    [Senate Hearing 116-445]
    [From the U.S. Government Publishing Office]

                                                           S. Hrg. 116-445

                      REVIEW OF THE FY 2021 BUDGET AND FY
                      2022 ADVANCE APPROPRIATIONS REQUEST
                           AND OVERSIGHT OF CARES ACT
                        SUPPLEMENTAL APPROPRIATIONS FOR
                       THE DEPARTMENT OF VETERANS AFFAIRS

    =======================================================================

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                  JUNE 3, 2020

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                                  __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    44-629 PDF                  WASHINGTON : 2021

    --------------------------------------------------------------------------------------

                     SENATE COMMITTEE ON VETERANS' AFFAIRS

                         Jerry Moran, Kansas, Chairman

    John Boozman, Arkansas               Jon Tester, Montana, Ranking
    Bill Cassidy, Louisiana                  Member
    Mike Rounds, South Dakota            Patty Murray, Washington
    Thom Tillis, North Carolina          Bernard Sanders, (I) Vermont
    Dan Sullivan, Alaska                 Sherrod Brown, Ohio
    Marsha Blackburn, Tennessee          Richard Blumenthal, Connecticut
    Kevin Cramer, North Dakota           Mazie K. Hirono, Hawaii
    Kelly Loeffler, Georgia              Joe Manchin III, West Virginia
                                         Kyrsten Sinema, Arizona

                Caroline R. Canfield, Republican Staff Director
                    Tony McClain, Democratic Staff Director

                                C O N T E N T S

                                  ----------

                                  JUNE 3, 2020

                                    SENATORS

                                                                       Page
    Moran, Hon. Jerry, Chairman, U.S. Senator from Kansas............     1
    Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     3
    Boozman, Hon. John, U.S. Senator from Arkansas...................    11
    Brown, Hon. Sherrod, U.S. Senator from Ohio......................    13
    Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    15
    Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    17
    Rounds, Hon. Mike, U.S. Senator from South Dakota................    20
    Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    21
    Tillis, Hon. Thom, U.S. Senator from North Carolina..............    23
    Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    25
    Sinema, Hon. Kyrsten, U.S. Senator from Arizona..................    29

                                   WITNESSES

    Wilkie, Hon. Robert, Secretary of Veterans Affairs; Accompanied
      by Richard Stone, MD, Executive in Charge of the Veterans
      Health Administration; Paul Lawrence, PhD, Under Secretary for
      Benefits; and Jon Rychalski, Assistant Secretary for Management
      and Chief Financial Officer....................................     5

                                    APPENDIX

    Moran, Hon. Jerry, Chairman, U.S. Senator from Kansas, prepared
      statement......................................................    36
    Wilkie, Hon. Robert, Secretary of Veterans Affairs, prepared
      statement......................................................    38
    Joint Statement of the Co-authors of the Independent Budget:
      Disabled American Veterans Paralyzed Veterans of America
      Veterans of Foreign Wars.......................................    58

    Response to hearing questions from Department of Veterans Affairs
    submitted by:
      Hon. Jerry Moran...............................................    71
        Attached PDFs................................................   167
      Hon. Jon Tester................................................    91
        Attached PDFs................................................   191
      Hon. Sherrod Brown.............................................   113
        Attached PDFs................................................   242
      Hon. Richard Blumenthal........................................   123
      Hon. Mazie K. Hirono...........................................   133
      Hon. Joe Manchin III...........................................   144
      Hon. Kyrsten Sinema............................................   146
      Hon. Mike Rounds...............................................   158
      Hon. Dan Sullivan..............................................   158
        Attached PDFs................................................   246
      Hon. Marsha Blackburn..........................................   160
      Hon. Kevin Cramer..............................................   164

                      REVIEW OF THE FY 2021 BUDGET AND FY
                      2022 ADVANCE APPROPRIATIONS REQUEST
                           AND OVERSIGHT OF CARES ACT
                        SUPPLEMENTAL APPROPRIATIONS FOR
                       THE DEPARTMENT OF VETERANS AFFAIRS

                                  ----------

                            WEDNESDAY, JUNE 3, 2020

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 3:12 p.m., in
    room SD-106, Dirksen Senate Office Building, Hon. Jerry Moran
    presiding.
        Present: Senators Moran, Boozman, Cassidy, Rounds, Tillis,
    Sullivan, Loeffler, Tester, Brown, Blumenthal, Hirono, Manchin,
    and Sinema.

                  OPENING STATEMENT OF CHAIRMAN MORAN

        Chairman Moran. Good afternoon everyone. The Committee will
    come to order.
        Before we proceed to today's hearing, I would like to take
    a moment to recognize that last Monday was Memorial Day. It was
    a different Memorial Day for me and for other Americans than
    normal, and it was more difficult for us to gather together.
    But last Monday gave us an opportunity that we should take
    every day, to pause and remember the brave Americans who gave
    their lives in defense of our country, and we honor the
    sacrifices they made to keep us free.
        While--let me start by saying that the veterans that we
    honored on Memorial Day, they served our country, and that
    peaceful protests are a demonstration of the freedom that our
    veterans served to safeguard and to protect. While we reject
    the defacing of our national monuments, I would take another
    moment to express my gratitude to the National Park Service,
    its employees and volunteers, who quickly restored our
    memorials, all of them, but especially those that recognize the
    service of our men and women, particularly the World War II
    memorial.
        I know that this Committee will continue to further our
    Nation's pledge--one nation under God, indivisible, with
    liberty for all. We do that by honoring those who served to
    make certain we live in that country and we, again, use this
    Committee as an opportunity to pay our regards and respect to
    veterans who lost their lives to protect our freedoms.
        Today's hearing is on the VA's Fiscal Year 2021 budget
    request and the supplemental appropriations contained in the
    CARES Act to respond to the COVID-19 outbreak. We welcome
    Secretary Wilkie as well as Dr. Richard Stone, Executive in
    Charge of the Veterans Health Administration; Dr. Paul
    Lawrence, Under Secretary for Benefits; and Jon Rychalski,
    Assistant Secretary for Management and Chief Financial Officer.
        I appreciate your presence here today and we certainly have
    done our job to socially distance. Mr. Secretary, despite the
    distance between you and me and your team, there is nothing
    other than COVID-19 that causes that to occur, and I look
    forward to continuing to work closely with you at every
    opportunity.
        I look forward to discussing with you all today how we can
    work together to improve outcomes for veterans in our country.
        I would also like to acknowledge the passing of veterans
    and VA personnel who lost their lives due to COVID-19. Part of
    our discussion today is to make certain the VA has every tool
    it needs to minimize the loss of life during these
    unprecedented times, and I also want to thank the VA nurses,
    our doctors, and support staff who work tirelessly to deliver
    care to veterans during the COVID-19 pandemic.
        In addition to serving veterans, the VA has executed its
    fourth mission, to support the American health care system
    struggling during this national emergency. This response from
    these health care professionals has been and continues to be
    admirable and important and necessary.
        While the VA continues to devote resources to suppress the
    pandemic, veterans will continue to rely on the VA for their
    needs, such as education, home financing, and transition
    services. To this end, the pursuit of the well-being of our
    Nation's veterans must continue unabated.
        Between the release of this budget and today's hearing,
    Congress passed legislation to support Federal agencies
    responding to the pandemic. Following a supplemental
    appropriation request from the President, Congress passed the
    CARES Act, signed into law on March the 27th. CARES provides
    $19.6 billion for medical services, including telehealth
    services, equipment, and supplies, personal protective
    equipment, and emergency room and urgent care. CARES also sets
    aside $2.2 billion for IT, in order to increase telework
    capacity and other telehealth needs.
        I am interested to learn how the COVID-19 emergency has
    affected the VA health services and its budget.
    Retrospectively, did the CARES Act appropriately fund the right
    places, and prospectively, given the shifting health care
    demands, does the President's Fiscal Year 2021 budget still
    address VHA's projected needs?
        Released before the COVID-19 emergency, the President's
    Fiscal Year 2021 budget request includes a proposed increase of
    $22.8 billion in funding for the VA for a total of $243.4
    billion. This represents a 10.2 percent increase above Fiscal
    Year 2020 enacted levels. I look forward to hearing from you
    how the proposed budgetary increase will create better outcomes
    for our Nation's veterans.
        I was pleased to see the budget request includes an
    increase for medical community care as the VA continues to
    implement the MISSION Act. As we have discussed, many veterans,
    especially those in rural States like Kansas, depend upon
    community care providers for access to timely and quality care.
        The MISSION Act was a bipartisan effort to transform
    veterans' access to community care, it is strongly supported by
    every veteran service organization, and you have been a
    champion, Mr. Secretary, to ensure its proper implementation.
    We all want veterans to receive the care they need through the
    VA or in their community, and I look forward to discussing the
    future of the MISSION Act today.
        Addressing another of the Committee's health priorities, I
    appreciate the additional requested funding for mental health
    and for suicide prevention. Mr. Secretary, I know you share our
    priority. In January, this Committee unanimously reported the
    Commander John Scott Hannon Veterans Mental Health Care
    Improvement Act to provid targeted resources toward research,
    grants for community partners, and improved coordination
    between the Department of Defense and the VA to quell the rates
    of veterans who die by suicide. It is my hope that you will
    continue working with us to get this bill signed into law soon.
        Mr. Secretary, as always, I thank you for being here. I
    appreciate the difficulty of your job as the Administration
    works to find a whole government solution to the pandemic. I
    look forward to hearing your views on the Fiscal Year budget,
    and I now turn to my colleague and the Ranking Member of this
    Committee, the Senator from Montana, Senator Tester, for his
    opening remarks.

