet with the program. i know all of the groups appear are watching to see how this

interacts. >> i does what you get your take. thank you. >> mr. o'rourke. >> thank you. the secretary and his team are here. i just wanted to make sure was noted for the record because if we are going to be successful in this team approach, it's going to take all of us being in the same room listening to each other. i thought that was important that you pointed it out. i wanted ask you and any person at the table to respond to this. the secretary also mentioned working collaboratively in terms of how we build and offer medical care beyond this question of the choice act. an example that we talked about last week in a hearing was this hospital in colorado, $604 million to $1.1 billion originally supposed to be affiliated with an academic institution, that affiliation is

broken. i could not help get the sense that veterans in that area were consistent that that be flagged solely as a v.a. facility. that might have had some costs and consequences. what is your thoughts on working collaboratively and involving other non-v.a. institutions and the provision of health care or the development of facilities or organizing how we deliver that health care in a community like el paso, where i don't know that we need a hospital, i don't know that working to get a $1.1 billion facility, so we may have door collaboratively. if i could start with you and work right words down the table. oh love you give your response. >> we have mixed feelings good we have seen other facilities particularly dod facilities where they have gone in together . sometimes their problems because the troops that are stationed there get deployed. the services start lacking.

i think some of the facilities up in great lake have been working fine with a federal the eighth kind of infrastructure. so it depends on the area and how it structured. >> we have to look at every option. we have to look at building standalone the hospitals. we need to look at public-private partnerships. we need to look at intergovernmental partnerships. we have to. it has to be right sized and the services need to be in place for veterans. every avenue, not just with university hospitals partnerships, but with county hospitals, city hospitals. i think it is based are landing on what they're going to replace in their -- for their needs. if there's room for v.a. at that same campus and it's a co-purchase. services are interoperable, then

it's a smart move. >> you mentioned city county private sector potential. where there is a gap in v.a. care, absolutely. >> mr. blake. >> i think it would be unreasonable to think they should not take advantage of partnerships to maximize those opportunities for health care. that being said, you mentioned or more of. part of the problem was figuring out -- i can member a time when the vision for that was like a joint facility that had a mixed of veteran patients and non-veteran patients, civilian patients. we ran in the challenges with something as simple as identification of the two. then you got into more complicated issues with governments, priority of access to service wednesday have to be careful when you get into that sort of concept. the denver issue is -- i think

it's even more unique and the problems that existed in las vegas, new orleans orlando. the denver project has been going on 20 plus years now. if nothing else, veterans of being left unsatisfied there because there are many promises that have been made and still no access to have -- health care there. >> thank you. >> i think it is a team sport. it is a country that takes care of veterans. we have certainly seen in the past, teaching hospitals working conjunction with field -- be a hospitals. i think there is some great partnerships that can be achieved there. there's a reason that a lot of our veterans like to go to the the a. it's because it something that understands them, but at the same time, if the going to be innovative, the going to be leading the way, that's going to involve partnerships.

that's going to involve finding the best people out there. >> can i have 30 seconds to answer? >> thank you. >> i would say that wealthy a certainly has many fine doctors and experts they don't corner the market. there are a lot of people in the civilian community who could bring new ideas, research, and other possibilities. to say that we should not be considering public-private partnerships, i think would be a serious mistake. >> thank you. thank you for your answers and your work. >> mr. brown college do have additional comments or questions? >> knows -- no, sir. >> thank you for being here. thank you for presented the independent. expect questions to the second panel, post hearing questions and to the first panel. there are some issues that we

were not able to bring out given the time, but mr. secretary, thank you for staying through the entire budget hearing. this hearing is adjourned.

>> new congress, best access on c-span. >> president obama last week signed a bill introducing -- intended to reduce military suicides. the suicide prevention for americans act is by a former marine who is served in iraq and afghanistan.

he was honorably discharged. the signing ceremony at the white house is 20 minutes. >> ladies and gentlemen, this is michelle obama. [applause] ladies and gentlemen, the president of the united states, accompanied by mr. jake would. -- wood. [applause]