Veterans' Affairs Secretary Dennis McDonough Testifies Before Senate Veterans' Affairs Committee

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Transcript

00:00:00 >>Chair Greg Musil: Okay. What the plan is here, if we get 10 of us, and you'll just

00:00:06 have to forgive me, if we get 10 senators here, we've got some leases we need to get

00:00:11 done, so if you're talking, I'm going to probably gavel you down, you can take up, we'll do

00:00:15 the business meeting, we'll get it done, so -- because these leases are very, very important,

00:00:21 and this is the way it has to be done. That being said, I want to welcome everybody

00:00:25 to today's hearing on the President's Fiscal Year 2025 Budget for the Department of Veterans

00:00:30 Affairs. Before we begin, I want -- that's why I just said this, all right. We're going

00:00:35 to be -- we are joined by the Honorable VA Secretary Dennis McDonough and the Veterans

00:00:40 Service Organization, authors of the independent budget. This year's request is $370 billion,

00:00:46 represents a 10% increase over FY '24. I look forward to discussing how this budget proposal

00:00:51 will ensure we're meeting our veterans' needs now and into the future. It is undeniably

00:00:55 a historic time for the VA and for veterans' health care and benefits. With the PAC Act

00:01:00 delivering the largest expansion of VA health care and benefits ever, and more folks coming

00:01:04 into the system, we have to ensure that the VA can deliver for those veterans timely and

00:01:10 in a way that they have earned. I know that is your primary focus, Mr. Secretary. VA's

00:01:17 recent hiring surge allowed the department to deliver an all-time record number of health

00:01:21 care appointments due in part to the PAC Act. VA needs to continue to build on this momentum

00:01:27 and continue to hire and retain quality personality, especially in critical specialties, mental

00:01:33 health, and especially in rural America. When veterans can't be seen in a timely manner

00:01:38 or they have to drive too far for services, they need to be connected up with community

00:01:43 care and quickly. In Montana, community care has played a key role in bolstering veterans'

00:01:48 access to care. Nationwide, in FY23, nearly 40% of VA's total care workload was delivered

00:01:56 in the community. But study after study shows that VA health care is as good or better to

00:02:03 what the folks are getting in the private sector. And veterans almost always like their

00:02:07 VA care more than non-veteran counterparts like in the private sector. So the VA needs

00:02:15 to maintain its capacity to deliver health care to veterans with an eye on safeguarding

00:02:19 its role in medical education, research, and acting as the nation's backstop in emergencies.

00:02:25 And it needs to right-size what health care it delivers and the health care that it buys.

00:02:30 In addition to investments in staffing, VA and Congress must continue to push for more

00:02:33 stable funding for improvements to infrastructure. At the moment, we're barely scratching the

00:02:37 surface. Without safe, modern buildings and equipment, VA's direct care system will struggle

00:02:42 to meet the ever-evolving needs of the veteran. On the benefits side of the ledger, VA needs

00:02:47 to continue to deliver veterans' quality claims decisions in a timely manner. It must also

00:02:52 ensure the Board of Veterans' Appeals is adequately funded to handle an increased workload. Passage

00:02:57 of the PAC Act makes that more important as ever. Mr. Secretary, I want to thank you for

00:03:02 being here today. I appreciate your continued leadership and dedication to our nation's

00:03:07 veterans. I also want to welcome our second panel of advocates to discuss these challenges

00:03:11 from a veteran's perspective on the ground and how this budget applies to them. With

00:03:15 that, I'm going to turn it over to Senator Moran for any opening comments he would like

00:03:18 to make. Chairman, thank you very much and welcome to Secretary McDonough and our VSO

00:03:24 witnesses. I'm anxious to discuss the VA's budget request and what resources the VA needs

00:03:29 to deliver care and benefits to our nation's veterans. Congress and this committee have

00:03:33 a long track record of working in a bipartisan manner to provide the VA with the resources

00:03:39 it requires. This committee has worked to address major challenges veterans face, including

00:03:44 streamlining access to disability compensation and providing health care for veterans exposed

00:03:48 to toxic substances during their military service. It is up to the VA workforce and

00:03:53 leadership to faithfully execute the legislation passed by Congress and deliver the care and

00:03:59 benefits our veterans rely on. I know many VA employees in Kansas and across the country

00:04:04 who selflessly serve our nation's veterans. However, I hear from VA employees that despite

00:04:11 record hiring and retention last year, the VA still faces staffing shortages which are

00:04:16 straining the workforce and increasing wait times for veterans. VA leaders have repeatedly

00:04:20 said there's not a hiring freeze, but that is not the message that the VA facilities

00:04:25 across the country have received. In contrast, the VA has noted that community care costs

00:04:30 are rising too rapidly and VA facilities must recapture care from the community. The VA

00:04:36 is also expecting to reduce 10,000 employees in the direct care system, yet VA's system

00:04:42 for assessing medical center performance for veterans shows "meaningful decline" in access

00:04:48 across the VHA. Mr. Secretary, I'd highlight a letter that I think the answer we were requesting

00:04:54 a due date today from Senator Tester and I on this topic of workforce and the 10,000.

00:05:00 Mr. Secretary, I hope this afternoon we can have a frank discussion on these conflicting

00:05:04 messages. Veterans deserve the right to decide when and where and how they seek the care

00:05:08 they need. I remain committed to making certain they continue to have the opportunity to make

00:05:13 informed choices about their own health care. VA has a responsibility to consistently provide

00:05:18 veterans with timely information, approvals, and improve veterans' experiences when seeking

00:05:23 care. I want to highlight this point and the Chairman mentioned this topic in his opening

00:05:31 statement, but I want to highlight again, non-VA emergency care costs are the biggest

00:05:36 driver of increased community cost care. Yet, the Department has not articulated a strategy

00:05:42 to address the emergency care spending. Additionally, I'd like to know the impact of VA's decision

00:05:49 to delay preventive care and cancel appointments during the pandemic and how that may now be

00:05:54 impacting the current increased demand for emergency care. I look forward to our discussion

00:05:59 today and I thank you, Mr. Chairman. I thank you, Mr. Secretary.

00:06:02 Thank you, Senator Moran. I want to welcome Secretary Dennis McDonough, Secretary of the

00:06:06 VA. The floor is yours to talk about the FY25 budget.

00:06:12 Thank you, Mr. Chairman, Ranking Member Moran, distinguished members of the committee. Thanks

00:06:16 for the opportunity to testify. Maureen Ropsh is an Air Force and Coast Guard vet who comes

00:06:22 from a long line of military service. Her family members served in Vietnam, World War

00:06:27 II, and the Korean War. Maureen qualifies for community care but chooses to get her

00:06:32 care at the Manchester VA Medical Center. After a recent routine mammogram, Maureen

00:06:38 was diagnosed with breast cancer. She says her VA nurse navigator, Kelly Hunt, was by

00:06:43 her side every step of the way, making sure that her surgery and radiation happened right

00:06:50 away. Today, thankfully, Maureen's cancer-free and receiving treatment to safeguard against

00:06:55 recurrence. Maureen says, "It's such a comfort knowing I have this team on my side." She

00:07:01 goes on to say, "The difference I feel when I get care at VA is significant. I feel like

00:07:05 I'm home. The providers take that extra time to understand my complex health history. I

00:07:11 feel like they see me." We owe vets like Maureen and all vets our very best. We're fighting

00:07:17 like hell to give them exactly that. We're delivering more care, more benefits to more

00:07:21 vets than at any other time in our nation's history. Since March 5th, expansion of health

00:07:27 care eligibility to all veterans with toxic exposures, we've enrolled more than 12,500

00:07:35 veterans under that PACT Act authority alone. That's just since March 5th. And over the

00:07:40 course of the last year, we enrolled over 400,000 new vets, 30% more than the previous

00:07:46 year, and an increase in all 50 states. 6.5 million vet patients had over 118 million

00:07:54 clinical visits, 47 million in the community, 42 million in person at VA, and 29 million

00:08:01 via telehealth. The last data point bears repeating. Millions of vets use VA telehealth.

00:08:09 Now on to benefits. We decided over 1.9 million claims, shattering the previous year's record

00:08:14 by 16%. We've all heard justifiable frustration with CMP exams. Yet in the last year, we processed

00:08:21 2.4 million CMP exams, a record by nearly 30%, and took an average of just 31 days to

00:08:28 complete them. In total, we've delivered $163 million in earned benefits, billion dollars

00:08:35 in earned benefits to over 6 million veterans and survivors, another record. And the PACT

00:08:41 Act has opened the door to millions of toxic exposed veterans and their survivors, bringing

00:08:45 generations of new vets to VA healthcare and expanding benefits for many more. The PACT

00:08:51 Act is also delivering additional benefits for veterans to the GI Bill, VR&E, home ownership,

00:08:57 survivors, pensions, and so much more. Benefits that not only improve the veterans' lives,

00:09:03 but strengthen the American economy. We still have a lot of work to do, and the President's

00:09:07 budget fully funds VA's ability to do that. That work is also about preventing veteran

00:09:12 suicide, ending veteran homelessness, supporting healthcare for women vets, modernizing our

00:09:18 IT systems, processing benefits, and honoring vets with eternal resting places. No single

00:09:25 investment is more critical to the veterans who we serve and VA's future than the people

00:09:31 we hire and retain. Teammates like Tarina Bruften, a housekeeping supervisor at the

00:09:38 Cincinnati VA Medical Center. Tarina's husband is a vet. She says she goes to work each day

00:09:44 striving to provide the kind of welcoming environment she'd want for him at VA. That's

00:09:50 the kind of deep devotion that characterizes VA's people. And Tarina says she's grateful

00:09:55 for the critical skills incentive that she received, a CSI. Her daughter's prescription

00:10:01 cost her $700 a month, and the CSI has allowed Tarina to focus on her work as a supervisor

00:10:08 without the financial stress of wondering whether she'll be able to afford her daughter's

00:10:12 life-saving medication. Now today marks the first day of Nurses Month, where we honor

00:10:19 VA's 122,000 nurses. Let me repeat, 122,000 nurses, the largest nursing workforce in the

00:10:29 country. That's up about 14,000 nurses since December 2021. Now, that's one reason why

00:10:42 we feel quite comfortable with the staffing numbers outlined in this budget. The work

00:10:48 for caring for brave men and women who fight our wars and their families, survivors, and

00:10:54 caregivers. Do you have 10, Mr. Chairman? If you've got 10, I'm happy to suspend.

00:11:02 >> We don't. We're looking for them, though.

00:11:04 >> It's in full swing and continues to grow. The Mission Act, the COVID pandemic, and the

00:11:11 PACT Act all over just the past six years have changed the American healthcare landscape,

00:11:18 and the statutory basis for the work we do at VA. Any one of those on its own would lead

00:11:25 to monumental change for VA. But together, they have changed the way we do business,

00:11:31 creating some challenges, but mostly opportunities for veterans and VA. And right now, we're

00:11:37 at a critical moment for shaping and securing the future of veteran healthcare. So we'll

00:11:43 work reliably to offer care options to every veteran, VA care options to every veteran,

00:11:51 even vets who qualify for community care under the Mission Act. We want to bring as many

00:11:55 vets as possible into our care, because study after study shows that vets do better when

00:12:01 they come and get their care with us. Whether in person via telehealth in our community

00:12:05 living centers, mobile medical units, or elsewhere, vets can access VA at every, almost every

00:12:12 turn. What we do this year and over the next several years, building on the generosity,

00:12:16 bipartisan generosity of Congress, and the innovative hard work of VA's workforce, the

00:12:21 best in the federal government, will determine what vets can expect from VA now, and how

00:12:27 we'll deliver that high standard of care well into the future. So we look forward to collaborating

00:12:32 even more effectively with you to build on what's working and being candid and addressing

00:12:37 what's not. Thank you. I look very much forward to your questions.

00:12:42 We appreciate your opening statement. I'm going to turn now to the Chairman of the Senate

00:12:46 Appropriations Committee, Patty Moran, for her questions.