                  OPENING STATEMENT OF SENATOR TESTER

        Senator Tester. Thank you, Chairman Moran, I want to thank
    you for having this hearing. Before I get into my prepared
    Statement, I want to say 10 days ago was Memorial Day, and it
    was a different Memorial Day than I have ever experienced. It
    gave me an opportunity to think about everything that veterans
    have given us in this country--the freedom and the promise to
    live with liberty and justice for all. I think it is
    appropriate that as we have all said, every day is Veterans Day
    in this country, because, quite frankly, without the
    sacrifices, without the job that our military has done over
    generations, this country would certainly be a different
    country than it is today.
        I hope with all my heart, that we keep in our mind that
    this country is about liberty, and it is about justice, and it
    is about liberty and justice for all.
        So thank you to the veterans out there, and, Secretary
    Wilkie, I want to thank you and I want to thank your leadership
    team for being at the hearing today. Today we get to go over
    the details of the President's budget request. In the last 4
    months, the world has changed, and the VA has changed. More
    than 106,000 Americans have died, many of them veterans who
    have returned from wars abroad to die fighting a very different
    battle here at home.
        The VA is our largest integrated health care system in the
    Nation, and I know the VA has been focused on saving as many
    veterans' lives as possible, with more than 12,000 veterans
    having been diagnosed with COVID-19 by the VA. While many are
    recovering or convalescing, we should never forget that more
    than 1,270 have died.
        As part of this mission, VA has also taken care of non-
    veterans and has deployed staff and supplies to non-VA
    facilities like State veterans' nursing homes.
        VA's front-line workers and their work force have done an
    incredible job and deserve more than just a thank-you, because
    that is not enough for the work that they have done. It has
    been stellar. We must ensure that the VA has everything it
    needs to keep the employees that we have safe and take care of
    our veterans in the process.
        Today's hearing is an opportunity for us to take stock of
    where we are and where we need to be. Mr. Secretary, at the
    outset of the Nation's response to COVID-19, Congress fulfilled
    VA's request for nearly $20 billion to support its ability to
    take care of veterans. We do need a better understanding of how
    VA has spent those funds and whether unspent dollars will be
    available to address veterans' needs, whether it be COVID-19 or
    otherwise, in this next fiscal year.
        We also need to ensure that the President's budget request
    for VA in-house care meets the anticipated health care demands
    of veterans when looked through the lens of the coronavirus. We
    also need to know whether private sector providers are prepared
    to safely administer care to veterans, given the virus'
    unprecedented effect on American health care. We must
    anticipate the economic ripple effects of coronavirus on
    industries across the board, prepare for a potential increase
    in enrollment and reliance on VA, and evaluate whether the
    President's budget meets those demands.
        We have seen the devastating physical effects that
    coronavirus has had on those who have contracted the disease,
    but I think we have also seen large-scale negative
    psychological impacts such as physical distancing and
    isolation, the death of loved ones and lack of access to
    traditional in-person mental health resources.
        The VA needs to look to new and innovative approaches to
    providing mental health care to veterans across the country,
    such as increased access to telehealth services. As we have
    seen with this COVID-19 crisis, VA facilities need more space
    and certainly not less. We need capacity, and we will not get
    there by short-changing VA's infrastructure.
        With veteran unemployment on the rise, it is also critical
    that the VA communicate what programs we need to support in
    order to get veterans educated, trained, back to work, and able
    to provide for their families. One way we help veterans provide
    for themselves and their families is to ensure their claims are
    processed timely and accurately. I am truly concerned with the
    mounting backlog of claims from the COVID-19 pandemic due to
    deferred and disrupted in-person examinations for veterans, and
    with how these delays will affect them and their families.
        So I look forward to today's hearing, and learn more about
    how this budget request and the Department's response to COVID-
    19 has progressed, and I look forward to our conversation. Once
    again, thank you, Mr. Chairman, for having this hearing, and I
    want to thank all the witnesses for being here today.
        Chairman Moran. Senator Tester, thank you for joining us. I
    appreciate the relationship that you and I have, whether we are
    close or far apart. Maybe sometimes this works better for us.
    But I am delighted that you are with us.
        I would tell the Secretary and his team that we have almost
    every member of the Committee present, either here, in person,
    or remotely. This is a hearing that our Committee members take
    seriously, and they are participating. While I am pleased that
    all of our members are here, I also want to acknowledge the
    presence of Senator Boozman, who chairs the MilCon-VA
    Appropriations Subcommittee, who has a lot of interest and
    involvement in your appropriations. So Senator Boozman, thank
    you especially for joining us with your expertise and interest.
        Mr. Secretary, before I introduce you I would say not only
    thank you for being here but you have been very kind with your
    time to Senator Tester and I throughout the pandemic. I could
    not ask for more opportunities to have conversations with you
    and your team, Dr. Stone and others, and that was very helpful
    as we explored, and hopefully made suggestions and asked
    questions that were beneficial to you in fulfilling your duties
    during this pandemic.
        Mr. Secretary, welcome, and please proceed with your
    testimony.

