▶ 0:19:46I just call. This is a test. Test test test. Okay. This a test. Okay. Cool. Thank you. Bye.
▶ 0:25:01No, I can't. I keep doing
▶ 0:26:55Don't know what the I'm guessing that too. Okay, here I can show you the order. I can show you where you're sitting. Right there. Right there. Okay.
▶ 0:27:35Well, you know, with my luck, I would standing or sitting.
▶ 0:28:07When we get started, everyone see the
▶ 1:02:57the members and witnesses to today's hearing. During this hearing, witnesses will share with us how VA works handinand with private doctors and providers to meet veterans specialty care needs throughout the VA community care program. Data show that veterans like and want community care just as they like and want their VA health care system. Polling has shown that Americans want veterans to be able to access shorter wait times and drive times to get their healthcare.
▶ 1:03:24Through the mission act, Congress has closed the gap that was crippling the delivery of care by the VA and oftentimes leaving veterans behind, stuck in line, and waiting for an appointment. This was especially true for specialty care. By virtue of being in the community, these providers are closer to veterans and their homes than a brick-and-mortar VA facility. That can mean shorter wait times and drive times for veterans. Through the mission act, the VA community care program created new opportunities for more resources uh than ever to serve veterans.
▶ 1:03:55Veterans enjoy shorter wait times and drive times for specialty care appointments because VA is allowed to cover specialty care in the community. Veterans have more specialty care through VA because of community care, not less. Three key indicators today and on the horizon show that the VA will continue to rely on providers in the community to meet the moment for specialty care for veterans. First, demand will increase for all specialty care needs as more women use the VA for health care.
▶ 1:04:22By 2040, the VA estimates that women will make up 18% of all veterans. More women veterans means not just an increase in female specific care, but an increase in specialty care services overall. Second, VA's workforce challenges mirror those of the health care industry as a whole. There is a national shortage of health care professionals, especially for physicians and nurses.
▶ 1:04:45The VA recently identified shortages for clinical roles like psychologist, medical technologist, diagnostic radiologist technologist, which is the same in the private sector. Uh and this is true across all VA facilities. Even though uh this committee and the the veterans affairs committee has increased pay uh to providers within the VA healthcare system. All of these roles play a part in if not directly provide specialty cares for veteran.
▶ 1:05:15The higher the ratio between veterans and healthcare staff, the more veterans will need community providers for VA covered specialty care. Third, and finally, the VA expects significant changes in demand for care in general, including specialty care. The VA projects major shifts in physical space demands for hospital operations by about 2030.
▶ 1:05:34Estimates range from an 850,000 $850,000 decrease in needed square feet in New Orleans, Louisiana to a 2,500,000 increase in needed square feet in Orlando, Florida. So having facilities where they're needed in accordance with the demographic shifts of the country sometimes we're far behind where that movement occurs.
▶ 1:06:00These are but two of the many estimates projecting dramatic increases and decreases in demand for physical space across the country and one of the reasons we introduced the chipin act in this committee as well as increases for funding infrastructure within the VA. The VA also projects highly variable demand in different facilities across different types of care. I hope you'll bear with me as I explain the numbers which paint a compelling picture of the veterans healthcare needs.
▶ 1:06:27The VA expects a 50% growth nationwide in outpatient, primary and specialty care uh combined. Related relatedly, the VA also expects a 13% decrease in inpatient acute medicine and uh surgery nationwide. And this too remembers what we see in all healthc care sector. But the VA expects an increase for inpatient acute mental health.
▶ 1:06:53That means more demand for psychiatric services at a hospital for severe mental health crisis. And as we know from hearings here uh in this room, the VA did not consider residential mental health care or residential substance abuse to be part of the mission act. So that's a lot of variation. Even within these numbers, the VA expects significant differences in demand from region to region.
▶ 1:07:17For example, with inpatient acute mental health care, the VA projects a 6% decrease nationally in demand for inpatient acute mental health. But when we dig another layer deeper, we see that the VA expects anywhere between a 19% decrease to a 14% increase across different regions of the country. I care deeply about mental health resources for veterans and I know that the VA will continue to provide valuable in-house care to veterans who need it.
▶ 1:07:45But with so many variables, the VA cannot expect in-house care alone to meet different demands from different communities. Veterans need inpatient mental health care when they need it and when they're in crisis. Veterans need specialty care when they need it. A condition in need of treatment doesn't wait for the facilitary infrastructure to be built and to catch up. And as a physician, I know this reality firsthand.
▶ 1:08:11And a veteran should not wait for treatment when community providers are already available to meet a need. To best serve veterans, the VA should pursue whatever gets quality care to veterans when they need it. The VA serves all veterans when it opens the door to community providers equipped to care for veterans at the right time at the right place with the right treatment. As a 24-year Army veteran and physician, I'm focused on working in lock step with the administration to ensure that this happens.
▶ 1:08:41The future of veterans healthcare depends on it. I now yield to Ranking Member Brownley for any opening remarks she may have. Thank you, Chairwoman Miller Meeks. At the outset of today's hearing, I'd like to set the scene a bit by describing the situation in which veterans and the VA currently find themselves. First, veterans across the country are losing access to VA healthcare due to numerous actions taken by the Trump administration. Why is this happening?
▶ 1:09:12With each passing day, VA is becoming a less and less desirable place to work. Upon taking office, President Trump ordered a governmentwide hiring freeze. The haphazard implementation at VA meant that essential occupations initially were not exempted from the freeze.
▶ 1:09:34Job offers for key employees who were already in the onboarding process were rescended, then reinstated, a flip-flopping that led many wouldbe hires to run the other way. Less than a month after that, VA terminated nearly 2400 proba probationary employees. While some have since been rehired, they may be ter terminated again after pending lawsuits have resolved.
▶ 1:10:04Many opted not to return after being offered their jobs back. Then, as a result of the Trump administration's returning to office policy, tens of thousands of VA employees who had been hired into fully remote positions were directed to report to offices that were illequipped and ills suited to accommodate them with little consideration for the effect it would have on their productivity or the quality of
▶ 1:10:34care delivery. We heard a week ago that while VA is no longer planning to pursue a largecale reduction in force or RIFF, it still anticipates losing nearly 30,000 employees by September 30th. That's about 6% of VA's overall workforce.
▶ 1:10:56This is happening through DRP, the deferred resignation buyout program, and VIRA, the voluntary early retirement authority, as well as employees choosing to resign or retire without any incentives. As this chart shows behind me here, as of May 31st, 2025, nearly 22,000 employees had separated from the Veterans Health Administration.
▶ 1:11:27While about half replaced as a whole, VHA has lost 10,310 more employees than it had hired so far this fiscal year. The secretary has repeatedly claimed that veterans will not lose access to health care as a result of the department's ongoing restructuring process.
▶ 1:11:51Maybe you're thinking that these losses are mostly non-essential occupations at VHA, but that is just simply not true. Losses of essential frontline employees are occurring at VA medical facilities The second chart shows VHA is currently operating at a loss of nearly 3,000 mission critical employees since the
▶ 1:12:22start of this fiscal year. This is after making significant gains in the overall number of frontline employees during the same period last fiscal year. Those new hires were helping VA deliver record numbers of appointments and serve the influx of new enroles that are coming into VA as a result of the PAC Act. Where are the losses of essential employees most significant?
▶ 1:12:53custodial workers, food service workers, nurses, physicians, social workers, employees that VA medical facilities simply cannot do without. At the Seabach that serves my constituents in Ventura, California, seven out of 12 mental health providers have left. This is driving up weight times for mental health appointments. As of Friday, the new patient wait time for a mental health appointment was 101 days.
▶ 1:13:24Now, maybe you're thinking to yourself, those veterans are eligible for community care. And while that is true, they need VA staff to coordinate their care in the community. And as this chart refers to shows that we are down more than 1,147 medical support assistance nationwide since the start of the fiscal year.
▶ 1:13:51Those are the staff who help veterans find community providers and schedule their appointments. It doesn't matter that so-called missionritical VHA staff were not eligible for the DRP and Vera separation incentives. They are leaving anyway because VA has become a toxic, unpredictable and hostile place to work.
▶ 1:14:16We are kidding ourselves if we think no riff is the end of it and that the loss of employees will stop at 30,000 folks. These losses will continue to grow. As long as VA's workforce continues to suffer, all aspects of VA care, including community care, will suffer. on July 4th, President Trump signed the one big beautiful betrayal bill into law.
▶ 1:14:45By most analysis, this law and its one trillion cut to Medicaid will have a wide ranging impact on the health care landscape in the United States. Researchers at the University of North Carolina have identified 338 rural hospitals that are already at risk for closure.
▶ 1:15:09Future loss of Medicaid coverage will elevate the risk of financial distress for hospitals, long-term care facilities, and other providers, further reducing veterans access to care.
▶ 1:15:25We cannot have a conversation about specialty care in the community without acknowledging both the strain that is currently being placed on VA's health care system and the strain that is about to be placed on nonVA providers. We should be shoring up VA care and making sure that there is capacity in the community when veterans need specialty care in the community.
