[Senate Hearing 116-483]
[From the U.S. Government Publishing Office]


                                         S. Hrg. 116-483

                VA'S RESPONSE TO COVID-19 ACROSS THE VA 
                                ENTERPRISE

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                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                            DECEMBER 9, 2020

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                 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

                              ----------                              

                      Wednesday, December 9, 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...................     8
Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    11
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    13
Manchin III, Hon. Joe, U.S. Senator from West Virginia...........    15
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    16
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    19
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    20
Loeffler, Hon. Kelly, U.S. Senator from Georgia..................    22
Sinema, Hon. Kyrsten, U.S. Senator from Arizona..................    23

                               WITNESSES

Dr. Paul R. Lawrence, Under Secretary for Benefits, Veterans 
  Benefits Administration, U.S. Department of Veterans Affairs...     5
Richard A. Stone, M.D., Executive in Charge, Veterans Health 
  Administration, U.S. Department of Veterans Affairs............     7

                                APPENDIX

Moran, Hon. Jerry, Chairman, prepared statement..................    34
Paul R. Lawrence, Ph.D., Under Secretary for Benefits, Veterans 
  Benefits Administration and Richard A. Stone, M.D.,Executive in 
  Charge, Veterans Health Administration Department of Veterans 
  Affairs, Joint prepared statement..............................    36
American Federation of Government Employees, AFL-CIO, prepared 
  statement......................................................    42
VA's Fourth Mission..............................................    52

 
           VA'S RESPONSE TO COVID-19 ACROSS THE VA ENTERPRISE

                              ----------                              


                      WEDNESDAY, DECEMBER 9, 2020

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:33 a.m., via 
videoconference and in room SD-G50, Dirksen Senate Office 
Building, Hon. Jerry Moran, Chairman of the Committee, 
presiding.
    Present: Senators Moran, Boozman, Cassidy, Tillis, 
Sullivan, Blackburn, Loeffler, Tester, Brown, Blumenthal, 
Hirono, Manchin, and Sinema.