00:12:50 Thank you very much, Mr. Chairman, and welcome, Mr. Secretary. Good to see you. Thank you

00:12:54 for all you do for our nation's veterans. We appreciate it. I want to ask you, as you're

00:13:00 probably not going to be surprised about the EHR system. It has two facilities in Washington

00:13:05 State, as you know, and I am still hearing from veterans and providers about their struggles

00:13:10 with that system and how it has undermined their health care. We're still hearing about

00:13:15 some outages and referrals or notes that aren't being recorded, canceled procedures. So it's

00:13:20 still a work in progress that we've got to focus on. And I know we're in a reset right

00:13:25 now. I know you're taking that seriously and trying to get this corrected. You are asking

00:13:31 for $894 million for the EHR program and FY '25. Can you talk to us about how VA will

00:13:38 use those funds to make safety improvements and IT updates?

00:13:42 Yeah. Thank you very much, and I'm not surprised by the question, Madam Chair. Our Deputy Secretary

00:13:46 just spent yesterday and the day before in Spokane, Oallala. She's now in Oregon, and

00:13:52 she'll be in Columbus tomorrow at the five sites. What we've said is that we've tried

00:13:59 to right-size our eyes and our stomach on this budget so that what we're asking for

00:14:04 is a significant drawback from what we would have anticipated under the original 10-year

00:14:11 plan. So we've also said that we won't leave reset until we're ready, but we don't intend

00:14:18 to stay in reset forever. So I hope that by the end of this fiscal year, we'll be in a

00:14:24 position to be out of reset. But that'll be determined by the facts on the ground. The

00:14:29 uptakes visit is a big part of that right now, as is, of course, the experience in your

00:14:34 two facilities. Now, since the last time we talked, where we're not in reset is in Lovell

00:14:40 in the Federal Healthcare System, Healthcare Center in Chicago. That's gone better than

00:14:45 expected based principally on the learnings from the five live sites. They've gone back

00:14:54 to much higher productivity than we had anticipated. So the investments we anticipate in '25 are

00:15:01 based on both the experience of the five sites and the experience in Lovell. That will get

00:15:06 us moving out on a more realistic timeline to new sites based on that facility. Now,

00:15:16 we've also forward deployed much of the funding in those-- for FY '25 in the next level of

00:15:23 facilities, getting them ready for pre-- with pre-investment for some of the deployments.

00:15:30 So we anticipate, as I say, by the end of this year, making that-- this fiscal year,

00:15:35 making that decision and moving out smartly with that more reduced investment in '25.

00:15:40 >> Okay. Thank you very much. Obviously, we're going to continue to follow that.

00:15:44 >> Yes.

00:15:45 >> I fully funded the President's 23 million request in the FY '24 bill to expand VA's

00:15:50 child care pilot program that we established back in 2010. It's really important to me

00:15:56 that veterans don't forego their health care because they don't have any child care.

00:16:01 >> Definitely.

00:16:02 >> And I have to say I am disappointed that VA is not making progress faster on this.

00:16:06 According to a recent study published by NIH, a staggering 58 percent of respondents reported

00:16:12 missing or canceling VA health care appointments due to child care challenges. Last year at

00:16:18 this hearing on your '24 budget request, you told me you would get the regulations moving

00:16:23 on the expansion. We're sitting here today. We've been told it may take another year now

00:16:27 for them to be finalized. When are we going to see movement on that initiative?

00:16:31 >> Well, we-- I think-- I appreciate the question very much. We have a two-pronged strategy

00:16:36 as we've discussed. One is to reimburse veterans for their care that they get somewhere else

00:16:42 and then consistent with your authorization to make sure that we have on-site child care

00:16:50 where possible. We think the two places most likely for that are Fresno and Shreveport.

00:16:56 And we're working with those two facilities to invest in those opportunities. The regulations

00:17:03 are in process and we're hoping to have those regulations done this year.

00:17:08 >> OK. The chairman's going to--

00:17:10 >> Hold that thought. Patty still gets a minute. We've got 10 folks here. I want to

00:17:16 recess, call executive session. We're to consider resolution to improve access to care for veterans

00:17:23 in South Carolina, Texas, Florida, Pennsylvania, New Jersey, and Delaware by approving 10 VA

00:17:30 major medical leases. These leases are from the FY 2024 budget submission information

00:17:35 that was distributed to senators back in December of last year. Again, last week it was distributed

00:17:41 and was also briefed to your staffs. Hopefully, you're familiar with it. Before we move to

00:17:46 vote on the resolution on today's agenda, any comments or debates, Senator Manchin?

00:17:51 >> Yes. As you know, I think I have a concern. And the concern is, is that we're paying for

00:17:56 everything. And whoever owns these facilities are getting-- reaping the rewards. And I understand

00:18:03 that we're going to increase from 31,000 to 151,000 square feet on a VA and an average

00:18:10 of 64.2 million. And we're making an infrastructure-- the average annual rent will increase from

00:18:16 1.1 million to 7.2 million and we're the ones spending the $64 million up front to enhance

00:18:23 these properties and paying someone that much more. Makes no sense to me. None of us would

00:18:28 do a business deal like this. None of us. But here we are. I guess it's-- printing money

00:18:34 is no problem, right? >> Yeah. No, it is-- it's always a problem.

00:18:38 And if I just might-- >> If you can-- someone can clarify this for

00:18:40 me. It would be very helpful. >> First of all, and you correct me if I'm

00:18:43 wrong, Mr. Secretary. We're talking about leases that are 10 or 15 years old that we're

00:18:48 replacing, OK? That's number one. Number two, the square footage, I believe, is matched

00:18:57 to the demand of the veterans. We've-- you know, we've been at war. I don't need to go

00:19:02 over that. But the fact is, as we have been and we're-- and VA has been doing a-- what

00:19:06 I think is a good job and they got to do more on this, by the way, of bringing in veterans

00:19:11 who are literally not in the system who have got problems. So the demand is growing plus

00:19:16 the PACT Act. The second thing I would say-- >> But the average increase is five times

00:19:19 greater than what the size is right now. The 31,000 is about the average of the 10.

00:19:24 >> Yeah. >> It's going to 151,000 square feet.

00:19:28 >> I've got you. But the fact is, is that the demand is there. I mean, we're doing medical

00:19:35 stuff, we're doing mental health stuff, we're doing all sorts of specialty cares that are

00:19:40 there. The only thing I would say is this. The VA in what month was it put out 31 leases

00:19:47 for bid? >> Yeah. Number.

00:19:50 >> And you may or may not know this, those bids came back, 10 of them were acceptable,

00:19:55 they were within the rate and the Secretary is going to hopefully approve those. There

00:20:00 were four or five that were within margins so they can negotiate. Seventeen about did

00:20:07 not-- were not and the Secretary said, "Look, man, we're going to go back and sharpen your

00:20:11 pencil or this ain't going to happen." And so I think your message is being heard, Joe.

00:20:16 >> Okay. The only thing, Senator, is what I'm saying is this. I'm okay with the expansion.

00:20:20 We want to give the service. If we're going five time increase, 5X increase, that's fine.

00:20:26 We have justified the services. It doesn't make sense to me that I own the building.

00:20:31 You're going to renovate my building completely for me on a 10-year lease. Most is amortized

00:20:36 20 to 30 years but 10-year lease, you're going to do all of it and still pay me the increases

00:20:41 of the additional footage. I understand. That's one heck of a deal for me as a landlord, one

00:20:47 heck of a deal. Now, I'd have to get some discount. I don't know what the square footage

00:20:51 rates are, things of this sort, but there has to be something that we can tell the taxpayers

00:20:56 that we got a little better deal. Right now, we're paying the full freight.

00:21:00 >> Gotcha. Folks, you do me no good. I should have had this a long time ago. All I'm going

00:21:07 to tell you, Joe-- >> I know. You all have to vote. I'm going

00:21:08 to vote against it because I think it's a bad deal.

00:21:11 >> That's fine. I'm just saying this has been approved through appropriations process. I

00:21:16 do not want to be in a position as a chairman of this committee running the VA. That's McDonough's

00:21:20 job. >> No, I trust the secretary with my life.

00:21:23 >> When they talk about square footage, they've got Elna Hall at the table and they've got

00:21:28 other folks at the table. >> Well, he's got somebody doing--I don't

00:21:30 know who's--I mean, raise your hand who's in charge of finances there, but I can tell

00:21:33 you this is a bad deal. It's a good deal for me. If I'm the landlord, you did a heck of

00:21:37 a deal for me. >> Can we have a comment on that?

00:21:39 >> Sure. Absolutely. Go ahead. >> I think it's a fair question. You know,

00:21:44 we're building the facilities where the vets are. You know, that's the whole strategy which

00:21:48 is we're trying to skate to the puck. We're trying to make sure that like the rest of

00:21:51 American healthcare, we're building based on outpatient structures rather than the old,

00:21:57 you know, big hospitals. We're trying to build these in communities where the vets are, one.

00:22:04 Two, the alternative for us is building brand new in many of these markets which is even

00:22:11 more expensive. And that's a function of interest rates where they are now and the supply costs

00:22:18 where they are now. And so, what we're doing, you know, healthcare inflation over the course

00:22:25 of the last 10 years is obviously a major challenge for us. But we want to make sure

00:22:29 that we're building where the vets are and we're finding the most cost-effective way

00:22:33 to do that. We think that these leases are that. >> Okay. Well, let me just--if I can

00:22:37 just say this. The average rent is going from 1.1 million to 7.2 million. That's the average.

00:22:44 The average size goes from 31,000 square feet to 151. I don't know how that is in every--every--it's

00:22:50 a little bit different on rent and all that. >> Right. >> But on top of that, then if I'm--if

00:22:55 you come to me and you'll give me a 10-year lease or a 30-year lease or whatever I can

00:22:59 get from the federal government, and you usually give me a spec of what you want me to provide

00:23:06 for you and then my rent's adjusted to the spec and this and that. But for you to come

00:23:11 in and pay the full load and I give you the space but you're paying the full conversion

00:23:17 and I get to own it in 10 years, I might say, "Okay, I can rent this to somebody more."

00:23:21 The taxpayers are paying the full load on this is the way it looks to me. It could be

00:23:25 wrong, I don't know. Somebody wants to explain it differently but it looks like that--it's

00:23:30 not a good deal. >> Look-- >> It is what it is. You guys got to vote, I understand. >> I'm

00:23:36 going to let Tellus say something. Senator Tellus, that is. >> The other thing I was

00:23:39 going to say is I just take the Jacksonville, North Carolina is not on the list. I think

00:23:45 overall we've got to start using these sort of vehicles or we're--we've already got a

00:23:49 backlog in terms of facilities requirements. It may not be perfect but it beats the heck

00:23:54 out of what it would take to take something out of the ground in Jacksonville, North Carolina.

00:23:58 I know we were in the mix. I've got some questions but I'm going to be voting now. >> Okay. If

00:24:04 there's no more debate, I'd like to invite a motion for a roll call vote on the pending

00:24:09 business. >> Mr. Chairman, I move the Committee on Veterans Affairs hold a roll call vote

00:24:13 to favorably report the major medical lease committee resolution. >> The clerk want to

00:24:20 call a roll. >> Mrs. Murray. >> Aye. >> Mr. Sanders. >> Aye by proxy. >> Mr. Brown. >> Aye

00:24:27 by proxy. >> Mr. Blumenthal. >> Aye. >> Ms. Serrano. >> Aye by proxy. >> Mr. Manchin. >> No

00:24:35 because of finances. >> Ms. Sinema. >> Aye by proxy. >> Ms. Hassan. >> Aye. >> Mr. King.

00:24:44 >> Aye by proxy. >> Mr. Brown. >> Aye. >> Mr. Tillis. >> Aye. >> Mr. Sullivan. >> Aye by

00:24:51 proxy. >> Mrs. Blackburn. >> Aye by proxy. >> Mr. Kramer. >> Aye by proxy. >> Mr. Tuberville.

00:25:10 >> Aye by proxy. >> Mr. Chairman. >> Aye. >> The motion to approve the major medical

00:25:15 leases has passed. No more remaining business for the committee. We will adjourn the business

00:25:22 meeting and I just want to thank all the Senators for being here. I very much appreciate you

00:25:27 showing up so we could get this done. And Joe, I appreciate you showing up and making

00:25:31 your points too, so thank you. >> Thank you. I appreciate being here and being heard and

00:25:35 I would like to talk to you financial people. >> Go on. >> They won't raise their hand,

00:25:39 but I know they're back there. >> They're not here. They're hiding. >> Now we'll come

00:25:43 out of recess and Patty Murray has one minute. >> Well, 45 seconds, so I'll just ask it really

00:25:48 quickly. In your 25 budget request, you assume that there's going to be 10 on-site centers

00:25:53 in 24 and 20 additional in 25. Will VA meet that goal? >> Yeah, it is our intent to, yes.

