Whistleblowers and GAO describe systemic problems at Veterans Crisis Line; VA commits to changes

WASHINGTON — At a Senate Veterans' Affairs Committee oversight hearing, a whistleblower and a former Veterans Crisis Line (VCL) responder described management practices they say put veterans and responders at risk, and the Government Accountability Office released a report that found procedural and workload problems at the VCL and recommended corrective action.

Brad Combs, identified to the committee as a whistleblower and the VCL's former lead internal auditor, told senators the VCL has longstanding problems across four areas: callers with complex needs, quality assurance, electronic media management (chat and text), and failures to disclose sentinel events. "It starts from the top," Combs said, faulting leadership for fostering “a culture of permissiveness” that prioritized metrics over lives.

The hearing included testimony from Marcia Blaine, introduced as a former VCL responder and licensed professional counselor, who described pressure to prioritize throughput and said responders faced repeated abuse from some callers while the specialized team for callers with complex needs was understaffed or disbanded. "There is a staff of highly trained individuals who are often told this is not a clinical position, so don't use that skill set," Blaine said, adding that the termination of social scientist assistants increased delays and “made all of us more vulnerable to misses.”

A Government Accountability Office official, Alicia Hundrep, testified that the GAO report released the same day found customer interactions across calls, chats and texts rose nearly 40% from fiscal 2021 through 2024 — about 3.8 million interactions total — and that by 2024 the VCL responded to over 2,500 calls per day. Hundrep said GAO identified three areas of concern most relevant to safety and responder workload: the management of callers with complex needs, workload and documentation practices for digital services, and a lack of VCL procedures for disclosing its involvement in critical incidents.

The GAO report described a procedural change for the customers with complex needs unit that now redirects those callers to the main line immediately when a CWCN‑trained responder is unavailable; previously that redirection occurred after three minutes. GAO said that change reduced abandoned calls but increased the number of complex interactions taken by main‑line responders without specialized CWCN training, creating risk to callers and higher stress for staff. GAO recommended the VCL assess the risk of adverse effects from that procedure change; Hundrep said VA agreed and planned an assessment by October.

GAO also reported that text and chat responders commonly handled concurrent interactions — sometimes two at once — while documenting in real time, unlike phone responders who document after a call. GAO recommended an assessment of how the digital workload affects service quality; VA agreed and set an October timeline for that work as well.

On disclosure of critical incidents, GAO found the VCL had withdrawn a prior procedure and currently has no process for disclosing VCL involvement in incidents to customers or families. GAO said that could mean missed opportunities for accountability. VA agreed to establish a disclosure procedure and targeted January 2026 to complete the work.

Representing the Department of Veterans Affairs, Dr. Thomas O'Toole, deputy assistant undersecretary for health for clinical services, and Dr. Christopher Watson, executive director of the VCL, told the committee the department is implementing recommendations from the Office of Inspector General and the GAO. "As of June 25 of this year VA has implemented and closed 12 of the 14 OIG recommendations and we are working diligently to close the final 2 recommendations by the end of fiscal year 2025," O'Toole said. Watson apologized for the problems described by the first panel and said VA must "be holding ourselves more accountable."

Lawmakers pressed VA officials about staffing, workload and funding. GAO told the committee the VCL had "more than 1,000 crisis responders on staff" as of March of that year; VA officials later said the VCL had 2,049 employees overall and had added 187 crisis responders in the fiscal year so far. VA officials told senators the agency was seeing between 80,000 and 90,000 VCL contacts per month this fiscal year and reported managing about 787,000 contacts in fiscal 2025 through May.

Senators also asked about budget requests. VA officials gave a figure of approximately $312 million for the veterans crisis line budget request for fiscal year 2026 and characterized that as roughly a $6 million increase over the current fiscal year. Committee members urged VA leadership to ensure resources match rising demand.

Committee members repeatedly raised concerns that production‑style metrics and supervisory messages about time on call discouraged responders from spending the time needed on high‑risk contacts. "Trying to operate a production mentality for human services will never be a win," Blaine said. Senators asked VA to reassess productivity targets and to make staffing, training and oversight changes recommended by GAO and the OIG.

The committee record will remain open for five legislative days for additional questions. GAO's and the OIG's recommendations require follow‑up; VA officials said they would perform the GAO‑recommended assessments, convene a multidisciplinary group to establish disclosure procedures and continue implementing OIG recommendations.

This hearing combined firsthand allegations from former staff with GAO's audit findings and VA's initial responses; it highlighted gaps in handling high‑risk callers, the workload strains of chat and text systems, and the need for clearer disclosure and accountability processes for critical incidents. The committee confirmed it will continue oversight as VA implements the recommended changes.