              OPENING STATEMENT OF CHAIRMAN MORAN

    Chairman Moran. Good morning, everyone, and welcome to the 
hearing on the Department of Veterans Affairs response to 
COVID-19 pandemic. All who are here, welcome, and those who are 
joining us by technology, we are glad to have you as well.
    As we know, this Committee has seen numerous times the 
challenges that have been faced. We, as Senators, have seen 
lots of challenges in our Nation. But we know, and especially 
we know that veterans are not unfamiliar with adversity. 
Adversity provides us an opportunity to evaluate 
vulnerabilities in our systems, reflect on what has worked, and 
to make improvements for the future. Unfortunately, the future 
is still with us. COVID has not disappeared, as many of us 
thought or hoped it would after a few months.
    As we discuss the Department's pandemic response thus far 
today I hope to hear what the VA has learned in a number of 
areas. The VA faced challenges relating to the administration 
of both benefits and disability compensation and pension exams 
as well as the provision of timely quality health care. Just 
like other health care providers, the VA had to work through 
closures due to the virus and difficulties acquiring vital 
personal protection equipment. While the VA continues to work 
diligently at local levels on behalf of our veterans and while 
also fulfilling its fourth mission, VA hospitals and clinics 
still face difficulty procuring supplies, finding availability 
for veterans' appointments, and making certain that veterans in 
rural areas had adequate access to health care.
    Many veterans living in rural areas in my State are hours 
away from any VA facility. Due to this, I am particularly 
interested in the VA's progress regarding broadband agreements 
to support increased utilization of telehealth to reach some of 
our most vulnerable veterans. We provided the VA with great 
latitude in the CARES Act, and I am anxious to make certain 
that the VA is using those capabilities to benefit our 
veterans.
    Dr. Stone, as you know, the challenges related to COVID-19 
are not over. I thank you for your work to date. I thank you 
for your work as we look into the future, and we want to help 
ensure that you have a robust opportunity to serve our veterans 
and that we have a frank conversation today about those 
efforts, under your leadership, to continue caring for our 
veterans.
    At the beginning of the pandemic, the VA chose to suspend 
veterans' access to Community Care Networks under the MISSION 
Act, which the VA did not have the authority to do. While VA 
claimed the suspension was done in the best interest of 
veterans, it failed to actually give veterans a say in the 
decisionmaking process. This completely contradict the MISSION 
Act, which specifically places veterans and their providers at 
the center of health care decisionmaking processes.
    Another justification the VA gave for suspension was the 
providers in the Community Care Networks were not accepting 
patients. However, during an October hearing of this Committee, 
both Optum and TriWest testified they had ample community 
providers at the time that were willing to treat veterans.
    Today I want to discuss how the VA can best leverage 
Community Care Networks to maintain continuity of care during 
the crisis as well as better ensure local access to care. While 
this pandemic and the demands that it has placed on the VA was 
unanticipated, Congress is still expecting the VA to work 
toward fully implementing the MISSION Act.
    With several vaccines pending, FDA emergency use 
authorization, another critical component of our conversation 
today, is VHA's preparation for the proper distribution of 
COVID-19 vaccines in the coming weeks. It is important that we 
work together to smooth the rollout of these vaccines, and I 
look forward to hearing the VA's strategy to reach veterans 
nationwide.
    During this pandemic, I worked with my colleagues to expand 
authority and resources for veterans experiencing and at risk 
of homelessness. This population is especially vulnerable to 
COVID-19, and members of this Committee, myself included, would 
like to learn about how VHA's recent initiatives to decrease 
the number of veterans experiencing that homeless condition.
    Dr. Lawrence, today's hearing is also an opportunity to 
discuss work the VBA is now conducting to address C&P backlog 
that has accrued due to COVID-19 limitations, both through 
internal VA exams or as a contractor.
    While we have also learned that those exposed to burn pits 
during military service are likely to be more susceptible to 
COVID-19, however, claims for these veterans are still denied 
at extremely high rates. My colleagues and I, along with the 
VSOs, are focused on tackling the many policy issues associated 
with health care and benefits for veterans who experience toxic 
exposure during military service. This hearing will allow us 
the opportunity to examine the many provisions we have passed 
to ensure the GI Bill continues during the pandemic, to make 
certain veterans' and their dependents' education is not overly 
disrupted.
    Additionally I am concerned by the rate of unemployed 
veterans and veteran spouses, and I look forward to hearing how 
VA is working with its agency partner across a Federal 
Government to mitigate veterans' unemployment.
    The VA has made great strides this year, and I thank them 
for that, but the VA has also made some decisions that are 
concerning as to how they will impact veterans and families 
during this stressful and uncertain time.
    Finally, as the Presidential inauguration quickly 
approaches, it marks a period of transition for this coming 
year. Our country will continue to face COVID-19 pandemic, a 
challenge of significant magnitude and consequence, much of 
which is still unknown, and we must make certain that all 
entities of our Federal Government can continue to work 
together to solve these problems. We must make certain that no 
matter what the future holds, there will be no lapse in care or 
benefits for our Nation's veterans.
    Mr. Tester, the Ranking Member, I now yield to you for your 
opening Statement.

