Hearings to examine medication management in VA healthcare

VA Budget and ModernizationSenate Veterans' Affairs · December 3, 2025 · 119th Congress
The Senate Veterans' Affairs Committee held this hearing to examine medication management practices in VA healthcare, prompted in part by Wall Street Journal reporting on the use of multiple central nervous system medications among veterans, sometimes called a "combat cocktail." Two panels testified: watchdog officials from GAO and the VA Office of Inspector General, plus a veterans' service organization on the first panel, followed by VA health officials on the second panel who also addressed three pending bills on naloxone access, telehealth prescribing, and informed consent. Begins at ▶ 0:15:40
Transcript
Highlights

Title

Oversight of polypharmacy and medication management for veterans

Purpose

The Senate Veterans' Affairs Committee held this hearing to examine medication management practices in VA healthcare, prompted in part by Wall Street Journal reporting on the use of multiple central nervous system medications among veterans, sometimes called a "combat cocktail." Two panels testified: watchdog officials from GAO and the VA Office of Inspector General, plus a veterans' service organization on the first panel, followed by VA health officials on the second panel who also addressed three pending bills on naloxone access, telehealth prescribing, and informed consent. Begins at▶ 0:15:40

Who spoke

• Chairman Jerry Moran (R-KS)▶ 0:15:40: Opened by describing the hearing's focus on combat-cocktail prescribing practices and VA oversight▶ 0:16:09; later pressed witnesses on accountability for overprescribing and foreign-manufactured drug oversight▶ 0:47:03▶ 0:49:51.

• Melissa Hundrup, GAO▶ 0:18:53: Said GAO found VA lacked guidance and monitoring of mental health treatment plan documentation and made two recommendations VA has since implemented▶ 0:20:13; cited that 37% of veterans with one mental health condition were prescribed psychiatric medication, with polypharmacy among PTSD patients ranging from 32% to 61% depending on provider type▶ 0:37:12▶ 0:37:32; called for updated VA data on polypharmacy prevalence▶ 0:37:58.

• Dr. Julie Kroviak, VA Office of Inspector General▶ 0:23:34: Testified only 37% of electronic health records at the Philadelphia VA had clear discharge medication instructions▶ 0:25:49; described a case where a veteran who died by suicide was prescribed an antidepressant without risk education or timely follow-up▶ 0:26:14; flagged inadequate oversight of opioid prescriptions by community care providers and deficiencies found at the VA Eastern Kansas Health Care System▶ 0:26:45▶ 0:27:15; said she was disappointed by the WSJ article's suggestion that VA hands out medications to avoid providing care▶ 0:40:12.

• Aaron Fletcher, Wounded Warrior Project▶ 0:28:28: Cited that 77% of surveyed warriors reported PTSD and 28% of post-9/11 veterans in VA mental health care met criteria for CNS polypharmacy▶ 0:28:51▶ 0:29:44; said warriors often encounter medication recommendations before therapy is offered▶ 0:40:42; noted 90% of veterans at Warrior Care Network sites return to VA for ongoing care▶ 0:33:09.

• Ranking Member Richard Blumenthal (D-CT)▶ 0:34:09: Said polypharmacy often stems from long wait times and insufficient clinical capacity, and that he wrote to Secretary Collins about deviations from evidence-based care▶ 0:34:29▶ 0:34:59; criticized new copayments for holistic treatments like yoga and meditation▶ 0:35:51; later cited a 208-day wait for a new mental health appointment at the Orange, CT VA clinic and pressed VA on reported caps on psychotherapy sessions▶ 1:25:08▶ 1:26:34.

• Sen. Katie Britt (R-AL) (identified by Alabama reference)▶ 0:46:38: Asked witnesses whether VA has a plan to hold providers accountable for overprescribing and about oversight of foreign-manufactured drugs▶ 0:47:03▶ 0:49:51; raised psychedelic-assisted therapy following an Alabama field hearing▶ 0:51:08.

• Sen. Mazie Hirono (D-HI)▶ 0:52:11: Pressed on whether the roughly half-million VA patients with PTSD each have individualized treatment plans▶ 0:52:40; questioned how oversight can be provided amid VA staffing cuts▶ 0:55:03.

