Ask Veterans Affairs Secretary David Shulkin what his biggest challenge is and his answer might not be immediately obvious.

It’s not improving wait times at VA medical centers across the country.

It’s not closing, disposing or selling more than 1,100 vacant, underused or outdated facilities.

It’s not finding a permanent fix for the Veterans Choice Program, which is running on emergency funding from Congress and may run out earlier than anticipated.

It’s hiring.

“It’s the single most challenging thing that I know of in VA,” Shulkin told the Senate Veterans Affairs Committee during a hearing on veterans suicide prevention Wednesday. “It shouldn’t be that hard to get people on board.”

Without the proper staff of medical and mental health professionals, experts who study veterans suicide say VA will never be able to reverse a series of startling statistics on veterans suicide.

According to the department’s most recent study on the topic, 20 veterans a day died by suicide in 2014. Six of those 20 veterans used Veterans Health Administration services, but 14 of them did not.

And in 2014, male veterans who used VHA services were 22 percent more likely to die by suicide than male veterans who did not use the VA.

Yet the suicide rate among veterans who did not use VHA services increased by 39 percent between 2001 and 2014. The suicide rate for veterans who did use the VA increased by 9 percent during the same time, according to the department.

Eliminating veterans suicide is Shulkin’s top clinical priority for the department. New treatment, education, outreach and research are all part of VA’s suicide prevention plan.

“We know from research that VA care saves lives, and we know that treatment works,” Shulkin said. “This is a matter of getting more people treated. What we’re trying to do is more aggressively than ever before outreach to veterans that aren’t getting access to care. But we can’t help those that we can’t see.”

Simply adding more staff won’t solve all of VA’s challenges. But the issue comes up time and again for the department, and Shulkin says a lengthy and complicated hiring process impedes nearly all of VA’s top priorities, including suicide prevention.

VA wants to hire 1,000 new mental health professionals by the end of 2017. But the department is struggling to meet that goal. It’s hired 649 mental health professionals since January, but Shulkin said those new employees have only filled previous vacancies.

“We are not succeeding at that 1,000 net new professionals,” he said.

Shulkin has spoken often of the 49,000 vacancies the department has yet to fill. The Veterans Health Administration alone has 45,000 clinical vacancies, and 1,500 of them were mental health positions as of May.

Direct hire authority for all critical health positions would help, Shulkin said.

Congress gave the department direct hire authority for medical center directors when it passed the VA Accountability and Whistleblower Protection Act in June. But the law only gives VA hiring flexibilities for medical center leaders, not other health professionals.

“That is really helpful to us,” Shulkin said of the hiring flexibility. “It allows us to skip over a lot of the red tape. I want that authority for all of our critical health professionals. I would urge us to work together on that. It’s just too hard to get people hired into the VA.”

Congress also included significant cuts to VA’s recruitment and retention budget as a way to pay for the department’s opioid-addiction treatment programs in the Comprehensive Addiction and Recovery Act of 2016.

“That was short-sighted, quite frankly,” Shulkin said. “We need the tools that the private sector has to be able to recruit the very best health professionals. If we’re serious about tackling this, don’t tie one of my hands behind my back.”

Committee members didn’t intimate whether they planned to immediately write new legislation that would give VA the direct hire authorities and professional development budget it says it needs, but many did agree the department’s employees needed proper training, particularly on suicide prevention.

“If you’re going to make this an attractive place for professionals to come to, then you better have professional development and a retention program similar to the private sector,” Sen. Thom Tillis (R-N.C.) said. “I saw the number that the VA was spending [on training] on a per employee basis, and it was pennies on the dollar compared to what I would have spent as a partner at Pricewaterhouse.  You’re never going to get to that ratio, but we need to make sure we’re not talking out of both sides of our mouth — on the one hand saying we need to give you recruiting and retention resources and then we want to micro-manage how you go about spending it.”

Status of Choice

The discussion on veterans suicide prevention comes as VA nears a pivotal legislative deadline in the coming months.

The department received $2.1 billion in emergency funding to continue the Veterans Choice Program, which lets eligible veterans seek health care from a private-sector provider. But as the Associated Press reported, VA may need additional funding as early as December or as late as March.

“I don’t believe there’s truth to that report,” Shulkin told reporters when asked about the status of Choice funding after Wednesday’s hearing. “We were given $2.1 billion. We’re at a run rate right now of about $280 million a month. We’ve always said that it’s important that Congress is going to need to act this fall, this legislative session so that we do not get into a funding crisis.”

The department is working with congressional leaders now on language for a new Choice proposal. Shulkin said they’re aiming to have new legislation finished by Thanksgiving.

“As we’ve seen, this is a very, very hard program to do accurate financial projections,” he said. “We’ve changed our projections before. But right now I’m telling you the data as of yesterday, that we do not anticipate this running out before the end of the year.”

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