              OPENING STATEMENT OF SENATOR TESTER

    Senator Tester. Well, thank you, Mr. Chairman, and I think 
this will be the last hearing of this Congress for the VA 
Committee, and with that in mind I want to point out that time 
flies when you are having fun. At least time flies, and this 
year has not been particularly fun. But Mr. Chairman, you have 
done a marvelous job over the last year keeping myself informed 
and running the VA Committee, and I want to thank you for what 
you have done and look forward to working with you and all the 
members on the Committee next Congress.
    What is interesting when I listen to Senator Moran's, 
Chairman Moran's comments, is that many of the things that he 
brought up in his opening Statement I will bring up in mine. 
And so I guess there is bipartisan concern on a lot of 
different fronts here.
    But I do want to thank Dr. Stone and Dr. Lawrence for being 
here. I know the pandemic, which has stretched on for nearly a 
year, and experts are saying the worst is yet to come, has hit 
the VA, just like it has hit everybody. You guys run the 
largest integrated health care system in the country, and 
during the coming weeks you will have the dual responsibility 
of caring for sick veterans while distributing a coronavirus 
vaccine. Once that vaccine is deemed safe and effective, you 
will be distributing it to veterans and staff across this 
Nation.
    The FDA officials plan to meet tomorrow to discuss 
emergency use of the Pfizer vaccine. My understanding is that 
the initial dose can be shipped within 24 hours after receiving 
FDA authorization. So with the first vaccine shipment 
potentially days away, I am troubled that VA has yet to publish 
a comprehensive plan detailing how it will allocate and 
distribute the vaccine to frontline workers, high-risk 
veterans, and other users of the system. Dr. Stone, I need to 
know what is causing the holdup of the final plan and what can 
be done to help things along.
    I am particularly concerned how the VA will reach staff and 
veterans in rural locations, where the coronavirus is spreading 
rapidly and overcrowding local hospitals. Whether it is a VA 
nursing home in Miles City, Montana, or Washington, DC, 
veterans and staff need to know there is a vaccine plan in 
place that will reach everyone, regardless of where they live 
or work.
    However, in my State I know there are no pharmacies 
currently--no VA pharmacies, I should say, currently equipped 
to receive or store the Pfizer vaccine, if approved. So I need 
to know a lot more about VA's plan for an equitable and safe 
distribution of COVID-19 vaccine, and how veterans and VA staff 
in Montana, and in other rural areas across our country, will 
be vaccinated against this deadly virus.
    I also want to know how the VA intends to educate staff and 
veterans on this vaccination plan. These folks need to know 
what to expect, when to expect it, and how the VA will notify 
them when it is their turn. And in the months it will take to 
get everybody vaccinated, VA's management of PPE, bed space, 
staffing, and more will continue to be important as this 
pandemic stretches on. Dr. Stone, it will be important for us 
to hear about the most challenging aspects of the next few 
months and what is currently keeping you up at night.
    I want to say thank you to VA staff, especially the 
frontline workers, who continue to serve our veterans 
throughout this crisis. I am also pleased to hear that the 
transition process is taking place at the VA. I very much 
appreciate the leadership team sharing their knowledge, and 
everybody, as far as that goes, their knowledge and insight 
with the incoming administration. Now more than ever, a smooth 
transition is critical. The incoming administration must know 
the toll this crisis is taking on delivery of health care and 
benefits to veterans everywhere. So I ask--and I know you 
will--continue to work closely with the transition team in the 
days ahead.
    Just in closing I just want to echo the Chairman's 
Statements. I want to thank both witnesses that are here today 
for their commitment to veterans. I know it is real. Look, we 
have disagreed at times and we are going to continue to 
disagree at times. But the bottom line is, I think, that you 
folks have my respect for what you have accomplished during 
your tenure at the VA. With that, Mr. Chairman, I will kick it 
back to you.
    Chairman Moran. Senator Tester, thank you, and thank you 
for your comments about working together, and I thank you for 
the relationship, the friendship, and the efforts, as 
colleagues on this Committee, that you have worked with me and 
I have worked with you in order to advance a cause we both 
share as a huge priority in our times, as a United States 
Senator, and I join you in commending and thanking Dr. Stone 
and Dr. Lawrence for their efforts, their work, their 
commitment, and their dedication to veterans of our country. I 
am very grateful to know both of you and I am very grateful for 
your service in care of other veterans, and I appreciate you 
being here.
    I would conclude my comments by indicating this is probably 
our last hearing of the year in this Committee, and it is 
certainly Caroline Canfield's last hearing as staff director of 
this Committee. Caroline came to my office as my military 
legislative assistant, and when I became Chairman she agreed to 
serve as the staff director for this Committee. She is a 
significant component of our ability to accomplish things on 
behalf of Kansans and Americans. She is highly professional, 
knowledgeable, and dedicated to cause, and works hard each and 
every day on behalf of this Committee and on behalf of the 
veterans we all choose to serve. So I take this as an 
opportunity to thank publicly Caroline and wish her well.
    I am almost always annoyed when my staff departs me and 
leave our office, but when they are returning to Kansas it is 
hard for me to complain. I understand that urge and that draw. 
And so Caroline, personally, for me, and for our team, and for 
the members of this Committee and their staff, thank you for 
your work on our behalf. Caroline, thank you.
    We will now turn to our witnesses. I am only checking to 
see which one of you have the joy of going first. Dr. Paul 
Lawrence, Under Secretary for Benefits at the Department of 
Veterans Affairs; Dr. Richard Stone, Executive in Charge for 
the Veterans Health Administration at the Department of 
Veterans Affairs. Thank you for both being here today. We will 
provide, on the clock, 5 minutes for each of you to deliver 
your remarks for your testimony today before our Committee.
    And so, Dr. Lawrence, you are now recognized for those five 
minutes. Thank you.

