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“Correcting Mismanagement of the Veterans Crisis Line”

Senate Veterans Affairs Committee Hearing

June 25, 2025 (recording here)

HEARING INFORMATION

Witnesses (linked) (Panel One):

• Brad Combs: Former Lead Auditor, Veterans Crisis Line, Veterans Health Administration, U.S. Department of Veterans Affairs

• Marcia Blane: Former Responder, Veterans Crisis Line, Veterans Health Administration, U.S. Department of Veterans Affairs

Witnesses & Written Testimony (linked) (Panel Two):

• Alyssa Hundrup: Director, Health Care Team, U.S. Government Accountability Office

• Dr. Thomas O’Toole: Deputy Assistant Undersecretary for Health for Clinical Services, Veterans Health Administration, U.S. Department of Veterans Affairs

• Dr. Christopher Watson: Executive Director, Veterans Crisis Line, Veterans Health Administration

Keywords mentioned:

• Whistleblower protections, veteran suicide, complex needs callers, quality assurance, digital services, responder training, leadership culture, workload challenges, disclosure procedures, VA reform, oversight recommendations

IN THEIR WORDS

OPENING STATEMENTS FROM THE COMMITTEE

• Ranking Member Richard Blumenthal mentioned the bipartisan origins of the Veterans Crisis Line (VCL), referencing cooperation between the late Senator John McCain and President Barack Obama. He criticized the Trump administration and VA Secretary Collins for undermining oversight mechanisms, including firing VA Inspector General (IG) Mike Missal and attacking the Government Accountability Office (GAO). Ranking Member Blumenthal condemned the administration's plans to terminate 83,000 VA employees, including many veterans, which he said had already caused distress and triggered calls to the VCL. He argued that the mismanagement and political interference at the VA had harmed the VCL's effectiveness, morale, and ability to serve veterans in crisis.

• Chairman Jerry Moran expressed gratitude to IG Missal for his contributions and acknowledged the importance of whistleblower input in improving veterans' services. He introduced the witnesses for the first panel and reaffirmed the Committee’s commitment to understanding and addressing the issues raised by the witnesses.

SUMMARY OF KEY POINTS (PANEL ONE)

• Mr. Brad Combs, a former lead internal auditor at the VCL, testified that he came forward because he believed the Committee had been misled. He identified four areas of serious concern: the handling of callers with complex needs, poor quality assurance standards, mismanagement of electronic media interactions, and the failure to disclose sentinel events. He described systemic failures in leadership, including known issues being ignored for years and retaliatory actions against whistleblowers. Mr. Combs asserted that VCL leadership remained in positions of influence despite repeated failures and that true reform would not occur until they were removed.

• Ms. Marcia Blane, a retired VCL responder and licensed mental health professional, described the devaluation of employees’ clinical expertise despite the life-saving nature of their work. She testified about persistent exposure to racially and sexually abusive callers and the lack of support or protocols from leadership to address it. Ms. Blane criticized the undermining of DEI efforts, the mishandling of callers with complex needs, and the harmful assumption that remote workers were not contributing. She underlined that VCL responders are highly skilled professionals who need better leadership, workplace protections, and investment to continue preventing veteran suicides.

• Chairman Moran asked Mr. Combs to describe the interaction that led to the September 2023 Office of the Inspector General (OIG) report. Mr. Combs explained that a veteran was actively attempting suicide and contacted the VCL via text, but the responder missed multiple cues indicating the severity of the crisis. The responder falsely reported that the call ended normally, and the veteran died 10 minutes later in his garage, just feet from his family.

• Chairman Moran asked whether a root cause analysis was conducted after the veteran’s death. Mr. Combs responded that no analysis was performed in 2021 because there was little concern at the time and no transcript. When the IG announced an investigation, leadership became concerned, but the executive director initially declined to perform a root cause analysis. One was not initiated until 2022, and even then, only superficially.