00:25:59 >> Okay, thank you. Thank you very much, Mr. Chairman. >> Senator Moran. >> Mr. Secretary,

00:26:05 thank you. This question is written for me to ask you to say yes or no. I dislike doing

00:26:10 that to people, but if you can answer it yes or no in a straightforward way, that would

00:26:14 be great. >> Good. >> Could you assure this committee, assure me, that even if the VA

00:26:19 acts to incorporate telehealth into access standards, a veteran who prefers an in-person

00:26:26 appointment will not lose their opportunity to seek community care if the VA is unable

00:26:32 to provide them an in-person appointment within the current access standards? >> I think the

00:26:37 answer is yes. >> Thank you. Same yes or no type question. Would any element of this budget

00:26:45 request restrict a veteran's ability to seek care in the community? >> No. The veterans

00:26:56 are guaranteed that based on the law that you passed in 2018. We anticipate updating

00:27:04 parts of that law and the regulations that govern it, but I've committed to you in this

00:27:09 hearing -- in this hearing room and in private that when we do that, that will be in the

00:27:13 light of day, and that's not necessarily anticipated by the budget request here, by any means.

00:27:20 >> Mr. Secretary, I'd only highlight for you that while if done in the light of day, that's

00:27:24 better than being done in darkness, but I still have concerns about it being done. >> I

00:27:28 hear you. The way we do it would be by rulemaking, and obviously that would be subject to public

00:27:36 comment and everything else. I just want to give you that assurance. >> On this growth

00:27:44 of employment, employees, you and other veteran leaders, VA leaders, have noted your intent

00:27:55 to recapture care in the community due to increased community care budgets, but community

00:28:02 care provides needed care access for veterans. If the VA wants to recapture care, VA's focus

00:28:10 should be on providing timely, high-quality care to veterans. This is why the decision

00:28:16 to implement the goal of net zero growth for the workforce while simultaneously expediting

00:28:23 PACT Act eligibility is confusing to me if the VA's goal is also to recapture care and

00:28:30 reduce reliance on the community. Can you confirm that any efforts to reduce community

00:28:34 care reliance will only include increasing the efficiency of direct care system and not

00:28:43 include pulling back veterans' ability to seek community care? >> The veterans' ability

00:28:47 to seek community care is a statutorily granted question. So I want us at VA to compete apple

00:28:58 to apple on that. So that's why, as I said in my opening statement, this year we hope

00:29:06 to ensure that every time a veteran qualifies for referral to the community, we also have

00:29:11 a conversation with that veteran to show what is available to him or to her in the direct

00:29:16 care system. This is based on not some kind of sociological or ideological view. It's

00:29:21 based on what we think is the highest quality engagement for the veteran. And so we want

00:29:27 to have the conversation about quality. Veterans are very discerning in their healthcare choices.

00:29:33 And I think when given those choices, they'll make the choice that's best for them. This

00:29:39 is about quality outcomes for veterans. That's the way we judge ourselves. That's the way

00:29:45 using the V-signal we judge each of our facilities, which is what is the veteran's satisfaction

00:29:51 with that care. And then when we're competing on that basis, I like our odds to be able

00:29:58 to provide timely access to care. That's high quality outcomes. And we'll see how that proceeds

00:30:04 during the course of this year. >> I see it, I think, in at least the way

00:30:07 you said it just now, which is we want the VA to provide the best absolute care possible

00:30:14 and then let the veteran make a choice where it is best for him or her to seek that care.

00:30:19 Is that true? >> That is true. And we think that overwhelmingly

00:30:25 the veteran will decide to stay with us. That's what our data suggests to us. That's not the

00:30:30 uniform case by any means. But we want to make sure that we're competing there and that

00:30:34 we demonstrate the courage of our conviction. Now, I'll just give you an example, you know,

00:30:39 in VISN 7. 70% of veterans qualify for a referral based on drive time alone. It's probably roughly

00:30:47 similar in Kansas, but I don't have that number. So in those cases, we're making a referral

00:30:54 for the veteran to the community. I want us to also tell the veteran, hey, if you want

00:30:58 to stay in with us, here's your options if you stay in the VA direct care system. And

00:31:05 since we're seeing such amount of change, especially in rural provision of health care

00:31:10 in the country, in your state and my state, we think that those are going to be very competitive

00:31:17 options and we want the vets to be able to make that choice.

00:31:19 >> And those who work for you in VA Central, in the VISN, and in the hospital across Kansas

00:31:27 and other states, they understand what you just said is how the VA operates when giving

00:31:33 a veteran the opportunity to choose where care occurs. Is that true?

00:31:37 >> Yeah. Like, I mean, we have 451,000 people with VA. They're awesome. They're the best

00:31:43 federal workforce, the best portion of the federal workforce that I've experienced by

00:31:47 far. So I think that -- I think, yes, they do believe that. And I want us to just demonstrate

00:31:55 the courage of our conviction, which is, hey, they all got in this business to provide care

00:31:58 to veterans. Let's give them -- let's make sure that we give vets a good option to come

00:32:03 get their care with us.

00:32:04 >> If my time returns to me, I'll ask you about state veterans home.

00:32:09 >> Good. Thank you. We can follow up if the time doesn't return to you.

00:32:14 >> Thank you, Senator Moran. Secretary, I'm going to continue on the community care line.

00:32:19 It grows between 16 and 20 percent over the last number of years. At the same time, VA

00:32:27 trust scores, which you've already pointed out, continues to measure very, very high,

00:32:33 almost 92 percent. Study after study shows the VA is doing a pretty damage. You've got

00:32:38 a good job providing health care. In fact, superior -- as good as or superior to the

00:32:44 private sector. With that as a bracket off, and knowing that this 16 to 20 percent increase

00:32:49 every year is not sustainable, unless you correct me on that, it's not sustainable.

00:32:54 What's the VA doing to find the right balance between community care and VA care?

00:32:58 >> Yeah, thanks very much. I mean, like, we want to make sure that we compete for the

00:33:04 veterans' care. And we can compete on quality, and we want to make sure that veterans know

00:33:10 that we're invested in their quality. We had a very good couple of years hiring. I just

00:33:15 said that we hired, on net, 14,000 nurses in the last two and a half years. There's

00:33:23 no health care system in the country that has seen growth like that in its nursing workforce.

00:33:27 We're not perfect on nurses, but we have the personnel. And when we have the personnel,

00:33:33 we should be able to compete. And when we compete on quality, and lay out the options

00:33:40 for the veterans, they're discerning choosers, they're discerning participants in their health

00:33:47 care choices. When we're operating on that level, I feel really good about our opportunities

00:33:52 to get this to the right place. At the end of the day, VA has always relied on the community.

00:33:57 And by the way, the community always relied on VA. We just got to make sure that this

00:34:01 is a decision about quality outcomes for veterans, quality health outcomes for veterans, rather

00:34:09 than simply a question of convenience. >> The chair -- the ranking member -- give

00:34:16 you an upgrade. The ranking member, yeah, talked about emergency care being a main driver

00:34:22 of community care costs, overall spending. 30%, in fact, I believe is what the figures

00:34:28 show. Go down the same line that Jerry talked about in his open statement. Is the VA reviewing

00:34:36 emergency care utilization, how to manage it, how to recapture some of those vets, get

00:34:41 them back into direct care? >> Yeah.

00:34:43 >> Let me know what you're doing about that, because 30% driver, that could have a major

00:34:47 impact. >> Yeah. Well, look, I mean, first, you know,

00:34:49 we want vets to make sure that they're having a relationship with their primary care provider.

00:34:53 When they need to see emergency care, they should see it. But if they need to see their

00:34:59 primary care docs and make sure that they're managing their health care over time, that's

00:35:03 first best, because that allows us to coordinate that care, one.

00:35:08 Two, we are in the field with one of our more innovative updates, I think, which is called

00:35:13 tele-emergency care. A veteran can arrive at tele-emergency care through our Veteran

00:35:21 Health Connect. Veteran Health Connect last year had 40 million enterprise-wide calls

00:35:28 in the VA system. This is like something that's available to each one of us. Well, you guys

00:35:33 have special access to care, but available to us at Blue Cross Blue Shield, you call

00:35:38 the nurse practitioner to triage, right? You call that, you can get connected to telehealth,

00:35:46 tele-emergency care with a trained emergency provider. You can discern whether what you're

00:35:53 experiencing is actually an emergency. Since October, we've seen roughly 16,000 cases.

00:36:06 Of that, 60% of those resolved, had issues resolved on the phone, and the median time

00:36:14 for that interaction is 10 minutes. So, a veteran doesn't have to get in his car, doesn't

00:36:18 have to drive and sit in an emergency room, and ends up having his issue resolved in 30

00:36:27 minutes or less. Those are the kinds of innovations that we want to make sure are happening.

00:36:32 The alternative is the veteran goes to an emergency department. The incentives in the

00:36:38 private system are for the veteran to be then checked into the hospital. And then we risk

00:36:46 being in a situation where we're over-utilizing care, where the veteran's getting care that's

00:36:51 not good for the veteran, is exposing the veteran to infection and further sickness.

00:36:58 Let's make sure that we get the veteran the care they need when they need it, where they

00:37:02 need it, and tele-emergency care is a good example of that.

00:37:06 >> Mr. Coverville. >> Thank you, Mr. Secretary. Thanks for being

00:37:12 here. In Alabama, we're having huge problems with doctors' exhaustion, nurse exhaustion,

00:37:20 lines are long. You hearing that? >> Yeah, well, interestingly, in our most

00:37:25 recent surveys, veteran burnout is down on our employee engagement surveys. That's a

00:37:32 good thing. That has to do a lot with the generous authorities you've given us for paid

00:37:39 increases and some decisions that we're making about how we're treating veterans. So we feel

00:37:48 much better this year than I did a year ago when I was talking to you.

00:37:50 >> So you're recruiting nurses and doctors as improving, down, up, since COVID, you know,

00:37:57 I understand the problems. >> Up. Up. Up. Up. Not only is recruiting

00:38:00 improving, but retention is at historic highs. >> Yeah. I had a situation in Tuscaloosa,

00:38:10 my VA over there. >> Yes.

00:38:12 >> Gentleman basically had to have some special service done.

00:38:15 >> Yes. >> Approved. A few days later, they called

00:38:18 me, you can't do community care in town. You've got to go 100, 150 miles away. What rules

00:38:27 and regulations do your doctors and administrators go by when it comes from VA care to community

00:38:35 care? I mean, does it have to be approved by somebody? Does it have to go up the chain?

00:38:40 Are they set by you and your staff? >> Yeah. Well, they're set by regulation and

00:38:44 by the law. >> Yeah.

00:38:45 >> And so it depends on what exactly this engagement was. And I'd obviously love to

00:38:49 follow up directly with you and with that veteran on it. It has to do with, A, is it

00:38:54 in the first instance primary care or is it specialty care? Then it has to do with where

00:39:00 that veteran's home is and how far is that home from Tuscaloosa. In your state and in

00:39:08 your vision, entirely 70% of veterans are eligible right now. In New Hampshire and in

00:39:17 Alaska, it's 100% of veterans because there's no full-service hospital.

00:39:22 So if that's the case, if you're 30 minutes from a facility for primary care, you qualify

00:39:31 off the bat, irrespective of whether the private provider is 45 minutes from where you are

00:39:38 or 60 minutes from where you are. So we just got to do a better job of making sure that

00:39:42 the veteran has an informed choice. >> Let me ask you about this one. This is

00:39:47 kind of old news here. The VA came to a settlement with the union related to the termination

00:39:54 of approximately 4,000 people who had been fired under the accountability authority enforced

00:40:00 by President Trump through Congress. In some instances, they were terminated because of

00:40:07 regis, criminal negligence. But they've been brought back. Correct?

