Oversight: Right Time, Right Place, Right Treatment with VA Community Care

1[House Hearing, 119 Congress]2[From the U.S. Government Publishing Office]34                     RIGHT TIME, RIGHT PLACE, RIGHT5                    TREATMENT WITH VA COMMUNITY CARE67=======================================================================89                                HEARING1011                              BEFORE THE1213                         SUBCOMMITTEE ON HEALTH1415                                 OF THE1617                     COMMITTEE ON VETERANS' AFFAIRS1819                     U.S. HOUSE OF REPRESENTATIVES2021                    ONE HUNDRED NINETEENTH CONGRESS2223                             FIRST SESSION2425                               __________2627                         TUESDAY, JULY 15, 20252829                               __________3031                           Serial No. 119-303233                               __________3435       Printed for the use of the Committee on Veterans' Affairs3637[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]3839                    Available via http://govinfo.gov4041                                __________4243                   U.S. GOVERNMENT PUBLISHING OFFICE4461-357                     WASHINGTON : 20254546-----------------------------------------------------------------------------------4748                     COMMITTEE ON VETERANS' AFFAIRS4950                     MIKE BOST, Illinois, Chairman5152AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking53    American Samoa, Vice-Chairwoman      Member54JACK BERGMAN, Michigan               JULIA BROWNLEY, California55NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire56MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,57GREGORY F. MURPHY, North Carolina        Florida58DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky59MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois60JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois61KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York62JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon63ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey64KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota65    Mariana Islands66TOM BARRETT, Michigan6768                       Jon Clark, Staff Director69                  Matt Reel, Democratic Staff Director7071                         SUBCOMMITTEE ON HEALTH7273               MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman7475JACK BERGMAN, Michigan               JULIA BROWNLEY, California,76GREGORY F. MURPHY, North Carolina        Ranking Member77DERRICK VAN ORDEN, Wisconsin         SHEILA CHERFILUS-MCCORMICK,78JEN KIGGANS, Virginia                    Florida79ABE HAMADEH, Arizona                 MAXINE DEXTER, Oregon80KIMBERLYN KING-HINDS, Northern       HERB CONAWAY, New Jersey81    Mariana Islands                  KELLY MORRISON, Minnesota8283Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public84hearing records of the Committee on Veterans' Affairs are also85published in electronic form. The printed hearing record remains the86official version. Because electronic submissions are used to prepare87both printed and electronic versions of the hearing record, the process88of converting between various electronic formats may introduce89unintentional errors or omissions. Such occurrences are inherent in the90current publication process and should diminish as the process is91further refined.9293                         C  O  N  T  E  N  T  S9495                              ----------9697                         TUESDAY, JULY 15, 20259899                                                                   Page100101                           OPENING STATEMENTS102103The Honorable Mariannette Miller-Meeks, Chairwoman...............     1104The Honorable Julia Brownley, Ranking Member.....................     3105106                               WITNESSES107                                Panel I108109Ms. Dallas Knight, Founder & President, Operation Juliet, Army110  Combat Veteran.................................................     6111112Dr. Meaghan Mobbs, Ph.D., Director, Center for American Safety113  and Security, Independent Women's Forum........................     8114115Ms. Amanda Newman, Chief Executive Officer, Western Illinois Home116  Health Care....................................................    10117118Ms. Kristina Keenan, Director of National Legislative Service,119  Veterans of Foreign Wars of the United States..................    11120121Dr. Kyleanne Hunter, Ph.D., Chief Executive Officer, Iraq and122  Afghanistan Veterans of America................................    13123124                                APPENDIX125                    Prepared Statements Of Witnesses126127Ms. Dallas Knight Prepared Statement.............................    35128Dr. Meaghan Mobbs, Ph.D. Prepared Statement......................   107129Ms. Amanda Newman Prepared Statement.............................   111130Ms. Kristina Keenan Prepared Statement...........................   116131Dr. Kyleanne Hunter, Ph.D. Prepared Statement....................   121132133                        Statement For The Record134135Cohen Veterans Network Prepared Statement........................   139136137    RIGHT TIME, RIGHT PLACE, RIGHT TREATMENT WITH VA COMMUNITY CARE138139                              ----------140141                         TUESDAY, JULY 15, 2025142143                    Subcommittee on Health,144                    Committee on Veterans' Affairs,145                             U.S. House of Representatives,146                                                    Washington, DC.147    The subcommittee met, pursuant to notice, at 2:43 p.m., in148room 360, Cannon House Office Building, Hon. Mariannette149Miller-Meek [chairwoman of the subcommittee] presiding.150    Present: Representatives Miller-Meek, Murphy, King-Hinds,151Brownley, Cherfilus-McCormick, Dexter, Conaway, and Morrison.152153   OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN154155    Ms. Miller-Meeks. Good afternoon. This legislative hearing156of the Subcommittee on Health will now come to order. I would157like to welcome all the members and witnesses to today's158hearing. During this hearing, witnesses will share with us how159U.S. Department of Veterans Affairs (VA) works hand-in-hand160with private doctors and providers to meet veterans' specialty161care needs throughout the VA Community Care Program.162    Data show that veterans like and want community care just163as they like and want their VA healthcare system. Polling has164shown that Americans want veterans to be able to access shorter165wait times and drive times to get their healthcare. Through the166John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA167Maintaining Internal Systems and Strengthening Integrated168Outside Networks (MISSION) Act, Congress has closed the gap169that was crippling the delivery of care by the VA and170oftentimes leaving veterans behind, stuck in line and waiting171for an appointment. This was especially true for specialty172care. By virtue of being in the community, these providers are173closer to veterans and their homes than a brick-and-mortar VA174facility. That can mean shorter wait times and drive times for175veterans.176    Through the MISSION Act, the VA Community Care Program177created new opportunities for more resources than ever to serve178veterans. Veterans enjoy shorter wait times and drive times for179specialty care appointments because VA is allowed to cover180specialty care in the community. Veterans have more specialty181care through VA because of community care, not less.182    Three key indicators today and on the horizon show that the183VA will continue to rely on providers in the community to meet184the moment for specialty care for veterans. First, demand will185increase for all specialty care needs as more women use the VA186for healthcare. By 2040, the VA estimates that women will make187up 18 percent of all veterans. More women veterans means not188just an increase in female-specific care, but an increase in189specialty care services overall.190    Second, VA's workforce challenges mirror those of the191healthcare industry as a whole. There is a national shortage of192healthcare professionals, especially for physicians and nurses.193The VA recently identified shortages for clinical roles like194psychologist, medical technologist, diagnostic radiologic195technologist, which is the same in the private sector. This is196true across all VA facilities, even though this committee and197the Veterans' Affairs Committee has increased pay to providers198within the VA healthcare system. All of these roles play a part199in, if not directly provide, specialty care for veterans. The200higher the ratio between veterans and healthcare staff, the201more veterans will need community providers for VA-covered202specialty care.203    Third, and finally, the VA expects significant changes in204demand for care in general, including specialty care. The VA205projects major shifts in physical space demands for hospital206operations by about 2030. Estimates range from an 850,000207decrease in needed square feet in New Orleans, Louisiana, to a2082,500,000 increase in needed square feet in Orlando, Florida.209Having facilities where they are needed in accordance with the210demographic shifts of the country, sometimes we are far behind211where that movement occurs. These are but two of the many212estimates projecting dramatic increases and decreases in demand213for physical space across the country and one of the reasons we214introduced the Communities Helping Invest through Property and215Improvements Needed for Veterans (CHIP IN) Act in this216committee, as well as increases for funding infrastructure217within the VA.218    The VA also projects highly variable demand in different219facilities across different types of care. I hope you will bear220with me as I explain the numbers which paint a compelling221picture of the veterans' healthcare needs.222    The VA expects a 50 percent growth nationwide in outpatient223primary and specialty care combined. Relatedly, the VA also224expects a 13 percent decrease in inpatient acute medicine and225surgery nationwide. This, too, mirrors what we see in all226healthcare sector. The VA expects an increase for inpatient227acute mental health. That means more demand for psychiatric228services at a hospital for severe mental health crisis. As we229know from hearings here in this room, the VA did not consider230residential mental healthcare or residential substance abuse231part of the MISSION Act. That is a lot of variation.232    Even within these numbers, the VA expects significant233differences in demand from region to region. For example, with234inpatient acute mental healthcare, the VA projects a 6 percent235decrease nationally in demand for inpatient acute mental236health. When we dig another layer deeper, we see that the VA237expects anywhere between a 19 percent decrease to a 14 percent238increase across different regions of the country.239    I care deeply about mental health resources for veterans. I240know that the VA will continue to provide valuable in-house241care to veterans who need it. With so many variables, the VA242cannot expect in-house care alone to meet different demands243from different communities. Veterans need inpatient mental244healthcare when they need it and when they are in crisis.245Veterans need specialty care when they need it. A condition in246need of treatment does not wait for the facilitary247infrastructure to be built and to catch up. As a physician, I248know this reality firsthand.249    A veteran should not wait for treatment when community250providers are already available to meet a need. To best serve251veterans, the VA should pursue whatever gets quality care to252veterans when they need it. The VA serves all veterans when it253opens the door to community providers equipped to care for254veterans at the right time, at the right place, with the right255treatment. As a 24-year Army veteran and physician, I am256focused on working in lockstep with the administration to257ensure that this happens. The future of veterans' healthcare258depends on it.259    I now yield to Ranking Member Brownley for any opening260remarks she may have.261262      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER263264    Ms. Brownley. Thank you, Chairwoman Miller-Meeks. At the265outset of today's hearing, I would like to set the scene a bit266by describing the situation in which veterans and the VA267currently find themselves.268    First, veterans across the country are losing access to VA269healthcare due to numerous actions taken by the Trump270administration. Why is this happening? With each passing day,271VA is becoming a less and less desirable place to work. Upon272taking office, President Trump ordered a governmentwide hiring273freeze. The haphazard implementation at VA meant the essential274occupations initially were not exempted from the freeze. Job275offers for key employees who were already in the onboarding276process were rescinded, then reinstated, a flip-flopping that277led many would-be hires to run the other way.278    Less than a month after that, VA terminated nearly 2,400279probationary employees. While some have since been rehired,280they may be terminated again after pending lawsuits have281resolved. Many opted not to return after being offered their282jobs back.283    Then as a result of the Trump administration's returning to284office policy, tens of thousands of VA employees who had been285hired into fully remote positions were directed to report to286offices that were ill-equipped and ill-suited to accommodate287them, with little consideration for the effect it would have on288their productivity or the quality of care delivery.289    We heard a week ago that while VA is no longer planning to290pursue a large-scale reduction in force, or RIF, it still291anticipates losing nearly 30,000 employees by September 30th.292That is about 6 percent of VA's overall workforce. This is293happening through DRP, the Deferred Resignation Buyout Program,294and VERA, the Voluntary Early Retirement Authority, as well as295employees choosing to resign or retire without any incentives.296    As this chart shows behind me here, as of May 31, 2025,297nearly 22,000 employees had separated from the Veterans Health298Administration (VHA). While about half have been replaced, as a299whole VHA has lost 10,310 more employees than it had hired so300far this fiscal year. The Secretary has repeatedly claimed that301veterans will not lose access to healthcare as a result of the302Department's ongoing restructuring process.303    Maybe you are thinking that these losses are mostly304nonessential occupations at VHA, but that is just simply not305true. Losses of essential frontline employees are occurring at306VA medical facilities nationwide.307    As the second chart shows VHA is currently operating at a308loss of nearly 3,000 mission-critical employees since the start309of this fiscal year. This is after making significant gains in310the overall number of frontline employees during the same311period last fiscal year. Those new hires were helping VA312deliver record numbers of appointments and serve the influx of313new enrollees that are coming into VA as a result of the The314Sergeant First Class Heath Robinson Honoring our Promise to315Address Comprehensive Toxics (PACT) Act.316    Where are the losses of essential employees most317significant? Custodial workers, food service workers, nurses,318physicians, social workers, employees that VA medical319facilities simply cannot do without.320    At the Community-Based Outpatient Clinic (CBOC) that serves321my constituents in Ventura, California, 7 out of 12 mental322health providers have left. This is driving up wait times for323mental health appointments. As of Friday, the new patient wait324time for a mental health appointment was 101 days.325    Now, maybe you are thinking to yourself those veterans are326eligible for community care and while that is true, they need327VA staff to coordinate their care in the community. As this328chart refers to, it shows that we are down more than 1,147329medical support assistants nationwide since the start of the330fiscal year. Those are the staff who help veterans find331community providers and schedule their appointments.332    It does not matter that so-called mission critical VHA333staff were not eligible for the DRP and VERA separation334incentives. They are leaving anyway because VA has become a335toxic, unpredictable, and hostile place to work. We are kidding336ourselves if we think no RIF is the end of it and that the loss337of employees will stop at 30,000 folks. These losses will338continue to grow. As long as VA's workforce continues to339suffer, all aspects of VA care, including community care, will340suffer.341    Second, on July Fourth, President Trump signed the One Big342Beautiful Betrayal Bill into law. By most analysis, this law343and its 1 trillion cut to Medicaid will have a wide-ranging344impact on the healthcare landscape in the United States.345Researchers at the University of North Carolina have identified346338 rural hospitals that are already at risk for closure.347Future loss of Medicaid coverage will elevate the risk of348financial distress for hospitals, long-term care facilities,349and other providers, further reducing veterans' access to care.350    We cannot have a conversation about specialty care in the351community without acknowledging both the strain that is352currently being placed on VA's healthcare system and the strain353that is about to be placed on non-VA providers. We should be354shoring up VA care and making sure that there is capacity in355the community when veterans need specialty care in the356community. Instead, under this administration we are seeing a357chaotic approach to delivering veterans' healthcare that358undercuts VA's internal capacity, shifts more and more care to359the community, and leaves veterans and VA employees in the360lurch. Insisting that those actions will not impact veterans'361healthcare does not make it so, and ignoring the unforeseen362consequences of this administration's actions will not make363them go away.364    As I have always acknowledged, VA will always need to offer365some level of community care because they cannot do it all.366However, for many veterans, VA is the right place for them to367receive care. They know their provider understands their368military service and what it