▶ 1:15:51Instead, under this administration, we are seeing a chaotic approach to delivering veterans health care that undercuts VA's internal capacity, shifts more and more care to the community, and leaves veterans and VA employees in the lurch. Insisting that those actions will not impact veterans health care does not make it so.
▶ 1:16:17and ignoring the unforeseen consequences of this administration's actions will not make them go away. As I have always acknowledged, VA will always need to offer some level of community care because they can't do it all. However, for many veterans, VA is the right place for them to receive care. They know their provider understands their military service and what it means to have served their country.
▶ 1:16:47They know they will receive world-class health care backed up by worldclass research. They know they won't have to explain to their VA provider what a presumptive condition is or their experience with military sexual trauma or how their service impacted their mental health. We also lack oversight of the care that veterans receive in the community.
▶ 1:17:14We know wait times for VA appointments because VA publishes them. Community providers are not required to report their weight times or how long it will actually take a veteran to be seen.
▶ 1:17:27We know that VA providers have received training on military cultural competencies, suicide prevention practices, opioid safety, and many others because VA requires them to receive such trainings and reports how they have completed them. Community providers are not required to take all of these trainings and veterans are not informed about whether their community providers have voluntarily taken such trainings.
▶ 1:17:59Based on the testimony from our witnesses, I think we can all agree that the administration of VA's community care program needs reform. Unfortunately, we find ourselves convened for an oversight hearing where there are no VA officials present to respond to questions about the barriers and challenges highlighted by our witnesses.
▶ 1:18:24I think that does them a disservice and I would respectfully ask the chairwoman to invite department witnesses to future oversight hearings so that we can have a more robust discussion about what is working well, what isn't, and how to fix it. And with that, Madam Chair, I yield back. Uh, thank you, uh, Ranking Member Brownley. Before I introduce our witnesses, I just want to be clear.
▶ 1:18:50Um, our colleagues have spent uh the past six months yelling from the sidelines and should have held their criticism of potential plans until a plan was actually in place. It's public knowledge that the VHA loses about 9% of its workforce annually through regular attrition or about 38,000 employees based on its current workforce. Those were the same statistics during the Biden administration and are the same statistics today.
▶ 1:19:17We also know the status quo is not working and will continue to cut through the nonsense and restore common sense at the VA to put veterans first. Additionally, during the past four years, the funding to the VA has dramatically increased. The numbers of employees increased by 80,000. Yet, the number of veterans applying for care had remained level nationwide. Most VA employees come to work and proudly serve our veterans.
▶ 1:19:43However, poor performing VA employees must be held accountable when they aren't putting veterans first, and we'll ensure that that message is clear. Chairman Bost, House Republicans, and myself have full confidence in Secretary Collins and the Trump administration to bring needed change to the VA. That's what we're focused on. I look forward to continuing to work with uh Ranking Member Brownley and those on the other side of the aisle so that we can affect real change for veterans that the VA serves.
▶ 1:20:11testifying before us today as I'd now like to introduce our witnesses. Dallas Knight, founder and president of Operation Juliet. She's an uh Army combat veteran. Megan uh Mobs, director of the Center for American Safety and Security at Independent Women's Forum. She's a clinical psychologist and also an Army combat veteran. Amanda Newman, CEO of Western Illinois Home Healthc Care. Western Illinois has operations close to my district.
▶ 1:20:38Christina Keenan, legislative director at Veterans of Foreign Wars and an Army veteran as well. Uh, and Kylan Kai Hunter, CEO of Iraq and Afghanistan Veterans of America and Marine Corps combat veteran. Miss Knight, you're now recognized for five minutes to present your testimony. Chairwoman, ranking member, and members of the subcommittee, my name is Dallas Knight. I'm an Army combat veteran and the founder of Operation Juliet, a nonprofit serving female veterans.
▶ 1:21:08I joined the army just two months before 9/11, intending to gain experience and work for the DEA. I had no idea how real that experience would become. I deployed to Iraq in 2003 and returned a year later with invisible wounds far worse than the physical ones. I avoided the VA after learning PTSD diagnoses would revoke your security clearance my entire career plan. So, I stuffed it down. I stayed silent and I told myself I was fine for 17 years.
▶ 1:21:38Eventually, the weight of what I saw, felt, and endured caught up with me. Finally, after enrolling in VA healthc care, I walked into the Billings Clinic for my first appointment and was asked if my husband needed help. Apparently, I didn't look like a veteran. That first appointment stuck with me. When I was asked if I had suicidal ideiations, I said, "Not recently." The provider responded by lecturing me on how selfish it would be to leave my children without a mother.
▶ 1:22:07Then, when I disclosed military sexual trauma, I was referred to a psychologist and handed a stack of prescriptions. No conversation about healing, just a follow-up call from a man temporarily filling in as the state MST coordinator notifying me I'd be receiving a pamphlet in the mail. At a neurology appointment, I was asked for graphic, unnecessary details about my TBI trauma. It felt more like an interrogation, questioning my integrity rather than a consultation, only stopping when the doctor noticed my visible discomfort.
▶ 1:22:38Despite our encyclopedia-ized files were expected to rehash and relive the very traumas were trying to escape. I don't believe these VA providers intended harm, but they were clearly undertrained and unequipped to treat trauma. That's when I realized there must be better care available because no one explained trauma-informed therapy. No one told me about community care and other options. Those options were only discovered from other veterans helping me to navigate the system.
▶ 1:23:06A lifeline passed from veteran to veteran. Requests for alternative therapies often took weeks, sometimes months for a response. I've hung up on my boss, my son, and walked out of meetings just to answer the VA's call, afraid of missing a rare chance at care. And as I scrambled to choose a provider from a rushed list, no context, no ratings, no reviews, I hung up relieved just to have an appointment at all. I'm not alone in my frustrations and disappointments. I told my community I'd be standing before you here today.
▶ 1:23:37And within days, nearly 600 women veterans responded eager and desperate to be heard. Hundreds of female veterans describing waiting months, sometimes over a year, for critical referrals, specialty care, or community- based treatment. These delays often compounded existing mental and physical health issues, leaving veterans to suffer in silence. Veterans living in rural or underserved areas detailed the near impossibility of accessing timely and appropriate care. Many faced multi-our drives, limited provider options, and a lack of female clinicians or trauma-informed specialists.
▶ 1:24:07For these women, geographic isolation added another barrier to healing, making community care feel like a broken promise. Veterans who bravely disclose histories of military sexual trauma shared disturbing accounts of retraumization within the VA system. Common themes included being forced to recount trauma repeatedly, being assigned male providers despite requests for female clinicians, and being denied or delayed access to mental health support. The lack of MST sensitive pathways reflects a systemic failure to prioritize survivor safety and dignity.
▶ 1:24:39I have hundreds of stories, but only five minutes to speak. So, I ask that you take the time to read their stories that I've submitted to you. But there's one story that I carry most heavily with me today. Lanessa Van Herk was born February 21st, 1989. Army MP, sergeant, daughter, sister, friend, hero. I never met Lanessa, but I know her through her mother. Now living every parent's worst nightmare. Lanessa served her country with honor.
▶ 1:25:07She asked for help repeatedly, but she was denied. delay, delayed, ignored, and even sexually assaulted at a VA impatient treatment facility. The VA failed her repeatedly. And on April 30th, 2022, at just 33 years old, Lanessa died from the long-term effects of untreated PTSD and trauma, left in a hospital bed with hematomas, liver failure, and no more chances. So today, I'm not just asking you to hear me. I'm asking you to hear all of us.
▶ 1:25:37Hear the hundreds of women who have come forward. here. Lanessa, female veterans are not invisible. We are not dramatic or broken. We are warriors, leaders, and we are asking boldly, urgently for a system that sees us, hears us, and serves us with dignity. Thank you for your time. Thank you, Miss Knights. Miss Mobs, you're now recognized for five minutes to pres present your testimony. Chairwoman Miller Meeks, Ranking Member Brownley, and members of the subcommittee.
▶ 1:26:06Thank you for the opportunity to testify today. My name is Dr. Megan Mobs, and I'm the director for the Center of American Safety and Security at Independent Women. I'm a combat veteran, former Army officer, and clinical psychologist who specialized in trauma, transition stress, and post-military reintegration. I trained in the VA system and currently teach through the Veterans Mental Health Primary Care Training Initiative for the New York State Psychiatric Association, helping civilian physicians better recognize and treat veterans.
▶ 1:26:34I've been on all sides of this system, soldier, clinician, educator, and advocate. And I've walked beside fellow veterans struggling to navigate the very bureaucracy designed to serve them. In 2018, when President Trump signed the bipartisan VA Mission Act, it was more than legislation. It was a solemn promise that what happened to the Phoenix VA where veterans died waiting for care would never happen again. The community care program was created to fulfill that promise.
▶ 1:27:02It acknowledged that while the VA is indispensable, it is not omnipresent. And too often bureaucracy stood where medical support should have. This program was never meant to be a replacement, but it was a direct response to institutional failure. It intended to put outcomes over promises and patients over paperwork. But we have not yet fulfilled that promise. And let me place it into some context. In 2001, the VA's hospital administration budget was 20.9 billion.