00:40:15 >> Not entirely correct. The action that was taken that you referred to was subject to

00:40:22 both administrative body review, so Merit System Protection Board, National Labor Relations

00:40:27 Board, and subject to federal judicial ruling, leaving us really very little option to manage.

00:40:39 So what I did is I engaged in a settlement arrangement with the union where I said those

00:40:45 employees alleged to have carried out, as you said, egregious activity would not be

00:40:52 welcomed back. And so they are not welcomed back. So I could get you the exact numbers

00:40:58 of the 4,000. We can get you an update. I think we're keeping your teams pretty well

00:41:02 updated on those numbers over time. But those, again, by virtue of the fact that we're before

00:41:08 administrative bodies and federal courts, that settlement includes a lot of things that

00:41:14 we wouldn't necessarily choose to do of our own accord, to include back pay, things like

00:41:19 that. But bringing these employees back who are charged with egregious misconduct was

00:41:29 not something I would agree to. >> You basically went case by case and looked

00:41:33 at it. >> Correct.

00:41:34 And we fought that out. >> Which is important to the veteran.

00:41:37 We don't want to put anybody in harm's way. Still haven't got the accounting of abortion

00:41:43 in the VA. >> Yeah.

00:41:44 >> Get that to me. >> I did promise you that. But I've also ascertained

00:41:49 that we've given those numbers I think relatively recently to the committee. And since generally

00:41:54 that's the kind of information that we treat that we would require a chairman or ranking

00:41:58 member letter on, we've also communicated to your team that that's available to the

00:42:03 committee. And we'll get you those updated numbers.

00:42:06 >> Well, I appreciate the chairman doesn't like people from Alabama. So he didn't pass

00:42:10 that down the line. >> Did you refer to Tuscaloosa sometime in

00:42:14 your questioning there? What kind of football team do they have there?

00:42:18 >> Used to be pretty good. We lost our coach. >> Senator King.

00:42:27 >> Thank you, Mr. Secretary. I want to start with a couple of compliments. Last week I

00:42:30 was at the ribbon cutting and opening of a new Seabuck and Presque Isle man.

00:42:35 And to give you an idea of where Presque Isle, Maine is, Portland, Maine is about halfway

00:42:39 between Presque Isle and New York City. So we're talking far north.

00:42:44 >> Way up there. >> It was wonderful. The design was almost

00:42:47 identical to the one that we toured last year in Rumford. Just a fantastic facility.

00:42:54 Your staff in Maine, your medical staff, Tracy Davis at Togas and her support are really

00:43:00 fabulous. >> We're really proud of them.

00:43:01 >> You should be. They're great. And I've never heard a negative word from a veteran

00:43:05 in Maine about the treatment. Second compliment, if you've onboarded 14,000 nurses in the last

00:43:13 couple of years, you're doing something really good.

00:43:16 >> You're doing it. You gave us the authorities to pay them.

00:43:18 >> There's a nationwide nursing shortage and it's amazing.

00:43:21 >> We're really thrilled about it. >> That's fabulous. Now, on the negative side,

00:43:25 as you know, there's a provision in your budget that sees a reduction in staff of about 10,000

00:43:30 and how do you justify that in terms of the growth and demand for services? How do we

00:43:38 be confident in this committee that we're not sacrificing the quality of service to

00:43:43 our veterans if we're reducing staff at the same time demand is going up?

00:43:50 >> The budget here reflects the budget agreement, the bipartisan budget agreement. I think it's

00:43:55 generous to VA but it does force some choices on us. And we've put those choices in black

00:44:00 and white in the budget. One. Two, we do believe that because of the strength of the hiring

00:44:09 in the last couple of years that we in particular are better, not 100%, obviously, but better

00:44:17 sourced with clinicians. The nurses are an example of that. Three, we have tested this

00:44:26 proposition with access sprints since last October. And between October and February

00:44:32 we saw 25,000 more new veterans, unique new veterans, for care than we did a year ago.

00:44:43 That is because in that -- >> That's a good thing. I just want to be

00:44:46 sure you have the staff to serve. >> Right. And that's because we did evening

00:44:52 clinics, weekend clinics. And third -- fourth point is as the chairman pointed out in his

00:45:02 opening comments with mental health care, we are -- we do have a goal of net zero FTE

00:45:10 in the course of the next year. That's to manage through attrition -- no, sorry, just

00:45:16 in overall health care. We can manage that through attrition, we believe. And we can

00:45:24 continue to strategically hire where we need care provision. For example, on mental health

00:45:30 care. Or recently I talked with our visiting director in Texas who working with our hospital

00:45:37 director in San Antonio made a decision to hire two GI docs which they had been looking

00:45:42 for for three years. That's strategic hiring. >> Let me change the subject. These are two

00:45:47 suggestions that are policy but could end up actually saving money and treating veterans.

00:45:53 90 plus percent of seniors want to stay in their houses as long as they possibly can.

00:45:58 I've never had anybody raise their hand and say I want to go to a nursing home. And yet

00:46:02 55% of your geriatric and extended care goes into institutions. I hope you can take a look

00:46:11 at that and think about how do you change the environment in people's homes so they

00:46:19 can stay longer. >> Yes.

00:46:21 >> Grab bars, non-skid mats on the floor, those kinds of things. Because people would

00:46:26 rather stay in their homes and it's a lot cheaper for the taxpayers if they stay in

00:46:29 their homes. I hope that's something you'll look at. If we want to keep people in their

00:46:34 homes we ought to be putting more money into what amounts to prevention.

00:46:39 >> I think we're there. Maybe not as much as you want to see or as much as I want to

00:46:43 see but we're bending that curve up. Home based primary care is one of our fastest growing

00:46:49 interventions. That's a place where we're hiring a lot of those nurses I talked about.

00:46:55 And if you look just to go back to this question about primary community care, after emergency

00:47:04 care, the next two or three highest investments in community care are various manifestations

00:47:13 of home based care. I think that's an example where community care allows us to skate to

00:47:20 the puck here. And by the way, save money over time for taxpayers.

00:47:26 >> I'm out of time but I want to follow up on this and we'll follow up for the record.

00:47:31 I'm going to be introducing legislation to have you take a special focus on falls.

00:47:35 >> Yes. >> Huge issue. Medicaid, Medicare spend $38

00:47:39 billion a year treating falls that many of them can be prevented.

00:47:44 So I want to follow up with you. I hope you'll keep an open mind because this is a way, it's

00:47:48 a lot cheaper to buy somebody a bath mat than to fix a broken hip.

00:47:52 >> Some of our best innovations in our innovation office are around these manifestations including

00:47:59 new AI innovations that track gait of a veteran. So these are things that we'd be more than

00:48:08 happy to have that conversation with. >> Thank you, Mr. Chairman.

00:48:10 >> With my apologies, Senator Cassidy. >> Thank you, Mr. Secretary. You mentioned

00:48:15 that you've hired 14,000 nurses. On net, how many more nurses do you have in the system

00:48:19 knowing that there's been attrition? >> Right. So that's a net number. So that's

00:48:23 a net increase of 14,000 in that period. The number we've hired is going to be substantially

00:48:29 more than that given the turn especially in 2022. Remember 2021, 2022.

00:48:33 >> I got that. Hang on. I got limited time. So on your red team, I didn't mean to be rude.

00:48:37 I just-- >> Yeah.

00:48:38 >> On your red team analysis you gave us, you mentioned that there is anecdotal reports

00:48:45 that there's--that the increased number of veterans to community care providers is adversely

00:48:50 impacting some VHA graduate medical education programs. Now, what I know that to mean is

00:48:55 that there's fewer patients. >> Correct.

00:48:57 >> In the hospital. >> That's what I understand. By the way, I

00:48:59 think your staff gave you that. I still have not seen that report but I'm glad you've seen

00:49:04 it but-- >> I think it's generated by your folks.

00:49:06 >> Well, it's generated by our red team that we asked to stand up to take an independent

00:49:11 look at what's happening. I still haven't seen it but it sounds like you guys have and

00:49:14 I think that's a good thing. >> Now, if there's fewer patients, there's

00:49:18 less staffing required, theoretically. Knowing that the union seems to be particularly strong

00:49:25 with the VA, are you allowed to decrease staffing if you don't have patients in the bed? Do

00:49:32 you follow what I'm saying? >> I do.

00:49:33 >> Do you still have the ward clerk there? Do you still have the nurses there even though

00:49:37 there aren't any patients? >> No, I mean, like this is--

00:49:39 >> Are you sure about that? >> I'll make sure that I come back to you

00:49:43 on it but we're, you know, we're in this budget. We're managing our workforce to try to meet

00:49:51 the budget targets that are laid out in the bipartisan integration.

00:49:54 >> But I'm just so struck that the unions are so powerful that I just want to be comfortable

00:49:58 that you're actually adjusting your staffing because if the residents don't have enough

00:50:02 patients to see but you're still short on nurses, then that-- somehow, this is not all

00:50:08 kind of connecting in my brain. >> Remember that, you know, again, I'd have

00:50:13 to ask the red team members about that and maybe you could if you meet with them. But

00:50:18 whether there's enough patients in the hospitals is-- could be a function of community care,

00:50:24 could also be a function of more outpatient-- >> Did they say specifically community care?

00:50:28 >> Yeah. So it could be a function of more reliance on outpatient care.

00:50:33 >> Can I move on? Prior auth, we've talked about that and I kind of mentioned I've been

00:50:37 interested and I've been interested in prior authorization and VA frankly always tells

00:50:42 me to get into it but it doesn't seem like it's ever gotten to.

00:50:45 So knowing that if it goes to a community care and there's no prior auth, in the private

00:50:50 hospital, in the private insurance experience, oftentimes there's overutilization of test.

00:50:56 So one, have you found increased intensity of services for the same diagnosis in the

00:51:02 community care versus the VA? And two, where are we in terms of instituting a prior authorization

00:51:09 process? >> Yeah. So we do see some evidence of multiple

00:51:14 tests for the same diagnosis and that's a function of our not doing a better job of

00:51:19 coordinating the care when we send it out. We don't do a good job of following up to

00:51:23 get the radiology report or something like that. So that's mostly on us but we ought

00:51:33 to do a better job of that. Second, our prior authorizations, we do a pretty good job of

00:51:40 this in dental by the way. And so that's worth looking at. But we, going back to 2019, do

00:51:47 standard episodes of care. And we, for example, cardiology appointments may come with 10,

00:51:54 12 standard episodes of care. And what we --

00:51:57 >> When you say episode of care, you mean visits to the doctor's office?

00:52:01 >> Could be, you know, after a shoulder replacement, then you're going to have PT associated with

00:52:08 that. So it's the shoulder operation. >> Let me kind of put a point on what my question

00:52:12 is. >> Right.

00:52:13 >> There's some, it's a fraction, but it's a small fraction, but it's an expensive fraction.

00:52:20 If you send the patient to that doctor, every test that's in that doctor's office is going

00:52:24 to be ordered. >> Correct.

00:52:26 >> Whether indicated or not. >> Correct.

00:52:27 >> And the point of prior authorization is to prevent that overutilization.

00:52:30 >> Correct. >> And so where are we in terms of prior authorization

00:52:35 in terms of preventing that sort of sometimes harmful activity, always expensive?

00:52:39 >> Yeah. Sometimes harmful, always expensive. We're, that's why we're looking at the standard

00:52:45 episodes of care because it's often under that, that these extra diagnostics are asked

00:52:53 for or in the instance of cardiology where we've looked at 300 C-Ox since 2019, we've

00:52:59 seen almost a 20% increase in the use of catheters, the imposition of catheters, for example,

00:53:07 in the community when during the same period where I have a 30 to 40% reduction in the

00:53:12 use of catheters in the VA system. So something is different there. That's prior authorization.

00:53:18 >> That's suggesting to me that there is not a prior authorization. If you're going to

00:53:21 do a catheterization, the VA has to approve it rather than the doctor wants to do it,

00:53:25 the doctor can do it. >> Correct. That's, because of our reliance

00:53:28 on standard episodes of care, that's what ends up happening too often.