means to have served their369country. They know they will receive world-class healthcare370backed up by world-class research. They know they will not have371to explain to their VA provider what a presumptive condition is372or their experience with Military Sexual Trauma (MST) or how373their service impacted their mental health.374    We also lack oversight of the care that veterans receive in375the community. We know wait times for VA appointments because376VA publishes them. Community providers are not required to377report their wait times or how long it will actually take a378veteran to be seen.379    We know that VA providers have received training on380military cultural competencies, suicide prevention practices,381opioid safety, and many others because VA requires them to382receive such trainings and report how they have completed them.383Community providers are not required to take all of these384trainings and veterans are not informed about whether their385community providers have voluntarily taken such trainings.386    Based on the testimony from our witnesses, I think we can387all agree that the administration of VA's Community Care388Program needs reform. Unfortunately, we find ourselves convened389for an oversight hearing where there are no VA officials390present to respond to questions about the barriers and391challenges highlighted by our witnesses. I think that does them392a disservice and I would respectfully ask the chairwoman to393invite Department witnesses to future oversight hearings so394that we can have a more robust discussion about what is working395well, what is not, and how to fix it.396    With that, Madam Chair, I yield back.397    Ms. Miller-Meeks. Thank you, Ranking Member Brownley.398    Before I introduce our witnesses, I just want to be clear,399our colleagues have spent the past 6 months yelling from the400sidelines and should have held their criticism of potential401plans until a plan was actually in place. It is public402knowledge that the VHA loses about 9 percent of its workforce403annually through regular attrition, or about 38,000 employees404based on its current workforce. Those were the same statistics405during the Biden administration and are the same statistics406today. We also know the status quo is not working and will407continue to cut through the nonsense and restore common sense408at the VA to put veterans first.409    Additionally, during the past 4 years, the funding to the410VA has dramatically increased. The numbers of employees411increased by 80,000, yet the number of veterans applying for412care had remained level nationwide. Most VA employees come to413work and proudly serve our veterans. However, poor performing414VA employees must be held accountable when they are not putting415veterans first, and we will ensure that that message is clear.416    Chairman Bost, House Republicans, and myself have full417confidence in Secretary Collins and the Trump administration to418bring needed change to the VA. That is what we are focused on.419I look forward to continuing to work with Ranking Member420Brownley and those on the other side of the aisle so that we421can affect real change for veterans that the VA serves.422    Testifying before us today, as I would now like to423introduce our witnesses, Dallas Knight, founder and president424of Operation Juliet. She is an Army combat veteran. Meaghan425Mobbs, director of the Center for American Safety and Security426at Independent Women's Forum. She is a clinical psychologist427and also an Army combat veteran. Amanda Newman, Chief Executive428Officer (CEO) of Western Illinois Home Health Care. Western429Illinois has operations close to my district. Kristina Keenan,430legislative director at Veterans of Foreign Wars (VFW) and an431Army veteran as well. Kyleanne ``Kai'' Hunter, CEO of Iraq and432Afghanistan Veterans of America and Marine Corps combat433veteran.434    Ms. Knight, you are now recognized for 5 minutes to present435your testimony.436437                   STATEMENT OF DALLAS KNIGHT438439    Ms. Knight. Chairwoman, Ranking Member, and members of the440subcommittee, my name is Dallas Knight. I am an Army combat441veteran and the founder of Operation Juliet, a nonprofit442serving female veterans.443    I joined the Army just 2 months before 9-11, intending to444gain experience and work for the Drug Enforcement445Administration (DEA). I had no idea how real that experience446would become. I deployed to Iraq in 2003, and returned a year447later with invisible wounds far worse than the physical ones. I448avoided the VA after learning Post-Traumatic Stress Disorder449(PTSD) diagnoses would revoke your security clearance, My450entire career plan. I stuffed it down, I stayed silent, and I451told myself I was fine for 17 years. Eventually, the weight of452what I saw, felt, and endured caught up with me.453    Finally, after enrolling in VA Healthcare, I walked into454the Billings clinic for my first appointment and was asked if455my husband needed help. Apparently, I did not look like a456veteran. That first appointment stuck with me. When I was asked457if I had suicidal ideations, I said not recently. The provider458responded by lecturing me on how selfish it would be to leave459my children without a mother. Then, when I disclosed military460sexual trauma, I was referred to a psychologist and handed a461stack of prescriptions. No conversation about healing, just a462follow-up call from a man temporarily filling in as the State463MST coordinator, notifying me I would be receiving a pamphlet464in the mail.465    At a neurology appointment, I was asked for graphic,466unnecessary details about my Traumatic Brain Injury (TBI)467trauma. It felt more like an interrogation, questioning my468integrity, rather than a consultation, only stopping when the469doctor noticed my visible discomfort. Despite our encyclopedia-470sized files, we are expected to rehash and relive the very471traumas we are trying to escape. I do not believe these VA472providers intended harm, but they were clearly undertrained and473unequipped to treat trauma. That is when I realized there must474be better care available.475    Because no one explained trauma-informed therapy, no one476told me about community care and other options, those options477were only discovered from other veterans, helping me to478navigate the system, a lifeline passed from veteran to veteran.479Requests for alternative therapies often took weeks, sometimes480months for a response. I have hung up on my boss, my son, and481walked out of meetings just to answer the VA's call, afraid of482missing a rare chance at care. As I scrambled to choose a483provider from a rushed list, no context, no ratings, no484reviews, I hung up relieved just to have an appointment at all.485    I am not alone in my frustrations and disappointments. I486told my community I would be standing before you here today and487within days, nearly 600 women veterans responded, eager and488desperate to be heard, hundreds of female veterans describing489waiting months, sometimes over a year, for critical referrals,490specialty care or community-based treatment. These delays often491compounded existing mental and physical health issues, leaving492veterans to suffer in silence.493    Veterans living in rural or underserved areas detailed the494near impossibility of accessing timely and appropriate care.495Many faced multi-hour drives, limited provider options, and a496lack of female clinicians or trauma-informed specialists. For497these women, geographic isolation added another barrier to498healing, making community care feel like a broken promise.499    Veterans who bravely disclosed histories of military sexual500trauma shared disturbing accounts of re-traumatization within501the VA system. Common themes included being forced to recount502trauma repeatedly, being assigned male providers despite503requests for female clinicians, and being denied or delayed504access to mental health support. The lack of MST-sensitive505pathways reflects a systemic failure to prioritize survivor506safety and dignity.507    I have hundreds of stories but only 5 minutes to speak, so508I ask that you take the time to read their stories that I have509submitted to you. There is one story that I carry most heavily510with me today. Lynessa Van Kirk was born February 21, 1989;511Army Military Police (MP) sergeant, daughter, sister, friend,512hero. I never met Lynessa, but I know her through her mother,513now living every parent's worst nightmare. Lynessa served her514country with honor. She asked for help repeatedly, but she was515denied, delayed, ignored, and even sexually assaulted at a VA516inpatient treatment facility. The VA failed her repeatedly. On517April 30, 2022, at just 33 years old, Lynessa died from the518long-term effects of untreated PTSD and trauma, left in a519hospital bed with hematomas, liver failure, and no more520chances.521    Today, I am not just asking you to hear me. I am asking you522to hear all of us. Hear the hundreds of women who have come523forward. Hear Lynessa. Female veterans are not invisible. We524are not dramatic or broken. We are warriors, leaders. We are525asking boldly, urgently for a system that sees us, hears us,526and serves us with dignity.527    Thank you for your time.528529    [The Prepared Statement Of Dallas Knight Appears In The530Appendix]531532    Ms. Miller-Meeks. Thank you, Ms. Knight.533    Ms. Mobbs, you are now recognized for 5 minutes to present534your testimony.535536                   STATEMENT OF MEAGHAN MOBBS537538    Dr. Mobbs. Chairwoman Miller-Meeks, Ranking Member539Brownley, and members of the subcommittee, thank you for the540opportunity to testify today. My name is Dr. Meaghan Mobbs and541I am the director for the Center of American Safety and542Security at Independent Women. I am a combat veteran, former543Army officer, and clinical psychologist who specialized in544trauma, transition stress, and post-military reintegration. I545trained in the VA system and currently teach through the546Veterans Mental Health Primary Care Training Initiative for the547New York State Psychiatric Association, helping civilian548physicians better recognize and treat veterans.549    I have been on all sides of the system: soldier, clinician,550educator, and advocate. I have walked beside fellow veterans551struggling to navigate the very bureaucracy designed to serve552them. In 2018, when President Trump signed the bipartisan VA553MISSION Act, it was more than legislation. It was a solemn554promise that what happened to the Phoenix VA, where veterans555died waiting for care, would never happen again. The Community556Care Program was created to fulfill that promise. It557acknowledged that while the VA is indispensable, it is not558omnipresent. Too often, bureaucracy stood where medical support559should have.560    This program was never meant to be a replacement, but it561was a direct response to institutional failure. It intended to562put outcomes over promises and patients over paperwork. We have563not yet fulfilled that promise. Let me place it in some564context.565    In 2001, the VA's hospital administration budget was 20.9566billion. At that time, we were tragically losing about 16.5567veterans a day to suicide. In 2024, after decades of war and568exponential growth in funding, now approximately 121 billion,569we are still losing 17.6 veterans a day to suicide. What faces570us is not a funding problem. It is a function problem and a571failure to adapt and decentralize to meet veterans where they572are.573    Veterans are still waiting weeks or driving hours for care574they should receive promptly and locally. Medical decisions are575too often driven by bureaucrats and not doctors. Community Care576was created to fix this. Today it provides nearly 40 percent of577all VA delivered care, and it is working. Veterans use it. They578are satisfied with it, especially in rural areas it has become579a lifeline. Instead of expanding it, some VA administrators580have undermined it.581    We have heard the stories. Last year, a Portland VA582official admitted they were intentionally keeping care in-583house, even where referrals were warranted. In Buffalo, a584veteran with cancer had his radiation therapy referrals denied585and then canceled, and he died in pain. To move forward, we586need a Community Care Program rooted in four principles:587flexibility, accessibility, rapidity, and accountability.588    First, flexibility. Veterans live in rural towns, suburbs,589and cities. They raise families, hold jobs, and carry injuries590both visible and invisible. They deserve a care system that591reflects that complexity. Community care gives them access when592the VA is too far, too slow, or lacks the right specialists.593That flexibility is especially crucial for women veterans.594Seventy percent prefer female providers for woman-specific care595and 50 percent even for general care. Recently, a VA facility596went 2 years without a full-time gynecologist.597    Second, accessibility. Only 55 percent of veterans live598within 40 miles of a VA facility and just 26 percent live near599specialty care. Community care reduces the physical and600financial burden of long-distance travel, and that improves601health outcomes and trust and adherence. With women expected to602make up nearly 20 percent of the veteran population by 2040,603many from minority backgrounds, we need a system that reflects604today's demographics, not those from 50 years ago.605    Third, rapidity. Delayed care is denied care. Veterans do606not need treatment eventually, they need it now. Today's607eligibility thresholds are arbitrary. I have personally worked608with veterans denied mental health services because they were609not sick enough or were forced into treatment that they did not610want. Whether it is PTSD, chronic pain, or substance use, every611delay or denial feels like administrative cruelty, and it is612costing lives.613    Fourth, accountability. Since 2018, the U.S. Government614Accountability Officer (GAO) has issued 27 recommendations to615approve the Community Care Program and, as of this year, only 9616have been fully implemented. The lack of enforceable standards,617inconsistent referral coordination, and inadequate oversight618does undermine the program. We need to measure timely access619and continuity of care. Otherwise, we are building a system620that is blind to its own failures.621    I want to commend Secretary Collins for accelerating the622implementation of the Senator Elizabeth Dole 21st Century623Veterans Healthcare and Benefits Improvement Act and it is a624meaningful step forward. Let me be clear, it is not enough to625offer a door. We must ensure that door is open, functional, and626that it leads somewhere worth going.627    I believe deeply in the VA. I trained there. I have628referred patients there, but no single system can meet every629need in every place at every time for every veteran. Community630care is not an indictment. It is just an extension of the631promise we made. Veterans do not need more bureaucracy. They632need choice, they need speed, and they need a system built to633serve them, not the other way around.634    Thank you and I look forward to your questions.635636    [The Prepared Statement Of Meaghan Mobbs Appears In The637Appendix]638639    Ms. Miller-Meeks. Thank you, Ms. Mobbs.640    Ms. Newman, you are now recognized for 5 minutes to present641your testimony.642643                   STATEMENT OF AMANDA NEWMAN644645    Ms. Newman. Thank you, Chairwoman Miller-Meeks, Ranking646Member Brownley, and the members of the committee for the647opportunity to speak on the critical topic of the VA's648Community Care Program. Thank you for the important legislation649that you have successfully led through the legislative process650to support veterans. I am honored to speak on behalf of the 121651Illinois veterans that we serve in our agency and on behalf of652veterans served by Home Care Association of America members653across the Nation.654    I am the second generation running a family owned home care655agency in West Central Illinois. We cover a 10-county, mostly656rural area and have worked with the VA for over 30 years. We657currently do so as a contracted provider in the VA Community658Care Network operated by Optum.659    Community care is not an alternative to the VA, it is an660extension of it. For many veterans, especially those living in661rural areas, community care represents a vital lifeline. These662veterans often face long travel times or limited services at663local VA facilities, making care in the home a necessary664option. The success of community care hinges on a shared665commitment to veteran-centered, team-based care where VA and666community providers work in partnership, not in competition.667    Over our 30 years working with the VA, we have always had668good relationships with the Veterans Integrated Service Network669(VISN) 23 Veteran Affairs Medical Center in Iowa City and our670local VA outpatient clinic in Galesburg, Illinois, working671together to meet veteran needs. Our experience has been that672process changes within the VA in the last year have created673barriers to veteran access and care. These changes do not674appear to be in line with the spirit of the MISSION Act.675    Three key barriers to veteran access that I have seen are676the VA reducing or eliminating community care services for many677veterans who have qualified for and relied on these services678for years; harming care stability and consistency for veterans679by reducing authorization periods from the prior standard of 12680months to 6 months or less, creating uncertainty for the681veteran and an overwhelming workload for the VA staff who682process authorizations; in the 2025 nonbundled fee schedule,683reducing rates to a point where veterans, especially in rural684areas, are at risk of losing critical services because the fee685schedule does not provide adequate reimbursement given the686travel involved.687    I would like to tell you about two of our veterans who688asked me to share their story. One veteran we care for is 79689years old. He lives alone in a small rural town and has690difficulty controlling his diabetes. He cannot cook for himself691or safely navigate the stairs in his home to do laundry. He was692denied homemaker services. When we requested Physical Therapy693(PT) to help him safely ambulate, this was also denied.694Instead, they required him to drive 53 miles each way in the695winter twice a week to go to the VA clinic for PT.696    We serve an 85-year-old veteran who has