       STATEMENT OF THE HONORABLE ROBERT WILKIE; ACCOMPANIED BY
            RICHARD STONE; PAUL LAWRENCE; AND JON RYCHALSKI

        Secretary Wilkie. Thank you, Mr. Chairman and Senator
    Tester. You stole the first line. I intended to say, and
    actually I will say, that in my experience working in this
    institution, everywhere from the majority leader's office to
    finishing with Senator Tillis, that I can say that there is no
    committee of authorization that has been more collaborative or
    more supportive of the Department that it oversees than this
    Committee, which is why I do say, with a straight face, it is a
    pleasure for me to be here.
        I also want to pick up on what you and Senator Tester said
    about the events of Memorial Day. Memorial Day has been part of
    my life for as long as I can remember. As Senator Tillis says,
    I was born in khaki diapers and am very proud of it. But this
    Memorial Day I looked out from the podium at the Quantico
    National Cemetery and saw three families scattered amongst the
    thousands of veterans at that cemetery and realized that this
    really was a different time.
        But I will say that we have, at VA, made sure that every
    obstacle possible was removed, so that on that day of days,
    those families could be in our cemetery, representing the 1.1
    million Americans who have lost their lives since the first
    shots were fired at Lexington in April of 1775.
        Mr. Chairman, you noted that last year we presented the
    largest budget in the history of this Department. That has now
    been surpassed by the budget presented to this Committee this
    year. But I want to say that your support in that budget
    reflects trust in VA that did not exist 6 years ago. This is
    not the VA you read about in 2014. Today we are rededicated to
    Lincoln's vision that we take care of all who have borne the
    battle and for their families.
        Our record of turnaround is something that may be
    unprecedented in the history of the Federal Government. In just
    a few short years we have implemented major reforms. Under the
    MISSION Act we have successfully given veterans real and
    permanent choice. While some said that the MISSION Act meant
    the privatization of Veterans Affairs, the numbers show that
    the opposite has happened.
        In the last fiscal year, we completed more than 59.9
    million internal episodes of care, a record high. While we were
    doing that, between June 6th and the declaration of the
    national emergency, we sent almost 4 million veterans into the
    private sector to fulfill the MISSION Act's mandate. We
    implemented critical updates to the Colmery Bill, we took on
    the new task of caring for thousands of Blue Water Navy
    veterans, and we continue to make progress in the highly
    complicated development of the electronic health care record
    that we will share with the Department of Defense so that
    people like my father will never be burdened with an 800-page
    paper record ever again.
        Today we continue to implement those reforms even as we
    cope with, as you and Senator Tester said, a radically new
    normal that none of us could have foreseen the last time I
    appeared before this Committee. This epidemic was a shock to
    health care systems around the planet, but you should be proud,
    as I am, the thousands of VA employees who put themselves in
    harm's way to create an indispensable resource, not only for
    our veterans but for our Nation.
        We continue to perform well because we took steps early on
    that allowed us to keep serving veterans even when there was so
    much uncertainty. Those steps included the immediate
    implementation of emergency management procedures in the last
    week of January, expanding telehealth access and prohibiting
    visitors to our VA nursing homes and spinal cord injury
    centers.
        Here is where we stand today. As of this week, more than
    12,000 veterans nationwide have been diagnosed with the virus,
    but 80 percent of those veterans are now at home, having
    recovered. We are caring, as we speak, for 1,200 veterans with
    the virus, a number that has fallen in the last 2 weeks from
    2,200. We have, currently, about 1,100 VA employees who have
    tested positive, but we estimate that our infection rate, with
    330,000 employees in Dr. Stone's department, to be one of the
    lowest infection rates of any health organization on the
    planet. It is less than .5 of 1 percent.
        Our staffing is stable because we have hired, in the last 7
    weeks, 16,000 Americans who have agreed to join us and serve
    veterans. That means 3,300 registered nurses, 22 CRNAs, 535
    physicians, and 202 nurse practitioners who are with us now
    full-time.
        More importantly, we have the lowest rate of infection
    amongst our nursing home residents, the lowest rate of
    infection of any system in the country, because early on we
    took very difficult steps to close off our veterans, sadly,
    from their families and their friends. Because of that we have
    19 veterans in our nursing homes, 19 out of the 7,000, who are
    infected with the virus. I believe that we have set an example
    on how to care for our Nation's most vulnerable.
        That stability in operations has allowed us to open our
    doors for the fourth mission, which is to back up the national
    health care system in times of crisis. We are now in 47 States
    and territories. By April, we were accepting requests to open
    dozens of our hospitals to non-veterans across the country. Our
    expertise in caring for nursing home residents is in the
    highest demand. We have deployed 294 VA staff to community
    nursing homes around America, and 330 VA staff have been
    deployed to help at State veterans' homes.
        The crisis, as I mentioned, was not costless for us. COVID
    has claimed the lives of 32 of our VA families. But in April,
    April brought us irrefutable evidence that the tide at VA has
    turned for the better. On the last day of the month we released
    a survey showing that a record 90 percent of veterans across
    the country now completely trust VA care. That is a record high
    and is a record high even in a pandemic.
        That is today's VA. It is a learning organization, filled
    with employees who can turn on a dime to keep veterans and non-
    veterans safe, even during this time of incredible uncertainty.
        Mr. Chairman and Senator Tester, I again thank you for your
    many courtesies to me and everything you do for our Nation's
    most deserving.
        Chairman Moran. Mr. Secretary, thank you very much. Let me
    begin with a handful of questions and then turn to Senator
    Tester. Committee, we will do this seniority, not knowing the
    presence of every member at the moment. We will work our way,
    alternating between Republicans and Democrats by seniority.
        Mr. Secretary, can you walk us through why we are seeing a
    steady growth and increasing funding in both internal VA
    medical services and community care? Let me use this
    opportunity to say that I believe that whether the care is
    provided in the community or provided internal to the VA, both
    are VA care. They are both part of the Department of Veterans
    Affairs and they are not separated.
        You indicated the hiring of 10,000 medical staff. This, in
    my mind, could lead toward a greater capability of seeing more
    people internally within the VA, and maybe result in less
    people involved in community care.
        You have also indicated, to me and Senator Tester over a
    long period of time, the increasing use of telehealth. How does
    that then have a consequence on the amount of veterans being
    seen internal and in community? I mean, I raise this question,
    in part, because we are being requested in this budget for more
    money in both categories, internal VA care and community care.
        Secretary Wilkie. Mr. Chairman, let me answer the
    telehealth question first, and I think that is a separate
    category because it rests on a priority that I gave to this
    Committee when I had my confirmation hearing.
        The two communities in this country who serve the Nation in
    higher numbers than any other communities are rural Americans
    and Native Americans, the two populations that are the hardest
    for us to reach, no matter what the MISSION Act does. But what
    we have done with telehealth is increase our footprint in rural
    and Native America.
        I will give you an example. In April, we had over 900,000
    telehealth encounters. That is an increase of several hundred
    percent. The reason that is important is at a time of crisis,
    when those veterans cannot get to our facilities, or they
    cannot get to their private sector provider, we have offered
    them a window to help with their health conditions. I intend to
    expand our footprint through telehealth into rural and Native
    America.
        On the community care side, I am fully committed to
    expanding that choice. Even during this time, 60 percent of our
    normal MISSION Act community care appointments have been
    carried out. The one thing that we have discovered during this
    crisis is that many of our veterans are not going into the
    private sector, and you have seen that all across the country
    with declining rates not only of wellness visits but visits to
    the emergency rooms.
        That has been the makeup of how we have reacted both to the
    expansion of MISSION but also the expansion in the confidence
    that people have in VA. I will let Dr. Stone add some comments
    about the numbers and budget.
        Dr. Stone. Mr. Chairman, the growth in the budget reflects
    enhanced enrollment--we are anticipating about 30,000 more
    veterans to be enrolled with us--and enhanced dependence upon
    the system. As you know, about 80 percent of the veterans that
    are enrolled with us have other health insurance. They do not
    get all of their care from us. About 20 percent do get all of
    their care. But increasing amounts of dependence upon us, as
    well as the growth in referral to community care.
        A small percentage of the increase is due to MISSION Act
    and the increased requirements of probably not more than 2, 2.5
    percent, but Jon will correct me if I am wrong on that number.
    But it is really dependence upon us and the enrollment. As we
    come out of this pandemic, we certainly are concerned that
    financial destabilization of the veteran population may result
    in even greater dependence upon us, and I will defer to Mr.
    Rychalski to correct anything I said.
        Chairman Moran. Mr. Rychalski?
        Mr. Rychalski. I have no corrections. I would say that from
    the enrollee health care projection model that we use to
    predict costs, I think the big cost driver is the reliance that
    Dr. Stone mentioned. I think more people are taking advantage
    of the VA. So we are a victim of our own success. I think there
    are more programs, more benefits, more access, different
    environment, and frankly people are coming and taking advantage
    of it.
        Chairman Moran. Is there a way to distinguish between
    increasing number of veterans accessing care and the cost of
    care in your calculations of a budget?
        Mr. Rychalski. There is. It gets very complicated. As you,
    I think, know, and Dr. Stone alluded to, I belong to a
    commercial health care plan and they sort of know that I am
    going to use their health care plan for all of my health care.
    The challenge that we have is, you know, we have beneficiaries
    that have all kinds of Medicare, TRICARE, private insurance,
    and the challenge for us is predicting how much of the VA they
    are going to use. You know, we may see an increase in VA
    because of this, you know, this COVID pandemic, people losing
    their job, and that is something that we are looking at very
    closely. But predicting that and sort of knowing is a very
    difficult thing to sort through.
        Chairman Moran. Thank you all for your responses. Let me
    turn now to Senator Tester.
        Senator Tester. Thank you. Thank you, Mr. Chairman. I want
    to thank everybody who has testified. Look, you guys touched on
    it, and I am going to followup where the Chairman was at. This
    budget was developed long before we knew there was going to be
    a pandemic, and, quite frankly, it is a boatload of money, it
    needs to be right-sized. It does not need to be overly
    inflated, and it certainly should not be less than you need.
        Each one of you talked a second ago about an April increase
    in the hundreds of percents. You talked about the fact that 80
    percent of the folks have health care insurance. I think with
    unemployment increasing--and you guys talked about this--you
    are going to see increased dependence upon the VA. We have seen
    Medicaid enrollment, for example, increase by 2.8 percent
    February to April, and it is going to increase some more moving
    forward.
        So I think we can anticipate there is going to be more
    pressure put on the VA, and I think we all can agree on that. I
    think you have already said that. The question is, does this
    budget account for that, since it was laid out long before we
    had the COVID-19 pandemic on our hands.
        Secretary Wilkie. Senator, let me--Senator--and Jon can
    give more details--the one silver lining in what has happened
    is that when I first started talking to you and talking to the
    Chairman, we were projecting hundreds of thousands of veterans
    being infected with this virus. We have mercifully been spared
    those numbers. Of the 9.5 million veterans we serve, 12,300
    have been infected.
        What does that mean for the CARES Act and the supplemental
    funding? That means of the $17.2 billion that the appropriators
    allocated to us for the CARES Act, we have spent $1.01 billion
    on medical services. Right now we have more than enough to
    anticipate the problems that you have just outlined.
        Our problems and our emphasis will be on making sure that
    the claims and that the education programs and the vocational
    programs are fully up and running so that when we get back to
    those face-to-face encounters we will be able to provide those
    veterans with the services they need.
        In terms of internal appointments, I do not see it going up
    much more than it has, because we have reached almost a
    saturation point in terms of the number of veterans that we
    have in the system, and the number of veterans across the
    country is going down.
        Jon, did you want to----
        Mr. Rychalski. I am sorry. Go ahead, Senator Tester.
        Senator Tester. Well, I would just say go ahead, very
    quickly, Jon, if you could, because I have some followups.
        Mr. Rychalski. Just to confirm what the Secretary said. You
    know, we did not anticipate this in the budget but we have a
    lot of flexibility.
        The one thing I would like to emphasize, though, where we
    could really use some help, is we did not get all the right
    money in all the right places. We do have a real need to move
    some of that CARES money into VBA--not a large amount--some
    into NCA, and some flexibility for IT as well. Those are three
    areas where we are going to be short. Other than that, I think
    we have adequate flexibility. I think the 2021 budget is
    adequate, but we did not know this when we started. It is not
    all in the right places but it is not bad.
        Senator Tester. So it is your intent that--and this is the
    question I was going to ask you, and you touched on it, Jon--if
    your intent is to get authorization to roll any unused CARES
    Act money into different line items, where you would need money
    in this budget?
        Mr. Rychalski. Yes. In fact, you have given us authority to
    move some money around within the medical care appropriation,
    but we would ask for your support in expanding that a bit
    with--you know, with congressional oversight, to be able to
    move it to some other areas. I think we are providing weekly
    execution reports. We are happy to be 100 percent transparent.
    But we are going to need to move some of that money around to
    other areas. That is true.
        Senator Tester. That is fine. That is good. That
    transparency is good, and I want to thank you for that
    Statement.
        So First of all, congratulations. I understand that there
    have been 16,000 new people hired to the VA in April and May,
    and if I am wrong you can correct me on that. So
    congratulations on that. The question is, are these folks in it
    for the long haul, or are these folks that have retired and
    came back, that you plan on losing again, or is this really
    something that we can get our arms around to help solve that
    vacancy problem?
        Secretary Wilkie. Yes, sir. I believe 90 percent are
    permanent, and that is one of the best news stories that we can
    have in government.
        Senator Tester, I want to followup on something you and I
    have talked about, and the reason I believe that this funding,
    the supplemental funding, is so important. I am cognizant that
    this will boomerang, or can boomerang on us in the fall and the
    winter. I think the supplemental funding that the Congress has
    provided us will be our hedge against what could possibly come.
    We have demonstrated, I think, that we have the procedures in
    place to ensure that if it does come back we will be ready, and
    I believe we have the funding to meet that challenge.
        Senator Tester. I appreciate that Statement, Mr. Secretary.
    Thank you for that. I also say that I do not know what happened
    in April and May. This is not to what you touched on, but what
    you said is incredibly important, because if this does
    boomerang back you have got to be prepared for it. It sounds
    like you are working in that direction. Thank you.
        Whatever you did in April and May, to hire 16,000 people,
    can you repeat that in June and July? If you do that for a few
    more quarters we will be in really good shape----
        Secretary Wilkie. Yes, sir.
        Senator Tester [continuing]. from an employment standpoint.
        Secretary Wilkie. Yes, sir.
        Senator Tester. The last thing, and I will be very quick
    because if my eyeballs do not deceive me I have got about 50
    seconds left. The issues around testing are really important,
    and you have said that any employee that wants to get tested
    can get tested. We are not hearing that. We are not hearing
    that from the folks on the ground. We are still hearing that
    they are not being tested. Could you shed some light on that as
    to what the heck is going on?
        Secretary Wilkie. Senator, you are exactly right. We are
    not there yet, although we have tested over 12 percent of our
    employees. It is our intent to have on-demand testing for all
    of our employees. We are not there yet. Most of that relates
    not to the machines that we need. We have the ability to do
    60,000 tests a week on our machines. It is the availability of
    cartridges that go into that from the various vendors and the
    availability of swabs.
        Simply, when we issued the guidance to go to on-demand
    testing for our employees, we ran out of swabs in a--because of
    some problems with UPS shipping. That was a national problem
    with the crashing of UPS systems for a weekend. We have now
    recovered from that. Right now we have about 60,000 tests
    available, but we do not have the ability to institute on-
    demand testing from our employees, but it is our intent to get
    there.
        Senator Tester. Mr. Secretary, thank you. If I am 3 minutes
    and 20 seconds over, Mr. Chairman, thanks for not gaveling me
    down, but I should have been. Sorry.
        Secretary Wilkie. Mr. Chairman. may I----
        Chairman Moran. Mr. Secretary.
        Secretary Wilkie [continuing]. may I add to that 3 minutes
    and 30 seconds, because Senator Tester just finished, but this
    is also addressed to Senator Sullivan and Senator Rounds, and
    those Senators who have large Native populations.
        We have brought into our VA over 2,000 Native Americans for
    treatment. We have gone into the Native nations, and we are in
    several of those communities, and it is my intention to expand
    our footprint there, some of our most vulnerable veterans but
    also some of our most vulnerable Americans. As Senator Sullivan
    knows, we have 114 individual Tribal agreements, and it is my
    intention to expand that so there is no Tribal community that
    we miss.
        But I did not want to go without mentioning our help for
    the Indian Health Service. Someone criticized me a few days ago
    for not getting payments. I will worry about that much later.
    The most important thing is getting those services and that
    treatment out into Indian country.
        Chairman Moran. Mr. Secretary, thank you. Senator Tester, 4
    minutes and 51 seconds over, if you include the Secretary's
    remarks, and I will try to be more disciplined with my
    colleagues.
        Senator Boozman?

                          SENATOR JOHN BOOZMAN

        Senator Boozman. That is almost twice.
        Chairman Moran. Almost twice.
        Senator Boozman. No, we appreciate you, Senator Moran, Mr.
    Chairman, and Ranking Member Tester for holding this hearing,
    which is so, so very important. We appreciate you, Secretary
    Wilkie, and your team for the great job that you do.
        This is just a comment. I hope that we can continue to give
    you the ability to do the hiring process like you are doing it
    now. I do not know how long it would normally take you to get
    those people on board, but it would be a long, long time. So
    again, we appreciate you all working so hard and using the
    flexibility we have given you.
        The Fiscal Year 2021 VHA veterans' health budget request is
    $90 billion, a $10.8 billion increase from the prior year. If
    you look at 10 years ago, in Fiscal Year 2011, the budget
    request for veterans' health then was $52.1 billion. It is
    really remarkable the growth--to be precise, 73 percent in the
    last 10 years.
        We talked about some of the drivers that were doing that,
    and I would argue, having been on the Committee in the House
    and now in the Senate for many years with our distinguished
    Chairman, veterans health is so much better than it used to be,
    and we have the confidence now. Lots of people using the
    system.
        We also--is it correct that we have an aging veteran
    population in a sense with our World War II, our Korea, Vietnam
    veterans, again, with multiple problems facing, and then the
    increase in health care costs. So it is a lot of money, but it
    is something certainly that we are committed to doing. But the
    good news is I think the thing that is spurring it, as much as
    anything, is just the confidence that we are seeing in our
    veterans in continuing to use veterans health care when they
    could go to Medicare or some other insurance.
        Dr. Lawrence, recently we visited, or the staff visited.
    They were told that the recent suspension of the C&P exams due
    to COVID that were understandably creating a significant
    backlog. We have worked so hard to get that down. Can you talk
    about the plan? What can we do to get that back under control?
    I think what are we, 116,000 exams, something like that? Is
    that in the ballpark?
        Mr. Lawrence. Yes, you are being charitable. This morning
    it was 119,000. You are correct, sir. On April 2d, when VHA
    stopped doing C&P exams, we follow their lead, so on April 3d
    we told our vendors they could no longer do in-person exams. We
    started conducting ACE exams and using their medical records to
    do things like fulfill their claim or provide partial benefits.
    But you are right. The simple math of what took place, and, you
    know, you all deserve some positive responsibility for that.
    Through the Blue Water Navy Act, we began to receive a lot of
    claims in January, and now there are over 125 days. So that is
    correct.
        We have a plan to open following VHA's lead, and that would
    begin--they opened 20 hospitals. We are opening in that area
    June 8th. We will startup again C&P exams in certain parts of
    the country, and we will continue that. The vendors know and
    they are making phone calls now to schedule it.
        We are not happy about the backlog. In November it was
    64,000. Our team is very proud of processing claims quickly, so
    we want to get that right away.
        Two things, sir, to answer your question. The first thing
    was what Mr. Rychalski just said about reprogramming some
    money, so we will have overtime money to do the claims. The
    second, we have a piece of legislation, a legislative request
    in front of you, to allow doctors to conduct C&P exams across
    borders, and in addition some flexibility for non-doctors to
    conduct the C&P exams, nurse practitioners and the like. We
    would ask you to consider that, and that would be one way for
    us to expand the capacity to work the C&P backlog--work the C&P
    exams and therefore the backlog.
        Senator Boozman. Very quickly, Secretary Wilkie, the fourth
    mission has been a big success. As a result of that, FEMA, HHS
    owes the VA some money. Can you talk quickly about the plan and
    actually recouping that? What is going on with that? Certainly
    that would be very helpful to us as we work through the budget.
        Secretary Wilkie. Jon might have exact figures, but as you
    know, statutorily, FEMA and HHS have to reimburse us when we go
    on missions that they have approved. One thing that I did,
    though, was I just started calling Governors. We went out ahead
    of many of those missions because particularly in State
    veterans' homes there was a crisis, and FEMA has caught up with
    those requests.
        But I will get you figures on how much we are owed so far,
    unless Jon has new figures.
        Mr. Rychalski. I was just going to say, sir, we are
    tracking it closely. We have worked with FEMA. We have not
    billed them nor collected anything, but we will be doing so. We
    can provide you a breakout of that.
        Senator Boozman. Thank you, Mr. Chairman.
        Chairman Moran. Senator Brown.