00:53:31 >> I will say, I think it's been a year and a half to two years that I've been told that

00:53:34 the VA is trying to put in a system to address that. And I can just tell you that that's

00:53:39 going to be, again, expensive and sometimes harmful. So, and that would be a way to rein

00:53:43 in the cost in some of this community. >> Agreed. This is among the things that we'll

00:53:46 be looking at as we're looking at each of these questions given the rapid growth in

00:53:53 community care and then the rapid rise in cost overall in health care. If, you know,

00:53:58 as I said to a couple of you guys on the phone, if we were growing at 15% and we weren't looking

00:54:03 at it, I think you would ask me what's going on. So we're trying to get our hands around

00:54:07 each of these things. Whether it's me who's over-promised to you on standard, prior authorizations,

00:54:13 I apologize for that. But I'll make sure that we stay on top of that.

00:54:20 >> Okay. Thank you. >> Thanks, Chairman. Good afternoon. Thank

00:54:22 you for your great work. >> Thank you.

00:54:25 >> Mr. Secretary, and thank you to the many, many men and women who work in the VA. They

00:54:31 are -- >> They're the best.

00:54:32 >> -- unsung heroes. And I know how hard they work to deliver benefits, health care, and

00:54:40 service to our veterans. I want to ask -- first of all, I appreciate what you're doing on

00:54:46 the New Haven facility. Money's in the budget. We need to do the authorization.

00:54:51 >> Definitely. >> And rather than berating you on that topic,

00:54:54 I'm very glad to be thanking you for the --

00:54:56 >> Well, I think it's you all who did it, so --

00:54:58 >> Well, with your leadership. I want to ask you about the PAC Act. I noted 1.3 million

00:55:09 claims, about 1.149 processed and completed. I may have missed it in the testimony, but

00:55:16 how many of those have been approved or disapproved, if you have a breakdown?

00:55:28 >> Yeah. About 9. -- sorry, 950,000 or so have been granted. So we're at a grant rate

00:55:37 of about between 70 and 75 percent, which is the beauty of the presumed service connection.

00:55:44 >> That is really the beauty of it.

00:55:47 >> Yeah.

00:55:47 >> And I am wondering what you anticipate will be necessary by way of outreach to the

00:55:54 many veterans who may not know about the PAC Act or about the expansion of it. And I was

00:56:02 really just overjoyed to see the expansion.

00:56:06 >> Well, so we have 550 outreach events scheduled yet this year. And so we think that there

00:56:13 are still a lot of veterans who don't know that they've qualified for this additional

00:56:21 care and/or additional options for benefits. And importantly, you'll recall that in the

00:56:27 run-up to last year's August 9th deadline, we reminded veterans that establishing an

00:56:35 intent to file by August 9th protected that August 10th, 2022 effective date, provided

00:56:42 once you establish that intent to file, in the next year you file a claim. So we're readying

00:56:50 an outreach plan right now where we will go back to each of the people who have filed

00:56:54 an intent to file to urge them to turn that intent to file into an actual claim before

00:57:01 August 9th again. Because what that will do is that will protect their August 10, 2022

00:57:07 effective date, which will be a meaningful benefit to those veterans who get their service

00:57:14 connection rating as a result of the PAC Act. So not only are we reaching out to veterans

00:57:20 who don't yet know, we are re-reaching out to veterans who have filed an intent to file,

00:57:25 which is near as I can tell there's no evidence of VA ever having done that before.

00:57:29 >> That's great. If you could let me know about events that you're planning in Connecticut,

00:57:35 I would love to be involved to help elevate them and help with the outreach.

00:57:39 >> Count on that.

00:57:41 >> Great. Let me ask about a painful but perennial topic, veteran suicide.

00:57:48 >> Yes.

00:57:49 >> Are we making any progress? I know the numbers are still too high. How do you feel

00:57:56 about how the VA is doing?

00:57:59 >> Well, the numbers went up last year for the first time in several years. And that

00:58:07 is heartbreaking. We also, I just want to underscore one more time that any individual

00:58:13 veteran suicide is one too many. This budget is generous as it relates to suicide prevention.

00:58:20 You all have been very generous as it relates to suicide prevention, including in giving

00:58:25 us new authorities, particularly under the Staff Sergeant Fox Local Grant Program, which

00:58:32 allows us to make investments in local organizations in each of your states who know your veterans

00:58:39 best. And I think that's a positive thing. You've also given us the Compact Act in the

00:58:48 last two years that allows any veteran who's experiencing acute mental health crisis to

00:58:55 go into any hospital, irrespective of his enrollment status with VA. So any VA hospital,

00:59:01 any private hospital, and to get care that day, and we pay for that. In the first year

00:59:07 of that, just over a year of that, 47,000, almost 48,000 veterans have taken advantage

00:59:13 of that. It's heartbreaking that there's still that many veterans who have to avail themselves

00:59:20 of that service, but it's there. So the tools are there, but the challenge is still a major

00:59:26 one and we'll stay on top of it until there's none.

00:59:29 Thank you. My time has expired. I just want to thank you for, again, for the work that

00:59:34 you're doing, particularly on women's health care in the VA. Thanks.

00:59:38 Senator Kelesh.

00:59:40 Secretary McDonough, thank you for the time on the phone earlier this week. I appreciate

00:59:45 it. And you really stand out as one of the more accessible members of the administration.

00:59:51 I really appreciate your work. We had the vote earlier about the lease and I was a little

00:59:57 bit jealous when I heard all those southern states listed and North Carolina not on it.

01:00:01 As you know, we had a lease, I believe, submitted for Jacksonville. Didn't make a cut.

01:00:08 Not yet. We're still working it, but not yet.

01:00:10 Can I just get a commitment to get a debrief, figure out what we can do to help on that

01:00:15 specific matter?

01:00:16 You got my command.

01:00:17 And I think it's also, in talking with the visiting director, we talked about the broader

01:00:23 issue of how do we get the brick and mortar facilities in place to meet the increasing

01:00:29 demand, particularly in a state like North Carolina, which is growing by leaps and bounds

01:00:33 massively.

01:00:34 For the veterans population. And what more, the question I have is do you already have

01:00:41 the authorities to come up with some creative ways for joint use, either with the DHA or

01:00:48 with the private sector? When I was on Senate Armed Services, we started doing some relationships

01:00:54 with the private sector, the trauma center down in Camp Lejeune. We ended up getting

01:00:57 into a public-private partnership there. And what more should we be doing and what more

01:01:02 authorities do you need to do that kind of stuff?

01:01:05 Yeah, so I think we have a lot of authorities that we're now starting to exercise. The most

01:01:10 important is working with DHA, with DOD. So we're having actually a summit in your state

01:01:18 later this summer on that, where we're trying to turbo charge our efforts there. We just

01:01:24 announced a new facility up in the Hudson Valley in New York, where we're seeing jointly

01:01:30 VA veterans and active duty. I think we have to make better use of that. We're also in

01:01:38 your state working with USDA-supported community hospitals to make clinical space available,

01:01:45 where we can forward to employ care teams to see veterans.

01:01:48 But you feel like then you don't need any more authority, you just need to better exploit

01:01:54 or use the authorities you have? Or are there any sticking points or things that we could

01:01:57 do that could facilitate that?

01:01:58 No, aside from the leases you just did, it's a big solid on the leases you just did. We

01:02:04 might have to come back to you and ask that you reauthorize at a higher cost level the

01:02:09 leases we talked about earlier in the week. Because of the high interest rates, we've

01:02:13 seen them anywhere from 60 to 150% above the authorized level, which we can't do under

01:02:18 current law. My theory is we really just at the end of the day need dollars. And we want

01:02:25 to prove to you that we've exhausted remedy using all of our authority. So this DOD cooperation,

01:02:32 the USDA cooperation, our academic partner cooperation in your state in particular working

01:02:38 with Duke is a really good example. And then maximizing community care. When we've done

01:02:46 all those things, then we can come to you and say, listen, I know it's like $1.5 to

01:02:51 $2 billion a hospital, but we've done everything else. We only can now do that.

01:02:56 Just think creatively for North Carolina in particular, because I'm happy to help with

01:03:02 the state legislature and the governor's office to come up with creative ways for our state

01:03:09 legislature to get engaged. We've done that with the DOD and the Department of Navy in

01:03:12 the past. I'd like to see if we can help you. When you and I talked, I discussed the -- I

01:03:21 see your budget request. I see that you're managing some of the employee, the position

01:03:26 cuts through attrition. But at the end of the day, you've got some future requirements

01:03:32 that are going to outstrip your current funding stream. So how do we get ahead of -- before

01:03:40 it just becomes this, we're flogging you because you're not hitting service levels, and you're

01:03:45 not hitting service levels because you don't have the funding till that you need it for

01:03:48 policies that we passed, tell me a little bit about what we should be thinking about

01:03:53 now. You know, it was not a vote that I was happy with, but I voted against the PACT Act

01:03:59 because I didn't think it was fully ready for prime time. Now I'm here to help get it

01:04:04 implemented. And it is one of several areas that I think are stressors that could affect

01:04:10 provision of care to veterans. So what do we need to be concerned with and step up to

01:04:15 make sure that gets implemented?

01:04:19 What I'm challenging our agency to do is to manage the dollars that we have now, mindful

01:04:25 that we're operating under a capped budget. And that means that, you know, we have two

01:04:32 big costs in the VHA side, which is one is the cost of the care, the provision of the

01:04:37 care in the direct care system, so that's people. And then what we pay to purchase the

01:04:42 care. And so we're mining both of those things, and we're trying to demonstrate that we can

01:04:48 manage that well. Meanwhile, we have a really big opportunity and challenge in the PACT

01:04:54 Act that says we can either go ask Congress for more money because we can't manage either

01:05:01 the workforce number or the provision of the care. Or we can go to Congress and ask

01:05:05 for more money because we have more veterans in our care. And that's what we're doing

01:05:10 now. As I said, 12,500 new veterans just since March 5th alone. So I feel much better coming

01:05:19 to have a conversation with you to say, "Hey, we're managing the workforce levels here.

01:05:24 We're managing access to care, care utilization, and we're doing that around quality. And by

01:05:32 the way, more veterans are choosing to get their care with us because they do see that

01:05:38 there is a care--they can leverage greater care--quality of care at VA." That's what

01:05:45 our goal is here. Now, it's facilitated by the fact that--or necessitated by the fact

01:05:50 that we're now operating under a budget cap. But you know what? You've done this in a lot

01:05:55 of different places. You got to manage your operation through the budget. And that's true

01:05:59 in the government as well. But again, if we need to ask for more money, which we may,

01:06:04 I'd much rather do that because we have more veterans than because we are not able to manage

01:06:10 our system. >> Thank you.

01:06:11 >> Senator Hassell. >> Thanks, Mr. Chair. And thank you, Mr. Secretary,

01:06:16 for being here, for the work you're doing, and for the work that your entire team does.

01:06:22 Our veterans are better for it. You mentioned that New Hampshire doesn't have a full-service

01:06:28 hospital along with Alaska. And you and I have had several discussions that not only

01:06:34 do--we don't have the full-service hospital, but we have a really aging facility in Manchester.

01:06:40 We have needed repairs and upgrades. It's a 70-year-old facility. And the services for

01:06:47 New Hampshire veterans have been disrupted by issues such as flood damage from pipes

01:06:50 that burst in 2022. And you always have this kind of sense of, are we going to keep doing

01:06:56 this with this 70-year-old facility? Is it a facility that we can really make sound,

01:07:03 right? So we've had these discussions as a result. We asked for a multiyear plan to improve

01:07:10 this facility, publicly released. I'm really glad you guys released that last September.

01:07:15 And I know that the VA has been working towards goals laid out in the plan. In fact, you broke

01:07:20 ground on the Women's Veterans Health Clinic in Manchester last Wednesday. So congratulations

01:07:25 on that step. But I just want to follow up today to get a detailed sense from you on

01:07:30 the timeline for several projects in that multiyear plan. Can you give us a sense of

01:07:35 when the Women's Veterans Clinic will be complete? And can you tell me what the next two projects

01:07:41 slated for completion are and what their timelines are?