                 STATEMENT OF PAUL R. LAWRENCE

    Mr. Lawrence. Chairman Moran, Ranking Member Tester, and 
other members of the Committee, I will focus my remarks on the 
performance of the Veterans Benefits Administration. I will 
provide information about the three areas you requested in your 
invitation.
    First, compensation and pension claims. Since Fiscal Year 
18, we have completed an average of 1.4 million claims per 
year. We complete these in about 100 days. We carefully monitor 
claims over 125 days. These are referred to as the backlog. In 
December 2019, due to aggressive management and improved 
technology, we reduced the backlog to the lowest ever in VBA 
history, 64,000.
    The effects of COVID-19 became clear in April 2020. On 
April 2nd, VHA stopped in-person C&P exams. Following their 
lead, we ordered contract medical examiners to stop in-person 
exams. We granted benefits using existing medical records, but 
without these in-person exams our completion of C&P claims 
slowed down and the backlog grew.
    In response to the need for in-person C&P exams, I 
appointed one of our most senior leaders to focus solely on 
this. In-person C&P exams restarted on June 8th. Today we are 
completing approximately 27,000 exams each week. Nonetheless, 
having stopped the exams for so long, the inventory of exams, 
normally 140,000, has grown by an additional 210,000.
    Another key bit of evidence we need to grant benefits is 
the veteran's military records. We get these from the NPRC in 
St. Louis, which is operated by NARA. With COVID-19, they 
stopped providing these records. NPRC reopened in September 
2020. We worked with them to allow 50 VBA employees into the 
facility to get the needed records. On November 5th, NARA 
greatly reduced operating hours in response to local 
conditions. We continue to work with them to obtain needed 
records, but our record retrieval has slowed.
    On July 31st, the backlog of claims was about 200,000. It 
has remained at about that level since then, indicating that we 
are processing at the rate we are receiving them and at the 
rate they are aging over 125 days. Our challenge and focus 
today is to reduce the C&P backlog to the pre-COVID-19 levels. 
Our plan is to do that by the end of Fiscal Year 21.
    Second, education. We completed the reset of the Colmery 
technology implementation on December 1, 2019. This enabled the 
accurate payment of the monthly housing allowance. For spring 
2020, using the new technology and other process improvements, 
we completed the GI Bill original claims in 18 days and 
supplemental claims in 7 days, well below our targets of 24 and 
14 days.
    In March 2020, schools shifted to online learning. We 
implemented the new laws protecting the monthly housing 
allowance, work-study and extension. We raised awareness 
through multiple emails to more than 800,000 students, school 
certifying officials, and State approving agencies. On November 
1, 2020, we completed implementing the information technology 
solutions for the remaining sections of the Colmery Act.
    With that said, education services IT systems are at their 
technical capacity and lack the ability to meet the demands and 
service expectations of GI Bill students and stakeholders. I 
ask for the opportunity to talk to you further about our plans 
to replace these antiquated systems with modern, commercially 
approved approach.
    Third, veteran readiness and employment. We have been 
modernizing VR&E since 2018. Through this modernization, VR&E 
implemented systems to enable telecounseling pre-COVID-19. 
Plus, when it was needed, we had it in place already and 
increased its usage. We successfully implemented the provisions 
of the new laws to support VR&E beneficiaries, including 
continued payments, extensions, and the ability to restore 
benefits.
    In summary, I want you to know that I have personally heard 
from veterans during COVID-19. In March, I started conducting 
telephone town halls with veterans in each State. I have 
conducted 107 town halls, covering all 50 States, plus a 
dedicated one for each of the major VSOs. I have connected with 
over 5 million veterans. I have fielded and answered questions 
from 1,600 veterans.
    Engagements in the town hall with military sexual trauma 
survivors led directly to increasing our emphasis on getting 
them assistance and benefits. We have increased resources 
focused on MST, increased our team's training, and streamlined 
our processes. Engagement with family members and spouses about 
survivor benefits also led to action.
    We have increased outreach to non-veteran family members so 
they can learn about benefits before the veteran passes. We 
have engaged with the States to prevent pension poachers, those 
who would charge family members to help with their benefits 
when such help is available free of charge.
    This firsthand experience has energized me and the entire 
team at VBA to get our veterans their benefits faster and 
better. And to do this we know we need to work together with 
the VSOs, the State Department of Veterans Affairs, and most 
importantly, the Congress.
    Thank you. I look forward to your questions.
    Chairman Moran. Dr. Lawrence, thank you. Dr. Stone.