                         SENATOR SHERROD BROWN

        Senator Brown. Thank you, Mr. Chairman and Mr. Secretary.
    Thank you and Ranking Member Tester. Thanks for eating up some
    of my time, Jon. I appreciate that.
        We are here to discuss VA's budget and the Department's
    COVID-19 pandemic responses. Today VA reported 1,200 veterans,
    32 VA employee deaths since the start of the pandemic. Our
    country is in a crisis. People are dying of a disease that
    continues to spread, particularly among seniors, and especially
    among the black and brown workers who are keeping our society
    afloat right now.
        We know who essential workers are. They are too often paid
    too little. One essential worker said to me, ``I do not feel
    essential. I feel expandable. I am not paid very well. My work
    conditions are not very good,'' and that is something that all
    of us on this Committee should think about, especially when
    they are veterans.
        Protesters are in the street now because their government
    is failing them. It is failing to protect our workers. Not only
    has it failed to protect black and brown American workers, for
    generations of people who are supposed to protect everyone it
    has too often been turned against them.
        Peaceful protesters should not be tear-gassed or pelted
    with rubber bullets so the President can exploit a house of
    worship, to stage a photo op. They are not terrorists. American
    cities are not battle spaces. I know that the great majority of
    veterans, I assume the great majority of VA workers agree with
    that, and they too are embarrassed when the President disbands
    peaceful protestors and then brandishes a Bible as a weapon.
        On this Committee we honor those who have chosen a life of
    service. Nothing is more patriotic than upholding the
    Constitution and exercising our fundamental rights. We need to
    continue working together to address injustice and inequality
    to ensure that all Americans are treated fairly.
        I have directly heard from student veterans about how this
    pandemic has affected their GI Bill benefits. Congress worked
    to provide relief. I am still concerned that the information
    from VBA is not reaching all the colleges and universities in a
    clear format. I urge the Secretary and the staff to work a
    little harder on that. We need to make sure work-study students
    still are paid or that when classes are only offered online, GI
    Bill benefits continue as if classes were in person. Even after
    we passed legislation to address these issues, my office has
    heard from veterans in schools.
        My First question, Dr. Lawrence. Would you commit to work
    with my staff, with Anna and Drew on my staff, if we hear of
    additional concerns about this?
        Mr. Lawrence. Absolutely.
        Senator Brown. Okay. Thank you. I figured you would say
    yes, and you have always been cooperative. Thank you.
        Mr. Secretary, I appreciate Senator Tester asking about
    vacancies. I had the same question. We need to continue to
    drive down the time it takes to hire medical professionals at
    VA. Can you commit to retain the expedited hiring practices
    that you have ably scaled up during the crisis?
        Secretary Wilkie. Oh, absolutely, and if I need additional
    authorities I will come to this Committee. I think we have
    shown, Senator Brown, that the government can work, and we have
    cut months, almost years off of the hiring process.
        One quick thing. One of the incentives that we gave is that
    we told people if you joined us you can stay in your hometown
    or in your home State should you so desire. I think that is a
    huge incentive.
        Senator Brown. That is very important. I wanted to take
    this opportunity to urge you to find a way to negotiate in good
    faith with the VA unions. I and veterans know they get better
    care, and employees know their concerns are addressed where
    union representation is at the table. We know that workers are
    more productive and they are better treated.
        Dr. Stone, Dr. Lawrence, have you reviewed the white paper
    released by the National Veterans Legal Services Program and
    the Jerome Frank Legal Service Organization at Yale Law School.
    Veterans who were stationed in Guam for a decade in the 1960's
    and 1970's were likely exposed to dioxin-containing herbicide
    agents, including Agent Orange. Have you looked at that paper
    and do you agree with the assessment? For Dr. Stone and Dr.
    Lawrence.
        Mr. Lawrence. Sir, let me go first. Yes, sir. We reviewed
    the paper and I believe we responded to a letter to you all
    about, you know, the inability of us to find the use of the
    dioxin in that area. I know it was a very complicated paper
    that required analysis from our team. I am happy to discuss it
    more with you, but yes, it has been reviewed.
        Senator Brown. Okay, thank you. Dr. Stone, do you want to
    add anything?
        Dr. Stone. Sir, I have reviewed the paper and I agree with
    Dr. Lawrence. It is very complex in its process and we look
    forward to coming to resolution on it.
        Senator Brown. Okay. It is important that the VA always
    stand--as you know, always stand with veterans and Agent
    Orange. We are sometimes slow to that. With burn pits and now
    with this study it is important always that we come down on the
    side of veterans.
        Last comment, Secretary Wilkie and Dr. Stone. The VA has
    made a major shift toward telehealth to decrease possible
    spread of COVID-19. When we passed the CARES Act we included
    specific funding to increase veterans' access to internet and
    telehealth. Some areas of Ohio are rural. Many of the Senators
    on this Committee have even more rural areas than I do. They do
    not have great access to broadband. This is especially
    important as veterans rely more heavily on telehealth for the
    foreseeable future.
        I hope you will share--my time is up, but please share with
    the Committee at some point what steps VA, or with my staff,
    what steps VA has taken to enter into contracts to expand
    broadband and telehealth services for our veterans.
        Thank you, Mr. Chairman. If you would just--you can answer
    that question in writing, or if you want to take the time now.
        Secretary Wilkie. We will. It is a priority for us,
    particular, as you mentioned, in rural America.
        I did want to say something about your opening comment
    about--I believe you mentioned gender disparities. We are in an
    interesting position at VA. Forty-nine percent of eligible male
    veterans are in our system. I can say to this Committee today
    that 42 percent of all eligible female veterans are now in the
    VA system. Dr. Stone has just hired an assistant, special
    assistant, to monitor those issues, any disparities, and report
    directly to him. I think we are the only health care system in
    the country to monitor gender and racial disparities in terms
    of health care and health care outcomes.
        So we are in the lead, and I think for many of those
    communities the health care outcomes are much better within our
    system than they are in the private sector. So I take your
    point to heart.
        Senator Brown. Thank you, Mr. Secretary. Thank you,
    Chairman Moran.
        Chairman Moran. Senator Cassidy. You are welcome.

                          SENATOR BILL CASSIDY

        Senator Cassidy. Thank you all. Thank you for your good
    service and thank you in New Orleans, which had a lot of COVID.
    You all did a lot of work to kind of mobilize resources. I
    really appreciate that.
        A couple of things. I have heard--again, as a physician I
    get these phone calls from physicians all over the country. Now
    one thing that has been said that in the referral to outside
    specialists for different aspects of care the intensity of the
    care is greater than it would be if it were given in the VA,
    that every test is done that is imaginable, and some of which
    you would not think would be indicated. Maybe you cannot
    establish that they are not, but they ordinarily would not be
    done in a more well-run system.
        We are speaking not just for the VA in general but we are
    also speaking for specific facilities, because you want to have
    a kind of a spectrum of that. Dr. Stone, I think you have been
    flagged for this.
        Dr. Stone. Yes, sir. We authorize standard episodes of care
    in which we define the scope of services to be done. But we do
    find a greater utilization of services out in the commercial
    space than we do----
        Senator Cassidy. Now that assumes, Dr. Stone, just because
    I have limited time, if you do have greater utilization of
    services, either there is an underutilization within the VA or
    an over on the side. Now I will just say, as a doc, if you do
    too much, bad things happen. It is not benign to do something
    which is not indicated. On the other hand, it should be done if
    indicated.
        So do you have a sense of inside versus outside as to the
    relative weight of that?
        Dr. Stone. Yes, and, sir, that is why we designed the
    Community Care Program to be highly integrated with the VA at
    the center and the primary care clinician at the center of
    that, to make decisions in the best interest of the veteran,
    and to work with the veteran for how to proceed. We fine, in
    some very simple areas, like physical therapy, dramatically
    higher uses in the commercial space that is done within VA.
        Senator Cassidy. But begging the question, is it
    appropriate increased intensity, or not?
        Dr. Stone. Not always.
        Senator Cassidy. So is there--I presume then that you all
    are taking measures, because that is one, expensive, but two,
    it is also perhaps contraindicated, which is more important.
        Dr. Stone. We are, and that is the beauty of the health
    information exchange, which allows us to utilize and to
    integrate health care information systems for the veteran so
    that there is not repetitive work being done, and we have full
    visibility.
        Senator Cassidy. Is it possible that you could give this
    Committee a report on a per-institution basis? The Dartmouth
    study suggests that it is regional, or even State, or even
    community located in which you have increased intensity of
    certain services. I think the individual members of the
    Committee would like to know how the VAs in their bailiwick, if
    you will, are responding to this challenge.
        Dr. Stone. We would be happy to work with your staff and
    the Committee staff to really work through that request.
        Senator Cassidy. Let me ask, Mr. Secretary, you mentioned
    the success in hiring new people, but I was recently told it
    can take as long as 6 months for someone to be offered a
    position for them to actually be onboarded and to be seeing
    patients. Any comments on that?
        Secretary Wilkie. Senator, before Dr. Stone answers that,
    as a physician might answer that, we have been able to cut
    through most of the Federal flotsam and jetsam when it comes to
    hiring people. I have shaved off weeks and months out of the
    hiring process. When people apply, that hiring application goes
    straight to the medical center or to the department that would
    be hiring that person. The onboarding is done quickly. So we
    have cut down years, months into weeks, and I do not know that
    anyone right now is experiencing that 6-month delay. Now there
    may be one or two specialties that might, but Dr. Stone can
    answer that.
        Dr. Stone. Sir, it was not uncommon for us to take 6 months
    to bring a clinician on, mainly because of the prime source of
    verification of their education. With the help of Office of
    Personnel Management we have cut that down to 7 days now, that
    if you apply today, in 7 days we will have you at work.
        Senator Cassidy. Really?
        Secretary Wilkie. We have hired almost 600 physicians just
    in the last 6 weeks.
        Senator Cassidy. I have got 36 seconds left. Let me ask you
    a 4-minute question. During the COVID, coronavirus crisis we
    have been using more tele mental health and telehealth
    services. To what degree can we continue to use those tele
    mental health? Have you found them as effective as traditional
    mental health services?
        Secretary Wilkie. We certainly have, and I think this is
    the wave of the future, particularly for mental health. In
    addition to what we have provided, we have now entered into
    agreements with--I will give you an example--Walmart. Senator
    Tillis knows, I cut the ribbon on a Walmart Veterans Health
    Clinic that exists behind the pharmacy wall, where a veteran
    can come in and talk to a mental health provider--this is in
    Asheboro, North Carolina--anywhere in the country.
        This is the wave of the future. It prevents veterans from
    having to experience the pressures of a large clinical setting.
    It takes the pressure off of their families. I expect it to
    grow. I think the one benefit of this epidemic, it has allowed
    us to stress the test.
        I will finish by saying--I am going to make a Louisiana
    comment. My grandmother is watching, in New Orleans. She was
    born in the middle of the Spanish Flu at the early part of the
    20th century. She is still in New Orleans. She survived this
    one. So that tells you the resilience of the Crescent City.
        Senator Cassidy. Thank you. I yield back.
        Chairman Moran. Senator Blumenthal.