01:07:43 Yeah, thank you very much. And you're generous to congratulate us on it. But it's just because

01:07:48 you and your fellow senator have kept the heat on and the delegation have kept the heat

01:07:52 on us. So the Women's Veterans Health Clinic is slated to open in fall 2025. The next two

01:08:00 projects are the renovation of the new lab suite. We awarded that. We will award that

01:08:09 in summer. And that will be completed in spring 2025. And then the specialty care clinic,

01:08:17 it's a minor construction project. So that's, you all did us a big solid, by the way, by

01:08:21 raising the threshold for minor construction projects up to $30 million in the defense

01:08:26 authorization bill. That's a major help to us. That specialty care clinic will have audiology

01:08:32 and optometry. That will also be awarded this summer. And we anticipate completing that

01:08:39 fall 2026. So the demolition of several outbuildings will be awarded in 2024 to make room for that.

01:08:54 So we should see progress on that as well. Thank you. And we will keep in touch about

01:08:58 it. And I just, it's really important that we have these discussions publicly so New

01:09:02 Hampshire veterans can get a sense of what's in store. I'm also going to take a minute

01:09:08 to repeat something you know, but I think veterans need to hear over and over and over

01:09:13 again, which is thanks to the PACT Act and the VA's decision to expedite enrollment eligibility,

01:09:19 veterans who were exposed to toxins as well as veterans who served in the Vietnam War,

01:09:23 Gulf War, Iraq, Afghanistan, the global war on terror, or any combat zone after 9/11 are

01:09:28 now eligible to enroll in VA health care. And I've just been trying to get that message

01:09:33 out as I know you have been. Now that we're providing care for these veterans to Senator

01:09:37 Tillis's point, we have to make sure we can do it for as long as they need. So just to

01:09:42 build on the discussion you had, and you don't have to repeat anything, but what is VA doing

01:09:47 to ensure that it can support and provide top quality care for PACT Act veterans now

01:09:52 and into the future? Yeah, well so like we again, it's there's no doubt that we are going

01:09:59 out to get new veterans into the system. And we're going to let that you know, because

01:10:05 the alternative is we hope that we get the investments in the system and then we can

01:10:09 lure the veterans. I think that the better the better investment is to take advantage

01:10:14 of this terrific opportunity PACT Act to get more veterans into our care. So how are we

01:10:19 going to do that? Well, we are tracking with each of our VISNs at a VISN level what their

01:10:26 spend is every month, what their enrollment is every month, and what their FTE count is

01:10:33 every month. And it's our intention to make all that information available to your staff

01:10:37 so you can follow right along with us and hold us to account on that. As we have more

01:10:45 robust patient census counts and we lay that against our access efforts. And I said those

01:10:51 as I said, those access sprints are in large measure those innovations we took, we put

01:11:00 in place last October. Many VISNs are maintaining those night clinics, week clinics. And so

01:11:06 we should be able to watch this develop and be in a position to make sure that we have

01:11:11 the people in the space to take care of those vets. Well, excellent. And I see that I am

01:11:17 out of time. I'm going to follow up with you on work that the VA is doing to support

01:11:22 surviving spouses because obviously spouses are part of the service too. I have a couple

01:11:27 of bills that address helping surviving spouses get some of the benefits that the veteran

01:11:34 themselves gets and just would like to follow up with you and your team. There's no question

01:11:39 we can do a better job on spouses and on survivors than we've done. We're working with the VSOs

01:11:44 on that. We're trying to learn that and directly with survivors with surviving spouses. So

01:11:51 we welcome any further help you can give us on that. Thank you. Thank you, Mr. Chairman.

01:11:56 Senator Sullivan. Thank you, Mr. Chairman. Mr. Secretary, good chatting with you yesterday.

01:12:00 I appreciated the time. I wanted to follow up on some of the topics we talked about.

01:12:06 One is this issue of the cemetery formulas that go to helping communities establish veteran

01:12:18 VA-based cemeteries. As I mentioned to you, with the exception of Metla-Catla, which is

01:12:23 our only Indian reservation in Alaska, we've actually never been granted that ever, which

01:12:30 is kind of shocking given that we have more vets per capita in the state and the country.

01:12:35 Under Secretary Quinn, when he testified a couple months ago, was pretty forward leaning,

01:12:39 saying, "Hey, we'll take a look at that, Senator, because a lot of our formulas have been focused

01:12:45 on maintenance of current cemeteries. We haven't done much, although the program allows for

01:12:54 money that goes into new cemeteries." As I mentioned, great veteran group in Fairbanks,

01:12:59 Alaska, has got land, selected land, bought land, and now they're trying to get a grant.

01:13:07 I'd like to just get your commitment. You probably can't say, "All right, they're going

01:13:10 to get it," but Under Secretary Quinn was pretty forward leaning on that topic, just

01:13:16 to make sure you're not just doing it for maintenance. It can go to new programs like

01:13:23 the people in my state who are working hard on this. Like I said, we've never gotten one.

01:13:28 We have this goal to increase the number of cemeteries within 75 miles of veterans and

01:13:36 survivors so that survivors can visit their veteran. It's consistent with that goal to

01:13:41 make sure that we're leaning in in a place like Alaska, which has not only got a lot

01:13:47 of vets, but it's got a lot of surface area. We'll make sure that we're biasing toward

01:13:53 that outcome. I want to be careful to not overpromise, but I get it. I understood the

01:13:58 arguments made yesterday. I talked to Matt about them. We'll lose Matt, unfortunately,

01:14:03 at the end of this month.

01:14:04 Yeah, he's doing a good job.

01:14:06 You've got my commitment to stay on top of this.

01:14:08 Great. Thank you. Next one we talked about, we were talking a lot about the PACT Act.

01:14:13 One of the big flaws was the Camp Lejeune component of that, which did not have trial

01:14:18 lawyer contingency fee caps. To his credit, the Attorney General of the United States

01:14:25 went and looked at the existing law and came back and said the Federal Tort Claims Act

01:14:32 actually covers this. The announcement made by him, you, Secretary of the Navy, del Toro,

01:14:38 was very helpful. I was disappointed. My team mentioned to me, I would have mentioned on

01:14:45 our call, we had asked a number of questions of the VA on this topic last year. We just

01:14:51 got the answers yesterday. You guys essentially didn't take a position. I hope you can be

01:14:56 a little bit more forward leaning the way the Attorney General was.

01:15:01 Here's the issue. Despite you guys, Secretary of the Navy, the AG, saying, "Hey, Veterans

01:15:08 of America, Camp Lejeune veterans, don't do anything above 20 or 25 percent," matter of

01:15:14 fact, the Attorney General of the United States said any law firm charging above that is subject

01:15:20 to civil and criminal liabilities. Some people don't follow the law. Saddle Rock Legal Group,

01:15:29 the AVA Law Group based in Montana, just recently my team was looking into these guys. They're

01:15:34 advertising on TV. They're still charging 60 percent contingency fees. The American

01:15:40 Legion, the VFW made this their number one issue, to get these law firms to stop ripping

01:15:45 off the families of sick Marines. We solved it. Guess what? These law firms don't give

01:15:51 a damn. They don't give a damn what the Attorney General says. We're reporting them to the

01:15:55 Attorney General. I hope he smacks them with criminal penalties. Sixty percent. That's

01:16:00 like highway robbery against veterans. Mr. Secretary, can you commit to me to continue

01:16:06 to work with us, but also, importantly, have at the local VA offices on your website, which

01:16:13 I think you already do, veterans, you should not sign up for anything more than 25 percent.

01:16:20 It's against the law. Don't get ripped off by these unscrupulous law firms. Can you strongly

01:16:27 stand with us? As I told you, and we discussed when the Attorney General did what he did,

01:16:33 that we supported him in that. We think this is the right thing to do to make sure that

01:16:38 vets get their fair share. Can you commit, though, to keep ... You guys have a great

01:16:44 network with veterans, VSOs, like I said, American Legion, VFW made this their top priority.

01:16:50 Keep trying to get the word out. Keep pushing. I saw these ads on TV like three weeks ago,

01:16:54 as I mentioned to you. It's just like, "Come on, right? Really? These cockroaches are trying

01:16:59 to take money from sick Marines and their families? It's just wrong. It's wrong. Gosh,

01:17:04 it's wrong." Let me just make one final quick question. I know on the community care, a

01:17:11 lot of discussion on that. Secretary Haasen mentioned Alaska, New Hampshire as not having

01:17:17 full service hospitals. Can I get, just maybe not right now, unless you have it, an update.

01:17:23 There was expansion plans for VA facilities, not hospitals, but clinics in Fairbanks, in

01:17:32 Anchorage, in the Mat-Su Valley, on the Kenai Peninsula, Homer, Juneau. What I'm concerned

01:17:39 about, Ms. Secretary, is you guys are looking to cut back on staffing. In Alaska, what's

01:17:49 worked is actually getting more staffing as we've built up these facilities. Like North

01:17:56 Carolina, we're seeing a big increase in our veteran population in our state. Can you make

01:18:03 sure as you're trying to right-size more broadly that the places where your facilities are

01:18:09 increasing, the veteran population is increasing, that you're not cutting there? We want more

01:18:16 VA officials, doctors, nurses. We love them in Alaska. As I mentioned, our referral backlog

01:18:24 alone, which is quite big, I mentioned the number 10,000, is important to make sure we

01:18:30 continue to have robust staffing as we're growing out the VA, not cuts.

01:18:35 Yeah. I had a good conversation with our visit lead. They've really appreciated the engagement

01:18:40 with you on that. Just two things. On the infrastructure, I'll be more than happy to

01:18:45 talk to you about our infrastructure plan for Alaska. We're not backing off that.

01:18:48 Thank you.

01:18:49 As I said, we're trying to skate to the puck. As I told Senator Tillis, exercising every

01:18:54 authority we have and being really creative about it, the next place to do this is JBEAR.

01:19:02 There's no reason that we should be sending vets downtown and active duty docs downtown

01:19:08 to operate on vets down there. We can do that right at JBEAR and save the taxpayer a lot

01:19:14 of money. We're not backing off the infrastructure plan.

01:19:19 On the backlog, we've seen substantial improvement since February. In large measure-

01:19:26 It's really big, though, as you have to acknowledge.

01:19:29 No, I'm not saying it's not. I don't see that number that you talked about, but I'm

01:19:34 going to leave this with you so that we're on the same page.

01:19:37 Okay.

01:19:38 We can find out if I'm looking at the wrong thing. In large measure, we've been able

01:19:44 to do that by ramping up MSAs. Those are the schedulers who help make those appointments.

01:19:53 Who need to be based in Alaska.

01:19:56 Exactly. That's an example of strategic hiring, where we need those kinds of personnel. We're

01:20:04 going to make those decisions. Again, when you're operating under a cap, you've got to

01:20:10 balance this somewhere. We put out the trade-offs in the budget. We're making good progress

01:20:16 here, working together with you guys. We're going to stay on top of it.

01:20:20 Okay. Thank you.

01:20:21 Again, we're not walking back from our infrastructure investments. We just have to prove to you

01:20:24 guys that we're really serious and we've done everything we can. Then we're going to come

01:20:27 and say, "Hey, we need the $2 billion per copy for hospitals. That's going to be really

01:20:36 expensive." I don't feel right that we should come to you with an aggressive ask like that

01:20:40 until we've done every single creative thing we can.

01:20:43 Great. Thank you, Mr. Secretary. Thank you, Mr. Chairman.

01:20:47 Before we conclude the first panel, I feel for tradition's sake, I've got to recognize

01:20:50 Telus just for five seconds.

01:20:52 Thank you, Mr. Chair. Senator Sullivan and I served together for eight years on Senate

01:20:56 Armed Services. He's repeatedly quotes on a per capita basis, "Alaska has more veterans."

01:21:04 I remind Senator Sullivan that we have more veterans than he has people. If you were to

01:21:11 cut my veterans population in half, we'd still have more veterans.

01:21:15 All right. It's true, Mr. Secretary. We have more veterans per capita. I think Montana's

01:21:20 second but Alaska's number one.

01:21:22 Seven thousand veterans a month in North Carolina, August, September, October last year. Seven

01:21:29 thousand a month, new ones.

01:21:31 Well, we just want to keep the predictability of the committee. With that, thank you, Secretary

01:21:37 McDonough.

01:21:38 Thank you, Mr. Chairman.

01:21:39 I will say this at the end of the hearing, but there will be questions I would ask that

01:21:41 you and your team answer them.