                 STATEMENT OF RICHARD A. STONE

    Dr. Stone. Good morning, Mr. Chairman, Ranking Member 
Tester, and members of the Committee. I want to thank you for 
the opportunity to discuss the incredible work that VA has done 
to combat the COVID-19 pandemic in our facilities, in our 
communities, and in service to America's veterans.
    The COVID-19 pandemic has challenged our Nation in ways we 
never could have imagined, and health care in the VA and across 
the United States will never be the same. Health care workers, 
including our VA staff, have rightfully emerged as the heroes 
of our response effort, as they are on the front lines of our 
battle against this deadly invisible enemy. I am privileged to 
work with the incredible men and women of the Veterans Health 
Administration, who serve our veterans every day. Our health 
care workers' dedication, their resilience, and their 
innovation in the face of uncertainty and unprecedented 
challenges, should inspire all of us.
    Procedures we now consider routine were revolutionary only 
a few months ago and were implemented only through our 
employees' hard work and knowledge. Teams of experts work to 
reshape our facilities' physical structures as well as our 
policies and procedures to keep our patients and our staff 
safe.
    Personally, I have learned so very much from this 
experience, which I consider one of the most challenging 
periods of my personal and professional life. First and 
foremost, I learned that as a senior leader I must embrace 
vulnerability, I must submit my decisions to constant re-
examination, and I must not hesitate to admit when new and 
better information requires us to change course.
    Over the past 11 months, I have tried to do exactly that 
and I have encouraged my senior leadership team to do the very 
same every single day, because the lives of veterans and our 
colleagues are at stake. This has allowed us to respond with 
unprecedented agility to evolving challenges.
    COVID-19 has shown the Nation the capabilities of the VA. 
We have continued to pursue all of our missions, first and 
foremost of which is caring for veterans, but we have also 
continued education and training for medical practitioners and 
our leadership in research, including participating in 
Operation Warp Speed.
    Our fourth mission, backing up the American health care 
system, continues to be a significant part of our response to 
the pandemic, and until this year we have performed our fourth 
mission primarily through local and regional responses to 
hurricanes and other natural disasters. This is the first time 
in our organizational history that we have mobilized at scale. 
We have sent PPE, subject matter experts, and personnel to 
almost every State and territory in response to State and 
Tribal requests. Our process for keeping VA nursing homes safe 
has been replicated across the country to protect America's 
most vulnerable citizens. It is my hope that one of the lessons 
to come from this pandemic will be that the VA is willing and 
is capable of being at the center of the Nation's response to 
future disasters.
    I learned during my service in the Army that while there is 
no substitute for experience, learning from others enhances 
each person's capability and our capacity to respond to 
challenges. We are facing a public health event unlike anything 
medicine has confronted in more than 100 years. In response, we 
are listening to our frontline workers, to our supply chain 
managers, to our logistics personnel, and to our facility 
engineers about how to keep our staff and veterans safe. By 
deferring to their expertise, we can rapidly craft policy and 
procedures that are effective in responding to COVID-19 
pandemic, and should be replicated by the rest of this Nation.
    On November 9th, we released our first COVID-19 response 
report. This report is a continuation of our pledge to share 
best practices and lessons learned with other government 
agencies and the private health care system, while the country 
fights this disease. It provides an extensive look at the 
complexity of our response. It also provides an unvarnished 
view of the challenges that we needed to address to fulfill our 
mission. The report is available to the public on our website, 
and we expect further addendum reports to document our evolving 
response to this pandemic, but most importantly, to document 
the resilience and dedication of our employees to serving 
veterans and the Nation.
    Finally, I would like to express my appreciation to each 
VHA employee for their tireless effort in serving veterans and 
members of the community.
    Mr. Chairman, this concludes my testimony, and I want to 
thank you for the opportunity to testify before this Committee 
today.
    Chairman Moran. Dr. Stone, thank you. We have three votes 
at 11:00, which is a challenge for us. I know I am going to be 
here until the end, but to try to accommodate my colleagues I 
am foregoing my round of questioning, at least initially. I 
will ask, toward the end, and therefore I recognize Senator 
Boozman.