                       SENATOR RICHARD BLUMENTHAL

        Senator Blumenthal. Thank you, Mr. Chairman. Thank you all
    for being here. Thanks for your service. I saw a report, I
    think this morning, in the Military Times, that the number of
    active COVID-19 cases at VA medical centers nationwide has
    risen by more than 7 percent in the last 5 days. That is a
    pretty alarming turnaround, in contrast----
        Secretary Wilkie. I can answer that. The system--the
    accounting system was down for several days. But overall, 9.5
    million veterans that we serve, we have had 12,300 infections.
    Of those 12,300 infections, we have less than 1,500 active
    infections. I think there is no health care system in the
    country that has been able to keep those numbers down as we
    have. I think we did it because we acted early. We were acting
    in February.
        Senator Blumenthal. My question to you, though, is the
    trend. What has been the trend over the last 5 days? Are you
    saying that the Military Times was in error?
        Secretary Wilkie. I am saying their interpretation was in
    error.
        Senator Blumenthal. Well, you are saying they were in
    error.
        Secretary Wilkie. I said their interpretation was in error.
        Senator Blumenthal. What are the numbers?
        Secretary Wilkie. I gave you the overall numbers.
        Dr. Stone. Sir, if I might add to this, I would ask you,
    Senator, to consider two things, one, the number of cases, and
    second, how many are hospitalized. Our hospitalization numbers
    are stable and are not increasing. I think as we increase
    testing, and we are doing 3,000 to 4,000 tests a day in
    veterans, you are going to get numbers going up. It is just
    like in each of your States, that as you penetrate with----
        Senator Blumenthal. Well, that is an explanation, but the
    numbers are showing an increase. Correct?
        Dr. Stone. The actual number is showing an increase, but
    not in hospitalizations. Hospitalizations----
        Senator Blumenthal. It is an increase in the number of
    active cases. I understand hospitalizations are different from
    active cases.
        Secretary Wilkie. Yes, and most of those cases are at home.
        Senator Blumenthal. At home?
        Secretary Wilkie. Because they do not require----
        Senator Blumenthal. Well, that may be true----
        Secretary Wilkie [continuing]. they do not require----
        Senator Blumenthal [continuing]. I am asking you for
    numbers.
        Secretary Wilkie. Well, I just gave you the numbers.
        Senator Blumenthal. I just want to make sure that I
    understand. The trend is up by around 7 percent of active
    coronavirus cases. The Military Times was correct in that
    report.
        Secretary Wilkie. The trend--Look. The interpretation is
    that there is an explosion.
        Senator Blumenthal. Let me move on to another topic because
    I am limited in terms of time. My understanding is that you
    have spent only--you have obligated only about $2 billion out
    of the $19.6 billion that has been provided under the CARES
    Act. Why so small a percentage of the funding obligated?
        Secretary Wilkie. Well, because mercifully the original
    projections that I discussed with the Chairman and Senator
    Tester of several hundred thousand infections did not play out.
    Those were the projections we were looking at at the beginning
    of this.
        Senator Blumenthal. So you do not need the money?
        Secretary Wilkie. I also mentioned earlier, Senator, that I
    am standing by for a rebound. We do not know what is going to
    happen in the fall and winter.
        Senator Blumenthal. So if that 7 percent trend that I just
    mentioned continues, you might need the money more than you do
    now?
        Secretary Wilkie. Well, I think with the rebound you would
    see people who have had no contact with the virus be
    susceptible to it in the fall and the winter.
        Senator Blumenthal. Let me ask you, with respect to PPE,
    how many--and this is relevant to the potential rebound--how
    many weeks of supplies do you have now in PPE?
        Secretary Wilkie. We have multiple months of supply of PPE.
        Senator Blumenthal. Multiple months?
        Secretary Wilkie. Yes.
        Senator Blumenthal. So you have more than ample personal
    protective equipment.
        Secretary Wilkie. If I can add, the Chairman and I have
    talked, and so has Senator Tester. We are setting up a system
    that is something that you were familiar with in your Marine
    Corps days. The Marine Corps and Navy had supply depots all
    over the country--spare parts, technicians. We are doing that
    with our PPE and our medicines. I think this is our hedge for
    the future, so that we will not be susceptible to a disruption
    in the supply chain. So I have adopted the models that I saw as
    a young naval officer, and we are preparing by stocking up.
        The other thing I would say is that we never fell below 2
    weeks of supplies during this crisis.
        Senator Blumenthal. I have one last question. I have many
    questions. Some I will submit in writing, but one more question
    I want to ask you here. I introduced a bill last year that was
    supposed by 18 veteran service organizations to remove the 1-
    year manifestation period for three illnesses linked to Agent
    Orange, and I would like your support for that bill, 50 years
    after the veterans suffered the harms that are still affected.
        Secretary Wilkie. Well, I certainly--as the son of a combat
    soldier from Vietnam I understand it probably as well as any
    dependent. Dr. Stone and I will be reviewing that, as well as
    several other studies that are tangential to your legislation,
    in the coming weeks.
        Senator Blumenthal. While you are reviewing that, maybe you
    could also indicate why you have not categorized as a
    presumptive disability three--several conditions that are
    classified by the National Academy of Sciences in that regard.
    I know that ordinarily you follow their recommendations. In
    2016, the National Academies recommended adding four new
    conditions to the Agent Orange presumptive disability list,
    including bladder cancer, hypothyroidism, hypertension, and
    Parkinson-like symptoms. Despite that scientific backing, you
    have not added those conditions.
        Dr. Stone. Sir, we and the Secretary have spoken previously
    about this, and we are waiting for these two additional studies
    to finish, that are broad studies of death rates as well as the
    health status of the Vietnam veteran before we come to
    agreement on that. We have talked to the National Academy of
    Sciences and looked at the statistical variance that they have,
    and frankly, I am not as convinced as the National Academy of
    Sciences is. But we will defer to those two studies and then
    make recommendations to the Secretary.
        Secretary Wilkie. Mr. Chairman, if you would indulge me to
    finish the original question Senator Blumenthal asked about the
    7 percent increase and why I was questioning the
    interpretation. We have 9.5 million veterans in our system. We
    have had 12,300 infected, mercifully, an incredibly low number.
    Of those 12,300, well over 9,000 have completely recovered. So
    a 7 percent increase--and why I was challenging the
    interpretation--sounds like there has been an explosion in
    terms of the number of veterans infected. It has been
    mercifully low if you look at the entirety of the community we
    serve.
        Senator Blumenthal. My time has expired. I thank you, Mr.
    Chairman.
        Chairman Moran. You are one of my Ranking Members, as is
    Senator Tester, and you almost got as much overtime as he did.
        Senator Rounds?

                          SENATOR MIKE ROUNDS

        Senator Blumenthal. Thank you.
        Senator Rounds. Thank you, Mr. Chairman. Mr. Secretary,
    gentlemen, thank you all for your service to our country.
        Mr. Secretary, in a call we had with you just a few weeks
    ago you were confident that any overdue provider claims were
    old Choice-era claims, but earlier this week, in preparation
    for this hearing, leaders from your department told members'
    staff that there are aged MISSION Act claims among the VA's
    current backlog. This does line up with your written testimony
    today, page six of your testimony, in which you have indicated,
    and I will quote, ``The VA realizes it needs to do a better job
    of paying claims from community providers.'' It is certainly
    reflective of what my experience is and what I continue to hear
    from my providers in South Dakota.
        Looking at your request for $18.5 billion for community
    care for Fiscal Year 2021, what I would like to know is, is
    this enough to make sure your department can do what needs to
    be done to get our community providers paid in the time that
    the law currently requires? Just as an example, is this enough
    money to get the eCams up and running at 100 percent capacity?
    I think according to discussions with staff earlier this week
    it is running at about 33 percent capacity. Our expectation,
    based on a February discussion, was that it would be up and
    running by about May 4th or so. So we have got a ways to go
    yet.
        Is this enough money to clear your backlog of the 2 million
    claims, and help the VAs transition out of the direct payer
    role altogether?
        Secretary Wilkie. Before Dr. Stone answers the way forward
    I will say, and I have been in South Dakota twice in the last 6
    months, since MISSION kicked in on June 6th of last year we
    have processed 22 million claims and disbursed $6.9 billion. I
    can say that with the coming of new management to our regions
    right now the number is at 57 percent of all claims are now
    paid within 7 days. That still means we have a backlog, but it
    is moving in the right direction.
        Dr. Stone. Senator, the last time you and I talked about
    this I had between 3.2 and 3.4 million claims in backlog. That
    number is now down to 1.9 million, and we disbursed over $1.3
    billion in payments last month, in the month of May. I think we
    are going in the right direction. eCams has not come on board
    at the rapidity at which we wanted, although it is running
    well. What we are looking for is auto-adjudication, where it,
    on an automatic basis, adjudicates a claim. That, you are
    exactly correct, it's not at the level it should be. I have
    been reassured by Dr. Mathews and her team, who are running
    Community Care that in the next month we will take a dramatic
    upturn in the amount of auto-adjudication that is driving this
    down.
        Now the first question you asked was, is $18 billion going
    to be enough? It looks like it. It looks like even with the
    growth in the dependents and the unknown that we have as we go
    into a potential second wave, or even third wave of this
    pandemic, we will be Ok with that number.
        So I am confident in that number. What I am still not happy
    with is the amount of backlog claims. We must be a good partner
    to every provider or we are not going to keep the 880,000
    providers who have pledged their commitment to Americans
    veterans.
        Senator Rounds. Thank you, and I think that is really the
    crux of it for us, is if we are not paying these providers in a
    timely fashion. A lot of them do not have real deep pockets,
    and if they cannot get paid to continue to pay their bills,
    then at some point--and so far none of them have declined the
    veterans, but we most certainly do not want to get them to the
    position where they feel that they may.
        Dr. Stone. Senator, they have not, and we are keenly aware
    that the American health care systems in the private space are
    losing $50 billion each year, and we have worked really hard to
    make sure that we can do our part to maintain their liquidity.
        Senator Rounds. Great. Thank you.
        Mr. Secretary, can you give me a walk-through of the
    decision to decrease your requested funding for the VA's Rural
    Health Initiative this year by 10 percent, from $300 million in
    Fiscal Year 2020 to $270 million in Fiscal Year 2021? It seems
    that with your emphasis--and I know you have been to South
    Dakota twice and you have talked about what we need to do to
    work with IHS in our rural areas. But to see that decrease kind
    of caught me by surprise.
        Secretary Wilkie. I will go back and look. I think it is
    because of the emphasis on telehealth, which has cut down on
    costs. But I will give you a line-by-line breakdown of why that
    happened.
        I would also add--and this is a parochial matter for you--I
    was on KELO yesterday, and I wanted you to know that I renewed
    the commitment to Hot Springs on South Dakota television, and
    my staff has been in contact with your staff to make sure that
    when we deal with that record of decision it is not only
    airtight, it is also in line with the legislation that you put
    in the appropriations bill.
        Senator Rounds. Thank you. Thank you, Mr. Chairman.
        Chairman Moran. Senator Rounds, thank you very much. I
    meant to mention after Senator Blumenthal's questions that this
    Committee will have a hearing next Tuesday. He was asking the
    Secretary--Senator Blumenthal was asking the Secretary about
    PPE. Our Committee will meet next Tuesday afternoon to have a
    hearing. The title of the--the subject is ``Building a More
    Resilient VA Supply Chain.'' So we are going to spend some more
    time with the Department in regard to this topic.
        Now Senator Hirono.