01:21:43 We'll get them back to you before a year from now.

01:21:46 As quick as you can. Thank you very much.

01:21:47 Thank you.

01:21:48 Now we're going to hear from three veteran service organizations responsible for the

01:21:52 independent budget. I want to introduce the folks on this next panel. Christina Keenan.

01:21:58 All these folks are familiar to the committee, by the way. Christina Keenan, Deputy Director

01:22:02 of the National Legislative Service at VFW. We have Roscoe Butler, Senior High Policy

01:22:09 Advisor for Paralyzed Veterans of America.

01:22:14 And last but certainly not least, we have Shane Lehrman, who's the Deputy National Legislative

01:22:17 Director for Disabled American Veterans.

01:22:22 I'm going to give you guys two minutes, but it'll be a -- I'm not going to drop the gavel

01:22:28 on you, all right? So make it quick, though, if you can, because we appreciate your input.

01:22:34 It's very, very important.

01:22:35 And please know this, just because it's Tillis and I are here, the people that really do

01:22:39 the work are the folks that sit behind us. And so we appreciate you being here.

01:22:43 And Christina, you have the floor.

01:22:47 >> Thank you, Governor Tester and members of the committee. On behalf of the independent

01:22:50 budget Veterans Service Organizations, DAV, PVA, and VFW, thank you for the opportunity

01:22:56 to present our recommendations for fiscal years 2025-2026. For more than 30 years, the

01:23:02 IBVSOs have provided independent budget recommendations to ensure that VA remains fully funded and

01:23:08 capable of carrying out its mission.

01:23:11 First, it's important to note that VA's full year appropriation was not enacted until

01:23:16 half the year had passed. The routine use of continuing resolutions limits VA's ability

01:23:23 to expand access to benefits and services for Veterans. Congress must do better.

01:23:29 A critical component of VA's health care delivery is its infrastructure. We're concerned that

01:23:34 VA's request for major and minor construction is one-third lower than what VA requested

01:23:39 last year and far below what is necessary. It's important to have modern and up-to-date

01:23:45 facilities. We recommend $5.2 billion for major construction, more than four times the

01:23:51 current funding, and $910 million for minor construction, a 30% increase.

01:23:58 VA infrastructure funding has remained stagnant for far too long. In the past 10 years, it

01:24:04 has only increased 5%. Meanwhile, the construction backlog has grown exponentially, 116% since

01:24:13 2014. Funding must increase to keep up. Private health care, on the other hand, invests considerably

01:24:20 more into the infrastructure of their networks. Last Congress, Kaiser Permanente testified

01:24:26 before this committee that they invest about 3% of their overall operating budget into

01:24:31 infrastructure. VA invests about 1%.

01:24:36 Unless there's a drastic increase in resources for VA, we will continue to see this backlog

01:24:41 grow. Infrastructure costs have increased year after year, and they will not get any

01:24:45 less expensive over time. I will now turn over to Roscoe Butler from PVA to present

01:24:50 our recommendations for VA health care.

01:24:53 Thank you for the opportunity to discuss the independent budget's recommendations for VA

01:24:58 medical services for fiscal year 2025. As noted in the independent budget, Veterans

01:25:04 Service Organization's written statement, the IBVSOs recommended approximately $151.8

01:25:13 billion in total resources for VA medical care for fiscal year FY25 appropriations.

01:25:19 Our FY2025 recommendation primarily reflects the increased funding baseline for all medical

01:25:27 care programs established over the past three years, continuing enrollment increases, continuing

01:25:34 inflation, a federal pay raise, and increased workloads. However, I would like to address

01:25:41 some findings, funding concerns the IB identified with funding trends in the VA's budget.

01:25:49 Over the past decade, VA's reliance on community care has risen dramatically. While we agree

01:25:56 that Veterans must have non-VA options to fill gaps in care, we believe VA must remain

01:26:02 the primary provider and coordinator of VA's care, of Veterans' care. While VA is requesting

01:26:10 an overall increase for medical care, the community care program is growing at a faster

01:26:15 rate than VA direct care. In addition, VA's request would cut 10,000 health care FTE,

01:26:24 including 600 physicians, 2,400 nurses, 509 physician providers, and over 2,000 health

01:26:32 care technicians, despite VA's reporting more than 66,000 health care vacancies at

01:26:42 the start of the year. We should not be cutting positions when we can't even fill the ones

01:26:49 that are already there. Also, we are concerned with VA's projected

01:26:54 use of $12.7 billion in carryover funding, rather than requesting new discretionary appropriations.

01:27:02 If VA's unobligated balance at the end of FY24 is less than projected, it could trigger

01:27:10 a funding shortfall next year. This concludes my oral statement. Now, Mr.

01:27:17 Lehmann from DAV will speak briefly about our funding recommendations for VA benefits

01:27:22 and services.

01:27:24 >> Veterans submitted over 2.4 million claims in FY23 for benefits, primarily disability

01:27:32 compensation, which is 39% higher than the prior year. The Veterans Benefits Administration

01:27:40 processed 1.9 million benefits claims in FY23, surpassing the previous all-time record by

01:27:48 16%. As of April 28, just a few days ago, there are over 946,000 claims pending within

01:27:57 VBA. 32% of them are considered backlogged. Therefore, it is critical that VBA be appropriately

01:28:05 funded, and the IBVSOs recommend a total of $6.2 billion for VBA in FY25, a 9% increase.

01:28:16 This includes plus-ups for more employees, as well as $130 million for overtime to process

01:28:23 the backlog and pending claims. The Board of Veterans' Appeals continues to resolve

01:28:28 more appeals in recent years, yet at the start of FY24, there were over 200,000 appeals pending

01:28:35 and 72,000 of those were awaiting hearings. Additionally, we are concerned that the Board

01:28:42 conducted 11,000 fewer hearings in FY23 than before. For FY25, the IBVSOs recommend $333

01:28:54 million for the Board, a 14% increase, which includes a plus-up of $220 new FTE to address

01:29:02 the backlogs of appeals and hearings. In closing, we believe that the greatest roadblock to

01:29:09 properly funding Veterans' benefits and services comes from budgetary enforcement mechanisms

01:29:16 designed to limit federal spending. To ensure that our nation meets its sacred obligation

01:29:22 and its moral imperative to our nation's veterans, we call on Congress to exempt veterans' programs,

01:29:30 services, and benefits from congressional pay-go and cut-go rules, as well as work to

01:29:37 eliminate the use of CRs for VA care and services. Mr. Chairman, that concludes our testimony.

01:29:45 We are prepared to answer any questions you may have.

01:29:47 >>Chairman Weiss: Thank all three of you for being here and for your testimony. Shane,

01:29:54 I think your last statement really speaks more to dysfunction in Congress than anything

01:29:58 else. The fact is, if we were getting our budgets done and done on time, we wouldn't

01:30:03 have to be talking about CRs that seem to happen far, far, far more often than we should.

01:30:08 So I very much appreciate all your comments and understand what you're saying, for sure.

01:30:13 Because the truth is, a Veteran serves this country and they serve it and we make promises.

01:30:18 And CRs don't live up to those promises, quite honestly.

01:30:23 So any one of you can answer this question. The testimony that you three brought forward

01:30:31 raises concerns about community care spending, especially as it compared to spending for

01:30:35 direct care. Given the memberships of your organizations and the impacts that their military

01:30:43 services had on their abilities physically and mentally, what should we keep in mind

01:30:48 as we emerge, as we engage in this conversation about community care versus direct care?

01:30:55 >>Mr. Smith-Everett I'll just say, Chairman, VA has always had

01:31:00 community care. That's nothing new. We need to continue to realize that direct care, to

01:31:09 maintain VA's -- to be able to be a provider of care, we need to ensure that acute care

01:31:19 is primary, or direct care is primary. And that only when VA cannot provide the care

01:31:30 in the community should community care be provided outside of the VA.

01:31:35 >>Okay. Appreciate that. >>Mr. Chairman, I'll just add really quickly,

01:31:41 our veterans consistently tell us that they prefer VA health care and that community care

01:31:46 can supplement when needed. So we hope and we ask that VA continue to focus and focus

01:31:54 even more on improving their direct care primarily.

01:31:59 >>Thank you. Okay. >>Yes. Thank you, Senator. One of our concerns

01:32:03 always is, is VA really managing that veteran? Once they go out in town, they do community

01:32:09 care. Is all that information, medications, treatment, being put back in the record, and

01:32:14 is the VA successfully managing it? Because if they're not, then we have concerns of polypharmacy.

01:32:21 Are veterans being overmedicated? Are the medications being interactive negatively?

01:32:25 Is anybody really looking at the negative impacts that this has on their long-term care?

01:32:31 >>Appreciate it. Appreciate all three. Look, we all know the importance of VA staffing,

01:32:37 especially VHA staffing. It's all important, though. But truthfully, when it comes to health

01:32:42 care, those health care workers are very important. Benefits are important, too. But I want to

01:32:50 focus on the VHA staff. The VA has hired a bunch of folks. There's no doubt about that.

01:32:58 It's been pretty well documented. It's also documented pretty well that they're stopping

01:33:03 for a second, they're taking a breath, they're going to analyze what they got. I don't necessarily

01:33:09 think that's a bad thing. But what I do think is a bad thing is after that analysis is done,

01:33:14 they either have to not hire or hire, depending on what that analysis is. Talk about shortcomings

01:33:21 of reduced staff and understaffing of VHA and what that does to the VA, especially when

01:33:27 we consider we're having record enrollments right now.

01:33:31 >>I'll just start. With record enrollment, as you said, we want to make sure that we're

01:33:36 not seeing increases in wait times either. We want to be able to serve the veterans that

01:33:41 we're estimating are going to be coming in in the next fiscal year. And VA has roughly

01:33:46 75,000 vacancies still. Our budget recommendations are to try to reach at least a quarter of

01:33:52 that. So we hope that VA will continue to rigorously hire.

01:33:57 >>So right now your predictions, before I get to you, Roscoe, your predictions right

01:34:01 now is that the VA is 75,000 short on health care workers?

01:34:05 >>Yes.

01:34:06 >>Okay. Go ahead, Roscoe.

01:34:09 >>VA's first quarter staffing report shows that there's 66,000 vacancies in VHA. For

01:34:17 us, you know, we go out and conduct site visits at VA medical centers, SCID centers. And the

01:34:23 impact we're seeing is that there are nursing shortages in the SCID program, and they're

01:34:31 not able to fill those vacancies. So that means that the current nursing staffs have

01:34:38 to take on more responsibilities and duties, burnout, and physician burnouts. And so, you

01:34:47 know, and it will only get worse with increasing enrollment as more veterans enroll in the

01:34:55 system unless we're hiring more people, then the shortages will -- and the staffing will

01:35:04 tend to burn out. And, you know, working in a unit like spinal cord is not the same as

01:35:12 working in an acute care setting.

01:35:16 >>Amen.

01:35:18 >>Obviously, when we don't have enough staff, veterans are not going to have the timely

01:35:24 access that they need. But then, if you think about it, we're actually now feeding into

01:35:29 community care. So the fewer appointments and physicians and nurses that are available,

01:35:36 the more we're going to be sending into community care, so then that cost is going to continue

01:35:40 to rise. And so then we're going to have less money to spend on direct care, and then we're

01:35:45 going to have less people. We're going to feed into this entire system if we're not

01:35:50 appropriately staffing healthcare now to make sure they're getting what they need up front

01:35:56 when veterans come in for assistance.

01:35:59 >>Appreciate that. Senator Tilson.

01:36:01 >>Thank you, Mr. Chair. Thank you all for being here. I've tried to reconcile the comments

01:36:09 from Secretary McDonough, which was to, through attrition, manage down 10,000 positions. Does

01:36:16 that mean that that number goes from 75,000 to 85,000 in your view?

01:36:22 >>Honestly, I'm not sure how attrition is going to affect vacancies. I think it's important

01:36:29 that attrition is stable. I think that's a very good thing, and we're happy to hear that.

01:36:35 >>But I guess I understand that your assessment that there are some 75,000 more positions

01:36:45 that need to be filled. Do you believe that that is the view and a priority of the VA?