▶ 1:27:30At that time, we were tragically losing about 16.5 veterans a day to suicide. In 2024, after decades of war and exponential growth in funding, now approximately 121 billion, we're still losing 17.6 veterans a day to suicide. What faces us is not a funding problem. It's a function problem and a failure to adapt and decentralize to meet veterans where they are. Veterans are still waiting weeks or driving hours for care they should receive promptly and locally.
▶ 1:27:59Medical decisions are too often driven by bureaucrats and not doctors. Community care was created to fix this. Today, it provides nearly 40% of all VA delivered care. And it's working. Veterans use it. They're satisfied with it. Especially in rural areas, it's become a lifeline. But instead of expanding it, some VA administrators have undermined it. We've heard the stories. Last year, a Portland VA official admitted they were intentionally keeping care inhouse, even where referrals were warranted.
▶ 1:28:26In Buffalo, a veteran with cancer had his radiation therapy referrals denied, and then canled, and he died in pain. To move forward, we need a community care program rooted in four principles: flexibility, accessibility, rapidity, and accountability. First, flexibility. Veterans live in rural towns, suburbs, and cities. They raise families, hold jobs, and carry injuries, both visible and invisible. They deserve a care system that reflects that complexity. Community care gives them access when the VA is too far, too slow, or lacks the right specialists.
▶ 1:28:55That flexibility is especially crucial for women veterans. 70% prefer female providers for women's specific care, and 50% even for general care. Recently, a VA facility went two years without a full-time gynecologist. Second, accessibility. Only 55% of veterans live within 40 miles of a VA facility and just 26% live near specialty care. Community care reduces the physical and financial burden of long-distance travel and that improves health outcomes and trust and adherence.
▶ 1:29:24With women expected to make up nearly 20% of the veteran population by 2040, many from minority backgrounds, we need a system that reflects today's demographics, not those from 50 years ago. Third, rapidity. Delayed care is denied care. Veterans don't need treatment eventually. They need it now. Today's eligibility thresholds are arbitrary. I've personally worked with veterans denied mental health services because they weren't sick enough or were forced into treatment that they did not want.
▶ 1:29:52Whether it's PTSD, chronic pain, or substance use, every delay or denial feels like administrative cruelty, and it's costing lives. Fourth, accountability. Since 2018, the GIO has issued 27 recommendations to improve the community care program, and as of this year, only nine have been fully implemented. The lack of enforceable standards, inconsistent referral coordination, and inadequate oversight does undermine the program. So, we need to measure timely access and continuity of care.
▶ 1:30:20Otherwise, we are building a system that is blinds to his own failures. I want to commend Secretary Collins for accelerating the implementation of the Senator Elizabeth Dole 21st Century Veterans Healthcare and Benefits Improvement Act. And it's a meaningful step forward. But let me be clear, it's not enough to offer a door. We must ensure that door is open, functional, and that it leads somewhere worth going. I believe deeply in the VA. I trained there. I've referred patients there.
▶ 1:30:46But no single system can meet every need in every place at every time for every veteran. Community care is not an indictment. It's just an extension of the promise we made. Veterans don't need more bureaucracy. They need choice. They need speed. And they need a system built to serve them, not the other way around. Thank you, and I look forward to your Thank you, Miss Mobs. Miss Newman, you are now recognized for five minutes to present your testimony.
▶ 1:31:12Thank you, Chairwoman Miller Meeks, Ranking Member Brownley, and the members of the committee for the opportunity to speak on the critical topic of the VA's community care program, and thank you for the important legislation that you have successfully led through the legislative process to support veterans. I'm honored to speak on behalf of the 121 Illinois veterans that we serve in our agency and on behalf of veterans served by Homeare Association of America members across the nation.
▶ 1:31:42I'm the second generation running a family-owned home care agency in West Central Illinois. We cover a 10count mostly rural area and have worked with the VA for over 30 years. We currently do so as a contracted provider in the VA community care network operated by Community care is not an alternative to the VA. It is an extension of it. For many veterans, especially those living in rural areas, community care represents a vital lifeline.
▶ 1:32:12These veterans often face long travel times or limited ser services at local VA facilities, making care in the home a necessary option. The success of community care hinges on a shared commitment to veteran centered team-based care where VA and community providers work in partnership, not in competition.
▶ 1:32:34Over our 30 years working with the VA, we have always had good relationships with the Vision 23 Veteran Affairs Medical Center in Iowa City and our local VA outpatient clinic in Gailsburg, Illinois, working together to meet veteran needs. Our experience has been that process changes within the VA in the last year have created barriers to veteran access and care. These changes do not appear to be in line with the spirit of the mission act.
▶ 1:33:04Three key barriers to veteran access that I have seen are the VA reducing or eliminating community care services for many veterans who have qualified for and relied on these services for years. harming care stability and consistency for veterans by reducing authorization periods from the prior standard of 12 months to six months or less, creating uncertainty for the veteran and an overwhelming workload for the VA staff who process authorizations.
▶ 1:33:36in the 2025 non-bundled fee schedule, reducing rates to a point where veterans, especially in rural areas, are at risk of losing critical services because the fee schedule does not provide adequate reimbursement given the travel involved. I'd like to tell you about two of our veterans who asked me to share their story. One veteran we care for is 79 years old. He lives alone in a small rural town and has difficulty controlling his diabetes.
▶ 1:34:05He cannot cook for himself or safely navigate the stairs in his home to do laundry. He was denied homemaker services. When we requested physical therapy to help him safely ambulate, this was also denied. Instead, they required him to drive 53 miles each way in the winter twice a week to go to the VA clinic for PT. We serve an 80 85year-old veteran who has difficulty ambulating.
▶ 1:34:33He uses a cane due to a stroke and can't stand for long. He was denied home health aid services because he reported on the phone that he can shave his beard. However, the VA team failed to take into account his ability to perform other activities of daily living such as bathing, ambulating, or dressing. Community care enhances access, expands capacity, and supports choice for veterans without replacing the foundational role of the VA.
▶ 1:35:04Community care is not a workaround. It is a necessary part of a comprehensive veteran first health care system. When community providers and the VA work together, veterans benefit from timely, compassionate, and coordinated care delivered wherever they are, whenever they need it.
▶ 1:35:25We have an opportunity and a responsibility to ensure that every veteran receives care that is timely, highquality, coordinated, and close to home. by strengthening community care as a complement to VA services, investing in home care and rural access, and ensuring providers are supported through fair reimbursement.
▶ 1:35:48We can fulfill the VA's sacred mission to those who have I thank you for your time and for your continued commitment to the health and dignity of America's veterans. Thank you, Miss Newman. Miss Keenan, you're now recognized for five minutes to present your testimony.
▶ 1:36:04Chairwoman Miller Meeks, Ranking Member Brownley, and members of the subcommittee, on behalf of the men and women of the Veterans of Foreign Wars of the United States and its auxiliary, thank you for the opportunity to provide the VFW's remarks and my personal story on the topic of community care. VA's community care program and its network of providers are a vital component of VA healthcare, particularly for specialized care that VA does not provide.
▶ 1:36:31Community providers are force multipliers, allowing VA to offer the world-class care that veterans prefer while also ensuring they have access to a range of services when they need them. When used appropriately, community care can save lives and improve health outcomes. However, problems with the coordination of that care can drive veterans away from VA altogether.
▶ 1:36:55VFW members have identified several coordination issues, including delays in VA paying for community care in a timely manner. VA referrals can also be unclear, especially understanding the types of care that are authorized, including lab work and procedures. Scheduling appointments for community care is also a reported point of confusion for our members.
▶ 1:37:18Not every VA medical center informs veterans when they have the option to use community care, nor when the veteran should set up the appointments or and if and when VA will schedule them. I have personally experienced these issues as nearly all of my women's specific care has been in the community. The first time I had a mammogram, it took VA six months to pay the $700 bill.
▶ 1:37:43I had to call both VA and the community provider several times and began receiving collections notices until the bill was paid. I have also used community care for maternity care, a type of specialized care that VA does not provide at all through its its direct care. The coordination of that care has been a source of frustration and stress at times.
▶ 1:38:05I actually had a pregnancy last year which sadly ended in My VA maternity care coordinator twice received incorrect information from my community provider and called me to ask me why I was trying to terminate my She called me at a later date and asked why I had proceeded with a termination procedure not approved by VA.
▶ 1:38:34In both instances, I had to tell her that her information was incorrect and then explain and reexplain that my pregnancy had not been viable. This is an example of poor record sharing between community providers and VA resulting in painful conversations made with an administrator and not even my primary care physician. I'm currently using VA coordinated maternity care again as I became pregnant this spring and have successfully made it into my second trimester.
▶ 1:39:04I am I am currently struggling with the bureaucracy of having genetic tests conducted by my community provider. Because of my age, the provider finds them especially necessary.