                          SENATOR MAZIE HIRONO

        Senator Hirono. Thank you very much, Mr. Chairman. What is
    happening in our country right now is a tremendous
    acknowledgment of the disparities that have existed in our
    country for far too long. The pandemic has further exposed the
    disproportionate access people of color have to critical
    services, like health care, housing, education, social
    supports, and protests are happening all over the world, in all
    of our country, including, of course, in Hawaii, in response to
    violence against black Americans.
        We are at a time in our country when we cannot just go back
    to doing things as usual, and if ever there was a time to have
    some kind of reckoning to move us forward, this is it.
        When the top leadership of our agencies does not reflect
    the people they serve, that can have real lasting consequences.
    So, Mr. Secretary, I would like to ask you, would you agree
    that diversity in those who are making decisions that impact
    the lives of all the diverse group of veterans that you serve,
    is not diversity in leadership a good thing in order to provide
    truly equitable services to veterans?
        Secretary Wilkie. Senator, I will be careful in my answer.
    I grew up in this world. I think you will find that the Armed
    Forces of the United States have been the great leveler when it
    comes to equal treatment. I have surrounded myself with people
    who have the same experiences. Everyone at this table has
    served in uniform. We understand the culture and we speak the
    language. My deputy, she graduated from--she graduated from the
    United States Air Force Academy. Our Assistant Secretary for
    Legislative Affairs, who is sitting behind me, I actually
    served under in the Air Force.
        We have one goal. It does not matter where we come from, we
    have all served. I think for us, at VA, that is the most
    important thing. I would also add what I said earlier. We are
    the only health care system, Senator--and you and I have talked
    about this--we follow gender disparities. We follow racial
    disparities. We have now brought up, just in the last few
    years, the percentage of veterans who are women to 42 percent.
    The percentage of veterans, eligible veterans, who are male are
    49 percent. So we are moving up.
        Just a few years ago there were only a few, less than
    200,000 women in the system. Today there are 500,000. So I
    think we have----
        Senator Hirono. I acknowledge that. What I am talking about
    are the people who are making decisions on behalf of the
    diverse group of veterans that you now have, and many of them
    are women. We are already acknowledging that they may have
    different kinds of health care and other kinds of needs, and
    therefore you are programmatically seeking to address those.
    But it is really the people who are making decisions.
        Let's face it. I am not disparaging anybody who is in the
    military, by the way, and there should be an acknowledgment
    that we all have implicit bias. No matter how fair we may all
    think we are, that unless you walk in the shoes of somebody
    else then it is--it is not the kind of thing where we can, ``Oh
    yes, I know what you feel. I know what you are thinking.''
        Secretary Wilkie. My, my----
        Senator Hirono. So this is why I would say, diversity in
    leadership is important.
        I do have a question for you before I run out of time.
        Secretary Wilkie. I will just say my deputy, she served 30
    years in the Air Force, and I think that is a testament to how
    far VA has advanced along the lines, that you----
        Senator Hirono. I am all for women in decisionmaking, but
    we all know within the military there are still major issues
    relating to sexual assault and sexual harassment, but that is a
    whole other matter. We also know there are disparities within
    the VA, and I am glad that you acknowledge it and you will, I
    hope, do something about it.
        But do you do implicit bias training within your leadership
    group in the VA?
        Secretary Wilkie. Yes, Senator, we do.
        Senator Hirono. Good to know. For years, I have brought up
    the Advanced Leeward Outpatient Health Care Access Project at
    hearings and meetings with VA leadership. The project was
    scheduled to be completed by Fiscal Year 2020, but has
    encountered multiple delays. Earlier this year, the VA said
    that this lease award was expected by mid-May, but in the
    recent weeks we have learned that that has been delayed due to
    COVID-19. Now a lease award is not expected until mid-August,
    and the project is not expected to be completed until spring of
    2023.
        You can see where the veterans are very concerned that this
    project keeps being delayed. Can you explain to me what exactly
    is causing yet another delay and how VA is working to address
    it and provide a--could you provide a detailed timeline for the
    ALOHA project so that I can let the veterans in Hawaii know
    when they can expect this facility to be built?
        Secretary Wilkie. Yes, Senator, and you know I have been in
    Hawaii several times, and the ALOHA Clinic is a classic example
    of what happens when there are too many layers of Federal
    bureaucracy. Some not attached to the VA gets involved in
    construction projects. This is a problem that I will bring to
    the Chairman, and I think I have mentioned it to Senator Tester
    as well. The way CBO scores these projects is not realistic.
    The other thing that I will bring to the Chairman is that for
    projects like the ALOHA Clinic in Hawaii, which have stopped
    and started because of CBO and GSA bureaucracy, we want to give
    more flexibility to the Department and to the leaders on the
    ground to be able to engage in these contracts, contracts that
    reflect the situation in Hawaii, and not a one size fits all.
        So I take your point. You are absolutely right, and we are
    working on providing this Committee with hopefully some
    legislative solutions so what happens in Hawaii does not happen
    again.
        Senator Hirono. Thank you so much for acknowledging that,
    and of course things are much more expensive in Hawaii, and one
    size fits all where the costs are not fixed do not do it for us
    in Hawaii. So I will do whatever I can to assist you, Mr.
    Secretary.
        I am glad that one of the----
        Chairman Moran. Senator, your time has expired.
        Senator Hirono. Oh, I am sorry. I will send more questions
    for the record. Thank you, Mr. Secretary.
        Chairman Moran. Thank you, Senator Hirono. The announcement
    about the vote has been delayed 10 minutes, so it is now at
    4:40. So we have--I do not know what we have.
        Senator Tillis?

                          SENATOR THOM TILLIS

        Senator Tillis. Just enough time for my round.
        Chairman Moran. Apparently you are the lucky one.
        Senator Tillis. Thank you, Mr. Chairman. Senator Tester, it
    is great to see you have found your flat top again. It is a
    good luck.
        Mr. Secretary and for all the witnesses, I want to go back
    on--I have completed 45 telephone town halls, updating people
    in North Carolina on COVID, and one thing it has required me to
    do is to take a look at the numbers and not view any one number
    in a vacuum. I am sure that you guys are taking a look at any
    increase in cases, you are adjusting that, you are looking at
    the rate of doubling, you are looking at how you adjust that
    for the rate of testing, and those numbers.
        So Dr. Stone, in your opinion, do you believe--because this
    hearing people could leave saying that the VA admitted there is
    a 7 percent spike. But are you looking at all those numbers,
    and in that context doing it as a manageable number that is
    within your expectations?
        Dr. Stone. Yes, sir. Early in this we were dealing with
    very rapid doubling rates. We are now dealing--your State has
    had gradually increasing numbers, but with a doubling rate that
    extends out to between 30 and 40 days.
        Senator Tillis. Right, and early in the crisis we were in
    5-and 10-day increments.
        Dr. Stone. We were in 1-and 3-day doublings. So yes, sir.
        Senator Tillis. So I just wanted to level-set that. Before
    anyone takes any one number they really need to understand the
    numbers if they want to do it justice----
        Dr. Stone. Yes, sir, and----
        Senator Tillis [continuing]. on the trends. Because clearly
    you would be surging if you had a concern.
        Secretary Wilkie. Senator Tillis, and I was not trying to
    be disrespectful, but--and you know that I went into the law
    because I could not do math.
        Senator Tillis. Yep.
        Secretary Wilkie. But when we have an infection rate that
    is as low as ours, a 7 percent increase is in the tens or
    maybe, at most, the dozens. That does not mean it is not
    serious, but it is not a crisis. I think we have shown since
    this began that we have been able to manage, and our veterans
    have responded. We have set out well over 50 million individual
    communications to veterans and families. We have warned them of
    what was out there. We have given them instructions and they
    have responded magnificently, which is why I think the numbers
    are as low as they are.
        Senator Tillis. Thank you. Jon, you mentioned the need for
    reprogramming some of the additional dollars. I think you have
    been good stewards. I think you would have spent all $18
    billion if you thought it was necessary. You are demonstrating
    good stewardship on the money that was allocated under the
    CARES Act.
        I would expect--I know IT is something that you mentioned--
    I would expect that as you scale up telehealth, as maybe you
    scale up capacity for some of the underlying information
    systems, that those are some areas where you need flexibility
    to deploy resources. We need to make sure that we get that
    information.
        I also think that--I am looking ahead to a surge. If we
    take a look at the breakdown of patients, particularly acute
    cases and deaths, it is clearly in congregate care facilities
    and populations where we have higher risk categories, over age
    65, underlying health conditions, et cetera.
        We are going to have another wave. The question is how many
    therapeutics do we have and what have we learned in terms of
    protocols to reduce the spread. But also I think, and
    particularly among the senior veteran populations and
    congregate care facilities writ large, we should already be
    creating a mentality for a posture that we take before we hear
    of the first case in November or December. Are you all taking
    those steps and trying to inculcate that as a part of your
    culture?
        Secretary Wilkie. So we have, and the nursing home
    community is the example. We serve a little under 8,000
    veterans in 134 nursing homes. We put in emergency protocols
    very early on in this. We test everyone in the nursing home. We
    also test all of the employees. We stopped visitors and
    families--a very difficult decision, because more than half of
    those veterans are from Korea and World War II.
        Senator Tillis. Yes, and Secretary Wilkie, because I want
    to ask an open-ended question and finish before the red light.
    I think it is just important. You know how heartbreaking it is
    when you want to go visit someone in these facilities. I think
    if we set the expectation now, so that they just know that that
    is standard operating practice, it is going to be easier to
    manage that and make it less likely that we see anything
    approaching it. I do not believe we will see anything
    approaching what we have in this wave.
        The last question, and it is really maybe something for you
    all to think about. I have had this discussion with DoD. As you
    are looking at deadlines and you are looking at other
    requirements Congress has placed on you, that you could
    rightfully assert that maybe you need a little bit more time to
    get certain things done--it could be projects, it could be
    reports, it could be any number of other things---I hope that
    you will report back to us and let us know, to the extent that
    that is going to require statutory action. I think you would
    have a rational basis for knowing what those are.
        Offline we will talk about the electronic health record
    implementation. I know it was delayed somewhat. I would be
    interested in knowing whether or not there are resources that
    we could put in so that we can continue it maybe through tele-
    implementation and a number of other things. I know the
    platform providers implement it in the private sector.
        Thank you.
        Chairman Moran. Thank you, Senator Tillis. Senator Manchin.