• Chairman Moran questioned the lack of response to this tragedy. Mr. Combs stated that the issue stemmed from a culture of permissiveness created by the executive director of the Suicide Prevention Program and supported by an out-of-touch management team outside the call centers. He claimed that frontline responders were dedicated, but management prioritized metrics over lives.

• The Chairman asked Ms. Blane to describe the leadership at the VCL. Ms. Blane testified that leadership lacked experience and understanding of federal protocols or union contracts. She described a culture where promotions were based on favoritism, not qualifications, and where her offers to train inexperienced managers were rejected. She said that poor leadership trickled down, harming responder effectiveness.

• Chairman Moran asked whether the individuals responsible for the issues raised were still employed at the VA. Ms. Blane replied that several of them were still employed, although some had left. The Chairman then asked whether employees who testified before Congress would be honored or punished. Ms. Blane believed that such employees would more likely be punished, citing an atmosphere of silence and fear of retaliation.

• Sen. Maggie Hassan asked what policy changes were most needed to support callers with complex needs and protect VCL responders. Mr. Combs said that a specialized team had been created in 2017 to support these callers and train responders, but that team was later dismantled, and key personnel left in protest. He stated that reconstituting such a team would be an essential first step.

• Sen. Hassan asked about the risks of requiring responders to handle multiple chats or texts simultaneously. Mr. Combs replied that it diverted attention dangerously, especially when someone was at acute risk. Ms. Blane added that responders were routinely assigned two or more digital interactions at once, leading to dangerous gaps in attention and an increased risk of missing critical cues. She advocated for individualized chat handling to reduce burnout and prevent mistakes.

• Sen. Hassan asked why children were contacting the VCL. Ms. Blane said that anytime entertainers mentioned 988, there was a spike in texts from young people, especially during school breaks. Most were not children of veterans but reached out due to boredom or anxiety, further taxing the system.

• Sen. Hassan asked how feedback and quality assurance could be improved at the VCL. Mr. Combs said that leadership needed to change and that strong congressional and IG oversight was essential to cultural reform. He stressed that the call center staff were not the issue—management was. Ms. Blane agreed, adding that the shift from service to productivity metrics harmed quality. She emphasized that applying a production model to human services was ineffective and dehumanizing.

• Sen. Angus King asked Ms. Blane to describe the productivity metrics imposed on responders. Ms. Blane shared that responders were monitored for call duration and often received distracting messages pressuring them to end calls. She explained that metrics were introduced by a new manager in 2018 with a traditional call center background, which clashed with the mission of the VCL.

• Sen. King asked how agency-level disorganization affected morale. Ms. Blane said that uncertainty around firings and reorganization deeply affected staff focus and mental health. She described vicarious trauma, economic anxiety, and peer-led informal support systems that emerged in response to overwhelming chaos.

• Sen. King asked about common call topics. Ms. Blane stated that they included military sexual trauma, combat-related PTSD, marital issues, homelessness, and feelings of being forgotten. She added that responders also acted as de facto marriage counselors and mental health navigators.

• Sen. King inquired whether responders were allowed to refer callers directly to other VA services. Ms. Blane said the formal protocol required blind transfers, but she often bypassed this to ensure elderly or distressed veterans received real help. She criticized rigid Standard Operating Procedures (SOPs) and called for a more humane, one-stop approach.

• Sen. Jim Banks asked whether the criticism that VCL management “sweeps problems under the rug” was accurate. Mr. Combs confirmed, saying leadership routinely ignored issues and resisted corrective action, even when problems violated policy or statute.

• Sen. Banks asked what was needed to make the VCL more effective. Mr. Combs replied that the problem was leadership, not resources. He explained that decisions about staffing and technology were made poorly by leadership focused on outdated models and resistant to change.

• Sen. Banks asked how responders ended up juggling multiple chats. Mr. Combs said that it was due to outdated staffing models and leadership choices. Ms. Blane added that understaffing, limited training, and flawed technology contributed, and said current responders were still being assigned multiple chats.