difficulty697ambulating. He uses a cane due to a stroke and cannot stand for698long. He was denied home health aid services because he699reported on the phone that he can shave his beard. However, the700VA team failed to take into account his ability to perform701other activities of daily living, such as bathing, ambulating,702or dressing.703    Community care enhances access, expands capacity, and704supports choice for veterans without replacing the foundational705role of the VA. Community care is not a workaround. It is a706necessary part of a comprehensive veteran first healthcare707system. When community providers and the VA work together,708veterans benefit from timely, compassionate, and coordinated709care delivered wherever they are, whenever they need it.710    We have an opportunity and a responsibility to ensure that711every veteran receives care that is timely, high quality,712coordinated, and close to home. By strengthening community care713as a complement to VA services, investing in home care and714rural access, and ensuring providers are supported through fair715reimbursement, we can fulfill the VA's sacred mission to those716who have served.717    I thank you for your time and for your continued commitment718to the health and dignity of America's veterans.719720    [The Prepared Statement Of Amanda Newman Appears In The721Appendix]722723    Ms. Miller-Meeks. Thank you, Ms. Newman.724    Ms. Keenan, you are now recognized for 5 minutes to present725your testimony.726727                  STATEMENT OF KRISTINA KEENAN728729    Ms. Keenan. Chairwoman Miller-Meeks, Ranking Member730Brownley, and members of the subcommittee, on behalf of the men731and women of the Veterans of Foreign Wars of the United States732and its auxiliary, thank you for the opportunity to provide the733VFW's remarks and my personal story on the topic of community734care.735    VA's Community Care Program and its network of providers736are a vital component of VA healthcare, particularly for737specialized care that VA does not provide. Community providers738are force multipliers, allowing VA to offer the world-class739care that veterans prefer while also ensuring they have access740to a range of services when they need them. When used741appropriately, community care can save lives and improve health742outcomes.743    However, problems with the coordination of that care can744drive veterans away from VA altogether. VFW members have745identified several coordination issues, including delays in VA746paying for community care in a timely manner. VA referrals can747also be unclear, especially understanding the types of care748that are authorized, including lab work and procedures.749Scheduling appointments for community care is also a reported750point of confusion for our members. Not every VA medical center751informs veterans when they have the option to use community752care, nor when the veterans should set up the appointments or753--and if and when VA will schedule them.754    I have personally experienced these issues as nearly all of755my woman-specific care has been in the community. The first756time I had a mammogram, it took VA 6 months to pay the $700757bill. I had to call both VA and the community provider several758times and began receiving collections notices until the bill759was paid.760    I have also used community care for maternity care, a type761of specialized care that VA does not provide at all through its762direct care. The coordination of that care has been a source of763frustration and stress at times. I actually had a pregnancy764last year which sadly ended in miscarriage. My VA maternity765care coordinator twice received incorrect information from my766community provider and called me to ask me why I was trying to767terminate my pregnancy. She called me at a later date and asked768why I had proceeded with a termination procedure not approved769by VA. In both instances, I had to tell her that her770information was incorrect and then explain and re-explain that771my pregnancy had not been viable. This is an example of poor772record-sharing between community providers and VA, resulting in773painful conversations made with an administrator and not even774my primary care physician.775    I am currently using VA-coordinated maternity care again as776I became pregnant this spring and have successfully made it777into my second trimester. I am currently struggling with the778bureaucracy of having genetic tests conducted by my community779provider. Because of my age, the provider finds them especially780necessary. After exchanging several secure messages with VA781about billing codes, I was told that two of the tests should be782covered by VA, but that I should also confirm with the lab,783likely LabCorp, to verify with them that the tests are indeed784covered by VA's insurance provider, Optum. This does not feel785like VA has approved these tests if I have to discuss the786billing codes myself with the non-VA provider, a subject with787which I have no familiarity. If I accept a test that VA does788not cover, that could be thousands of dollars that I have to789pay out of pocket.790    Despite these and other coordination issues mentioned in my791written statements, I am very happy with the quality of care792that I have received in the community and I like that I have793had the choice of my providers. We must find ways to improve794the coordination of community care.795    The VFW supports Chairman Bost's H.R. 740, the Veterans796Access Act of 2025, as it represents a critical step forward in797enhancing access to community care for veterans. Additional798legislative measures should also be considered to address the799issues that I and VFW members have mentioned. While veterans800consistently report to us that they prefer direct care at VA,801when needed community care should be coordinated appropriately802and not create additional bureaucratic frustrations for803veterans.804    Chairwoman Miller-Meeks, Ranking Member Brownley, this805concludes my testimony. I am prepared to take any questions you806or the subcommittee members may have. Thank you.807808    [The Prepared Statement Of Kristina Keenan Appears In The809Appendix]810811    Ms. Miller-Meeks. Thank you, Ms. Keenan.812    Ms. Hunter, you are now recognized for 5 minutes to present813your testimony.814815                  STATEMENT OF KYLEANNE HUNTER816817    Dr. Hunter. Chairwoman Miller-Meeks, Ranking Member818Brownley, and members of the committee, thank you for the819opportunity to testify today. I am the CEO of Iraq and820Afghanistan Veterans of America, but I am also a public policy821researcher and a service-connected disabled veteran who822utilizes VA services.823    I am honored to represent the post 9-11 veteran community.824This is a diverse population with unique healthcare needs,825which includes illnesses and injuries that are a result of826cumulative and compound exposures, latent impacts of blast-827related injuries, and the interaction of several physical and828mental healthcare issues. Community care is a vital part of829overall veterans' healthcare, but especially as we consider830rising costs, we need to be clear that the evidence does not831bear out that community care is a meaningful replacement for832all direct VA care. For a detailed discussion of the research833underlying this, I ask that you please reference my written834testimony that has been submitted for the record.835    Community care does play a critical role for some patients836and this is most evident for veterans who live in rural or837remote areas for whom it would be time prohibitive to travel838for direct care or for those who need specialty care that has a839narrow focus or serves a small population and it would not be840efficient or effective for the VA to maintain these services.841However, the evidence is also clear that VA direct care842provides better health outcomes for the majority of veterans.843    First, direct care does have lower wait times than844community care and wait times are not about convenience or845hassle, but about health and well-being. Prolonged wait times846are associated with deteriorating health outcomes among847multiple dimensions. When compared to community care, direct848care has markedly better health outcomes, such as a849significantly lower postsurgical 28-day mortality rate, lower850hospital readmission rates, and quicker hospitalization return851to work rates.852    For our most vulnerable veterans, the disparity of outcomes853is even more stark. For suicide rates, veterans who receive854community care have a 25 percent higher suicide rate than those855enrolled in VA direct mental healthcare, and too many of our856post 9-11 veterans are falling into this category.857    VA direct care also has more positive outcomes related to858toxic screenings for veterans with compound exposures, which859include environmental toxins, traumatic brain injuries, acute860injuries, and mental health conditions. Evidence from PACT Act861implementation, a process many of our veterans have benefited862from, shows that VA direct care providers were able to identify863exposure-related illnesses at a faster and more accurate rate864than community care providers.865    VA direct care does not just provide better patient866outcomes, it provides cost savings to the U.S. Government. In867side-by-side comparisons with community care, VA patients have868a 24 percent year over year primary and preventive care cost869savings. More contributing to the cost savings, veterans870receiving direct care experienced 43 percent fewer871hospitalizations, 58 percent fewer days when they were in a872hospital, and 43 percent outpatient surgical procedures. As873more patients are being seen by the VA, we will see more cost874savings.875    Between fiscal years 2023 and 2024, the VA saw 14 million876additional episodes of care. This upward trend is indicative of877both the expanded population that is seeking VA care and the878conditions most common in post 9-11 veterans that require well-879coordinated and integrated care, which leads to the fact that880the VA is unique in its ability to coordinate care between881primary and specialty care providers through its patient-882aligned care teams. This reduces the burden on the veteran for883scheduling and managing their own care, and ensures that884veterans do not receive unnecessary medical treatment. Many885recent studies have found that community care providers too886frequently administered high-cost and medically unnecessary887procedures to veterans without coordinating with their care888teams, thereby exposing veterans to unnecessary treatment889without medical benefit.890    VA-run community-based outpatient clinics also provide a891necessary direct care service in many areas that there is not892one of the 170 VA medical centers. These should be expanded893upon and invested in at this time. In my written testimony I894detail the importance of investing in CBOCs in four key areas895that align with the Veterans Service Organization (VSO)896independent budget recommendations. By focusing on targeted897expansions and improvements, CBOCs can more fully realize their898designated purpose.899    Community care is best used when originally intended, to900meet the needs of those patients in rural and remote areas and901for particular specialty care. For the majority of veterans'902healthcare needs, the evidence presented just indicates that VA903care is better care.904    Thank you and I look forward to your questions.905906    [The Prepared Statement Of Kyleanne Hunter Appears In The907Appendix]908909    Ms. Miller-Meeks. Thank you, Ms. Hunter.910    I just want to take a moment to, this is I think a little911unusual, but thank our witnesses for their service. Four of our912witnesses have served, so thank you for your service.913    As is my typical practice, I will reserve my time until all914of the members have had a chance to ask their questions. I now915recognize Ranking Member Brownley for 5 minutes for any916questions she may have.917    Ms. Brownley. Thank you, Madam Chair. I, too, want to thank918all of you for your service to our Nation's veterans. We919appreciate it very, very much.920    Dr. Hunter, I appreciate that in your testimony you921highlighted the importance of military cultural competency and922training. Can you expand on why VA providers are so uniquely923positioned to care for veterans and what it means for your924members that their providers understand their unique needs?925    Dr. Hunter. Thank you so much. VA providers are required to926undergo extensive training on military cultural competency.927This includes things like multiple compound exposures, whether928it is toxins, the interaction between mental and physical929healthcare, as well as emerging research on some of our930technologies. Additionally, VA providers, some of which are931actually cleared to be able to access classified medical932records and so they can understand environmental exposures that933were there.934    For myself, this was life-saving. At a regular, routine935optometry appointment that I had where I was experiencing936vision changes, and I thought it was because maybe I was just937over the age of 40, my VA optometrist was able to connect938symptoms I was experiencing to exposures from my service time939and get me screened for ocular melanoma. Turned out I had it.940We caught it super early at this case, but in every single941community care optometry appointment I had, not once had I been942asked about my time in military service, where might I have943been, the type of exposures that I would have seen.944    If we look at the post 9-11 generation and we look at what945was found in the PACT Act, the ideas of presumptive connections946for things like toxic exposures, but we are seeing more and947more aviation equipment, the time around fueling, as well as948the compound traumas with military sexual trauma and PTSD, it949is essential that our veterans are seen by providers who950understand that. In the community, while the MISSION Act says951they should have training, we actually have no idea what sort952of training they are getting. We do not have oversight on that953in a real and meaningful way, the way we do have oversight on954the types of training that VA providers have.955    Ms. Brownley. Thank you for that. I think in reading Dr.956Mobbs' testimony, she cited a RAND's article --excuse me, a957Research and Development (RAND) article stating that or at958least making the assertion that VA providers are not trained. I959know that you have previously worked at RAND. Are you familiar960with this article at all?961    Dr. Hunter. Yes, I was one of the contributing authors to962that study.963    Ms. Brownley. Is that true what the conclusion of that964article said?965    Dr. Hunter. No, the article said that we are aware of the966training that VA providers received. We do not have oversight967on the training that community care providers received.968    Ms. Brownley. Thank you for that. Another thing I969appreciate about your testimony was that you included extensive970citations throughout to articles in academic journals, to971studies from nonpartisan entities, like RAND, GAO, and the972Congressional Budget Office (CBO). One thing that worries me973about the way legislation sometimes comes together is that it974is informed by anecdotes and the experiences of perhaps a vocal975minority voice rather than by the true evidence. What does the976evidence say about where veterans prefer to receive their care977and where the quality and outcomes are better?978    Dr. Hunter. The preponderance of the evidence shows that979veterans prefer VA care. When we look at some of the very, very980tragic stories that we see and the antidotes that we hear, we981need to take every single one of them seriously and look into982what has happened. The VA does have significant measures to983actually address providers that provide subpar care. We also984need to be reminded, as I was often in my doctoral studies,985that the plural of antidote is not data. If we look at the986preponderance of the data, the data lead us to VA care987providing better care. In surveys of our own members, only 14988percent express any confidence in community care being able to989address and coordinate their complex medical needs.990    Ms. Brownley. Thanks for that. You know, do you have any991suggestions on really how we help veterans, the public for that992matter, to better understand the evidence and overcome this993perception that the VA care is not as good as community care?994    Dr. Hunter. I think it is very incumbent upon VSOs to take995an educating role on what the VA is and also incumbent on996Members of Congress to continue to engage with VA providers to997ensure that we have appropriate oversight and engagement to998understand the quality of care that exists.999    Ms. Brownley. Thank you for that. I yield back.1000    Ms. Miller-Meeks. Thank you, Ranking Member Brownley.1001    I now recognize Dr. Murphy for 5 minutes for any questions1002he may have.1003    Mr. Murphy. Thank you, Madam Chairman. Thank each of you1004for your service and the work that you are doing to try to make1005our care for our veterans as best as possible, regardless of1006where it comes from.1007    You know, I wish this was not an either/or kind of1008situation. This needs to be an and/yes, a yes/and situation,1009because the VA cannot handle all the healthcare that it needs1010to handle for our veterans, period. There are not the1011resources, some of which is negligence, on the behalf of the1012medical education system of the United States. We simply do not1013have the doctors. We simply do not have the doctors. It just1014kind of hurts me that people want to say this is better, that1015is better, and against one care or the other.1016    Dr. Hunter, since you brought it up, if you do not mind, I1017am going to ask you about your ocular melanoma. Are you saying1018that the VA doctor picked that up because they knew you might1019be exposed to something or are you saying your optometrist out1020in the community missed it?1021    Dr. Hunter. I had had a appointment with a optometrist out1022in the community who did miss it. Six months later, I had an1023appointment with an optometrist at the VA who was able to1024recognize it.1025    Mr. Murphy. Did the optometrist do an ocular examination?1026Did he look in your eye and look all around your quadrants?1027    Dr. Hunter. Yes.1028    Mr. Murphy. Did you, by any chance, get films from them1029before then? Because they always make films.1030    Dr. Hunter. My ----1031    Mr. Murphy. Because ocular melanomas can happen in 61032months.1033    Dr. Hunter. Yes, yes, there were films. It was present in1034the films when my VA provider had reviewed them later on, and1035it was not discussed or addressed ----1036    Mr. Murphy. I would just submit that that is a difference1037between two physicians. It does not matter where they are1038coming from, whether you could flip them the other way itself.1039To say one is better just because of the place where they work,1040I think is just not being correct.1041    Also, delving into some of your comments about1042postoperative care, can you give me a breakdown of the type of1043patients that are referred out to community care for surgery1044versus those that are kept in-house?1045    Dr. Hunter. I can take that question for the record and get1046you the breakdown.1047    Mr. Murphy. I can tell you what it is. You do not refer1048things out to the VA unless it is specialty care. I am a1049specialty surgeon. I get specialty referrals for specialty care1050that cannot be happened within the hospital. By definition,1051those are more costly because they are more time-effective,1052they are more specialty-oriented, and their risk rates are1053higher. Doing, actually, a risk ratio would be factual to this1054rather than just saying postoperative care is better at the VA,1055the outcomes are better than they are in the community, because1056they are two entirely different populations. You refer people1057out who need specialty care, who, by definition, have greater1058needs than they do.1059    I just do not like the tenor that we are putting, they were1060battling against, you know, saying that community care doctors,1061of which I am one, are better or are worse. I do not think that1062is fair. That is not fair to our veterans. Then what are you1063saying to them? Anybody who gets referred out, well, we are1064saying we are sending you out for inferior care? That is not1065fair. I do not think that is fair.1066    Ms. Knight, let me ask you this. You know, and there are1067questions about, which has bothered me since I have been on1068this committee, about our electronic medical record, which I1069think is just derelict in the VA through how many1070administrations that we have been going through. I still1071cannot. I had a patient last week who was a VA and I said, did1072you bring your records? He said, no, they said you would have1073them. Of course, they never sent them, and I cannot get access1074to them. Can you explain to me how just the community care has1075helped you to access more or less --excuse me, giving you more1076or less access to VA-covered healthcare?1077    Ms. Knight. I have more options. I live in Montana, so the1078biggest city in Montana at 150,000 people, so it is quite1079small, actually. There are not a lot of providers, let alone1080specialty providers, from within the VA. I see a chiropractor1081and an acupuncturist to help with my chronic migraines, of1082which neither are available within the VA. As I have shared in1083my testimony, I have had pretty horrid stories and experiences1084within the VA and good experiences within the community.1085    My chiropractor, who is a male, actually took the time to1086review what information was passed to him from the VA with my1087referral and asked me on my preference on whether or not I1088wanted a man or a woman physician, which was the first time I1089have ever been asked as a proactive manner on my preference,1090given my military sexual trauma.1091    Mr. Murphy. There are good experiences or bad experiences,1092really, probably within both systems?1093    Ms. Knight. Absolutely. I would ask to just have more1094control and choice over where I want to go. As I also mentioned1095in my testimony, most times the gatekeeper within the VA calls1096and says, here is your list of providers. Where do you want to1097go? I feel like I am on this ticking time bomb and of making a1098decision while, you know, momentarily taking a time out of my1099workplace, because it is usually Monday through Friday, 9 to 5.1100In that effort, my typical question is, well, what is closest1101to me as a convenience for me? Not necessarily are they man?1102Are they woman? Do they have good reviews? Can I do research on1103them? I would ask to better understand what my options are, so1104that I can make a more informed and educated decision for1105myself.1106    Mr. Murphy. Thank you. You know, Dr. Mobbs, it hurt my1107heart to hear that somebody in administration would withhold1108care because they would not have the compassion, much less the1109medical competence, to send somebody out to the community and1110withhold care. I hope that person, I do not want to say1111disciplined, I hope they got shown the door because what an1112absolute disservice it would be to whoever veteran, sadly1113enough, if they die in pain because they did not get their1114radiation. That is horrible. That is a horrible story.1115    Ms. Keenan, in your opinion, if you will, where does1116community care fit in?1117    Am I already over? I am sorry, I have been yakking too1118much. I apologize. I will yield back.1119    Ms. Miller-Meeks. Thank you, Dr. Murphy.1120    The chair now recognizes Dr. Morrison for 5 minutes for any1121questions she may have.1122    Ms. Morrison. Thank you very much, Madam Chair. I want to1123thank the witnesses for your testimony and thank you for your1124service to our Nation and thank you for sharing your very1125personal stories today. That is not easy to do and I know we1126are all to going grateful, so thank you for that.1127    Today's hearing really touches on struggles and1128frustrations that are all too familiar to me as a physician.1129One of the reasons that compelled me to serve in Congress was1130my firsthand experience with how difficult navigating the1131healthcare system in our country can be at times. Patients and1132physicians have no shortage of exceedingly valid frustrations1133with navigating healthcare in the United States. A Gallup poll1134actually earlier this year found that one in four Americans1135ranked improving healthcare access and affordability as their1136highest priority. Over half of Americans ranked healthcare1137among their top three priorities for government leaders. There1138is no question that Americans are looking to their elected1139leaders to act on the issue of healthcare.1140    The testimony from today's witnesses highlights the reality1141that like the majority of their fellow Americans, far too many1142veterans are facing barriers that prevent them from accessing1143the healthcare we made a commitment to provide. They are asking1144Congress to make meaningful progress toward improving their1145quality of care and making sure we are delivering on the1146promises we made to those who have served our country.1147    Today's hearing title includes ``Right Time, Right Place,''1148and ``Right Treatment,'' and I could not agree more that1149pursuing improvements to healthcare at the VA does require1150considering time, place, and treatment. We should absolutely be1151evaluating whether veterans are receiving the care they need in1152a timely manner. We should absolutely be focusing on fostering1153and preserving the specialized care that research continuously1154demonstrates is critical to veteran health outcomes. We should1155absolutely be committed to reviewing cutting-edge scientific1156evidence and research to bring novel treatments to veterans1157without delay.1158    However, if we attempt to pursue all of those goals without1159considering the present circumstances of the VA or preserving a1160commitment to evidence-based treatments and rigorous standards,1161then we cannot in good faith claim to be delivering on what1162veterans have asked of us. Losing an estimated 30,000 staff in1163less than 12 months will move veterans seeking direct VA care1164and coordinated community care away from the ``right time.''1165Devastating Medicaid cuts from the so-called One Big Beautiful1166Bill that President Trump signed into law threaten rural1167hospitals and access to community care, costing veterans the1168potential ``right places'' across areas that need it them most.1169I worry that if we are not vigilant, the pace at which1170community care funds are growing will strain VA research and1171direct care that is indispensable to getting to the ``right1172treatment.''1173    Dr. Hunter, with that in mind, in your testimony you1174emphasize the importance of following the data. What does the1175data tell us about how to improve access to timely quality care1176at the VA?1177    Dr. Hunter. Thank you so much for that. We share your1178concern and commitment for having the right care at the right1179time.1180    The biggest thing that the data are telling us is the1181importance of investing in the patient-centered care teams that1182exist. Far too often these care teams are cut out of the loop.1183They are often sometimes the first employees to get cut or1184deemed nonessential. What we know is that they are the most1185essential.1186    The other aspect that is incredibly important, as the data1187said, is to hold community care to some of the same rigorous1188standards and information sharing, so that the patient-aligned1189care team can effectively create an entire course of treatment.1190In our conversations with medical directors at the VA, what we1191are finding too often is that community care providers are not1192required to provide back the full course of treatment that they1193are engaging in with the patients, which makes it more1194difficult and adds time to having to understand what the1195patient is going through, and often leads to patients having to1196relive horrible stories and events time and time and again1197because there is not that coordination.1198    Keeping that patient-aligned care team coordination as the1199center, investing in it, and strengthening the resources for1200that team is what is absolutely essential to get the right care1201to our veterans at the right time.1202    Ms. Morrison. Thank you, Dr. Hunter. I agree. VA direct1203care is vital to meeting unique veteran health needs. There is1204no question that there are circumstances in which community1205care is appropriate and essential. This committee cannot claim1206a serious commitment to either while advancing legislation and1207cosigning leadership decisions that undermine VA's stability1208and capacity to deliver on its core missions.1209    Thank you, Madam Chair. With that, I yield back.1210    Ms. Miller-Meeks. Thank you. The chair now recognizes1211Representative King-Hinds for 5 minutes.1212    Ms. King-Hinds. First of all, thank you to all of you for1213appearing before us today. Thank you for your service. I just1214have to say, man, go women power, because just phenomenal women1215appearing before this committee.1216    I come from the Northern Marianas, where access to service1217is very limited. We do not have a CBOC. I think people are1218going to get sick of me saying that because I am going to say1219it over and over again until we actually do get access to care,1220which is why, you know, looking at community care programs is1221very important to me because of that reason.1222    Now, one of the things that I am hearing from all of you is1223that things could be better with regards to the way we deliver1224those programs. There are gaps.1225    Dr. Mobbs, is it ``Mobs''? You spoke of, in your written1226testimony that you submitted, you talked about a comprehensive1227metrics system that needs to be put in place. Can you just kind1228of dive into that a little bit? Because I am looking for1229opportunities to improve --to ensure that some of these1230challenges and gaps that we are talking about and hearing about1231today are actually addressed in the legislation and that we can1232improve the system.1233    Dr. Mobbs. Thank you very much for that question. I think1234this is critically important. I am certainly a advocate for the1235--not the either/or, but the and. We have to have both a strong1236VA and strong community care.1237    As part of that, the GAO has provided extensive1238recommendations regarding the opportunity to improve oversight1239and accountability around community care. In particular, some1240of the things that have been mentioned here do need to be1241improved upon. The ability to track scheduling performance, for1242example; metrics aligned with those timeframes are imperative;1243meaningful accountability around those metrics. Then, for1244example, the VA's referral coordination initiative, which was1245meant to streamline specialty care, has suffered from somewhat1246inconsistent implementation, unclear guidance about its use,1247and inadequate performance metrics.1248    I would simply say that the work has been done around1249assessing VA Community Care opportunities for improvement. I1250would just say that we should be looking very extensively at1251the recommendations provided by GAO in order to enhance them.1252    Ms. King-Hinds. Thank you for that.1253    This is a question to you, Dr. Hunter, because I do agree.1254I am an attorney by practice, and, you know, when you appear in1255front of a jury, you have to submit data evidence. Right?1256Sometimes the anecdote does win. Too often, as a matter of1257fact, in the community that I come from, these stories are what1258I hear every single time I meet with constituents. For as long1259as I have sat in this committee, in this last 7 months, these1260are the stories that we hear.1261    You know, you spoke of some of the gaps to include1262accessibility to recordkeeping and being able to have a more1263seamless process whereby there is a little bit more1264accountability with regards to the program itself. Can you give1265us suggestions as to how we can improve the current situation?1266    Dr. Hunter. Thank you so much for that. Because, you know,1267again, we understand that this is not a either/or. That is not1268how this should be characterized. It is a yes/and. We really1269need to improve the coordination side of community care, so it1270is held to some of the same standards that VA care is.1271    If we are thinking about the coordination piece, there are1272a few things that can be done. One is there needs to be some1273more deliberate looking into some of the VA modernization and1274the enterprise systems that are being rolled out. This work is1275sort of early on, preliminary. We are really excited to work1276with the committee to better understand and ensure that the1277electronic healthcare record system is being rolled out in an1278appropriate manner that allows for better coordination.1279    Because right now, what we are seeing far too often is that1280the VA, where there are very well-coordinated records kept, is1281not able to communicate well with community providers, and1282things are falling through the cracks. We are not getting full1283care plans. We are not able to ensure that veterans are1284receiving the same standard and quality of care. First, making1285sure that process is going well, as well as ensuring oversight1286and enforcement of the quality standards and training that are1287required of our community care providers.1288    You know, the MISSION Act said that needed to happen, but1289according to multiple independent medical associations, there1290is not yet a published transparent standard for what community1291care needs to meet or what sort of records need to be provided1292back to the VA care teams to ensure the comprehensive1293continuity of care. In those two areas, I think there is a lot1294of room to be done, and I think this committee is primed to be1295able to engage in that sort of oversight.1296    Ms. King-Hinds. Thank you. I am out of time. I yield my1297time. I yield back.1298    Ms. Miller-Meeks. Thank you very much, Representative King-1299Hinds.1300    The chair now recognizes Dr. Conaway for 5 minutes for any1301questions he may have.1302    Mr. Conaway. Thank you, Madam Chair. Thank you, ladies, for1303your service and your commitment to veterans and their1304healthcare. I want to make a few comments and observations.1305    Since both sitting on this committee and what I have heard1306today, I hope there is consensus on this committee and across1307the House, across the government, that we need to have a strong1308VA healthcare system and that we need community providers1309because we know the VA does not exist everywhere, particularly1310in rural areas. We know this partnership needs to exist.1311    One of the problems, as a physician, practicing physician1312for 30 years myself, worked on an Air Force base in New Jersey1313taking care of veterans and in the community and private1314practice, what my experience tells me and what I have read1315about and what the research shows and what we all know with the1316problems with our information system is that there is not1317coordination across those systems. Once you move outside of a1318system, even within hospitals in my own little State of New1319Jersey, getting records to move from hospital to hospital, if1320they are not on the same platform, is a very difficult thing to1321achieve. You will have, and particularly --and so you are going1322to have patients, if they move to different locales, having to1323repeat their stories. It is terrible when it involves things1324like trauma.1325    When you are in a teaching institution, a resident might1326see you, might be a medical student, then a resident, then the1327attending. This is part of the teaching process in teaching1328institutions. Unfortunately, we will hear stories about people1329being re-traumatized as this information is collected. That1330iterative process in teaching institutions is part of driving1331great outcomes.1332    I would also say that, you know, we have to rely on data,1333as you mentioned, and the data has been consistent over many1334years and repeated that VA care for veterans provides great1335outcomes. Veterans want the care there. If you think a moment1336about the different exposures, the experience in the military,1337where they have been, the experience of people taking care of1338numbers of veterans over the years that is unlikely to be1339replicated in most communities, it does not surprise me that1340outcomes are better in the VA system.1341    Our problem is that it is hard --well, maybe I should speak1342for myself, but I think I am speaking for a lot of others, too.1343When we understand that the administration is cutting tens of1344thousands of people out of a system