• Sen. Tim Sheehy (R-MT)▶ 0:58:00: Argued community care is more critical in rural states like Montana where clinics can be hours apart▶ 0:58:00; described veterans traveling abroad for psychedelic treatment and urged VA openness to outside innovation▶ 0:58:56; discussed his written informed consent legislation▶ 1:00:14.

• Sen. Angus King (I-ME)▶ 1:04:41: Emphasized that overprescribing risks stem from poor electronic medical record coordination between DOD and VA, calling the EHR rollout "a debacle"▶ 1:05:40; suggested AI could help flag dangerous drug interactions▶ 1:06:33; asked about routine medication reviews, which GAO confirmed occur via EHR alerts▶ 1:08:02▶ 1:08:23.

• Sen. Maggie Hassan (D-NH)▶ 1:10:38: Asked about GAO's recommendation for a DOD/VA joint committee to assess mental health access during the transition period, noting programs like Solid Start and In Transition identified veterans too late▶ 1:11:39; pressed Kroviak on unimplemented 2023 recommendations regarding community-care opioid oversight▶ 1:13:59.

• Dr. Ilse Wiechers, VA Deputy Assistant Undersecretary for Health for Patient Care Services▶ 1:19:06: Testified VA has cut opioid prescribing 68% and current opioid-benzodiazepine co-prescribing 90% since 2013▶ 1:20:40; described the Psychotropic Drug Safety Initiative and a request for innovative de-prescribing software▶ 1:21:07▶ 1:21:37; outlined VA's support, with amendments, for the End Veterans Overdose Act, telemedicine access bill, and concerns about the Written Informed Consent Act▶ 1:22:05▶ 1:23:06; disputed the existence of a national policy capping psychotherapy sessions▶ 1:27:01▶ 1:27:47.

• Dr. Tom Emmendorfer, VA Executive Director of Pharmacy Benefits Management Services▶ 1:19:06: Reported the pharmacogenomics (PHASER) program has expanded to nearly every VA facility, with remaining seven expected by end of 2026, and over 1,000 providers trained▶ 1:30:42▶ 1:31:02; explained the program uses patient DNA to guide medication selection and avoid ineffective trials▶ 1:31:59.

Key moments

• Kroviak described a veteran's suicide linked to an antidepressant prescribed without risk education or timely follow-up▶ 0:26:14.

• Hundrup testified that only 37% of electronic health records at the Philadelphia VA had clear discharge medication instructions▶ 0:25:49.

• Hirono pressed on whether over 500,000 VA patients with PTSD have individual treatment plans and whether VA staffing cuts undermine the oversight witnesses were recommending, without receiving a direct resolution▶ 0:52:11▶ 0:55:03.

• Wiechers stated VA has reduced opioid prescribing by 68% and current opioid-benzodiazepine co-prescribing by 90% since 2013▶ 1:20:40.

• Blumenthal cited a 208-day wait time for new mental health appointments at the Orange, CT VA clinic and pressed Wiechers on reports of imposed caps on psychotherapy sessions, which she disputed exist as national policy▶ 1:25:08▶ 1:27:01.

• Kroviak said VA's Eastern Kansas Health Care System review found incomplete documentation and lack of medication reconciliation by community providers▶ 0:27:15.

• Blumenthal cited the WSJ finding that only 15% of veterans diagnosed with depression, PTSD, or anxiety are offered psychotherapy in lieu of medication, per a 2019 GAO report, and Kroviak could not confirm whether the figure remains accurate▶ 1:17:38▶ 1:18:06.

• Sheehy said veterans are traveling to Mexico, the Middle East, and Turkey for psychedelic treatment for PTSD and TBI, finding it "safer, healthier, and far more effective"▶ 0:58:56.

• King argued a lack of interoperable electronic medical records between DOD and VA underlies polypharmacy risk, calling billions spent on the new EHR system "a debacle"▶ 1:05:40.

• Emmendorfer reported the PHASER pharmacogenomics program will reach all VA medical facilities by the end of 2026, with over 1,000 providers trained and roughly 100 medications covered by evidence-based testing▶ 1:30:42▶ 1:31:31.

Metadata

CommitteeSenate Veterans' Affairs
Chamber / CongressSenate · 119th Congress
DateDecember 3, 2025
TypeMeeting
Witnesses
(none listed in event metadata)
Videosenate-isvp
Transcript171 caption blocks · 10,670 words · 1:34:07 runtime
EventCongress.gov 337709