• Sen. Banks asked whether the lack of progress despite budget increases pointed to leadership failure. Ms. Blane agreed, citing inexperienced hires, lack of abuse training, generational stress differences, and a failure to evolve. She claimed that resistance to confronting abuse and change had caused burnout and a damaging revolving door at the VCL.

• Sen. Tammy Duckworth asked Mr. Combs whether trained responders were the only employees answering the phones at the VCL during his tenure. Mr. Combs clarified that while trained responders typically answered calls, during high-demand overtime periods, other VCL employees who had previously completed responder training were brought in to help. These individuals had been responders before but had moved into different roles within the VCL.

• Sen. Duckworth asked whether those non-responders received updated training before being allowed to answer calls again. Mr. Combs responded that the OIG’s 2023 report indicated this practice ended in February 2022, after a serious incident. After that point, only full-time responders or designated operations staff were permitted to answer veteran calls.

• Sen. Duckworth asked Ms. Blane to confirm whether, as of May 2025, only responders were answering the phones. Ms. Blane confirmed that as of May 2025, only responders were handling phone calls on the VCL.

• Sen. Duckworth then asked Ms. Blane to elaborate on the delays caused by wrongful terminations and what guidance responders received to mitigate those delays. Ms. Blane said that communication from leadership was minimal and inconsistent. Responders were told little beyond that operations were continuing as usual, despite the internal disruption. She criticized the lack of trust in supervisors and called it a failure of leadership, adding that leaders should lead, not simply manage, without empowering others.

• Ranking Member Blumenthal praised Ms. Blane’s professionalism and experience and asked her to elaborate on why terminating Social Science Assistants (SSAs) was harmful to VCL operations. Ms. Blane compared SSAs to 911 operators, describing them as critical to locating veterans in crisis. Their work allowed responders to focus on the caller while the SSAs gathered vital information and coordinated emergency interventions. She claimed that their termination left both responders and veterans vulnerable, reducing the ability to effectively manage high-risk situations.

• The Ranking Member asked Ms. Blane to explain her statement that VCL professionals were encouraged to "dim their lights and just answer the call." Ms. Blane explained that in 2018, a clinical operations manager introduced a production-based mindset that prioritized call volume over human connection. Staff were told to conform or leave, and this undermined the clinical and life-saving nature of their work. She argued that trying to run a crisis line like a commercial call center was fundamentally flawed and dehumanizing.

• Ranking Member Blumenthal agreed and illustrated the difference between returning a product and saving a life. He then asked whether, between January and May 2025, employees felt more or less confident in reporting waste, fraud, or abuse without fear of retaliation. Ms. Blane said that staff were less likely to report wrongdoing due to fear of firings, especially after the 2024 election. The threat of retaliation created a chilling effect on whistleblowing, and this was reflected in persistently low employee survey participation.

• Chairman Moran asked Mr. Combs whether whistleblower protections at the VA were functioning. Mr. Combs shared that just before he left, the deputy director’s wife was hired by the deputy’s direct report, which he reported. However, the Office of Accountability and Whistleblower Protection (OAWP) ruled that nepotism had not occurred, despite clear evidence. He concluded that the OAWP could not be trusted and that whistleblower protections within the VA were ineffective.

• Chairman Moran acknowledged the disappointing nature of that answer but thanked Mr. Combs for his honesty. He then asked both witnesses whether there was anything they wanted to say that had not been covered. Ms. Blane said that the questions had provided a good insight into the VCL from the responders’ perspective and thanked the Committee. Mr. Combs also expressed gratitude to the Chairman and to staffers for protecting the whistleblowers’ identities and listening throughout the two-year process.