that is already stressed,1345it is hard to imagine that you can achieve the kind of outcome1346standards that you could achieve if those people were not out1347of the system.1348    Now, reform, looking at how things are done, making sure1349training is correct, maybe having a special access for women1350who are having particular problems, whether it be reproductive1351healthcare or sexual trauma in the service, those things are1352important to put in a system. I think you are more likely to1353get that in the VA than very often you are in the community, by1354the way away, because of the sensitivities in the VA system for1355this, I suspect. As I look at the numbers we have about the1356people who have been --who are leaving the service now, as I1357look at the numbers, two-thirds of them are clinical staff:1358physicians, nurses, support staff.1359    If we were to decide to bring in or try to recruit more1360women to deal with sexual trauma in the service, I cannot1361imagine how that would not be decried as a Diversity, Equity,1362and Inclusion (DEI) program within the government. You cannot1363even recognize women who have served, you know, honorably1364overseas because it is, you know, recognizing women, never mind1365people of color.1366    I want to ask this question of you, Ms. Newman, because you1367work in a rural area and we know now that there are a number of1368studies that are coming out showing that these Medicaid cuts1369are going to be particularly devastating in rural areas where1370Medicaid might make up 40 to 50 percent of their revenue. We1371heard 338 hospitals at risk. You live and others on this panel1372live and get care in rural areas. Describe how the loss of1373hospitals in the community is going to impact access to care,1374the access that we know veterans need.1375    Ms. Newman. Thank you for the question. Yes, I do live in a1376rural area. In my particular area, we already have lost access1377to hospitals. We are an independent home care agency. These1378cuts are not going to, in particular, impact our agency, but1379our --people in our area, they are already used to traveling to1380receive care.1381    Mr. Conaway. Just reclaiming my time because I am running1382out of time. Thank you for that. I think it is obvious that if1383hospitals close, there is going to be an access to care1384problem.1385    I asked Secretary Collins at a hearing just like this one1386about whether or not cuts to Medicare and food assistance is1387going to impact veterans. He says, I do not foresee that1388happening now. Well, now it has happened. We know as a result1389of that big, ugly bill that we are going to see, really, quite1390devastating dislocation across the land, and particularly in1391rural areas and also impacting veterans. That is a shame, given1392the commitment this country needs to keep to our veteran1393community.1394    Thank you, Madam Chair. I yield back.1395    Ms. Miller-Meeks. Thank you, Dr. Conaway.1396    The chair now recognizes Representative Cherfilus-McCormick1397for 5 minutes for any questions she may have.1398    Ms. Cherfilus-McCormick. Thank you so much, Chairwoman, and1399thank you so much for your testimony. It is truly an honor to1400be here listening to your testimony.1401    I do have a background in home health, also. I am second1402generation and I kind of miss being in there and finding1403solutions to these problems. I do believe also that community1404care is imperative to serving our veterans. However, we do need1405to have bipartisan legislation that can help us fill in those1406gaps. I was very delighted when I heard what Dr. Hunter was1407talking about. The need for standardization as far as to make1408sure that we have accessibility, but also communicating what is1409going on with the community care doctors, specifically getting1410on-time or real-time information for our patients, which even1411in the private side and community care, we are still trying to1412get up to date.1413    I wanted to talk to Dr. Hunter a little bit more about1414that. What recommendations would you put in place so we can1415actually bridge that gap, specifically when it comes to1416community care and our veterans' offices?1417    Dr. Hunter. Thank you so much for that question. As we1418said, we know community care is vital, but we know there needs1419to be better direct communication so that patients are1420receiving that same quality, integrated, coordinated VA care1421that leads to better outcomes.1422    If we look at recommendations that can improve this, one is1423having the same types of care standards that are required for1424community care providers as for VA healthcare providers. This1425is seen very clearly in the mental health area, where when a1426patient is seen internally to VA direct care, VA direct care1427mental health providers are required to set a evidence-based1428course of care for that patient that hits very significant1429benchmarks that are there.1430    When they are referred out to the community, they were1431referred out for a time-based episodes of care. 6 months, 121432months, and then it is reevaluated. Right now there is not a1433requirement to actually share back with the patient care team1434what the decided course of care is. In fact, all that is1435required is a yes, this patient showed up for an appointment1436and it is either improving or not improving.1437    First and foremost, to strengthen this is to set the same1438standards for evidence-based care for VA care and community1439care and require that transparency, so that all providers1440within the VA system know what the course of treatment is1441across all sorts of specialty care that are provided. This is1442one very specific example for mental healthcare, but we see1443this happen in other forms of care as well.1444    Ms. Cherfilus-McCormick. Now, you touched upon the problems1445that we are having with electronic medical records. My other1446subcommittee is Technology and Modernization. I really hope1447that we can have a joint hearing so we can be discussing this1448together. I know we already have strains in even getting the1449VA's system up to task and up to snuff. I know it will be1450challenging for us to do that with community care. Do you have1451any recommendations that you can give us when it comes to1452electronic medical records?1453    Dr. Hunter. I think we do need to take a very close look at1454the current implementation of electronic health records within1455the VA. We know it is plagued with problems from the get-go.1456This is an area that I am new in this seat. I have been a CEO1457here for a month, but it is one of the things that I have1458really wanted to dive into to be able to provide those better1459recommendations to you all as to how we can effectively1460modernize the VA and create better synergies and more seamless1461communication between VA and community care, and would love to1462work with your office to do just that.1463    Ms. Cherfilus-McCormick. Thank you. I want to pivot a1464little bit over back to our home health issues that are1465happening. When I was the CEO of a healthcare company, what we1466did, we also had rural areas, Clewiston, Belle Glade, and we1467were servicing there. We had huge issues when it came to1468recruiting healthcare professionals to get out there. Also, we1469did have a good number of Medicaid recipients.1470    Now, do you have any Medicaid recipients who are actually1471with your organization?1472    Ms. Newman. We have very little in our particular1473organization. We are a standalone home care agency.1474    Ms. Cherfilus-McCormick. Right now we are looking at $11475trillion in cuts when it comes to Medicaid. I have deep1476concerns about the compound effects with the cuts that we have1477in the VA combined with the $1 trillion in Medicaid cuts and1478how we are going to keep organizations like yourself, who play1479such an imperative role in making sure that our veterans can1480actually retire at home with dignity, with their family, but1481still get their services. Could you touch on some of those1482effects for your organization's other home healthcare agencies1483that will be servicing our Medicaid patients and our veterans?1484    Ms. Newman. Sure. Of course, as I stated, our particular1485payer mix, we have very little of the Medicaid and so for us,1486personally, it will not have a large impact. What we do is, as1487with any other agency, is we try to meet everybody's needs. In1488our particular area, we are not hearing feedback.1489    Ms. Cherfilus-McCormick. Well, I have a few more seconds1490and I just wanted to ask you this one question. One of the1491things I am hearing from home care agencies is that they have1492real concerns about the people who are going to be kicked off1493of Medicaid. They cannot abandon those patients. How do you1494transition that person who is homebound, cannot get up, cannot1495take care of themselves, how do you rip their insurance, and1496how do you leave them there?1497    Have you guys thought about that transition process? Are we1498just going to abandon these patients to leave them to1499themselves?1500    Ms. Newman. Well, if I can circle it back to the VA, we are1501actually actively seeing that now with our veterans, where on1502the VA services, where they have lost homemaker services, home1503health aide services due to internal cuts within the VA. We are1504seeing that they have lost access to care. I think it is1505already happening within the VA, but this started a year ago1506based off of decisions within the VA.1507    Ms. Cherfilus-McCormick. So the compound ----1508    Ms. Miller-Meeks. Thank you very much. Your time has1509expired.1510    Ms. Cherfilus-McCormick. Thank you.1511    Ms. Miller-Meeks. The chair now recognizes Dr. Dexter for 51512minutes for any questions she may have.1513    Ms. Dexter. Thank you, Madam Chair, and thank you all again1514for your service and for being here today. Really, really1515appreciate it.1516    One thing that struck me listening to all of you, that I1517continue to struggle with being new here in Congress and coming1518here as a physician, is what feels like a binary choice between1519community care and in-VA care. I know nobody here is advocating1520necessarily for one versus the other, but I think that is how1521it feels in this committee at times. One quote that one of you1522shared was community care is not an alternative to the VA. It1523is an extension of it. That should be what it is, but it is not1524what it ends up being because this is a fixed pie that when we1525take money out of the VA direct care services and get it out to1526the community, it is a loss from being able to buildup the VA1527care to the quality that we know.1528    Dr. Hunter, you spoke to, when we get it to our veterans,1529it is better quality care and they are more satisfied. The1530problem is, as Ms. Keenan and so many people have talked to, it1531is getting them that care and having them available or be able1532to get availability.1533    One thing that I would like us to try to center, it is1534truly a bipartisan endeavor, I believe, is to get our veterans1535at the center of what we are trying to do and make sure that1536their needs and their access and quality are what drives our1537decisions rather than protecting community care, protecting the1538VA system in district care.1539    Ms. Hunter and several of you have talked about the data,1540and I wonder what kind of data would be most compelling for you1541as a veteran? I will start with you, Dr. Hunter. What would be1542the most compelling data for you as an advocate for veterans,1543especially our women veterans who are underserved in so many1544ways? I do not want to be disproportionately focused on that.1545What would you want to see? What would help you make decisions1546about advocating for community care versus in the VA system1547care, direct care?1548    Dr. Hunter. Thank you so much for that question. When we1549look about where the compelling data is, I will put my1550researcher hat on, I look at outcomes. Right? Outcomes matter1551and we know that patient-centered outcomes are better when with1552VA care because of the coordination, which does not mean that1553community care cannot get there, but the coordination needs to1554get there.1555    One thing you noted that I really want to touch on is some1556of the concerns that are coming from the fixed budget. What we1557are seeing more and more is mandatory spending being directed1558toward mandatory spending for community care, which1559necessitates making cuts at the VA. We are hearing from several1560VA providers that that results in not being able to fill1561positions, not being able to actually hire the people they need1562to hire, which creates an unfortunate cycle of demonization of1563the VA because we have lower morale, lower staff, which leads1564to longer wait times and sometimes worse outcomes. Again,1565centering the patient in the outcomes is absolutely essential1566there.1567    I think as we are looking at this and we are talking about1568choice in all of this, and choice is essential, but we need to1569ensure that we do not remove the ability of veterans to choose1570VA and to choose a provider at the VA as a one-stop shop for1571their care.1572    Ms. Dexter. No, I appreciate that. I think what I certainly1573am interested in working across the aisle and with this1574subcommittee on is centering how do we get the data that we1575need to make the decisions that really do deliver the quality,1576access, and service to our veterans that they deserve? It may1577be that it is wound care in the community is the most effective1578way, especially in rural areas. Let us have the data so that we1579understand how long it takes to get for a wound care1580appointment and how far you have to drive, and then let the1581patients have a choice.1582    I do think making clear at the VA that patients or veterans1583have a choice is important. I heard several of you speak to1584that, that we should not be trying to deter people from getting1585care at the VA, but we should not shield them from a choice,1586but making that choice tangible. I hope that everyone on this1587committee consider that. I look forward to working with you all1588on how we get policy amendments, however it looks, so that we1589can get the right outcomes for our veterans.1590    Because again, I do not want to be shielding Optum and1591TRICARE and trying to get them dollars. I want to get those1592dollars to the VA and to our veterans.1593    Okay, thank you. With that, I yield back.1594    Ms. Miller-Meeks. Thank you very much, Dr. Dexter.1595    The chair now recognizes herself for 5 minutes.1596    Ms. Hunter, you mentioned several times about the1597challenges of information and training and whether VA-specific1598providers had specific types of training that did not happen in1599community care. Is not that a failing of the VA?1600    Dr. Hunter. If we think about the training, it could be a1601failing of the VA.1602    Ms. Miller-Meeks. Yes.1603    Dr. Hunter. Could be a failing.1604    Ms. Miller-Meeks. I have got 5 minutes.1605    Dr. Hunter. Yes. It could be a VA. We just ----1606    Ms. Miller-Meeks. I just want a simple yes and no question.1607It is a failing of the VA, agree, disagree?1608    Dr. Hunter. We do not have the data, so we cannot say where1609the failure is.1610    Ms. Miller-Meeks. Okay. Is not the VA responsible for that?1611The VA can set the standards for community care.1612    Dr. Hunter. They can.1613    Ms. Miller-Meeks. Ms. Mobbs, can the VA set the standards1614for community care?1615    Dr. Mobbs. They absolutely can. That is correct.1616    Ms. Miller-Meeks. You mentioned the training. You also1617mentioned the Red Report. I think perhaps you might have some1618comments you wanted to make on testimony, so I am going to give1619you an opportunity to clarify that.1620    Dr. Mobbs. Thank you, Chairwoman. First off, I never said1621that they do not receive training. That that is an inaccurate1622characterization of what I said.1623    I think it is really important if we are talking about1624specifically data here, and I am going to go where I am an1625expert in, which is mental health. In the VA system, for1626example, we prioritized two performance metrics-based, data-1627driven therapies for post-traumatic stress disorder: prolonged1628exposure, combat processing therapy. Unfortunately, because1629that was a trauma-centered therapy, the majority of veterans1630left after 2.4 sessions, therefore wanting a different type of1631therapy that they were not allowed to receive in the VA because1632they were given a PTSD diagnosis and qualification.1633Unfortunately, other evidence-based cares like interpersonal1634therapy, community care providers are trained in, were unable1635to see those veterans and they dropped out and then we could1636not follow them.1637    All that to say just because there is training in the VA1638does not always mean it is the right training. To the1639chairwoman's point, you can absolutely receive care in the1640community set by the VA to ensure that they are evidence-based1641therapies to provide for veterans.1642    Ms. Miller-Meeks. I admit that as a community care1643provider, as an ophthalmologist, I am given a specific type of1644treatment for a specific disorder I am supposed to address.1645There were questions that may have been asked of other type of1646conditions that I did not need training from the VA for.1647    Ms. Knight, I am going to ask you to comment because you1648mentioned receiving care at the VA and care in the community,1649and you have heard how this specific training better equips VA1650physicians to handle either PTSD or the variety of issues. I1651did not hear that in your testimony. Can you comment upon1652whether you thought that this training uniquely qualified VA1653physicians, and did you receive better treatment at the VA1654versus in community care?1655    Ms. Knight. My answer would be no, Chairwoman. No, I had1656three different accounts of VA providers, one of whom was a1657veteran herself. All three, again, I felt more like I was1658interrogated at times, questioned and validated on my combat1659service and what I had endured, and drilled.1660    I would also add that so many of our community providers1661out there deal with other patients who are similar in trauma1662exposure, such as our police and firefighters. There are an1663array of providers, both in the VA and outside of the VA that1664are more than qualified to meet the standards. I just