▶ 1:39:19After exchanging several secure messages with VA about billing codes, I was told that two of the tests should be covered by VA, but that I should also confirm with the lab, likely LabCore, to verify with them that the tests are indeed covered by VA's insurance provider, Optum. This does not feel like VA has approved these tests if I have to discuss the billing codes myself with the nonVA provider, a subject with with which I have no familiarity.
▶ 1:39:48If I accept a test that VA does not cover, that could be thousands of dollars that I have to pay out of Despite these and other coordination issues mentioned in my written statements, I am very happy with the quality of care that I've received in the community and I like that I have had the choice of my providers. We must find ways to improve the coordination of community care.
▶ 1:40:13The VFW supports chairman boss HR740, the Veterans Access Act of 2025, as it represents a critical step forward in enhancing access to community care for veterans. Additional legislative measures should also be considered to address the issues that I and VFW members have mentioned.
▶ 1:40:33While veterans consistently report to us that they prefer direct care at VA when needed, community care should be coordinated appropriately and not create additional bureaucratic frustrations for veterans. Chairwoman Chairwoman Miller Meeks, Ranking Member Brownley, this concludes my testimony for I'm prepared to take any questions you or the subcommittee members may have. Thank you. Thank you, Miss Keenan. Miss Hunter, you're now recognized for five minutes uh to present your testimony.
▶ 1:41:01Chairwoman Miller Meeks, Ranking Member Brownley, and members of the committee. Thank you for the opportunity to testify today. I am the CEO of Iraq and Afghanistan Veterans of America, but I'm also a public policy researcher and a service connected disabled veteran who utilizes VA services. I am honored to represent the post 911 veteran community.
▶ 1:41:21This is a diverse population with unique health care needs which includes illnesses and injuries that are a result of cumulative and compound exposures, latent impacts of blast related injuries and the interaction of several physical and mental health care Community care is a vital part of overall veterans healthcare. But especially as we consider rising costs, we need to be clear that the evidence does not bear out that community care is a meaningful replacement for all direct VA care.
▶ 1:41:51For a detailed discussion of the research underlying this, I ask that you please reference my written testimony that has been submitted for the record. Community care does play a critical role for some patients and this is most evident for veterans who live in rural or remote areas for whom it would be time prohibitive to travel for direct care or for those who need specialty care that has a narrow focus or serves a small population and it would not be efficient or effective for the VA to maintain these services.
▶ 1:42:18However, the evidence is also clear that VA direct care provides better health outcomes for the majority of veterans. First, direct care does have lower weight times than community care. And wait times are not about convenience or hassle, but about health and well-being. Prolonged weight times are associated with deteriorating health outcomes among multiple dimensions.
▶ 1:42:39And when compared to community care, direct care is marketkedly better health outcomes such as a significantly lower post-surgical 28-day mortality rate, lower hospital readmission rates, and quickos quicker hospitalization return to work rates. And for our most vulnerable veterans, the disparity of outcomes is even more stark. For suicide rates, veterans who receive community care have a 25% su higher suicide rate than those enrolled in VA direct mental health care. And too many of our post 911 veterans are falling into this category.
▶ 1:43:10VA direct care also has more positive outcomes related to toxic screenings for veterans with compound exposures, which include environmental toxins, traumatic brain injuries, acute injuries, and mental health conditions. Evidence from past act implementation, a process many of our veterans have benefited from, shows that VA direct care providers were able to identify exposure- related illnesses at a faster and more accurate rate than community care providers.
▶ 1:43:36And VA direct care doesn't just provide better patient outcomes, it provides cost savings to the US government. In side-by-side comparisons with community care, VA patients have a 24% year-over-year primary and preventative care cost savings. more contributing to the cost savings. Veterans receiving direct care experienced 43% fewer hospitalizations, 58% fewer days when they were in a hospital, and 43% outpatient surgical procedures.
▶ 1:44:03And as more patients are being seen by the VA, we will see more cost savings. Between fiscal years 2023 and 2024, the VA saw 14 million additional episodes of care. This upward trend is indicative of both the expanded population that is seeking VA care and the conditions most common in post 911 veterans that require well-coordinated and integrated care which leads to the fact that the VA is unique in its ability to coordinate care between primary and specialty care providers
▶ 1:44:34through its patient aligned care teams. This reduces the burden on the veteran for scheduling and managing their own care and ensures that veterans do not receive unnecessary medical treatment. Many recent studies have found that community care providers too frequently administered highcost and medically unnecessary procedures to veterans without coordinating with their care teams, thereby exposing veterans to unnecessary treatment without medical VA run community-based outpatient clinics also
▶ 1:45:04provide a necessary direct care service in many areas that there is not one of the 170 VA medical centers. These should be expanded upon and invested in at this time. In my written testimony, I detail the importance of investing in Seabox in four key areas that align with the VSO independent bud budget recommendations. By focusing on targeted expansions and improvements, Seabox can more fully realize their designated purpose.
▶ 1:45:31Community care is best used when originally intended to meet the needs of those patients in rural and remote areas and for particular specialty care. But for the majority of veterans healthcare needs, the evidence presented just indicates that VA care is better care. Thank you, and I look forward to your Uh thank you, Miss Hunter. And I just want to take a moment to uh this is uh um I think a little unusual but thank our witnesses for their service. So four of our witnesses have served. So thank you for your service.
▶ 1:46:01Um as is my typical practice, I'll reserve my time until all of the members have had a chance to ask their questions. I now recognize Ranking Member Brownley for five minutes for any questions she may Thank you, Madam Chair, and I too want to thank all of you for your service to our nation's veterans. We appreciate it very, very much. Uh, Dr. Hunter, um, I appreciate that in your testimony you highlighted the importance of military cultural competency and training.
▶ 1:46:28Can you expand on why VA providers are so uniquely position to care for veterans and what it means for your members that their providers understand their unique Thank you so much. VA providers are required to go undergo extensive training on military cultural competency.
▶ 1:46:49This includes things like multiple compound compound exposures, whether it is toxins, the interaction between mental and physical health care as well as emerging research on some of our technologies. Additionally, VA providers, some of which are actually cleared to act to be able to access classified medical records and so they can understand environmental exposures that were there. For myself, this was life-saving.
▶ 1:47:16at a regular routine optometry appointment that I had where I was experiencing vision changes and I thought it was because maybe I was just over the age of 40. Um, my VA optometrist was able to connect symptoms I was experiencing to exposures from my service time and get me screened for ocular melanoma. Turned out I had it. We caught it super early at at this case.
▶ 1:47:41But in every single community care optometry appointment I had, not once had I been asked about my time in military service, where might I have been, the type of exposures that that I would have seen. And if we look at the post 911 generation and we look at what was found in the pact, the ideas of presumptive uh connections for things like toxic exposures, but we're seeing more and more aviation equipment that think time around fueling as well as the compound traumas with military sexual trauma
▶ 1:48:11and PTSD. It is essential that our our veterans are seen by pri providers who understand that and in the community while the uh mission act says they should have training we actually have no idea what they what sort of training they're getting. We don't have oversight on that in a real and meaningful way the way we do have oversight on the types of training that VA providers have. Thank you for that. And um I I think in reading uh Dr.
▶ 1:48:37Mob's testimony, she cited a RAND article, excuse me, a Rand article stating that uh at least making the assertion that VA providers aren't trained. Um I know that uh you've previously worked at RAN. Are you familiar with this article at all? Uh yes, I was one of the contributing authors to that study. C are you? So can you is that true the what the conclusion of that article said?
▶ 1:49:05No, the the article said that we are aware of the training that VA providers received. We do not have oversight on the training that community care providers received. Thank you for that. And um another thing I appreciate about your testimony was that you included extensive citations throughout uh to articles and academic journals to studies from nonpartisan entities like Rand uh GAO and the CBO.
▶ 1:49:32One thing that worries me about the way legislation sometimes comes together is that it is informed by anecdotes and the experiences of perhaps vocal a vocal minority voice um rather than by the true uh evidence. So what does the evidence say about where veterans prefer to receive their care and where the quality and outcomes are better?
▶ 1:49:58The the preponderance of the evidence shows that V Veterans prefer VA care. And when we look at some of the very very tragic stories that we see and the anidotes that we hear, we need to take every single one of them seriously and look into what has happened. And the VA does have significant measures to actually address providers that provide subpar care. But we also need to be reminded as I was often in my doctoral studies that the plural of antidote isn't data.
▶ 1:50:26And if we look at the preponderance of the data, the data lead us to VA care providing better care. And in surveys of our own members, only 14% expressed any confidence in community care being able to address and coordinate their complex medical needs. Thanks for that.
▶ 1:50:43and you know, do you have any suggestions on really how we help veterans um the the public for that matter um to better understand the evidence and and overcome this perception that the VA care isn't as good as community care?
▶ 1:51:02I I think it is very incumbent upon VSOs to take an educating role on what the the VA is and also incumbent on members of Congress to continue to engage with VA providers to ensure that we have appropriate oversight and engagement to understand the quality of care that that Thank you for that. I yield back. Thank you. And thank you, Ranking Member Brownley. Um I now recognize uh Dr. Murphy for five minutes for any questions you may have.