                          SENATOR JOE MANCHIN

        Senator Manchin. Thank you, Mr. Chairman. I thank all of
    you for being here before us today.
        First of all, I am just going to take a moment to thank all
    of the Veterans Affairs employees that we have in our State,
    and that you have around the country, because they have been
    stalwarts. They have been on the front line there and they have
    done a great job. They really have.
        My concern has been, and I think Secretary Wilkie and I
    spoke about this, the testing. Veterans are having a hard time.
    They are confused about the testing. They are told they have to
    pay for it, and that it has been, you know, pre-approved, and
    going through all the red tape. Have you been able, Dr. Stone,
    maybe to work through that, that clarifies this for them, to
    make sure that our veterans can get tested if needed?
        Dr. Stone. Sir, I appreciate your advocacy for this, and
    you and I have talked about it. Where we are having trouble is
    this drive-through testing. When the drive-through testing is
    being done by somebody not enrolled in our system is where we
    are having trouble with it. What we would like to get, and what
    we have reached out to do is try and look at every drive-
    through testing, any place we can find it, and try to enroll
    those health care systems in this.
        Unfortunately, some of them----
        Senator Manchin. Is there something we can do to help you?
    Is there anything that we can do legislatively, or something
    through our office officially to help you?
        Dr. Stone. Yes. I think that we will work with your staff
    on it. Right now Community Care believed that they were well on
    their way to working their way through this, to make sure that
    there was no bill sent out to any veteran. I can reassure you
    that within our system there have been no bills sent out for
    COVID testing, and if there is we will reconcile it.
        Senator Manchin. Okay. Well also--and, Mr. Chairman, you
    have said that the PPE, we are going to be doing that next
    week?
        Chairman Moran. I am sorry. Yes.
        Senator Manchin. The PPE? Because I know--we have put
    nearly $20 billion in that in order to train, so we will get an
    accounting. There is no use for me to ask that question if you
    are going to get back into that next week.
        Chairman Moran. We will.
        Senator Manchin. Sir, and Dr. Stone, on the VA in
    Clarksburg, 2 years. The rumors going around now are just
    unbelievable in the local circles, about even the person of
    interest maybe still working, or being employed, or coming back
    as a contractor. Have you been----
        Dr. Stone. Sir, I can reassure you, as of a discussion
    yesterday, that is absolutely untrue.
        Senator Manchin. Well, I think it is too. It is a vicious
    rumor going around that is hurting an awful lot of families.
    But the most important thing is the 2-years. Do you see any end
    in sight?
        Dr. Stone. Sir, the answer to that question has to be done
    by the IG and the Justice Department.
        Secretary Wilkie. Senator, I have expressed my frustration
    with this. You and I talked, and Senator Capito was on the
    phone. This investigation began before I was Secretary.
        Senator Manchin. Right.
        Secretary Wilkie. That is a disservice to the people of
    West Virginia.
        Senator Manchin. It is just--I cannot explain it. I mean,
    you can imagine what the families are going through. Why would
    you put anybody through this? I know you are not
    intentionally--I know that, Secretary Wilkie, you could not
    believe either, the insensitivity of what is going on. But we
    have got to get an answer. I am going to go, I think, to
    Attorney General Barr. I have got to go to Attorney General
    Barr. I have gone there before but now it is urgent now, 2
    years. Now with these rumors starting to creep up, you
    understand the whole uncertainty of what is going on and these
    people being left in limbo like that. It is just-----
        Secretary Wilkie. Sir, this is a disservice to every
    veteran in that community, and as you know, this is a small
    community. These employees have done a great job of cooperating
    every step of the way, and we look forward to resolution.
        Senator Manchin. Anything you can do to help us we
    appreciate.
        Secretary Wilkie. Thank you.
        Senator Manchin. Thank you.
        Chairman Moran. The next senator--I think we only have
    Senator Sinema left, and she is to call in at 4:40, which is
    now. Senator Sinema, are you available?
        [Pause.]
        Chairman Moran. Let me ask a question then, Mr. Secretary,
    which I had intended to ask at the end of the hearing. I was
    caught--my attention was caught by the two questions by both a
    Republican and Democrat about testing and about the 7 percent
    increase. I want to make sure I understand what that reflects.
        My assumption is that as more people are tested we are
    going to see more positive numbers. Perhaps this is a question
    for Dr. Stone, but what is it that we should--what---if
    something happens, what should we be concerned about? What is
    the standard by which it raises a concern or a significant
    challenge for the VA, based upon its numbers, in caring for
    veterans?
        Dr. Stone. So what you should be concerned about in a
    community is the prevalence of the disease. We began this whole
    thing when we built the budget for this, anticipating that 2 to
    3 percent of the population would be infected. We are dealing
    with a fraction of that, frankly. We are dealing with a tenth
    of that.
        Second, what VA must be concerned about is the ability to
    take care of sick people. About 20 percent of the positive are
    really sick, and do we have enough beds, do we have enough
    equipment, do we have enough personnel to care for them? Hence,
    the reconfiguration of the VA's delivery system to grow by
    almost 4,000 beds as we went through this, and the hiring of
    massive numbers of people, and the reconfiguration and
    retraining of ambulatory nurses and providers to provide care
    and support for the less ill, so our critical care providers
    can care for that.
        The VA is well positioned to remain the backstop of the
    American health care system and to fulfill the mission that the
    Secretary gave us and that you all expect of us. At this time,
    as we enter this, I am at 37 percent on our ICU occupancy,
    meaning that two-thirds of our ICU beds are now empty today,
    across the system. Second, we are at about 53 percent occupancy
    on our medical-surgical beds. Those are the key questions that
    you want to know as we walk through.
        Now what we have seen across this Nation is this slow
    background of cases, not in rapid spikes like we saw earlier in
    the disease, in late February and early March, where we saw
    these huge spikes. We have seen this slow background. We
    anticipate having about 600 patients as inpatients for COVID
    right through the fall.
        The question will be, will this repeat the activity of
    summer to fall 1918, where wave two is much more malignant, a
    much tougher disease, so that wave two really resulted in
    dramatic deaths in late 1918 and in the early winter of 1919,
    January, February.
        Chairman Moran. Dr. Stone, what does medical scientific
    evidence have to say about that at this point? Anything?
        Dr. Stone. At this time we have no idea. But what I think
    your expectation of us should be, and I know what the
    Secretary's expectation of me and my leaders is to build a
    system that can appropriately backstop.
        Secretary Wilkie. Mr. Chairman, I mentioned that we started
    preparing for this early on. We have done things like purchase
    mobile hospitals that we did not have to deploy but they are
    ready. I also mentioned the creation of a military-like depot
    system.
        The other part of that is that I signed a memorandum of
    agreement with the Defense Logistics Agency so that we are
    joined at the hip with them and their computerized systems so
    that VA is no longer the ad hoc system that it has been. The
    year that I became Secretary there were over 4 million credit
    card transactions, buying everything from tongue depressors to
    radiological equipment. These reforms go a long way to
    eliminating that and making us better prepared for what may
    come in the fall.
        Chairman Moran. Thank you, Mr. Secretary. Thank you, Dr.
    Stone. I am going to turn to Senator Tester for a second
    question, and then Senator Sinema is joining us now.
        Senator Tester?
        Senator Tester. Thank you, Mr. Chairman. A couple of
    things, and these could be really quick, guys. But on masks I
    know there have been multiple versions of guidances put out on
    masks about how they are to be used, if they are to be reused,
    all that stuff. Have you guys been able to put anything in
    writing, to direct the staff so they know what the expectations
    are on the N95s?
        Dr. Stone. Yes, sir. The guidance you reflect occurred on
    the 7th of April, and then when we went to a crisis mode, and
    then we went to contingency mode on the 14th or 15th of April,
    and I will get you the exact date. So it was only for 1 week in
    this that we went to crisis mode on utilization, and we remain
    at the guidance that was given on the 14th or 15th of April,
    which provides one mask per day, per patient that needs an N95,
    which is those employees in direct contact with COVID patients.
        Senator Tester. Okay. That is good. I mean, I think that
    there is some confusion out there, but if you guys got it out
    and you field it, that information is flowed to the proper
    sources, that is all you can ask for.
        Electronic health records. I do not really want to talk
    about this, but I have got to.
        Secretary Wilkie. Well, I want to talk about it.
        Senator Tester. Well, I mean, here is the deal. It seems
    like every position I have ever been in in government, an
    elected position, over the last 20 years, has dealt with a
    fiasco when it comes to programming. We have spent about $2.5
    billion so far, and I think--and correct me if I am wrong,
    Secretary Wilkie--there is a request for about $2.6 billion for
    electronic health records. I think everybody around the table,
    everybody on this Committee understands that this is important
    or we would not be allocating the money and we would not be
    pushing to get it done.
        I guess the question is, and I know you have been impacted
    by COVID, but what have we gotten done so far? Have we got
    value for the money we have spent? What kind of timeline are we
    on here to get this up? Is it going to be user friendly enough,
    where we do not have to send doctors and nurses to training
    for, you know, a month, to be able to get them to be able to
    understand how to use the damn record when they should be
    treating patients?
        Secretary Wilkie. So this is a good-news story. I mentioned
    in my opening Statement that I believe VA has demonstrated that
    it is the most agile of the Federal departments. We have been
    working EHRM even this pandemic, and on April 18th we were able
    to show that the Joint Health Information Exchange works. We
    talk to DoD. DoD talks to us. The private sector can work the
    records.
        We are going to be going live on the scheduling portion in
    Columbus, Ohio, and then I expect that Spokane and then later
    Seattle will be up and running sometime later this year.
        You are correct that we took practitioners off of the
    program to put them on the front lines, but we are in a
    position that I do not think a lot of people thought we would
    be in. As a matter of fact, all 73 interfaces between DoD, VA,
    and the private sector now work, and I am confident that we
    have a good-news story here. It will revolutionize now. The
    increase that you are talking about is to spread--and it is
    something that is near and dear to your heart--the
    infrastructure remodeling of our institutions so that they can
    handle the electronics required for this system. As you know,
    particularly out West, many of our facilities have buildings
    that date back to the 19th century. That was certainly the case
    in Washington State, where we were testing this.
        We are in a much better position than we were when I spoke
    to this Committee last.
        Chairman Moran. Senator Tester, Senator Sinema is
    available, and for us to make certain she has a chance to ask
    her question before we need to conclude for the vote, I am
    going to recognize her now.