feel very1665strongly that, again, one, they need to ask the questions, but1666that can be resolved by the patient, by understanding and being1667educated on who the providers are, whether that is ratings or1668reviews or anything of that nature. Right now, we are not given1669that choice. We are not giving that option. We are told where1670to go. It is more or less being in the military.1671    If I may, if we are going to talk technology, I would love1672to see the transition of documentation from U.S. Department of1673Defense (DOD) to VA fixed first.1674    Ms. Miller-Meeks. Kudos. As an Army veteran, I will say1675kudos to that. We have been asking for that.1676    Ms. Newman, have you noticed any decrease in community care1677referrals for home care services?1678    Ms. Newman. Yes. In 2024, we noticed a marked decrease,1679both within our agency and members across the Nation.1680    Ms. Miller-Meeks. Have you heard what the reason for the1681decrease in referrals would be?1682    Ms. Newman. In our particular VISN, there was an extra1683layer of oversight and bureaucracy where their intent was to1684find reasons to reduce the amount of care authorized.1685    Ms. Miller-Meeks. I can tell you from my exposure, my talks1686with veterans, it was felt that they were encouraged not to1687send patients into the community. As a community care provider,1688it can be extraordinarily challenging dealing with the VA, even1689when someone is 60 miles away from a center that could give1690them care.1691    I think veterans do appreciate and like the care that they1692receive at the VA. There is a reason why the MISSION Act and1693Community Care exist. The reason was because people were dying1694waiting for care at the VA.1695    Ms. Hunter, do you know how much the budget for the VA has1696increased in the past 4 years?1697    Dr. Hunter. Yes, I have that data right here.1698    Ms. Miller-Meeks. Is it flat?1699    Dr. Hunter. No, the budget has continued to increase.1700    Ms. Miller-Meeks. The budget has continued to increase. We1701know community care is comprised in about 40 percent of care1702now within the VA, but we also know they do it at about 251703percent of the cost to the regular VA. I am just going to say1704that, you know, implicating that community care is a downward1705spiral for the VA and taking money away from the direct care1706system, I am going to say that does not bear out by the facts1707when you look at the budget and you look where the spending1708goes.1709    I also want to say that we keep talking about this as a1710fixed budget. If you have providers going to community care,1711they are not going to get direct care because the budget is the1712same and there is never any increase in funding. That is1713patently incorrect. I mean, there has been more appropriation1714dollars from Congress. This spring, Congress voted billions1715more into VA, VHA medical services, $75 billion to be exact. I1716think some of the arguments are poorly founded, although they1717sound very dramatic.1718    With that, I yield back my time, as I, too, am over time.1719    Thank everyone for their participation in today's hearing,1720for the discussions we have heard on the important topic. I am1721going to yield to Ms. Brownley if she has any closing comments.1722    Ms. Brownley. I do have some closing comments. I wanted to1723just respond, Madam Chair, to what you just said about an1724increase in the VA budget. I agree, there has been an increase1725in that budget. There has also been an increase in the1726community care budget. The issue is the community care budget1727is increasing at a more rapid pace than the VA. I want to put1728that sort of fact out there.1729    The way I want to kind of conclude today's comments is to1730respond to Dr. Murphy, and I think Dr. Dexter actually did a1731very good job of responding to some of the things that he was1732saying. He talked about he was tired of talking about an1733either/or scenario. He said we need to get to, I believe what1734he said was ``yes'' and ``and''. I agree with him, ``yes'' and1735``and.''1736    I think what Dr. Dexter was saying, you know, we should1737not, you know, we should not have a binary choice, an either/or1738choice, but the community care should be an extension of the VA1739care, which in my mind is the yes/and scenario. The point I am1740trying to make, and I think Dr. Dexter made the point with1741regards to, you know, one pot of resources can only go so far,1742and we have got to make those choices.1743    The other issue I want to make here is, the chart is behind1744me, is this data that I have here is VA data. It is not anybody1745else's data. It comes directly from the VA. What it says is1746that from 2022 to 2023, there was a net gain of employees of a1747little bit more than 18,000 employees. The next bar chart is1748from 2023 to 2024, the net gain for employees was almost 14,0001749people. Excuse me. The last bar chart here is 2024 to 2025.1750This shows that there is a net loss of a little over 10,0001751employees. What I see here is a trajectory going in a direction1752that is not going to be good relative to what quality care1753looks like at the VA.1754    I just believe that as the workforce at the VA continues to1755decline, I think as the data shows, and, again, this is VA1756data, it will absolutely begin to limit the choice a veteran1757should have, whether they want to get their care at the VA or1758whether they want to get their care in the community. We will1759get to a point, I am not saying we are going to get there today1760or tomorrow, but we could get there to a point where a veteran1761will only have one choice, and that will be to go to the1762community for their care.1763    I think it is very clear, and the data is very clear about1764this, that veterans want to receive their care at the VA. Now,1765if you are a female veteran, you have got to go out to the1766community for --if you are pregnant and you have got to go out1767to the community to get your care, and you should have your1768choice of providers when you go to the community care.1769Generally, veterans want to get their care at the VA because1770they believe they have more quality time with the doctor, they1771believe that they understand the veteran better, et cetera.1772This is just the point that I am trying to make, that we do not1773want to go down this road.1774    Secondarily, what is a concern with regards to community1775care is the impact of a $1 trillion cut to Medicaid. I1776mentioned in my opening comments, the University of North1777Carolina has identified 338 rural hospitals at risk for1778closure. One of the main reasons why we started the MISSION Act1779and moved toward community care was for rural areas. If these1780community hospitals are going to have to shut down because of1781lack of resources, there is not going to be a choice. The only1782choice then will be the VA. Then, yet, you know, people are1783resigning, people are retiring, people are leaving because it1784is just not a healthy place to work and they are not going to1785be able to provide the resources.1786    This is what I am just --the point that I am trying to get1787across. The point, I think, we are trying to avoid a1788deterioration of the VA, and we do not want to deteriorate1789community care either. We have got, as I said so many times in1790these hearings, we have got to find the right balance here.1791    I worry about this chart. I think the chairwoman said at1792the beginning, this is just normal attrition what is going on1793at the VA. This is not normal attrition.1794    With that, I will yield back. Thank you, Madam Chair.1795    Ms. Miller-Meeks. Thank you, Ranking Member Brownley.1796Again, 9 percent of the workforce of VHA is lost annually1797through attrition. These are the VA's figures, about 38,0001798employees based on its current workforce. That is the VA1799numbers. Those are facts.1800    For me, this is not an either/or. This should be that1801veterans have choice over where they receive care. I am a1802veteran. Neither my husband nor I desire to receive care at the1803VA hospital. We prefer to receive care in our community either1804through private health insurance or through Medicare. Would it1805save us money if we went to the VA hospital? Possibly. We would1806not have copays or deductibles, but we choose to receive our1807care in the community. We are asking for the same choice for1808all veterans and the veterans on this panel.1809    There is a consensus in my mind that we want both community1810care and, and VA care. Why both? We are trying to serve1811veterans and serve veterans first and foremost. There would not1812be a need for community care had the VA been able to serve1813veterans, not keep them on waiting lists, not have veterans1814die, not have the big Public Relations (PR) nightmare of1815veterans waiting for care and dying waiting for care, a suicide1816rate that remains at 17 percent and has not gone down. A VA who1817here in this room in testimony admitted that they did not think1818that residential mental healthcare, the most critical of care,1819or residential substance use disorder care fell under the1820MISSION Act. If you were in a mental health crisis from the VA,1821it was okay if you waited 30 days or 60 days or 90 days or, by1822God, a year, or you can go to a VISN two VISNs away, 300 miles1823away.1824    That is why we are having this conversation. If the VA was1825not actively trying to prevent people from going to community1826care, from my standpoint, it is not adversarial. Let us have1827the consensus that VA care is community care. That our goal is1828and always on this committee and in Congress is to serve our1829veterans.1830    With that, I would like to thank everyone for their1831participation in today's hearing, for the discussions we have1832had on a critically important topic. The complete written1833statements of today's witnesses will be entered into the1834hearing record. I ask unanimous consent that all members have 51835legislative days to revise and extend their remarks and include1836extraneous material.1837    Hearing no objections, so ordered.1838    I thank the members and the witnesses for their attendance1839and their participation today. This hearing is now adjourned.1840    [Whereupon, at 4:19 p.m., the subcommittee was adjourned.]18411842=======================================================================18431844                         A  P  P  E  N  D  I  X18451846=======================================================================18471848                    Prepared Statements of Witnesses18491850                              ----------18511852                  Prepared Statement of Dallas Knight1853[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]18541855                  Prepared Statement of Meaghan Mobbs18561857    Chairman Miller-Meeks, Ranking Member Brownley, and members of the1858subcommittee, thank you for the opportunity to testify today.1859    It's an honor to speak on an issue that is both deeply personal and1860profoundly consequential.1861    My name is Meaghan Mobbs, and I sit before you as the Director for1862the Center of American Safety and Security at Independent Women. I am a1863combat veteran and former Army officer, as well as a clinical1864psychologist whose research has focused on trauma, transition stress,1865and post-military reintegration. I completed my internship in the VA1866system and currently teach under the Veterans Mental Health-Primary1867Care Training Initiative through the New York State Psychiatric1868Association. That program trains physicians and hospital-based1869clinicians across New York State to identify, treat, and appropriately1870refer veterans in civilian care settings--because, too often, providers1871fail to recognize the cultural and clinical complexities that define1872military and post-military life.1873    I've been on every side of this system: as a soldier, as a1874clinician, as an educator, and as someone who has walked beside my1875fellow veterans--men and women--struggling to navigate the bureaucracy1876meant to serve them.1877    In 2018, when President Donald Trump signed the bipartisan VA1878MISSION Act, it wasn't just legislation, it was a solemn promise: that1879what happened at the Phoenix VA, where veterans died waiting for care,1880would never happen again.\1\1881---------------------------------------------------------------------------1882    \1\ Sen. Johnny Isakson. John S. McCain III, Daniel K. Akaka, and1883Samuel R. Johnson. ``VA Maintaining Internal Systems and Strengthening1884Integrated Outside Networks Act of 2018 (VA MISSION Act of 2018).''1885115th Congress, S. 2372. Introduced Feb. 5, 2018; enacted June 6, 20181886(Public Law No. 115-182). https://www.Congress.gov/bill/115th-congress/1887senate-bill/2372/.1888---------------------------------------------------------------------------1889    The VA Community Care Program was born of that promise. It was1890built on the understanding that the VA, while indispensable, is not1891omnipresent.\2\ That in too many places, at too many times, bureaucracy1892has stood where medical support should have. The Community Care Program1893was designed to bridge that gap.1894---------------------------------------------------------------------------1895    \2\ Department of Veterans Affairs. ``VA Makes It Easier for1896Veterans to Use Community Care.'' Wilmington VA Medical Center, May 19,18972025.https://www.va.gov/wilmington-health-care/news-releases/va-makes-1898it-easier-for-veterans-to-use-comm unity-care/.1899---------------------------------------------------------------------------1900    It was a direct response to bureaucratic failure, not a detour1901around it. It put the focus where it belongs: on outcomes, not process;1902on veterans, not institutions.1903    The VA Community Care Program is not just helpful, it is essential.1904It is a critical tool that helps us uphold our moral and national1905obligation to veterans.1906    But that promise has not been fully realized.19071908The Reality We Face19091910    In 2001, as America entered the Global War on Terror, the VA1911Hospital Administration received $20.9 billion in funding.\3\ That same1912year, we lost 16.5 veterans a day to suicide.1913---------------------------------------------------------------------------1914    \3\ Department of Veterans Affairs. ``Administration Seeks Record1915VA Budget Increase.'' VA News, Feb. 7, 2000. https://news.va.gov/press-1916room/administration-seeks-record-va-budget-increase/.1917---------------------------------------------------------------------------1918    In 2024, after nearly two decades of war and massive Federal1919investment, the VA now receives $121 billion, a 479 percent increase.1920    And yet, at the end of last year, the VA reported the suicide rate1921at 17.6 veterans a day.\4\ Of note, this figure is from 2022, as there1922is a significant data lag in veteran suicide statistics reporting.1923---------------------------------------------------------------------------1924    \4\ Department of Veterans Affairs. ``VA Releases 2024 National1925Veteran Suicide Prevention Annual Report.'' VA News, Dec. 19, 2024.1926https://news.va.gov/137221/va-2024-suicide-prevention-annual-report/.1927---------------------------------------------------------------------------1928    But these figures are more than just numbers. They serve as a stark1929reminder that money alone doesn't solve structural failure. It is1930increasingly apparent, we do not have a funding problem; we have a1931function problem. It is a system-design problem and a failure to adapt,1932to decentralize, and to meet veterans where they are.1933    It is a system that, despite its scale and sincerity, continues to1934force veterans to wait weeks or drive hours for care that should be1935available promptly and locally. And it's a system where decisions about1936who gets timely treatment are too often made by bureaucrats with a1937budget, not doctors with a diagnosis.1938    The Community Care Program was created to address that failure. It1939offers veterans an alternative path to care when the VA cannot meet1940their needs in a timely or appropriate manner. It is the answer to wait1941lists, distance barriers, specialty gaps, and overwhelmed facilities.1942    Today, roughly 40 percent of VA health care is delivered through1943community care.\5\ Veterans are using it. They're satisfied with it.1944It's mostly working.1945---------------------------------------------------------------------------1946    \5\ Petra Rasmussen and Carrie M Farmer.. ``The Promise and1947Challenges of VA Community Care: Veterans' Issues in Focus.'' Rand1948Health Quarterly, Jun. 16, 2023, Vol 10(3):9. https://1949pmc.ncbi.nlm.nih.gov/articles/PMC10273892/.1950---------------------------------------------------------------------------1951    Community providers have stepped up, filling critical gaps in1952mental health, oncology, pain management, women's health, and substance1953use treatment. And in rural areas, especially, where VA facilities may1954be hours away, community care has become a lifeline.1955    But instead of expanding access, some VA administrators have worked1956to restrict it, undermining the law, the intent of the MISSION Act, and1957the trust of the veterans they serve..1958    Let me be specific. Last year at the Portland VA, a senior official1959admitted to oversight staff that they were deliberately trying to keep1960care ``in-house,'' even when referrals were warranted.\6\ In Buffalo, a1961veteran with cancer saw his radiation therapy referrals delayed, then1962canceled.