01:36:52 >>I mean, from anecdotal evidence, we've heard that there's been a pause. We hope that that

01:36:59 really is just a regroup, and we're strongly urging VA to continue hiring and to fill those

01:37:05 vacancies.

01:37:06 >>Here's what I talk with Secretary McDonough, and incidentally, I'm very positive about

01:37:13 Secretary McDonough. He's very prepared. I think he's doing a good job. Everybody can

01:37:18 improve. I'm sure you all could say that about your own organizations. But I feel like we're

01:37:24 not really addressing the elephant in the room, and that is we are going to get more

01:37:30 enrollments. I was going to talk to you all about maybe the increase in disability claims

01:37:35 as a result of the PACT Act. I'm kind of interested. It seems like they're triaging the claims

01:37:40 pretty quickly. I'm kind of interested in the quality of those exams on the back end

01:37:44 and the timeliness. Maybe I can get to that, but I want to get to a macro thing here. Maybe

01:37:51 I could be disproven. Maybe I should have thought twice about voting against the PACT

01:37:56 Act that had Team Act in there, Camp Lejeune Toxics. I know that you all know my office

01:38:03 was carrying that through. But I worried about making sure that we got all this stuff squared,

01:38:11 and I worry about whether or not we have the funding tail, the staffing tail. At what point

01:38:16 do these bills come due? At what point are we potentially going to run into a cliff in

01:38:22 the VA for all the commitments we've made versus the positions we can hire and the money

01:38:28 we can appropriate? We've got to really step back and make sure. See, in the same way that

01:38:34 we're running into a fiscal cliff with Social Security that's probably going to hit somewhere

01:38:39 in the next six or eight years, that's when you don't have the money, and you start cutting

01:38:46 and breaking the promises you've made. How would you all suggest we kind of get a big

01:38:53 picture view of -- I feel like we're kind of talking past each other when I hear we're

01:38:59 managing down 10,000 fewer positions. We need 75,000 more positions. We need less community

01:39:06 care, but we're not producing -- we don't want to put an emphasis on community care,

01:39:12 but we're not producing enough indigenous capacity to handle the veterans and the populations

01:39:17 growing. So am I just being overly cynical, or do I feel like cool hand Luke? What we

01:39:22 have here is a failure to communicate.

01:39:25 Actually, I think all three of us would agree. When we went to the budget briefings and we

01:39:32 discussed all of this internally, we're still trying to wrap our head around some of these

01:39:37 concepts as well. We're going to lose 10,000 positions due to attrition, but yet we still

01:39:44 need 75,000 more. To your point, it doesn't make sense. So our concern, I think, will

01:39:49 always be making sure there is enough staffing so veterans have the high-quality VA health

01:39:57 care when they need it so we're not over-reliant on community care.

01:40:03 If I may address the PACT Act real quick, just because I was very involved in that and

01:40:07 I do a lot of the claims and benefits for this team. We've been pleasantly surprised.

01:40:15 Over 956,000, I think, roughly is how many claims have been actually granted. The 1.9

01:40:22 million PACT Act or 1.2 million PACT Act claims that have been filed. So they've actually

01:40:29 done a great job in processing the claims. They really have. As far as examinations,

01:40:34 I'm always willing to bend somebody's ear for a few hours to talk about VA exams. I

01:40:39 won't do that right now, but I think we've seen some improvement in that area.

01:40:43 But overall, I think they've done a great job on the PACT Act. Now, right now, as I

01:40:48 noted, Senator, 32% of the claims that are pending are backlogged. We knew there was

01:40:54 going to be a peak of claims and a backlog of claims because of the sheer volume coming

01:41:01 through. Overall, I think VA has done a great job with the PACT Act. Obviously, there's

01:41:07 more things that they could improve on, they could do better, and we can discuss that later,

01:41:11 I can, with your team. But I really think overall, they've done much better than most

01:41:17 of us were expecting from them.

01:41:19 And I'm glad to hear that, because in spite of the fact I voted against it, I'm rooting

01:41:22 for it, a lot of the policy in there, but I still worry about this cliff out there,

01:41:30 because I stipulate what you all say as being accurate, needs that are unmet. I just don't

01:41:36 see how those all square, and I just don't know over what period of time. And Mr. Chair,

01:41:41 the only other thing that I'm, I hear almost a billion dollar funding request for the electronic

01:41:48 health record, is that what I heard? And there's got to be more if they decide not to step

01:41:56 back from it, which I hope they don't do, but there's just so much stuff out there.

01:42:01 And it would be nice over the course of this Congress, if we could get it written down,

01:42:05 or just soothe my worries, out your worries, we could have a change of administration next

01:42:11 year, we could have a change of VA secretaries, we could, you know, a lot of stuff needs to

01:42:18 be documented, finished to start. How do we make sure that we're not going to run over

01:42:23 a cliff here with all these deficiencies, either in funding and manpower? That's what

01:42:28 I'm mainly worried about, and mainly worried about it for the sake of the veterans. Thank

01:42:33 you all.

01:42:34 Let me just, Mr. Tillis, let me say to your question, we're at that tipping point. And

01:42:40 the Secretary pretty much is telling us that, because he said they have to make difficult

01:42:46 decisions, and they've made those difficult decisions. And so, how you turn things around,

01:42:55 that's the question. Because at some point, if community care continues to rise over direct

01:43:03 care, if staffing, they're not filling all of the vacancies that they need to fill, people

01:43:10 continue to work longer hours and get burned out, then that has a very negative impact

01:43:18 on the quality of care VA provides.

01:43:23 I'll just add one last thing. A lot of the budget recommendations that we're making is

01:43:27 to make VA more efficient, and that's going to be cost-saving over time. Thank you.

01:43:41 I still can't think of that word when people revolt and take your job.

01:43:45 Who did not?

01:43:46 There wasn't one of those?

01:43:49 Mr. Chairman, thank you. I think many of the points on questions I would have raised with

01:43:57 you and asked for your views and your points have been asked, I'm told, because a lot of

01:44:02 my questions always relate to community care, and that has been addressed by my colleagues.

01:44:07 A couple of things I would ask you, though. The PACT Act directed that the VA hold quarterly

01:44:14 engagements with VSOs to help evaluate presumptions of service connection. From these engagements,

01:44:22 tell me about the engagements. Are they mattering? Importantly, do you feel the VA's resourcing,

01:44:27 the vet home, the Office of Research and Development, and the broader execution of the presumptive

01:44:32 decision process, are those things adequate and focused on delivering the promises of

01:44:39 the PACT Act?

01:44:43 Thank you, Senator. They do have quarterly meetings that we've been invited to off-sites

01:44:47 about PACT Act implementation. However, specifically to diseases and what they're looking at and

01:44:55 with the home, I don't believe any of those have happened. If they have, they haven't

01:45:01 invited DAV, PVA, or VFW, not to say that they haven't, but we've been asking those

01:45:07 questions about when are the presumptions being done. They are informing us they are

01:45:12 looking at different categories of diseases. I believe the K2 study will be out in June.

01:45:20 They're looking at a few other diseases, but overall, we're not aware of those quarterly

01:45:25 meetings have actually started. They haven't with the VSOs.

01:45:30 That's useful information. Assuming that you want those meetings to take place, I would

01:45:34 guess that Senator Tester and I would join each other in insisting, encouraging that

01:45:38 the department do what the law requires them to do.

01:45:42 Let me talk a moment about the independent budget. PACT Act implementation has led to

01:45:48 a large uptick in disability claims filed and processed. Can you speak to what your

01:45:57 service officers are seeing with access to disability claims and the quality of these

01:46:01 exams during this process? Are your service officers and veterans in your organization

01:46:08 seeing any decline in the quality of the outcomes of adjudicated claims? Do you believe that

01:46:15 processors are receiving the proper training to adjudicate both PACT Act related claims,

01:46:19 but also specialty claims?

01:46:22 From the perspective of the VFW service officers, we have a wide network of service officers

01:46:26 throughout the country. There seem some positive outcomes with PACT Act claims. For the veterans

01:46:33 that we represent, they are being processed in a timely manner. Of course, it could be

01:46:38 quicker. We are seeing positive outcomes. There's always more to be worked on. From

01:46:46 this point of view, for the moment, those PACT Act claims are going through.

01:46:52 We are recommending through our budget recommendations that VA hire more claims processors, raters,

01:47:00 and that they constantly have the oversight over C&P exams so that veterans can, if need

01:47:05 be, reschedule depending on their daily lives, that kind of thing. We are continuing to monitor

01:47:11 this, but we are optimistic that this has been a good outcome with the PACT Act. The

01:47:19 VA is taking this seriously, and they are processing more claims than ever before in

01:47:23 history.

01:47:24 Christina, do you see any reduction in the quality of the examination of the determination?

01:47:33 We know that the approvals for PACT Act claims have gone up percentage-wise. That was a big

01:47:41 concern of ours before the PACT Act. That is a positive change. There are always going

01:47:47 to be some cases where we are not satisfied or the veteran is not satisfied. We think

01:47:53 oversight and quality assurance is key to monitoring that process.

01:47:58 Thank you for both of your answers. This is a question that I was going to ask the Secretary,

01:48:05 but I would like for you to express your views on this topic. State veterans' homes play

01:48:14 an important role in caring for aging veterans and are critical partners of the VA. I am

01:48:19 concerned that the VA is only requesting $141 million for grants for construction of state

01:48:24 home facilities, which represents a 14 percent decrease from FY '24. The current priority

01:48:31 list is over 100 projects with a total VA cost share of nearly $1.8 billion. That doesn't

01:48:39 come close to meeting the need. I would like your response. Since I can't ask the Secretary

01:48:46 the justification, maybe you can help me make the case for either this is appropriate or

01:48:52 insufficient.

01:48:55 Just looking at the numbers, $141 million is what VA is requesting. Collectively, the

01:49:01 IBVSOs are suggesting $600 million for state veteran home construction grants. We see there

01:49:10 is a strong need. We have an aging veteran population. We need to be considerate of all

01:49:15 aspects of health care for veterans.

01:49:19 If I may, there is a local cemetery -- excuse me. State home. It has been a long day. Not

01:49:31 too far from where I live, I am active in a chapter in northern Virginia. There was

01:49:36 a state veteran home that was authorized and paid for for grants by VA and by the state.

01:49:42 It has been built and empty for two years. We try to get answers so that our aging members

01:49:49 in that area can have access. We are being told by the state of Virginia that the problem

01:49:57 is actually a federal VA problem because VA needs to make decisions. VA is saying no,

01:50:04 we gave you the grants. You have everything you need.

01:50:08 An example of a problem within the system for grants and getting it done, there is a

01:50:13 nursing home in northern Virginia that has been complete for two years and nobody has

01:50:18 occupied it.

01:50:19 >> Mr. Learman, you used your time just like I did to get somebody else to highlight a

01:50:24 problem in hopes that they fix it. We will work with you on this as well to see if we

01:50:30 can't get VA attention.

01:50:32 Mr. Chairman, that concludes my questions.

01:50:35 >> I was going to close with a comment. It is not being used. Is this a state veteran's

01:50:46 home or a federal?

01:50:47 >> That is the problem. It is a state veteran's home, but we are being told it is controlled

01:50:53 by the federal.

01:50:54 >> You ping pong things back and forth. The truth is there is an expenditure of taxpayer

01:51:00 dollars here that was a total waste of money unless they get that thing opened up and provide

01:51:05 the services. I will get a hold of Cain and the other fellow's name. What is his name?

01:51:12 I can't remember.

01:51:13 >> You are not asking me. You are asking your staff.

01:51:17 >> At any rate, I say that in jest. We will get a hold of the two senators from Virginia.

01:51:22 >> Virginia, I do know those guys.

01:51:24 >> Do you? We will put them to work. The truth of the matter is this is crazy. It is just

01:51:31 flat stupid. We will do that. They might be calling you. It is good. I want to thank you

01:51:39 guys for being here. Gals, guys, everybody for the independent budget. Of course, thank

01:51:44 the secretary. Both of these panels are critically important as we work through the 2025 appropriations

01:51:50 process. This record will be open for a week. Any questions, I would ask that you respond

01:51:56 to them as quickly as you can. This hearing is now adjourned.

01:51:59 [GAVEL]

01:52:00 [END]

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