▶ 1:51:27Thank you, Madam Chairman, and thank each of you for your service and the the work that you're doing to try to make our care for our veterans as best as possible regardless of where it comes from. Um, you know, I wish this was not an eitheror kind of situation. This needs to be an and yes, a yes and situation because the VA cannot handle all the health care that it needs to handle for our veterans. Period. There are not the resources, some of which is negligence on the behalf of the medical education uh system of the United States.
▶ 1:51:58We simply don't have the doctors. We simply don't have the doctors. But it it it just kind of hurts me that people want to say um this is better, that is better, and against one care or the other. So um Dr. uh Hunter, since you brought it up, you don't mind, I'm going to ask you about your ocular melanoma. So, are you saying that the VA doctor picked that up because they knew you might be exposed to something or are you saying your optometrist out in the community missed it?
▶ 1:52:24Uh, I had had a appointment with a optometrist out in the community who did miss it. Six months later, I had an appointment with an optometrist at the VA who was able to recognize it. So, did the optometrist do an ocular Did look in your eye and look all around your quadrants? Did you by any chance get films from them before then? Because they always make films. I alcular melanomas can happen in six Yes, I there were films it was present in the films when my VA provider had reviewed them later on and it wasn't discussed or addressed.
▶ 1:52:53So I I would I I would just submit that that's a difference between two physicians. It doesn't matter where they're coming from whether you could flip them the other way itself to say one is better just because of the place where they work I think is is is just not being um correct. Uh, also delving into some of your comments about post-operative care.
▶ 1:53:12Um, can you give me a breakdown of the type of patients that are referred out to community care for surgery versus those that are kept in I can take that question for the record and get you the breakdown for I can I can tell you what it is. You don't refer things out to the VA unless it's specialty care. I'm a specialty surgeon. I get specialty referrals for specialty care that cannot be happened within the hospital. By definition, those are more costly because they're more timeeffective. They're more uh specialty oriented and their risks rates are higher.
▶ 1:53:42So, doing actually a risk ratio would be factual to this rather than just saying post-operative care is better at the VA, the outcomes are better than they are in the community because they're two entirely different populations. You refer people out who need specialty care, who by definition have greater needs than they do. I just don't like the tenor that we're putting uh there or battling against, you know, saying that uh the community care doctors, of which I am one, are better or are worse. I don't think that's fair. That's not fair to our veterans.
▶ 1:54:12Then what are you saying to them? Anybody who gets referred out while we're saying we're sending you out for inferior care, that's not fair. I don't think that is fair. Um Miss Knight, um let me ask you this. you know, and there there questions about which has bothered me since I've been on this committee about our electronic medical record, which I think is just derelict in the VA through how many administrations that we've been going through. I still can't I had a patient last week who was a VA and I said, "Did you bring your records?" And he said, "No, they said you'd have them.
▶ 1:54:41Of course, they never sent them and I can't get access to them." Can can you let me can you explain to me how just the community care has helped you to access more or less I'm excuse me, given you more or or less access to VA covered I have more options. I live in Montana, the biggest city in Montana at 150,000 people. So, it's quite small, actually. And there are not a lot of providers, let alone specialty providers from within the DA VA.
▶ 1:55:08Uh, I see a chiropract with my chronic migraines, of which neither are available within the VA. And as I've shared in my testimony, I've had pretty horrid stories and experiences within the VA. um and good experiences within the community.
▶ 1:55:26My chiropractor, who is a male, actually took the time to review what information was passed to him from the VA with my referral and asked me on my preference on whether or not I wanted a man or a woman physician, which was the first time I've ever been asked um as a proactive manner on my preference given my military sexual trauma. So, so they're good experiences or bad experiences really probably within both systems. Absolutely.
▶ 1:55:56I would ask to just have more control and choice over where I want to go. As I also mentioned in my testimony, most times the gatekeeper within the VA uh calls and says, "Here's your list of providers. Where do you want to go?" And I feel like I'm on this ticking time bomb of making a decision while, you know, momentarily taking a time out of my workplace because it's usually Monday through Friday 9 to5. And in that effort, my typical question is, well, what's closest to me as a convenience for me?
▶ 1:56:24Not necessarily, are they man? Are they woman? Do they have good reviews? Can I do research on them? I would ask to better understand what my options are so that I can make a more informed and educated decision for Thank you. You know, Dr. Mobs, it hurt my heart to hear that somebody in an administration would withhold care because they wouldn't they wouldn't have the um compassion, much less the medical competence to send somebody out to the community and withhold care. I hope that person um I don't want to say disciplined.
▶ 1:56:54I hope they got shown the door. Um because what an absolute disservice it would be to whoever veteran sadly enough if they die in pain because they didn't get their radiation. That's horrible. That is a horrible story. Um, Miss Keenan, in in your opinion, um, if you will, where does community care fit in? Am I already over? I'm sorry. I've been yacking too much. I apologize. I'll yield back. Thank you, Dr. Murphy. The chair now recognizes Dr. Morrison for five minutes for any questions you may have. Thank you very much, Madam Chair.
▶ 1:57:24Uh, I want to thank the, uh, witnesses for your testimony. Thank you for your service to our nation, and and thank you for sharing your very personal stories today. That is not easy to do. and I know we're all grateful. So, thank you for that. Uh, today's hearing really touches on struggles and frustrations that are all too familiar to me as a physician. One of the one of the reasons that compelled me to serve in Congress was my firsthand experience with how difficult navigating the health care system in our country can be at times.
▶ 1:57:52Patients and physicians have no shortage of exceedingly valid frustrations with navigating health care in the United States. A Gallup poll actually earlier this year found that one in four Americans ranked improving health care access and affordability as their highest priority and over half of Americans ranked health care among their top three priorities for government leaders. There is no question that Americans are looking to their elected leaders to act on the issue of health care.
▶ 1:58:20The testimony from today's witnesses highlights the reality that like the majority of their fellow Americans, far too many veterans are facing barriers that prevent them from accessing the health care we made a commitment to provide. They are asking Congress to make meaningful progress toward improving their quality of care and making sure we are delivering on the promises we made to those who have served our country. Today's hearing title includes right time, right place, and right treatment.
▶ 1:58:46And I could not agree more that pursuing improvements to health care at the VA does require considering time, place, and treatment. We should absolutely be evaluating whether veterans are receiving the care they need in a timely manner. We should absolutely be focusing on fostering, preserving the specialized care that research continuously demonstrates is critical to veteran health outcomes.
▶ 1:59:09We should absolutely be committed to reviewing cutting edge scientific evidence and research to bring no novel treatments to veterans without delay. However, if we attempt to pursue all of those goals without considering the present circumstances of the VA or preserving a commitment to evidence-based treatments and rigorous standards, then we cannot in good faith claim to be delivering on what veterans have asked of us.
▶ 1:59:35Losing an estimated 30,000 staff in less than 12 months will move veterans seeking direct VA care and coordinated community care away from the right time. Devastating Medicaid cuts from the so-called one big beautiful bill that President Trump signed into law threaten rural hospitals and access to community care costing veterans the potential right places across areas that needed them most.
▶ 1:59:59And I worry that if we aren't vigilant, the pace at which community care funds are growing will strain VA research and direct care that is indispensable to getting to the right treatment. So, Dr. Hunter, with that in mind, in your testimony, you emphasize the importance of following the data. What does the data tell us about how to improve access to timely quality care at the VA? Thank you so much for that.
▶ 2:00:25and we share your concern and commitment for having the right care at the right time. The the biggest thing that the data are telling us is the important in of investing in the patient centered care teams that that exist. Far too often these care teams are cut out of the loop. They are often sometimes the first employees to to get cut or deemed non-essential. And what we know is that they are the most essential.
▶ 2:00:50The other aspect that is incredibly important as the data said is to hold community care to some of the same rigorous standards and information sharing so that the patient aligned care team can effectively create an entire course of treatment. In our conversations with medical directors at the VA, what we're finding too often is that community care providers are not required to provide back the full course of treatment that they are engaging in with the patient, which makes it more difficult and adds time to having to understand what the
▶ 2:01:20patient is going through and often leads to patients having to relive horrible stories and events time and time and again because there isn't that coordination. So keeping that patient aligned care team coordination as the center, investing in it and strengthening the resources for that team is what is absolutely essential to get the right care to our veterans at the right time. Thank you Dr. Hunter. I agree. VA direct care is vital to meeting unique veteran health needs and there is no question that there are circumstances in which community care is appropriate and essential.
▶ 2:01:51But this committee can't claim a serious commitment to either while advancing legislation and co-signing leadership decisions that undermine VA's stability and capacity to deliver on its core missions. Thank you, Madam Chair. With that, I yield back. Thank you. The chair now recognizes Representative King Hines for five First of all, thank you to all of you for appearing before us today. Thank you for your service.
▶ 2:02:19And uh I just have to say man, go women power cuz uh just phenomenal women appearing before this committee. Um I come from the northern Marianas where access to service is very limited. we don't have a seabach.