\7\ He died in pain. That is not a system error. That is1963systemic negligence.1964---------------------------------------------------------------------------1965    \6\ Oregon Public Broadcasting. ``Wyden: Roseburg VA Officials1966Admitted To `Inappropriate Admissions' System.'' OPB News, Jun. 24,19672025.https://www.opb.org/news/article/roseburg-va-admissions-system-1968ron-wyden/1969    \7\  Office of Healthcare Inspection. ``Leaders Failed to Address1970Community Care Consult Delays Despite Staff's Advocacy Efforts at1971VA...'' Department of Veterans Affairs Office of Inspector General,1972Audit Report No. 23-03679-262. Sept. 27, 2024.https://www.vaoig.gov/1973sites/default/files/reports/2024-09/vaoig-23-03679-262.pdf1974---------------------------------------------------------------------------1975    While VA has taken steps to improve the Veterans Community Care1976Program, key gaps in timeliness, oversight, and care coordination1977remain.1978    If we are serious about honoring the promise made to every man and1979woman who has served, we must get this right. And that begins with1980clarity of mission, guided by four principles: flexibility,1981accessibility, rapidity, and accountability.19821983Flexibility: Real Choice, Not Red Tape19841985    Veterans do not live neatly within institutional boundaries. They1986live in rural towns, sprawling suburbs, and city centers. They manage1987jobs, raise families, and carry injuries--both visible and invisible.1988And they deserve a care system that reflects that complexity.1989    The Community Care Program allows them to seek care outside the VA1990when it is too far, too slow, or lacks the necessary capability. This1991is particularly critical for specialized services--such as orthopedics,1992trauma therapy, neurology, reproductive health, and substance use1993treatment.1994    The system must respond to the reality of the modern veteran, a1995population that is younger, more diverse, geographically dispersed, and1996managing complex civilian and military transitions. When a VA system1997goes 2 years without a full-time gynecologist, as was documented in a19982020 Inspector General report, that's not a scheduling issue; it's a1999failure of access and management.\8\ And with 70 percent of women2000veterans preferring female providers for women-specific care, and 502001percent even for general care, flexibility becomes a clinical2002imperative.\9\2003---------------------------------------------------------------------------2004    \8\ Office of Healthcare Inspections. ``Comprehensive Healthcare2005Inspection of the Alaska VA Healthcare System, Anchorage, Alaska.''2006Department of Veterans Affairs Office of Inspector General, Audit2007Report No. 19-06378-73, Jan. 23, 2020.https://www.vaoig.gov/sites/2008default/files/reports/2020-01/VAOIG-19-06378-73.pdf.2009    \9\ Kate L. Sheahan, Karen M. Golstein, Elizabeth M. Yano, et. al.2010``Women Veterans' Healthcare Needs, Utilization, and Preferences in2011Veterans Affairs Primary Care Settings.'' Journal of General Internal2012Medicine, Aug. 30, 2022, Vol. 37(Suppl 3):791-798.https://2013link.springer.com/article/10.1007/s11606-022-07585-320142015---------------------------------------------------------------------------2016Accessibility: Geography Should Not Determine Health Outcomes20172018    Let's be blunt: If a veteran has to drive 3 hours each way to get2019care, that's not access, that's denial of care.2020    Only 55 percent of veterans live within 40 miles of a VA medical2021center. Just 26 percent live near a facility with full specialty2022care.\10\ These numbers are even more dismal for veterans in rural2023communities, many of whom are older, sicker, and less mobile.2024---------------------------------------------------------------------------2025    \10\ Petra Rasmussen and Carrie M Farmer.. ``The Promise and2026Challenges of VA Community Care: Veterans' Issues in Focus.'' Rand2027Health Quarterly, Jun. 16, 2023, Vol 10(3):9. https://2028pmc.ncbi.nlm.nih.gov/articles/PMC10273892/.2029---------------------------------------------------------------------------2030    Community Care helps correct that. It allows veterans to seek2031treatment locally, reducing both the physical and financial burden of2032long-distance travel. That doesn't just improve health outcomes. It2033improves trust, adherence, and it keeps veterans engaged.2034    And with the veteran population shifting rapidly--2.2 million women2035veterans expected by 2025, nearly 18 percent of the total veteran2036population by 2040, and 43 percent of women VA users in 2020 from2037racial or ethnic minority backgrounds--it's no longer acceptable to2038offer a model built for the demographics of 50 years ago.\11\2039---------------------------------------------------------------------------2040    \11\  U.S. Department of Veterans Affairs, Office of Women's2041Health. ``Facts and Statistics.'' Women Veterans Health Care, accessed2042Jul. 10, 2025.https://www.womenshealth.va.gov/materials-and-resources/2043facts-and-statistics.asp.2044---------------------------------------------------------------------------2045    Veterans deserve care where they live, not just where we've2046historically placed facilities.20472048Rapidity: Delayed Care is Denied Care20492050    In that regard, veterans don't need care eventually, they need care2051now.2052    VA outpatient satisfaction ratings reached 91.8 percent in 2024,2053that is a number to be celebrated, but it also runs the risk of masking2054regional and categorical disparities.\12\ It does not speak to the2055veteran experiencing PTSD symptoms today. It does not help the veteran2056with worsening chronic pain who's told to wait 28 days before seeing a2057specialist.2058---------------------------------------------------------------------------2059    \12\ Department of Veterans Affairs. ``Trust in VA Among Veteran2060Patients Rises to 91.8 percent, Up 6 percent Since 2018.'' Wilmington2061VA Medical Center Press Release, Apr. 17, 2024.https://www.va.gov/2062wilmington-health-care/news-releases/trust-in-va-among-veteran-2063patients-rises-to-918-up-6-since-2018/2064---------------------------------------------------------------------------2065    Under current rules, veterans are often forced to endure arbitrary2066thresholds before becoming eligible for Community Care--20-day waits2067and 60-minute drive times. These are numbers written on paper, not2068reflections of actual urgency.2069    I've worked with veterans denied certain types of mental health2070treatment or experienced significant delay in access to specialty2071mental health care. Others were turned away because they weren't sick2072enough. Still others were forced to partake in a type of therapeutic2073intervention at odds with their preferred course of treatment.2074    Many times these decisions were not meant to be negligent, but2075hyper process-oriented. Irrespective of intent, such moments are often2076perceived as administrative cruelty and institutional malaise. And it2077is costing well-being and lives.20782079Accountability: Structure Must Serve the Mission20802081    I believe in oversight. And I believe that no system--public or2082private--should operate without guardrails. But accountability should2083be about ensuring quality and responsiveness, not erecting barriers2084that keep veterans out.2085    Despite ongoing efforts to improve the Veterans Community Care2086Program, the Department of Veterans Affairs continues to fall short in2087fully addressing longstanding structural and operational deficiencies.2088    These reforms are designed to ensure veterans can more easily2089obtain the health care that best fits their needs, whether within VA2090facilities or through qualified community providers.2091    Since 2018, the Government Accountability Office (GAO) has issued209227 recommendations to strengthen the program's performance,2093particularly in the areas of appointment scheduling, wait time2094monitoring, contract oversight, and network adequacy. As of early 2025,2095only nine of these recommendations have been fully implemented.\13\2096This sluggish pace of reform has tangible consequences for veterans who2097rely on community care when timely services are not available within2098the VA system.2099---------------------------------------------------------------------------2100    \13\ Sharon M. Silas. ``Veterans Health Care: Opportunities to2101Improve Access to Care Through the Veterans Community Care Program.''2102U.S. Government Accountability Office, Feb. 12, 2025. https://2103files.gao.gov/reports/GAO-25-108101/index.html.2104---------------------------------------------------------------------------2105    A central and unresolved issue remains the lack of a clearly2106defined, enforceable standard for how quickly veterans must receive2107community care appointments. While the VA has implemented some2108mechanisms to track scheduling performance, it has not yet established2109comprehensive metrics aligned with those timeframes, leaving the system2110without meaningful accountability.2111    The VA's Referral Coordination Initiative, intended to streamline2112specialty care referrals, has likewise suffered from inconsistent2113implementation, unclear guidance, and inadequate performance metrics.2114These shortcomings create variability in veteran experience and2115undermine trust in the VA's ability to deliver timely, coordinated care2116across its network.2117    Equally concerning is the state of contract oversight and provider2118network adequacy. Although the VA has taken steps to improve data2119systems and oversight processes, critical vulnerabilities remain. The2120current methodology for assessing whether provider networks are2121adequate, particularly in the realm of specialty and mental health2122care, risks obscuring the extent to which veterans have real access to2123services. Without reforms to oversight processes and more accurate2124measurement tools, the VA risks misallocating resources and failing to2125ensure that community networks meet veterans' needs.2126    Finally, as the use of community care continues to grow, especially2127in behavioral health, the VA must prioritize seamless coordination2128between VA facilities and outside providers. Preliminary findings show2129that the majority of veterans who seek mental health services in the2130community continue to rely on the VA for ongoing care. This underscores2131the urgent need for standardized, reliable systems to ensure timely2132medical documentation exchange and continuity of treatment.2133    In light of all of these critical issues, I want to commend2134Secretary Collins on his recent announcement that the VA will expedite2135the implementation of the Senator Elizabeth Dole 21st Century Veterans2136Healthcare and Benefits Improvement Act--enacted earlier this year--2137which addresses some of these concerns and includes critical provisions2138to expand and streamline veterans' access to the Community Care2139program.2140    Because let's be clear: It is not enough to offer a door, we must2141ensure that the door is open, functional, and leads somewhere worth2142going.21432144Conclusion21452146    I completed my training in the VA system. I've referred patients2147there. I believe deeply in the VA and the essential mission it fulfills2148for our veterans. But no system, no matter how well-intentioned, can2149serve every need, in every place, for every veteran.2150    That's why Community Care matters. It's not an indictment of the2151VA, it's an extension of the promise made. A veteran's health outcomes2152should not depend on geography, paperwork, or luck. They should depend2153on whether we've built a system that puts their needs first.2154    Veterans don't need more bureaucracy--they need choice, speed, and2155accountability.2156    Thank you for your time, your leadership, and your continued2157commitment to those who've served. I welcome your questions.21582159                  Prepared Statement of Amanda Newman2160[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]21612162                 Prepared Statement of Kristina Keenan21632164    Chairwoman Miller-Meeks, Ranking Member Brownley, and members of2165the subcommittee, on behalf of the men and women of the Veterans of2166Foreign Wars of the United States (VFW) and its Auxiliary, thank you2167for the opportunity to provide the VFW's and my personal remarks on2168this important topic.2169    The VFW believes the Department of Veterans Affairs (VA) community2170care program and its Community Care Network (CCN) of providers are a2171vital component of VA health care as it delivers the care and services2172that VA hospitals and community-based outpatient clinics either cannot2173or do not provide. Since no institution can be everything for2174everybody, community care providers are force multipliers, allowing VA2175to continue providing the world-class care that veterans prefer,2176deserve, and have earned, while also ensuring they have access to the2177range of services they may need throughout their lives.2178    When appropriately used, community care can save lives and improve2179the health outcomes for countless veterans, but the problems that arise2180can drive people away from the care they have earned. We have also2181called on VA to rely on its third-party administrators to ensure2182consistent delivery of community care to eligible veterans. The VFW has2183been unequivocal that community care must be a part of VA care since2184the 2014 Phoenix crisis. It always has been. However, veterans expect2185consistency. When 23 Veterans Integrated Services Networks interpret2186the VA MISSION Act of 2018 in 23 different ways, veterans are2187overlooked, as the VA Inspector General pointed out last year in2188Buffalo, New York.21892190Background21912192    VA provided fee-based care through non-VA providers before 2014,2193under limited circumstances, to veterans residing in rural areas who2194could not access a VA facility, and for services that the local VA2195facility could not provide. Following the VA wait-time scandal in2196Phoenix, the Veterans Access, Choice, and Accountability Act of 2014,2197called the Choice Act, was passed to establish the Veterans Choice2198Program (VCP). The Choice Act enabled eligibility for community care2199for those living far from a VA facility or facing excessive wait times,2200which was overseen by third-party administrators managing provider2201networks. In 2018, VCP was replaced with the more unified and permanent2202Veterans Community Care Program (VCCP) through the passage of the VA2203MISSION Act of 2018. This change provided community care if VA services2204were not available in a timely manner, were not readily accessible,2205were in the veteran's best medical interest, or if the veteran and2206provider agreed that community care was the best option. Currently,2207VCCP eligibility is determined based on clinical need, rather than2208distance or wait time. It is coordinated through VA Care Teams, which2209include urgent care, primary care, specialty care, and mental health2210services. Third-party administrators manage community care networks,2211such as Optum Serve (East Region) and TriWest Healthcare Alliance (West2212Region).22132214Specialty Care22152216    VCCP provides a wide range of specialty care services to ensure2217that veterans can access medical care that may not be immediately2218available in VA facilities. These may include cardiology, audiology,2219otolaryngology, gastroenterology, dental and oral surgery, mental2220health and behavioral services, and women's health, among others.2221    As the number of women serving in the military has increased, so2222has the women veteran population. For these VA patients, community care2223has become essential, particularly for their gender-specific services2224like mammograms, fertility treatment, and maternity care. Veterans2225living in rural and underserved areas that are greater distances from2226VA medical facilities rely heavily on this option. Additionally,2227veterans experiencing mental health crises who require inpatient care2228may need to be referred to community care providers for specialized2229treatment. All veterans must receive timely, high-quality, and2230consistent care that meets their individual needs and preferences.22312232My Story22332234    I use VA for all my health care except dental care, which is not2235currently covered for veterans without a dental-related service-2236connected disability. The specialty care that I have received as part2237of VA's community care program includes mammograms and maternity care.2238    The care I have received through VA's community care providers has2239been high quality and has met my needs and preferences. VA coordinated2240my care during a pregnancy last year, which sadly ended in miscarriage.2241I became pregnant again this spring, and VA is again coordinating my2242maternity care in the community. In both instances when I became2243pregnant, a VA maternity care coordinator sent me a list of 27 medical2244facilities for covered maternity care within the Washington, DC. metro2245area. I was able to select both the facility and provider of my choice2246based on availability. I selected a hospital five miles from my home2247(which is 30 minutes of city driving time), and that is next to my VA2248medical center. I was pleasantly surprised to learn that I could even2249select midwifery services at my hospital of choice, which was my top2250preference for maternity care. I appreciated the exceptional compassion2251and bedside manner of my providers, especially during the difficulties2252of my first pregnancy. In both cases, VA processed my community care2253referrals in a timely manner, and I received communications both2254electronically and by phone about my health care through a maternity2255care coordinator.2256    While I have had very positive experiences with community care, I2257have also encountered several challenges along the way in how that care2258was coordinated by VA. First, for my mammogram screening, I received a2259bill for nearly $700 that VA failed to pay even though it made the2260appointment for that care. Each time I received a bill, I called the2261community care provider and gave my VA referral information. As I2262continued to receive bills and saw the threatening words in red letters2263that I could face collections if I failed to pay, I would call again2264and was always told it would be taken care of. After approximately 62265months of receiving bills and calling to try to remedy the situation,2266the bills finally stopped.2267    Second, the process to set up my initial appointments during my2268maternity care was quite confusing. It was unclear to me if VA was2269going to set up the first community care appointment or if I needed to2270call providers from the approved VA list. The first time, I was told to2271wait for VA to call me to schedule the appointment. Then, after a2272couple of weeks, I was told that I could make the appointment myself.2273Once I received the VA referral, I made an appointment with the2274approved provider, but at the same time VA made an appointment with2275that same provider though my name was misspelled. When I tried to2276cancel the VA-scheduled appointment, which was weeks later than the2277appointment I had scheduled, the CCN provider could not locate it2278because of the misspelling. When I called the VA appointment phone2279number, I was