                         SENATOR KYRSTEN SINEMA

        Senator Sinema. Thank you so much, Mr. Chairman, and thanks
    to the Committee for their patience with our technical issues.
    So thank you both for holding this hearing, Chairman Moran and
    Ranking Member Tester, and thanks to all our witnesses for
    being here today.
        You know, organizations in Arizona supporting the homeless
    veteran community have continued to express concerns for the
    safety of those they serve and the staff that they employ. They
    also do not feel the VA is providing the necessary assistance
    to this vulnerable population during the coronavirus pandemic.
    One key reason is VA does not have a national coordinated plan
    to support homeless veterans. A national plan should include
    testing strategies for homeless populations, access to PPE for
    all staff working with these communities and plans to care for
    veterans who test positive for the coronavirus.
        I know the VA is in need of additional flexibilities to
    fully support the homeless veteran community during this time,
    and I am proud to work with Senator Sullivan to introduce our
    Homeless Veteran Coronavirus Response Act of 2020, which will
    largely address the VA's needs.
        But Secretary Wilkie, as we work to increase the resources
    and flexibilities, the VA has to support homeless veterans, it
    is important for VA to lead on a national strategy, support the
    homeless veteran community, in collaboration with the
    organizations who provide direct services to the community.
        What do you need to do this, and why has it not been done
    thus far?
        Secretary Wilkie. Well, Senator, thank you, and I know that
    this Committee and you and Senator Sullivan have been working
    on this, and that is--your efforts are designed to give us more
    flexibility. I can tell you what we have been doing during this
    epidemic. We have used $300 million in additional funding to
    augment the three major programs that we have. First is the
    support to--supportive services for veterans and families, to
    increase the number of vouchers available for transition and
    housing. We have tripled the per diem amounts so that we are
    now addressing the basic food needs of our veterans, and we
    have augmented our emergency shelter programs.
        In hot spots like Los Angeles, we have been out actively
    working with the community to bring veterans inside the fence.
    Regardless of whether they want to partake of our health care,
    getting them inside the fence at least allows them access to
    the food and to whatever services they will agree to have. But
    that is to protect them.
        I will be announcing later this month our national roadmap
    on suicide prevention. As I said when I first addressed this
    with you, if it was just a roadmap looking at the last tragic
    act in a veteran's life it would not be worth much. So we are
    taking a broad look at not only mental health and addiction but
    also homelessness, the three things that, more often than not,
    those three areas that the Nation as a whole has ignored.
        I will let Dr. Stone answer any of the medical questions
    that you have raised.
        Dr. Stone. Senator, I appreciate your advocacy for this,
    and it is one of the areas that we are deeply concern. I talked
    earlier, as did the Secretary, about the financial instability
    and the risks to this population.
        We have added $300 million through the supplemental funding
    to our support for homelessness. As you know that is a $1.83
    billion program that we have asked to increase to $1.9 billion
    in 2021. Part of that is we have increased, by 70 percent, in
    the supportive services for veteran families, about $202
    million that we have added to the $300 million that was already
    there. We have also added $88 million in the grant per diem.
    That is for emergency housing, primarily in hotels, to get
    veterans off the street, especially so that we can help manage
    the potential illnesses in that population.
        As you know, in certain high-cost areas we were very
    gratified that HUD was given enhanced dollars to raise the
    amount for the HUD VASH vouchers. We have also added $10
    million more to ensure that there is adequate personnel to work
    those.
        But we continue to be pleased with your advocacy for this
    population as we work our way through this.
        Senator Sinema. Just a quick followup, because I know that
    my time is expiring, Mr. Chairman, and that is I would love to
    circle back and talk more about this. As we know, most of the
    efforts providing direct services to homeless veterans happens
    at the local level, outside of the VA system. I think that is
    what is leading this to be a somewhat disjointed operation
    throughout the country, and again why I am advocating so
    strongly for us to have a national strategy where we can work
    with our local partners outside of the VA facilities to address
    this pandemic.
        Thank you, Mr. Chairman.
        Secretary Wilkie. Um----
        Senator Sinema. I appreciate your time.
        Chairman Moran. Thank you, Senator Sinema.
        Secretary Wilkie. Senator, let me indulge the Chairman's
    patience. I think that is one of the reasons why the Chairman
    has introduced the legislation that is still working its way
    through something that we support, that we have those more
    robust relationships with the States and localities, and
    charities, nongovernmental organizations, so that we can get
    into those places that VA is not.
        I cannot thank the Committee enough for taking that idea
    that you have just expressed and putting it into action. I
    think this Committee has taken a huge step forward.
        Senator Sinema. Thank you. Thank you, Mr. Chairman.
        Chairman Moran. Thank you, Senator Sinema. I am going to
    ask just two quick questions, Mr. Secretary, and then I am
    going to see if Senator Tester has any quick questions, and we
    do then need to conclude our hearing. Two more questions
    related to community care, Mr. Secretary.
        Your staff shared with my staff that there were 173,721
    authorizations, excluding emergency and urgent care, were
    written for community care from March 24 to April 29, 2020, so
    while we have been through the pandemic. Could you tell me how
    many authorizations of community care were provided in that
    same timeframe a year ago, so I can make a comparison?
        Secretary Wilkie. I am going to have to take that for the
    record, and I believe we are getting that information to your
    staff.
        Chairman Moran. Thank you.
        Secretary Wilkie. Yes, sir.
        Chairman Moran. Second, your reopening plan mentions that
    the VA will schedule community care and virtual care
    appointments where, quote, ``clinically appropriate.'' I want
    to make certain that the veteran is front and center and that
    ``clinically appropriate'' is not a phrase that will be used to
    deny community care as appropriate, which, in most instances,
    is when it is in the best interest of the veteran.
        Secretary Wilkie. Yes, sir. Your interpretation is my
    interpretation. I would also add that what I have seen during
    this epidemic with veterans is similar to what practitioners
    have seen across the country. Most instances of veterans not
    going into the community have been on their wishes, and we are
    going to do everything we can to ramp this thing up back to
    where it was. Sixty percent is not good enough. It is not in
    line with the forums that you have championed and the forums
    that I believe in.
        Chairman Moran. So ``clinically appropriate'' is not an
    impediment to MISSION and CARE Act in the community?
        Secretary Wilkie. No, sir.
        Chairman Moran. Thank you. Senator Tester?
        Senator Tester. Thank you, Mr. Chairman. Very quickly, the
    Chairman mentioned this in his opening remarks, and it has been
    alluded to throughout this hearing. Because especially with
    COVID-19 I think that the challenges around mental health are
    going to increase. I appreciate the work that you and your
    staff have done with our staffs to make sure that the John
    Scott Hannon bill is ready for prime time. I would encourage
    you to keep that up, and I will encourage my side to keep that
    up, because I think this bill is important. I do not think that
    Senator Moran and myself would have introduced it if we did not
    think that veteran mental health is a problem, and I do not
    think you guys see it any differently either. We have just got
    to get this going, because I am not sure that we have got our
    arms around it yet. So we need to use every tool we have
    available.
        If you would like to comment to that, you can, but I would
    just like to say I appreciate working on it, and I think we
    need to get it done. It did pass the Committee unanimously, and
    you know the differences of the political spectrum on this
    Committee are wide. We all agreed that this was the right thing
    to do.
        The last thing I would say, in closing, and thank you, Mr.
    Chairman, is that, you know, you guys, I have been looking at
    you on TV for the last 2 hours, and I would just tell you that
    if you decide to give up the VA, all four of you could be news
    announcers on your local TV stations.
        Secretary Wilkie. Thank you, sir.
        Chairman Moran. Senator Tester, I do not know whether there
    was a compliment in there. I was distracted. But I agree----
        Senator Tester. They look good.
        Chairman Moran. But I will assume there was a compliment
    there.
        Secretary Wilkie. I agree with your Statement.
        Senator Tester. They look really good. Even on high def
    they look good.
        Secretary Wilkie. I agree with your sentiment about the
    legislation. It is vital.
        Chairman Moran. Senator Tester, there are two bills pending
    unanimous consent request in the Senate. I was informed today
    that I think one of them is ready. The other, it is cleared on
    our side and not yours. If you would check with your staff.
    This is something that you and I both support and something
    that the Department has been asking for.
        Senator Tester. I am on it, Jerry. Thank you.
        Chairman Moran. Thanks very much, Jon.
        Mr. Secretary, I always give witnesses in front of my
    committees the opportunity to clarify, to retract, make any
    corrections of something that they said or something that wish
    they had said.
        Secretary Wilkie. I will go back and look, but that is not
    going to stop me from thanking the Committee, as I did at the
    beginning. There is no better committee when it comes to the
    oversight of the Department for which you have responsibility,
    or a more collaborative committee.
        I do want to say one thing. Thousands of VA employees have
    put themselves in harm's way. I think they--well, I do not
    think--they deserve the thanks of the American people. We have
    opened our hospitals. We have sent people into extremely
    dangerous situations. They have responded magnificently. One of
    the things I would add is that we actually have a lower
    absentee rate and a lower leave request rate this year than we
    did last year, because people have responded to the call to
    duty, as they always do, and I am very proud to be part of
    their family. I thank you, sir.
        Chairman Moran. Mr. Secretary, thank you for your presence
    and your team here today. I thought the hearing was valuable
    and I appreciate your testimony and our conversations. I would
    express my gratitude on behalf of all Kansans, on behalf of all
    Americans for the men and women who work at the Department of
    Veterans Affairs, many of them veterans themselves, who arose
    to the cause of caring for their brothers and sisters at the
    Department of Veterans Affairs. We are very grateful for the
    risks they take and the anxiety they and their families must
    have about that service. So thank you for your reiteration of
    that, and I join you in that sentiment.
        Secretary Wilkie. Thank you, sir.
        Chairman Moran. The Disabled American Veterans, the
    Paralyzed Veterans of America, and the Veterans of Foreign Wars
    have each year produced an independent budget based on their
    analysis of the funding needs of the VA. For this hearing we
    asked those VSO partners to submit written testimony on the
    President's budget request for the VA, and they provided
    valuable feedback. They have done so, and without objection I
    will include their written testimony into the record. So
    ordered.
        Chairman Moran. Committee members, you have the opportunity
    to submit for us today additional questions for the witnesses.
    Please do so in the next 5 days. Mr. Secretary, please ask your
    Department to respond as quickly as possible to our Committee's
    further question.
        Secretary Wilkie. Yes, sir.
        Chairman Moran. Without further conversation we are
    adjourned.
        [Whereupon, at 5:02 p.m., the Committee was adjourned.]

                                    APPENDIX

                                  ----------

                   Material Submitted for the Hearing Record

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                      [all]