▶ 2:02:33And I think people are going to get sick of me saying that because I'm going to say it over and over again until we actually do get um access to care which is why um you know looking at uh community care programs is very important to me because of that reason. Now one of the things that I I'm hearing from all of you is that things could be better with regards to the way we deliver this programs. There are gaps. Dr.
▶ 2:03:02Mobs, uh is it Mobs? You you spoke of uh in your test in your written testimony that you submitted, um you talked about a comprehensive metrics system that needs to be put in place.
▶ 2:03:18Um, can you just kind of dive into that a little bit because I'm looking for opportunities to improve to ensure that some of these challenges and gaps that we're talking about and hearing about today uh are actually addressed in the legislation and um and that we we we can improve the And thank you very much for that question.
▶ 2:03:39And I think this is critically important and I I am certainly a a advocate for the not the either or but the and we have to have both a strong VA and strong community care and as part of that the GAO has provided extensive recommendations regarding the opportunity to improve uh oversight and accountability around community care and in particular some of the things that have been mentioned here do need to be improved upon. The ability to track scheduling performance for example metrics aligned with those time frames are imperative. meaningful accountability around those metrics.
▶ 2:04:08And then, for example, the VA's referral coordination initiative, which was meant to streamline specialty care, has suffered from somewhat inconsistent implementation, unclear guidance about its use, and inquade performance metrics. So, I would simply say that the work has been done around assessing VA community care, opportunities for improvement, and I would just say that we should be looking very extensively at the recommendations provided G by GAO in order to enhance them. Thank you for that. And this is a question to to you, Dr.
▶ 2:04:38Hunter, because I I I do agree. I'm an attorney by practice, and you know, when you appear before in front of a jury, you have to submit data, evidence, right? But sometimes the anecdote does win. And too often, as a matter of fact, from the in the community that I come from, these stories are what I hear every single time I meet with constituents. And for as long as I've sat in this committee in this last seven months, these are the stories uh that we hear.
▶ 2:05:08And so, you know, you spoke of some of the gaps to include uh accessibility to recordkeeping and being able to um have a more seamless process whereby there's a little bit more accountability with regards to the program itself. Can you give us suggestions as as to how we can improve the the current situation?
▶ 2:05:34Thank you so much for that because you know again we understand that this isn't a a eitheror. That's not how this should be characterized. It's a yes and but we really need to improve the coordination side of community care. So it is held to some of the same standards that VA care is. And so if we're thinking about the coordination piece there there are a few things that can be done. one is there needs to be uh some more deliberate looking into some of the VA modernization and the the enterprise systems that are being rolled out. Um this work is sort of early on preliminary.
▶ 2:06:05We are are really excited to to work with the committee to better understand and ensure that the electronic health care record system is being rolled out in an appropriate appropriate manner that allows for better coordination because right now what we're seeing far too often is that the VA where there are very well-coordinated records kept is not able to communicate well with community providers and things are falling through the cracks. We are we are not getting full care plans.
▶ 2:06:31we are not able to uh ensure that that veterans are receiving the same standard and quality of care. And so first making sure that process is going well as well as ensuring uh oversight and enforcement of the quality standards and training that are required of our community care providers.
▶ 2:06:48You know, the the Mission Act said that needed to happen, but according to multiple independent medical associations, there is not yet a published transparent standard for what community care needs to meet or what sort of records need to be provided back to the VA care teams to ensure the comprehensive continuity of care. And so, in those two areas, I think there's a lot of room to to be done.
▶ 2:07:12And I think this committee is is primed to be able to engage in that in that sort of Thank you. I'm out of time. I yield my time. I I yield back. Uh thank you very much, Representative King Hines. The chair now recognizes Dr. Conaway for five minutes for any questions you may have. Uh thank you, Madam Chair, and thank you u ladies for your service and your commitment to veterans and their healthcare. Want to make a a few comments and observations.
▶ 2:07:40uh since both sitting on this committee and what I've heard today I hope there is consensus uh on this committee and across the house across the government that there that we need to have a strong VA healthcare system and that we need uh community providers because we know the VA doesn't exist everywhere particularly in rural areas and so we know this partnership needs to exist one of the problems as a physician practicing physician for 30 years myself worked uh on a
▶ 2:08:10on an Air Force base in New Jersey taking care of veterans and in the community and private practice. Uh what I I'm my experience tells me and what I have read about what the research shows and what we all know with the problems with our information system is that there's not uh coordination across those systems once you move outside of a system even within hospitals in my own little state of New Jersey.
▶ 2:08:33getting records to move from hospital to hospital if they're not on the same platform is a very difficult thing to achieve and you will have and particularly and so you're going to have patients if they move to different loces having to repeat their stories and it's terrible when it involves things like trauma uh when you're in a teaching institution uh your resident might see you uh might be a medical student then a resident then the attending and so um uh this is part of the teaching process and teaching institutions and unfortunately um we will hear stories about
▶ 2:09:03people being retraumatized uh as these um as this information is collected. Uh but that iterative process and teaching institutions is part of driving great outcomes. I would also say uh that um you know we have to rely on data as you mentioned and and the data has been consistent over many years and repeated uh that VA care for veterans um is uh is provides great outcomes. Veterans want care there.
▶ 2:09:30And if you think a moment about the different exposures, the experience um in the military where they have been uh the experience of people taking care of numbers of veterans over years of the years that is unlikely to be replicated in most communities. Uh it doesn't surprise me that outcomes are better than the VA system. Our problem is that it's hard. Well, I maybe I should speak for myself, but I think I'm speaking for a lot of others, too.
▶ 2:09:53When we understand that the administration is cutting tens of thousands of people out of a system that's already stressed, it's hard to imagine that you can um achieve the kind of outcome standards that that you could achieve if those people weren't out of the system. Now, reform, looking at how things are done, making sure training is correct, maybe having a special uh access for women who are having particular problems, whether it be reproductive health care or sexual trauma in the service. Um, those things are important to put in a system.
▶ 2:10:22I think you're more likely to get that in the VA. Very often you're in the community, by the way, because of the sensitivities in the VA system for this, I suspect. Um, and as I look at the numbers we have about the people who have been um, who are leaving the service now, as I look at the numbers, twothirds of them are clinical staff, physicians, uh, nurses, support staff.
▶ 2:10:42And so, um, if we were to decide to bring in or try to recruit more women to deal with sexual trauma in the service, I I can't imagine how that wouldn't be decrieded as a DEI program within the government. you can't even recognize women who've served um you know honorably overseas because it's you know recognizing women and never mind people of color.
▶ 2:11:02So um I want to ask uh this question of you Miss Newman because you work in a rural area and we know now that there are a number of studies that are coming out showing that these Medicaid cuts are going to be particularly devastating in rural areas where Medicaid might make up 40 to 50% of the revenue. Uh we heard 338 hospitals at risk. You live and others on this panel um live and get care in rural areas.
▶ 2:11:28Can describe how the loss of hospitals in the community is going to impact uh access to care, the the excess that we know veterans need. Thank you for the question. Um yes, I do live in a rural area. In my particular area, um we already have lost access to hospitals.
▶ 2:11:51Um we are an independent home care agency and these cuts are not um going to in particular impact our agency. Um but our um people in our area, they're already used to um traveling to receive care. just reclaiming my time because I'm running out of time. Uh and thank you for for that. I I think it is um it's obvious uh that if hospitals close uh there's going to be an access to care problem.
▶ 2:12:20I asked Secretary Collins uh at a hearing just like this one about um whether or not cuts to Medicare and and food assistance is going to impact veterans. He says, "I don't foresee that happening." Now, well, now it's happened. And we know uh as a result of that uh big ugly bill that we're going to see really u quite devastating dislocation across the land and particularly in rural areas and also impacting veterans and that's that's a shame uh given the commitment this country needs to keep to our veteran community.
▶ 2:12:51Thank you madam chair. I yield back. Thank you Dr. Conway. The chair now recognizes Representative Sherilis McCormack for five minutes for any questions she may have. Thank you so much um Chairwoman and thank you so much for your testimony. Um it's truly an honor to be here listening to your testimony. I do have a background in home health. Also, I am second generation and I kind of miss being in there and finding um solutions to these problems. And I do believe also that community care is imperative to serving our veterans.
▶ 2:13:18However, we do need to have bipartisan legislation that can help us fill in those gaps. So, I was very delighted when I heard what Dr. Hunter was talking about the need for standardization as far as to make sure that we have accessibility but also communicating what is going on with the community care doctors specifically getting on time or real time information for our patients which even in the private side and community care we're still trying to get up to date. So I wanted to talk to Dr. Hunter a little bit more about that.
▶ 2:13:47what recommendations would you put in place so we can actually um bridge that gap specifically when it comes to community care and our veterans offices? Thank you so much for that question. You as we said we know community care is vital but we know there needs to be better direct communication so that patients are receiving that same quality integrated coordinated VA care that leads to better outcomes.
▶ 2:14:11And so if we look at recommendations that can can improve this one is having the same types of care standards that are required for community care providers as uh for VA healthcare providers.