told that VA was obligated to keep the scheduled2280appointment even if I did not attend it, so there was no way for me to2281cancel or change that appointment.2282    Third, also during my maternity care, my CCN provider attempted to2283send a prescription to my VA pharmacy for me to pick up since this was2284the only way that VA would cover the cost of the medication. I asked2285for a written prescription to hand carry to the pharmacy, but my2286provider said that prescriptions could only be sent electronically. I2287walked over to the VA medical center, across the street from my2288community care facility and waited for it to be filled. Once it was2289clear that VA never received the request, I walked back to the CCN2290provider, but by then it was late in the afternoon on a Friday and2291already closed. I walked back to the VA pharmacy and was told I should2292have requested a paper prescription or had the provider send it by fax.2293None of this information was provided to me or the CCN provider, nor2294was it on my VA referral documents. Frustrated with the situation, the2295pharmacist advised me to walk to the VA women's clinic and attempt to2296speak with my primary care physician. I spoke with a nurse, and she was2297able to relay a message to my doctor. When the nurse returned, she said2298that my doctor had put in an electronic prescription request for the2299same medication at the VA pharmacy. I was grateful that the staff at my2300VA facility were there to help me before the facility closed for the2301weekend. This could have been avoided with better information sharing2302between VA and the CCN provider.2303    Fourth, during my first pregnancy, which ceased to be viable after2304the first few weeks, I received a phone call from my VA maternity care2305coordinator. She said that she had been informed that I wanted to2306terminate my pregnancy. I had the impression that she was calling to2307tell me that VA could not cover the termination. She said she thought I2308was happy to have become pregnant. The information she received was2309incredibly hurtful and completely incorrect. I informed her that my2310pregnancy was likely not viable and that I may need additional care to2311manage the miscarriage. She apologized and reassured me that my care2312would be covered. I learned later that the care I opted for did in fact2313need VA approvals. My coordinator called me again to ask why I had2314received a certain procedure related to my miscarriage that was not2315normally approved by VA. Again, she had been misinformed because I had2316not had any procedures at that point. Accurate information sharing2317between VA and community care providers is absolutely critical to2318ensure providers have all the information needed to provide high-2319quality continuity of care. The need for accuracy of medical records2320cannot be understated. Additionally, when veterans receive care within2321VA, there is never a worry about insurance or coverage because VA2322providers can be clear about what they can and cannot provide. Using2323community care exposes veterans to confusing insurance coverage and2324required approvals that can cause delays and frustration.2325    Last, during my current pregnancy, my community care provider2326indicated that I should have three genetic tests performed to rule out2327certain conditions that may affect my baby. She said that because of my2328age, these tests were critical and, depending on the results, could2329require me to take additional medications or treatments during my2330pregnancy to lower the risks of negative outcomes for my child. My VA2331referral document simply states that it covers ``Laboratory and2332pathology services to include screening and testing as clinically2333indicated and relevant...Also includes medically indicated genetic2334testing.'' Since the referral did not list any specific tests, I have2335not scheduled any yet, but contacted my VA maternity coordinator to2336inquire if they are covered. The coordinator asked me what the billing2337codes are for the recommended tests. She also sent me a list of 1732338billing codes, some of which were accompanied by the text ``Pre-2339Certification Required.'' At my next appointment 2 weeks later, I asked2340my CCN provider about the billing codes for the recommended tests. She2341said they can be found online simply by using Google. I sent my VA2342coordinator a follow-up message with the codes that I researched myself2343for the three recommended tests. Even though all three of the billing2344codes were on the VA list of approved screenings, two of them required2345pre-certification. This means that I need to wait until my next monthly2346appointment with my CCN provider so they can fill out a VA Form 10-234710172, Request for Additional Services (RFS). After several secure2348messages and a follow-up phone call with my maternity coordinator, it2349was explained to me that I would have to send these VA forms back to2350her and she would then forward them to both my VA primary care2351physician and the VA community care office for approval. If approved,2352she advised me to ensure that when I received the screenings, likely at2353a Labcorp office, I should also be sure that the tests are indeed2354covered by VA's insurance provider, Optum Serve.2355    The problem with these challenges in the coordination of my2356specialty care in the community is that it would have been easier to2357disregard the tests or pay my prescriptions out of pocket, rather than2358experience the extensive amount of bureaucracy. In these cases the2359costs have been high, so I have been extra vigilant to ensure VA will2360cover the expenses. I have had VA deny medical bills, even for urgent2361care that was coordinated by VA, so I am being particularly careful2362with potentially costly maternity care.2363    Despite the fact that I have had wonderful care in the community,2364the coordination of that care has been particularly stressful. As a2365woman veteran who cannot receive any of these services within VA2366itself, it is disappointing that I must manage these challenges at a2367time when additional stress is detrimental to my health and that of my2368baby. Issues with scheduling, pharmacy, screenings, coverage,2369information sharing, and billing need to improve before VA sends more2370veterans to community care providers.23712372Issues Reported by VFW Members23732374    Billing issues and confusing VA referrals related to community care2375have also affected veterans and VFW members nationwide. One problem is2376the lack of communication regarding the appropriate procedures veterans2377must follow when receiving care in the community, including whether a2378referral is involved, as well as who to contact for assistance.2379    Consider the case of an 88-year-old veteran in Pennsylvania who2380collapsed in a VA parking lot a few years ago. He was transported by2381ambulance to a civilian hospital for treatment. Instead of billing2382Medicare first, the civilian hospital billed VA. VA authorized and paid2383for the service, but then billed the veteran more than 2 years after2384the incident. This delayed billing occurred beyond any timeframe for2385disputing charges with either VA or the civilian facility. Despite the2386veteran having settled all debts, he continues to receive additional2387bills for this care. Upon reviewing the situation, it became clear that2388the veteran was not at fault. The initial error arose from the civilian2389facility's decision to bill VA before Medicare, and VA's subsequent2390coverage of those costs. Unfortunately, VA took several years to bill2391the veteran due to an internal processing issue. As a result, the2392veteran is being held financially responsible despite not being at2393fault. This situation is causing significant financial stress and2394creating barriers to accessing care. Further review also revealed that2395the veteran has been paying copayments that he should not have had to2396cover.2397    In a separate case in Washington, DC, veterans were approved to2398visit urgent care facilities. However, the urgent care institution2399faced difficulties processing the billing under VA authorization and2400reached out to VA for assistance, but received no response. VA2401instructed the veterans to pay out of pocket for the care, which they2402did. This situation arose from an authorization and billing issue that2403required submission for upfront VA coverage, but VA was unable to2404assist. If VA authorized the care, why was it unable to provide the2405appropriate billing codes? Veterans should not be burdened with costs2406due to VA's inability to provide accurate billing information to CCN2407providers.2408    A veteran from Virginia received a referral for CCN dental care,2409however, when the dentist determined that surgery was necessary, the2410veteran had to wait for VA approval. This required a further evaluation2411by a VA dentist to get the needed procedure approved. As a result,2412previous referrals for preventive dental care were canceled.2413    In California, veterans have experienced issues with referral2414approvals, possibly linked to TriWest Healthcare Alliance system2415problems, resulting in inconsistent care appointments. One veteran has2416had an active referral for 12 specialty service sessions scheduled2417between April 1, 2025, and September 30, 2025. Unfortunately, no2418further care was provided after the initial appointment. The veteran2419reported that VA instructed the CCN provider to hold off on care. The2420reason is unknown.2421    Several veterans received letters from both VA and their CCN2422providers stating that the CCN provider could no longer offer the2423specified care and that they would begin receiving services through VA2424instead. This change required veterans to travel excessive distances2425for appointments, sometimes multiple times a week, which significantly2426impacted their ability to work and manage other responsibilities.2427    In Texas, a veteran was referred to community care for vision care2428but was informed by the CCN provider that surgery was required. Both2429the CCN provider and the veteran notified VA, which then scheduled the2430veteran for a VA follow up to determine the next steps. The veteran is2431currently frustrated about having to wait beyond the required2432timeframes to be seen by VA, especially after being referred to CCN due2433to long wait times for his vision care.24342435Solutions24362437    VA's community care program is plagued with numerous challenges2438that require thoughtful solutions. Care in the community is necessary2439for some veterans, but if given the choice, our members routinely tell2440us they prefer VA direct care. Negative experiences with the community2441care coordination process contribute to that sentiment. We must fix2442those issues because our veterans have earned quality care regardless2443of who provides it.2444    The VFW supports H.R. 740, Veterans' ACCESS Act of 2025, as it2445represents a critical step forward in enhancing access to care for2446veterans, particularly in ensuring timely, effective, and consistent2447health care options through the CCN to streamline care, reduce2448bureaucratic obstacles, and expand access to care. Key provisions2449include codifying community care access standards based on wait times2450and driving distance, notifications regarding available services and2451provider preferences, transparency about denials of community care2452services and appeals rights, extensions for billing deadlines, and2453expedited access to mental health services.2454    The VFW appreciates the provision to improve the policies and2455processes that govern access to VA's Mental Health Residential2456Rehabilitation Treatment Program (MH RRTP) as we recognize it needs2457serious attention. We would ask that the standards for accessing these2458programs be thoughtfully considered due to their different nature.2459Priority admission standards should be developed differently than2460routine admission standards because many of these programs, whether VA-2461provided or in the CCN, are typically not local to veterans.2462    Additional legislative measures should also be considered to2463improve VA's community care program. Sharing health records and care2464integration must be addressed and improved between VA and community2465care providers. We urge the committee to prioritize not only the2466improvement of community care coordination but also the continuous2467support and enhancement of VA direct care services. This approach will2468help prevent over reliance on the community care system and ensure that2469veterans receive the comprehensive care they rightfully deserve. We owe2470it to our veterans to ensure that their access to care is not hindered2471by bureaucracy or geographical limitations. Expanding and integrating2472community care options is not just a policy choice; it is a moral2473obligation to those who have served.2474    Chairwoman Miller-Meeks, Ranking Member Brownley, this concludes my2475testimony. I welcome any questions from you or members of the2476subcommittee.2477Information Required by Rule XI2(g)(4) of the House of Representatives24782479Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW has2480not received any Federal grants in Fiscal Year 2025, nor has it2481received any Federal grants in the two previous Fiscal Years.24822483The VFW has not received payments or contracts from any foreign2484governments in the current year or preceding two calendar years.24852486                 Prepared Statement of Kyleanne Hunter2487[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]24882489                        Statement for the Record24902491                              ----------24922493              Prepared Statement of Cohen Veterans Network24942495    As the committee examines the best ways to ensure our Nation's2496veterans have access to the highest quality care, particularly as it2497relates to mental health, I wanted to provide some background for you2498on how Cohen Veterans Network (CVN) is working with the Department of2499Veterans Affairs (VA) to provide mental health services to Veterans and2500their families. Our clinics strive to be the ``right time, right place,2501right treatment'' model for community care that the committee seeks to2502strengthen for veterans and their families.2503    CVN is a not-for-profit philanthropic organization founded in 20162504that serves veterans, service members, and military families through a2505nationwide system of mental health clinics. CVN operates 22 clinics2506that provide care across 20 states, including telehealth services. Our2507clinics provide treatment for depression, anxiety, adjustment issues,2508substance misuse, anger, PTSD, grief and loss, family issues,2509transition challenges, sleep problems, relationship problems, and2510children's behavioral problems. We also provide comprehensive case2511management services to address social drivers of health issues,2512including unemployment, food insecurity, finances, housing, and more.2513    While the VA has invested heavily in expanding mental health2514services, significant challenges remain in the Community Care program2515and the suicide epidemic persists. Veterans often face long delays,2516limited local access, and administrative hurdles that discourage them2517from pursuing care when they need it most. CVN helps relieve this2518pressure by serving the whole family (as defined by the veteran or2519service member) and providing barrier-free, high-quality outpatient2520treatment in trusted community settings. CVN does not turn veterans2521away based on discharge status or insurance.2522    Since its inception in 2016, CVN has served nearly 90,000 clients2523in almost 800,000 clinical sessions and provided more than 440,0002524telehealth sessions. More than 56 percent of the clients served have2525been veterans and service members. Approximately 29 percent have been2526non-veteran adult family members and 15 percent of family members were2527children. 31 percent of our veteran clients to date are female2528veterans.2529    Over the past decade, the demand for high-quality, accessible2530mental health care for veteran and military families has only grown.2531Through public-private partnerships, CVN has worked to fill gaps where2532and when they exist. Our care model is focused on being military2533culturally competent and is based on both data analytics and2534operational research.2535    Our clinicians are trained in evidence-based practices and deliver2536measurable outcomes. As part of our mission to continually improve and2537enhance care, we track satisfaction and clinical improvement across all2538clinics. According to our metrics, over 90 percent of our clients would2539recommend CVN services to others.2540    CVN is proud to complement the VA's mission and extend its reach in2541the community. To strengthen and scale this kind of work, we support2542pending legislation like the RECOVER Act (H.R. 2283), which would2543establish a pilot grant program to support non-profit clinics2544delivering culturally competent, evidence-based mental health care at2545no cost to the veteran. By encouraging public-private partnerships, the2546RECOVER Act can help close access gaps, especially in underserved2547areas, and provide a lifeline to family members who are too often left2548out of the traditional VA system.2549    A recent study entitled Experiences With VA-Purchased Community2550Care for US Veterans With Mental Health Conditions (JAMA Network Open,255121 May 25) observed, ``These findings underscore the challenges2552vulnerable veterans experience when navigating and receiving community2553care and highlight an opportunity for targeted quality and care2554coordination strategies. (p.9). CVN strongly agrees.2555    Community care for veterans is a critical resource and mechanism2556for filling gaps in care and improving access. To fully address the2557need, the VA and Community Care must continue to function as2558complementary elements with each providing vital resources which2559jointly offer improved access and options for veterans while2560maintaining an appropriate standard of care.2561    CVN stands ready to continue supporting these efforts and pledges2562to work with the committee and administration to help veteran and2563military families. Thank you for your leadership and for advancing2564solutions that meet the full scope of veterans' mental health needs,2565including their families.25662567                                 [all]