                      SENATOR JOHN BOOZMAN

    Senator Boozman. Thank you. I am all wired up now.
    Thank you, Mr. Chairman and Ranking Member Tester, for 
holding this hearing. I cannot imagine a more important topic 
that we could be discussing right now, taking care of our 
veterans during one of the most trying times in our generation 
regarding health care.
    I have had the opportunity to visit with our frontline 
workers in Arkansas at the VA. They are doing a tremendous job, 
and I just want to publicly thank them for their dedication, 
their steadfast service throughout this time, and again, them 
being representatives of the entire system. So I thank them, 
and I thank you all for the great work that you all are doing.
    The pandemic has led to a backlog of over 200,000 new 
disability claims at the VA. I know you were making great 
progress prior to this and getting things up to snuff, getting 
the backlog down, but unfortunately, due to COVID, we are back 
to very high numbers. In addition to not being able to conduct 
C&P exams in person, the National Personnel Center is operating 
at minimal capacity. These two things are going to continue to 
exacerbate the C&P backlog problem that has been building since 
March.
    Dr. Lawrence, understanding you would like to outsource 
more C&P exams from the VHA to contractors, what is your plan 
to ensure a high-quality exam and hold contractors 
underperforming accountable? Dr. Stone, are you concerned about 
contractors providing C&P exams not specializing in MST, PTS, 
and brain injury symptoms from being able to accurately 
evaluate veterans with these underlying issues? Can either of 
you share the analysis and data with me and my colleagues that 
informed you to increase the outsource of C&P exams from the 
VHA to contractors and the data that suggests this is the best 
approach as we go forward?
    Mr. Lawrence. Let me start with this one, Okay? We were 
authorized by Congress to expand nationwide with the contract 
C&P exams in 2017. It was focused on the convenience, the 
access to our veterans, and the like. We measure, we give a 
survey to every veteran in terms of their satisfaction with the 
process, not just the exam itself but the arrangement for the 
appointment and any followup.
    The surveys indicate that about 92 percent have a positive 
experience with us. I do get complaints and I do investigate 
some of those. Where we can compare the quality of care in two 
special focus reviews, between VHA and the contract medical 
examiners, the contract medical examiners came out slightly 
ahead. It is a concern for us the quality of the exams, but so 
far we have seen that they are very strong and very good, and 
they are available.
    We are working directly with the contractors to expand 
their capacity and locations, for our homebound veterans and 
the like, to make sure we can get as many of those going so we 
can reduce the claims backlog. Again, this was the same team 
that was working with us pre the pandemic, when the backlog was 
at the lowest level ever in our history. We anticipate that we 
will have the backlog of the C&P exams, which the inventory 
right now is normally 140,000. It is at 350,000. We will have 
that down to 140,000 by July, and we think that will set us at 
a good pace to deal with the claims backlog, which we will have 
done by the end of the fiscal year.
    Dr. Stone, I will ask you to jump in on the medical 
question, please.
    Dr. Stone. Senator, VHA will remain part of the delivery of 
comp and pen exams. In the first 6 weeks of this year we did 
over 26,000 exams. Now you asked a question about our 
satisfaction with quality of the exam. The data we have is the 
same data that Dr. Lawrence has on veteran satisfaction with 
the contracted exams. However, we are required----
    Senator Boozman. How about, and I do not mean to interrupt, 
but we are going to have votes. How about the lack of knowledge 
in some of these various areas? Is that a concern?
    Dr. Stone. It is a concern, and we are required, in six 
separate areas, to provide exams. One of those includes if 
there is a major psychosis or a veteran is hospitalized or if a 
veteran was a former prisoner of war, are three of the areas 
that require us to continue to work in this area, and to 
provide consultations to VBA in areas where they feel that they 
need our expertise.
    Senator Boozman. Thank you, Mr. Chairman, and again, thank 
you all for your hard work. I know that these are extraordinary 
times.