▶ 2:14:25This is seen very clearly in the mental health area where when a a patient is seen internally to VA direct care, VA direct care mental health providers are required to set a evidence-based course of care for that patient that hits very significant benchmarks that are there. When they're referred out to the community, they were referred out for a timebased episodes of care. So 6 months, 12 months, and then it's re-evaluated.
▶ 2:14:50But right now there is not a requirement to actually share back with the patient care team what the decided course of care is. And in fact all that's required is a yes this patient showed up for an appointment and it's either improving or not improving.
▶ 2:15:05So first and foremost to to strengthen this is to set the same standards for evidence-based care for VA care and community care and require that that transparency so that all providers within the VA system know what the course of treatment is across all sorts of specialty care that are are provided. You know this is one very specific example for mental health care but we see this happen in other forms of care as well. Now you touched upon um the problems that we're having with electronic medical records.
▶ 2:15:33My other subcommittee is technology modernization and I really hope that we can have a joint hearing so we can be discussing this together and so I know we already have strains in even getting the VA's system up to task and up to snuff. So I know it will be challenging for us to do that with community care but do you have any recommendations that you can give us when it comes to electronic medical records? I think we we do need to take a very close look at the the current implementation of electronic health records within in the VA.
▶ 2:16:03We know it is plagued with problems from the from the get-go. Um this is an area that I am I am new in this seat. I've been a CEO here for a month, but it is one of the things that I have really wanted to to dive into to be able to provide those better recommendations to you all as to how we can effectively modernize the VA and create better synergies and more seamless communication between VA community care and would love to to work with your office to do just that. Thank you. Um I want to pivot a little bit over back to our home health issues that are happening.
▶ 2:16:32Um so when I was a CEO of a healthcare company what we did we also had rural areas Kiston Belgrade and we were servicing there we had huge issues when it came to recruiting healthcare professionals to get out there but also we did have a good number of Medicaid recipients. Now do you have any Medicaid recipients who are actually with your organization? We we have very little in our in our particular organization. We're a standalone homeare agency. So right now we're looking at $1 trillion in cuts when it comes to Medicaid.
▶ 2:17:03And so I have deep concerns about the compound effects with the cuts that we have in the VA combined with the $1 trillion in Medicaid cuts and how we're going to keep organizations like yourself who play such an imperative role in making sure that our veterans can actually retire at home with dignity with their family but still get their services. So could you touch on some of those effects for your organizations, other home health carees um agencies that will be servicing our Medicaid patients and our Sure.
▶ 2:17:33Um of course, as I stated, we um our particular payer mix um we have very little of the Medicaid. Um and so for us personally, it won't have a large impact. What we do is what um as with any other agency is we we try to meet everybody's needs. Um, in our particular area, we're not hearing feedback. Well, I have a few more seconds and I just wanted to ask you this one question. One of the things I'm hearing from home care agencies is that they have real concerns about the people who are going to be kicked off of Medicaid.
▶ 2:18:02They can't abandon those patients. How do you transition that person who is homebound, cannot get up, can't take care of themselves. How do you rip their insurance and how do you leave them there? So, have you guys thought about that transition process? Are we just going to abandon these patients to leave them to themselves?
▶ 2:18:18Well, if I can circle it back to the VA, um, we are actually actively seeing that now with our veterans where on the VA services where they've lost homemaker services, home health aid services due to internal cuts within the VA, we are seeing that they've lost access to care. And so, um, I think it's already happening within the VA, but this started a year ago, um, based off of decisions within the VA. So, the compound Thank you very much. Your time has Thank you. The chair now recognizes Dr.
▶ 2:18:48Dexter for five minutes for any questions she may have. Thank you, Madam Chair, and thank you all again for your service and for being here today. Really, really appreciate it. Um, one thing that struck me listening to all of you um that I continue to struggle with being new here in Congress and coming here as a physician is what feels like a binary choice between community care and VA care.
▶ 2:19:12Um I know nobody here is advocating necessarily for one versus the other but I think that is how it feels in this committee at times and one quote um that one of you shared was community care is not an alternative to the VA.
▶ 2:19:26is an extension of it and that should be what it is but it's not what it ends up being because this is a fixed pie that when we take money out of the VA direct care services it and get it out to the community it is a loss from being able to build up the VA care to the quality that we know Dr. Hunter you spoke to um when we get it to our veterans it's better quality care and they're more satisfied.
▶ 2:19:55The problem is as Miss Keenan and so many people have talked to it's getting them that care and and having them available um or be able to get availability. So, one thing that I'd like us to try to center, it's truly a bipartisan endeavor, I believe, is to get our veterans at the center of what we're trying to do and make sure that their needs and their um access and and quality are are what drives our decisions rather than protecting community care, protecting VA
▶ 2:20:26um in or in district care. Um, so Miss Hunter and several of you have talked about the data and I wonder what kind of data would be most compelling for you as a veteran. And so I'll start with you, Dr. Hunter. Um, what would be the most compelling data for you as an advocate for veterans, especially our women veterans who are underserved in so many ways, but I I don't want to be disproportionately focused on that.
▶ 2:20:56Um, what would you want to see? what what would help you make decisions about advocating for community care versus in the VA system care direct care? Thank you so much for that that question. When we look about where the the compelling data is, you I'll put my researcher hat on. I look at outcomes, right? And outcomes matter and we know that patient centered outcomes are better when with VA care because of the coordination, which doesn't mean that community care can't get there, but the coordination needs to get there.
▶ 2:21:25And one thing you noted that I I really want to touch on is is some of the concerns that are coming from the fixed budget. And what we're seeing more and more is mandatory spending being directed towards mandatory spending for community care, which necessitates making cuts at the VA.
▶ 2:21:42And we're hearing from several VA providers that that results in not being able to fill positions, not being able to actually hire the people they need to hire, which creates an unfortunate cycle of demonization of the VA because we have lower morale, lower staff, which leads to longer weight times, and sometimes worse outcomes. So again, centering the patient in the outcomes is absolutely essential there.
▶ 2:22:08And I think as we're looking at this and we're talking about choice in all of this and choice is essential, but we need to ensure that we do not remove the ability of veterans to choose VA and to choose a provider at the VA as a one-stop shop for their care. No, I appreciate that.
▶ 2:22:23And so I think what I certainly am interested in working across the aisle and and with this committee subcommittee on is um centering how do we get the data that we need to make the decisions that really do deliver the quality access and service to our veterans that they deserve. And it may be that it is wound care in the community is the most effective way especially in rural areas.
▶ 2:22:49but let's have the data so that we understand how long it takes to get for a wound care appointment, how far you have to drive, and then let the the patients have a choice. And so I do think um making clear at the VA that patients or veterans have a choice is important and I heard several of you speak to that that we should not be trying to deter people from getting care at the VA but we should not shield them from a choice but making that choice
▶ 2:23:19tangible and I hope that everyone on this committee can center that. Um, I look forward to working with you all on how we get policy amendments, however it looks, um, so that we can get the right outcomes for our veterans because again, I I don't want to be shielding Optum and Triricare and trying to get them dollars. I want to get those dollars to the VA and to our veterans. Okay. Thank you. With that, I yield back. And thank you very much, uh, Doc Dr. Dexter. The chair now recognizes herself for, um, five minutes.
▶ 2:23:49Um, Miss Hunter, you mentioned several times about the um the challenges of uh information and training and whether VA specific providers had specific types of training that didn't happen in community care. But isn't that a failing of the VA? So, if we think about the training, it could be a failing of the VA. It could be just as I'm I've got I've got five minutes. Just want a simple yes and no question. It's a failing of the VA. Agree, disagree.
▶ 2:24:19We don't have the data, so we can't say where the failing is. Okay. But is not the VA responsible for that? The VA can set the standards for community care. Miss Mobs, can the VA set the standards for community care? They absolutely can. That's correct. Um, and so and and you mentioned the training, you also mentioned the red report, and I think perhaps you might have some comments you wanted to make on testimony. Um, so I'm going to give you an opportunity to clarify that. Thank you, Chairwoman.
▶ 2:24:45So, so first off, I never said that they don't receive training that that's an inaccurate characterization of what I said. And I think it's really important if we're talking about specifically data here. And I'm going to go where I'm an expert in, which is mental health. In the VA system, for example, we prioritized two uh performance metrics based datadriven therapies for post-traumatic stress disorder, prolonged exposure combat processing therapy.
▶ 2:25:06Unfortunately, because that was a trauma- centered therapy, the majority of veterans left after 2.4 four sessions, therefore wanting a different type of therapy that they weren't allowed to receive in the VA because they were given a PTSD diagnosis and qualification. And so, unfortunately, other evidence-based cares like interpersonal therapy, community care providers are trained in were unable to see those veterans and they dropped out and then we couldn't follow them. So, all that to say, just because there is training in the VA doesn't always mean it's the right training.