SUMMARY OF KEY POINTS (PANEL TWO)

• Ms. Alyssa Hundrup testified that the GAO’s newly released report identified multiple concerns with how the VA manages the VCL, especially given the line's increased usage and critical role in suicide prevention. She stated that a procedural change in the complex needs unit led to untrained responders handling more difficult calls, raising risks to service quality and staff burnout. She also noted that responders managing texts and chats were required to document interactions in real-time, unlike call responders, creating safety and workload issues that have not yet been fully assessed. Additionally, Ms. Hundrup reported that the VCL currently lacks a procedure for disclosing serious incidents to veterans or their families, and recommended that the VA establish one. The VA agreed to implement these recommendations by early 2026.

• Dr. Thomas O’Toole acknowledged the growing demand for the VCL and highlighted that it is uniquely integrated into the VA healthcare system, allowing for crisis intervention and follow-up care. He said that the VA has implemented 12 of 14 OIG recommendations from the September 2023 report and is working to close the remaining two by the end of FY 2025. Dr. O'Toole described several recent reforms, including expanded training, standardized call escalation procedures, assessments of complex needs calls, and improvements in digital service documentation and chat management. He underscored that the VA is convening a multi-disciplinary work group to finalize a standardized disclosure process and reaffirmed the agency’s commitment to transparency, accountability, and continuous improvement.

• Chairman Moran asked Dr. O'Toole whether he disputed the culture described by the first panel at the VCL. Dr. O'Toole said that he was deeply disturbed by what he heard and found it unacceptable. He thanked the whistleblowers for their courage and affirmed that the VA must hold itself accountable. He confirmed that he had no reason to dispute the testimony and looked forward to addressing the issues.

• Chairman Moran asked why it took a GAO or OIG report to prompt action instead of the VA taking internal steps to fix systemic problems. Dr. O'Toole acknowledged that the VA had not always lived up to its standards and that he could not speak for prior leadership, but he reiterated the current commitment to making improvements.

• The Chairman asked how such issues could persist for so long without intervention. Dr. Christopher Watson stated that he had only been in his VCL role since April 2024 and could not speak to past leadership decisions, although he had been with the VA since 1993.

• Chairman Moran commented that this pattern of mismanagement extended beyond the VCL and asked why the VA struggled with addressing wrongdoing. Dr. O'Toole said that VCL work was among the most emotionally taxing jobs in the VA and agreed that the VA needed to better support its employees.

• Chairman Moran then asked why it was so difficult to fire employees responsible for misconduct. Dr. O'Toole explained that the VA was required to follow due process when investigating and disciplining employees, which could delay removals. He stated that in some cases, employees were reassigned during investigations to protect veterans, and that 18 individuals had been investigated in this matter.

• Ranking Member Blumenthal expressed concern about responders handling multiple interactions at once. Ms. Hundrup explained that responders were sometimes required to manage two or even three concurrent chats or texts while simultaneously documenting them. She emphasized that these overlapping responsibilities, along with outdated staffing models, contributed to burnout and safety risks.

• Ranking Member Blumenthal asked whether responders were expected to handle phone calls and chats simultaneously. Ms. Hundrup clarified that responders typically worked one modality per shift—phone, chat, or text—but might be reassigned based on demand. However, even in those roles, they could still be handling multiple chats or texts at once.

• The Ranking Member asked about the use of productivity standards and time limits for calls. Dr. Watson acknowledged that the VCL tried to balance efficiency with quality care. He confirmed that there were productivity targets in place but said they were under review following GAO recommendations.

• Sen. King asked for the VCL budget request for FY 2026 and how it compares to FY 2025. Dr. O'Toole reported that the request for FY 2026 was approximately $312 million, up slightly from $306 million in FY 2025. When asked whether the documents had been submitted to Congress, he said he was unsure and would follow up.

• Sen. King noted that the Committee had received reports of major increases in VCL contact volume since the start of the year. Dr. Watson confirmed that the VCL had seen an appreciable increase in calls, chats, and texts. He said some of the increase came from repeat contacts, including from callers in the Complex Needs Unit, but also acknowledged that greater awareness and possibly broader mental health challenges contributed to the rise.