    Chairman Moran. Senator Boozman, thank you. Senator Tester?
    Senator Tester. Thank you, Mr. Chairman, and my questions 
are going to be really focused on the vaccine distribution. And 
so, Dr. Stone, you are kind of going to be on the Budweiser hot 
seat for a little bit here.
    We anticipate a coronavirus vaccine is going to be 
distributed very soon, in the next few days--approval for that 
distribution, I should say. You guys have the largest health 
care system in the country. You have got a lot of frontline 
workers. There are lot of veterans across this country. And I 
am concerned that the VA will be behind the curve.
    Why do I say that? You know, the CDC, the States, even IHS 
have all released public vaccine plans. To my knowledge, the VA 
has yet to do so, and, quite frankly, this is going to be an 
undertaking that we have never seen before in this country, and 
the VA is a big part of that undertaking.
    So can you just explain to me, what is stopping the VA from 
putting out a vaccine plan right now? And please do not tell me 
that you have not talked about this, because I know better. I 
think I know better than that. So why hasn't there been a plan 
put out? Why can't we be more transparent about what the staff 
and the veterans need to expect?
    Dr. Stone. Senator, I appreciate the question. Our vaccine 
plan is with the CDC, and that vaccine plan is still dependent 
upon our ability to move the Pfizer vaccine, which requires a -
70 degrees Fahrenheit refrigeration and freezing, across the 
Nation. We have 37 sites prepared to accept the vaccine.
    We submitted an order for 73,000 doses last week. Those 
doses will be distributed after the emergency use authorization 
is obtained, or at least that is what we are anticipating that 
will occur at the end of this week or through the weekend. We 
do anticipate that that shipment will occur across the Nation, 
and then it will depend upon whether we can secondarily ship 
that -70 degree vaccine further. That decision has not been 
made by CDC, which is why you have not seen our really robust 
vaccine distribution plan.
    Senator Tester. You have 37 sites. Are those up for 
public--do people know where they are?
    Dr. Stone. Yes.
    Senator Tester. Do we know where those sites are, No. 1?
    Dr. Stone. Yes, sir.
    Senator Tester. Okay. And the No. 2, have you been in 
contact with the staff at those sites to let them know what the 
expectations are going to be once this vaccine reaches those 
sites?
    Dr. Stone. Every single medical center has done a sandbox 
testing, where they walk through the distribution of the 
vaccine right up to the point of actually administering the 
vaccine in a simulation. We also have 188 sites that will be 
able to accept the Moderna vaccine, and those sites, we 
actually submitted for 122,000 doses of that, and we look 
forward to receiving those in the not too distant future. The 
big advantage of that vaccine is its ease of transportation. 
But please remember, each of these vaccines will require two 
doses, at 21-and 28-day intervals. Therefore, tracking of the 
veteran and the employee who receives them is going to be a 
herculean effort.
    Senator Tester. So I am assuming that the 37 sites for the 
Pfizer vaccine, there will be more than that in the end, or is 
37 where you are going to be and you are going to use Moderna 
to fill out the other part?
    Dr. Stone. We have additional 36 freezers that are coming 
in for -70 degrees.
    Senator Tester. More than the 37? So you will have 73 in 
total, Doctor?
    Dr. Stone. Exactly.
    Senator Tester. Okay. That is good. So you said that you 
are going to request 73,000 doses of the Pfizer vaccine, and 
120,000 of the Moderna, something about that. How quickly do 
you anticipate those are going out, No. 1, and No. 2, is that 
adequate? Can you handle them, No. 1; can you handle the 
distribution, No. 1; and No. 2, is an adequate amount for the 
largest health care system in the nation?
    Dr. Stone. It is not an adequate amount, and this will be a 
long process for us to reach all 7 million veterans who we 
believe will want vaccination from us, as well as all 400,000 
employees of the agency.
    We do anticipate, sir, weekly distribution, and it remains 
to be seen how robust that weekly distribution will be.
    Senator Tester. Okay. I have got some other questions for 
the record. I will let you go now. Thank you. Thank you both. 
We will talk to you soon.
    Chairman Moran. Thank you, Senator Tester. Senator Cassidy.