▶ 2:25:34And to the chairwoman's point, you can absolutely receive care in the community set by the VA to ensure that they are evidence-based therapies to provide for veterans. Admit that as a community care provider as an opthalmologist. Um, I'm given a specific type of treatment uh for a specific disorder I'm supposed to address. So, there were questions that may have been asked of other type of uh of conditions that I did not need training from the VA for.
▶ 2:26:04And Miss Knight, I I'm going to ask you to comment because you mentioned receiving care at the VA and care in the community and you've heard how this specific training better equips VA physicians to handle either the PTSD or the variety of issues, but I didn't hear that in your testimony. So, can you comment upon whether you thought that this training uniquely qualified VA physicians and did you receive better treatment at the VA versus in community care?
▶ 2:26:34Uh, my answer would be no, chairwoman, no. I had three different accounts of VA providers. Um, one of whom was a veteran herself. And all three, again, I felt more like I was interrogated at times, questioned and validated on my combat service and what I had endured and drilled.
▶ 2:26:54Um, I would also add that so many of our community providers out there deal with other patients who are similar in trauma exposure, such as our police and firefighters. So there are an array of providers both in the VA and outside of the VA that are more than qualified to meet the standards.
▶ 2:27:18I just feel very strongly that again one they need to ask the questions but that can be resolved by the patient by understanding and being educated on who the providers are whether that's ratings or reviews or anything of that nature. Right now we are not given that choice. We're not given that option. We are told where to go. It's more or less being in the military. And if I may, if we're going to talk technology, I would love to see the transition of documentation from DoD to VA fixed first.
▶ 2:27:49Um, kudos. Uh, as an Army veteran, I will say kudos to that. We've been asking for that. Miss Newman, um, have you noticed any decrease in community care referrals for home care services? Yes, in 2024 we noticed a marketked decrease um both within our agency and members across the nation. And um have you heard what the reason for the decrease in referrals would be? there.
▶ 2:28:15Um, in our particular vision, there was an extra layer of um, oversight and bureaucracy where um, their intent was to find reasons to reduce um, the amount of care or And I can tell you from my exposure, my uh, talks with veterans, uh, it was felt that they were encouraged not to send patients into the community.
▶ 2:28:37Uh, and as a community care provider, it can be extraordinarily challenging dealing with the VA, even when someone is 60 miles away from a center that could give them care. And I think veterans do appreciate and like the care that they receive at the VA. Um, but there is a reason why the mission act and community care exist. And the reason was because people were dying waiting for care at the VA. Miss Hunter, do you know how much the budget for the VA has increased in the past four years? Yes.
▶ 2:29:06I have that data right here. Um, is it flat? Yeah. No, the the the the budget has continued to increase. So, the budgets continued to increase. We know community care is comprising about 40% of care now within the VA, but we also know they do it at about 25% of the cost to the regular VA. So, I'm just going to say that, you know, implicating that community care is a downward spiral for the VA and taking money away from the direct care system.
▶ 2:29:34I'm going to say that doesn't bear out by the facts when you look at the budget and you look where the spending goes. I also want to say that we keep talking it about this as a fixed budget. And so if you have uh providers going to community care, they're not going to get direct care because the budget is the same and there's never any increase in funding. That's patently incorrect. I mean, um there has been more appropriation dollars from Congress.
▶ 2:30:00This spring, Congress voted billions more into VA VHA medical services. $75 billion to be exact. Um, so I I think some of the arguments are poorly founded, although they sound very dramatic. Um, so with that, I yield back my time as I too am overtime.
▶ 2:30:25thank everyone for their participation in today's hearings, for the discussions we've heard on the important topic. I'm going to uh yield to Miss Brownley if she has any closing comments. I do have some closing comments. Um, I wanted to just respond uh, Madam Chair to what you just said about an increase in the VA budget. I agree there has been an increase in that budget. There's also been an increase in the community care budget.
▶ 2:30:53So the issue is the community care budget is increasing at a more rapid pace uh than the the VA. So I just I want to put that sort of fact out there. But the way I want to kind of conclude today's comments is to respond to Dr. Murphy and I and I think uh Dr. Dexter actually did a very good job of responding to some of the things that he was saying.
▶ 2:31:20He talked about he was tired of talking about an eitheror scenario. Um and he said we need to get to I believe what he said was yes and and. So I agree with him yes and and I think uh what Dr. Dexter was saying, you know, we we we shouldn't uh you know, we shouldn't have a binary choice, an eitheror choice.
▶ 2:31:46Um but the community care should be an extension of the VA care, which in my mind is the yes and uh scenario. So the point I'm trying to make, and I think Dr. Dexter made the point with regards to, you know, one one pot of resources can only go so far, and we've got to make those those choices.
▶ 2:32:08The other issue I want to make here is if oh the chart is behind me is this data that I have here is VA data. It's not anybody else's data. It it comes directly from the VA. And what it says is that from 2022 to 2023 there was a net gain of employees of a little bit more than 18,000 employees.
▶ 2:32:35from 20 the then the the next bar chart is from 2023 to 2024 the net gain for employees was almost people excuse me the the last bar chart here is 2024 to 2025 that this shows that there's a net loss of a little over 10,000 employees employees.
▶ 2:33:05So I what what I see here is a trajectory going in a direction that's not going to be good relative to what quality care looks like at at the VA. So I I just believe that as the workforce at the VA continues to decline, I think as the data shows, and again this is VA data, it will absolutely begin to limit the choice a veteran should have whether they want to get their care at the
▶ 2:33:35VA or whether they want to get their care uh in the community. Um, and we will get to a point, I'm not saying we're going to get there today or tomorrow, but we could get there to a point where a a veteran will only have one choice, and that will be to go to the community for their care.
▶ 2:33:56And I think it is a very clear, and the data is very clear about this, that veterans want to receive their care at the VA. Now, if you're a a female veteran, you've got to go out to the community for if if you're you're pregnant and and you've got to go out to the community to get your care. Um and and you should have your choice of providers when you go to the community care.
▶ 2:34:23So, but but generally veterans want to get their care at the VA because they believe they have more quality time with the doctor. They believe that they understand the veteran better, etc. So this is the this is just the point that I'm trying to make that we don't want to go down this road. Secondarily, what is a a concern with regards to community care is is the impact of a a $1 trillion cut to Medicaid.
▶ 2:34:53And I mentioned in my opening comments, the University of North Carolina has identified 338 rural hospitals at risk for closure. One of the main reasons why we started the mission act and move towards community care was for rural areas. And if these community hospitals are going to have to shut down because of lack of there's not going to be a choice.
▶ 2:35:21Um, and the only choice then will will be the VA. But then yet we've we're you know people are resigning, people are retiring, people are leaving because it's just not a a a healthy place to work and they're not going to be able to provide the resources. So this is what I'm just the point that I'm trying to get across.
▶ 2:35:41Uh the point um I think we're trying to avoid um a deterioration of the VA and we don't want to deteriorate community care either. But we've got, as I said so many times in these hearings, we've got to find the right balance here. But I worry about this chart and uh I I think uh the chairwoman said at the beginning, this is just normal attrition. What's going on at the VA?
▶ 2:36:10This is not normal attrition. Um and um with that, I will yield back. Thank you, Madam Chair. Uh thank you, Ranking Member Brownley. Again, 9% of the workforce at VHA is lost annually through attrition. These are the VA's figures. About 38,000 employees based on its current workforce. That's the VA numbers. Those are facts. Uh for me, this is not an eitheror.
▶ 2:36:38This should be that veterans have choice over where they receive care. I'm a veteran. Neither my husband or I desire to receive care at the VA hospital. We prefer to receive care in our community either through private health insurance or through Medicare. Would it save us money if we went to the VA hospital? Possibly. We wouldn't have co-pays or deductibles, but we choose to receive our care in the community.
▶ 2:37:05We're asking for the same choice for all veterans and the veterans on this panel. There is a consensus in my mind that we want both community care and VA care. And why both? Because we're trying to serve veterans and serve veterans first and foremost.
▶ 2:37:26There would not be a need for community care had the VA been able to serve veterans, not keep them on waiting lists, not have veterans die, not have the big PR nightmare of veterans waiting for care and dying waiting for care. A suicide rate that remains at 17% and has not gone down.
▶ 2:37:48a VA who here in this room in testimony admitted that they did not think that residential mental health care, the most critical of care or residential substance use disorder care fell under the mission act.
▶ 2:38:06So if you were in a mental health crisis from the VA, it was okay if you waited 30 days or 60 days or 90 days or by God a year or you can go to a vision two visions away 300 miles That's why we're having this conversation. If the VA wasn't actively trying to prevent people from going to community care, from my standpoint, it is not adversarial.
▶ 2:38:33Let's have the consensus that VA care is community care. That our goal is and always on this committee and in Congress is to serve our veterans. So with that, I'd like to thank everyone for their participation in today's hearing for the discussions we've had on a critically important topic. The complete written statements of today's witnesses will be entered into the hearing record.
▶ 2:39:00I ask unanimous consent that all members have five legislative days to revise and extend their remarks and include extraneous material. Hearing no objections, so ordered. I thank the members and the witnesses for their attendance and their participation today. This hearing is now injured.