• Sen. King suggested that increased anxiety and fear—such as fear of job loss among VA employees—could be contributing to the uptick. Dr. Watson agreed that was possible.

• Sen. King returned to the issue of funding and mentioned that a $6 million increase in the budget was minimal given the reported 80% increase in texting volume over four years. Dr. O'Toole agreed that further analysis was needed and said they would examine the relationship between demand and resources. Dr. Watson added that the VCL received between 80,000 and 90,000 calls per month but did not have comparative data on hand for the previous year.

• Ranking Member Blumenthal supported Sen. King’s concerns and asked whether it was reasonable to conclude that current resources were inadequate. Dr. O'Toole agreed that it was a reasonable hypothesis and said the VA would follow up with more precise data.

• Sen. King asked that VCL staff be thanked for their hard work and dedication, acknowledging how difficult and mission-driven their job is. Dr. Watson and Dr. O'Toole expressed appreciation and agreed to convey those sentiments.

• Ranking Member Blumenthal also asked Dr. O'Toole to follow up on the number of SSAs currently employed, given their essential role in locating at-risk veterans. Dr. O'Toole did not have the numbers on hand but would provide them. He also noted that 187 new crisis responders had been added this fiscal year.

• The Ranking Member asked if the VA had policies to prevent discrimination against LGBTQ+ veterans and young people. Dr. O'Toole said that he was unaware of any discrimination and stated that such behavior would be illegal. Dr. Watson affirmed that VA policy prohibits discrimination.

• Ranking Member Blumenthal asked whether whistleblower protections were in place. Dr. O'Toole confirmed that they were and said that the VA took retaliation seriously, encouraging reporting and promising to investigate and respond to any violations.

• Sen. Mazie Hirono asked whether a veteran in Hawaii being directed to the VCL after losing access to a VA mental health provider was a one-off mistake or part of a broader practice. Dr. O'Toole said that should not be happening and hoped it was an isolated incident. He stated that the veteran should have been assigned a new provider within the VA or referred to community care and offered to follow up. Dr. Watson agreed, stating the VCL is intended for veterans in crisis—not for routine mental health care—and affirmed that such ongoing treatment should take place at a facility or through community referral.

• Sen. Hirono asked who the veteran should have contacted to get a new provider. Dr. O'Toole responded that the VA should have proactively ensured continuity of care without the veteran needing to initiate it and reiterated the VA’s willingness to follow up directly to correct the issue.

• Sen. Hirono then asked whether the VCL had seen spikes in contact volume following disruptive administrative actions like proposed mass firings. Dr. Watson confirmed that the VCL had observed increases in outreach, though not all veterans disclosed the reasons for their distress. He said the VA tracked the data and monitored these patterns closely.

• Sen. Hirono asked how many people were currently staffing the VCL across the country. Dr. Watson stated that the VCL currently employed 2,049 staff, including approximately 1,500 crisis responders. He said that the workforce grew significantly after the 988 press-one initiative was implemented in July 2022. Dr. Watson estimated that staffing increased by nearly 1,000 employees at that time but said he would follow up with exact figures, as the change occurred before his tenure began in April 2024.

• Sen. Hirono asked whether the VCL is often a veteran’s first point of contact with VA services. Dr. Watson said yes, that is the hope, given the VCL's integration with broader VA services and its visibility through the 988 system.

• Sen. Hirono then asked about the training VCL staff receive to prepare for high-stakes crisis situations. Dr. Watson reported that staff undergo extensive training, including formal instruction, review processes, and a precepting program before they are allowed to answer calls. Sen. Hirono asked for a written description of the VCL training curriculum and the center’s staff retention rates.

• Chairman Moran closed the hearing by thanking the witnesses and acknowledging that his criticisms were aimed at leadership, not frontline staff. He asked the witnesses to convey the Committee’s deep appreciation to VCL and VA employees for their service during a challenging time. He also emphasized that most senators shared this sentiment and expressed concern about the impacts of budget cuts and staff reductions.

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