                      SENATOR BILL CASSIDY

    Senator Cassidy. Thank you all. Thank you, Gentlemen.
    Dr. Stone, you and I both know that it is going to be 
extremely important to track who has been vaccinated. If there 
is something, for example, that allows somebody to go on an 
airplane without wearing a mask because they have been 
vaccinated, there has to be some way to get that information.
    The States all have a Federal Government, taxpayer-funded 
immunization system, the IIS, the Immunization Information 
System. I am told that the VA has not integrated into that. So, 
theoretically, a veteran can get a Pfizer vaccine outside the 
VA, come to the VA and desire to have the second vaccine, and 
you have to go through the process of figuring out what they 
have as opposed to logging on. We can go through the 
ramifications.
    Does VA plan on getting within the IIS, and can you give me 
an idea of why we are not, and then--and try and keep your 
answers brief because I have a couple more questions, please.
    Dr. Stone. The answer is no, our intention is not to tie 
into the IIS. We have tied through an API into the CDC website. 
That tracking site allows us to order the vaccine. So our 
primary connection will be the CDC, and we will submit data on 
the utilization----
    Senator Cassidy. So if I can, the IIS, though, allows 
epidemiologists to figure out how many people in a community 
have been immunized. It allows rapid access of a university to 
see if somebody has been immunized. The CDC, although involved 
with this, does not--obviously it is the State that does it. 
Why would the VA not be involved with the IIS since it is such 
an important public health tool as well as important for the 
individual?
    Dr. Stone. So what my epidemiologists have told me is that 
the States are connecting the CDC site to obtain our data. Now 
I am completely open to re-examining that decision and taking a 
look at whether we should connect to the 50 States and 
territories separately, in addition to our work that we have 
committed to with the CDC.
    Senator Cassidy. Okay. I was not aware. We will track that 
down. I understand, though, that you are sharing deidentified 
data. Is that correct?
    Dr. Stone. That is correct.
    Senator Cassidy. So if you are sharing deidentified data, 
it could not be used to integrate into the IIS. I am not quite 
sure how we are really serving the veteran as well as we could 
if, when the veteran goes to graduate school and is required to 
give proof, instead of logging on as they would if they were 
vaccinated some place else, pulling down their record and 
showing it to them, instead they have to call the VA and get 
the kind of rigamarole of getting records transferred. Why 
wouldn't we do the IIS?
    Dr. Stone. I am completely open to re-examining the 
decision. It was my understanding that IIS was connecting to 
the CDC websites using the same APIs we are.
    Senator Cassidy. But you wouldn't be able to download 
deidentified data. That is the only issue. And IIS has 
identified data, which allows me to download my records and 
hand them to somebody, should I need it for employment.
    Dr. Stone. Senator, my first priority has been to make sure 
that I complied with every requirement to get adequate supplies 
shipped to us, and this is a methodology in which we 
demonstrate our need for future vaccine, and so that has been 
the first priority. If IIS is something we should connect with 
for good care of the veteran, we will certainly do so.
    Senator Cassidy. That is great.
    Second set of questions. I see that State veterans nursing 
homes are not being inspected, and VA does not have a plan to 
inspect them until November 2021. Now I am not quite sure but I 
know that--and, by the way, CMS is doing inspections of nursing 
homes, and so it seems like this could be avoided. I have been 
told by other agencies that some of these essential services 
are not being executed because union contracts basically keep 
the union workers from having to go out and do things if the 
union objects.
    Is the reason the VA is not coming up with a plan to 
inspect these State-run veterans' homes because of union 
contracts or is there another reason why?
    Dr. Stone. Sir, I heard this yesterday. This is absolutely 
incorrect information. We remain active in our inspection of 
nursing homes. We are active today in 100 State veterans' 
homes. We inspected veterans' homes in the last quarter.
    Now, our work is at substantially reduced because of 
safety, in many of these communities, and just like the Joint 
Commission has moved to virtual inspections we have been 
working our way through virtual inspections. I do recognize the 
fact that a contract with a vendor has come to an end and we 
are renewing that contract, or recompeting that contract at 
this time. That may be where this information came from. But it 
is completely unacceptable to me that we would not be in the 
State veterans' homes, actively participating as partners, to 
make sure that they are providing appropriate care to America's 
veterans.
    Senator Cassidy. Well, I am out of time so thank you, and 
thank you both for your service. I yield back.
    Chairman Moran. Dr. Cassidy, thank you. I recognize Senator 
Blumenthal.

                   SENATOR RICHARD BLUMENTHAL

    Senator Blumenthal. Thank you both for being here. Thanks, 
Mr. Chairman, for organizing this very, very important hearing.
    Before I go to my questions about the vaccine I want to 
first again express my condolences to the two individuals who 
perished at the VA facility in West Haven--I hope you are 
familiar with that tragedy--Euel Sims, a longtime employee of 
the VA and a veteran, and Joseph O'Donnell both died as a 
result of an explosion at the VA facility on November 13th. And 
I have been to the facility and I have talked to Al Montoya, 
the director. He has told me there is an investigation. I 
extend my condolences again to their families and loved ones. I 
would like to know how soon we can expect a completion of that 
investigation.
    Dr. Stone. Senator, I appreciate the fact that you went out 
there the day of explosion, or within 24 hours, and the 
Secretary and I were there within the next 24 hours, and we 
walked the facility, we walked the area. This is a tragedy that 
is just unacceptable.
    That investigation is not in our hands. It is in OSHA's 
hands as well as NIOSH as well as the State inspector's.
    Senator Blumenthal. The VA is not conducting its own 
internal investigation?
    Dr. Stone. That investigation is being done as part of our 
safety investigation, yes, and I anticipate the results of that 
to coincide with the release of the other Federal and State 
investigations.
    As you know, this was a steam line that exploded, and we 
are going through all of the pieces that led to that, and we 
will release that in as transparent a manner as is possible.
    Senator Blumenthal. I am told that VA officials were 
informed by other employees and possibly by Mr. O'Donnell and 
Mr. Sims of maintenance problems at the facility. Are you aware 
of those reports?
    Dr. Stone. I am aware that there are maintenance issues at 
that facility. It is an old building. You actually spoke of 
that in your comments. It is an old building. But please 
remember that this was distant from the actual care facility. 
It actually was in the basement of a maintenance facility. And 
I am not aware of that area, where those valves were turned, 
even was repaired that day. This was a blunt line that finished 
in that basement area, and I just have to wait for the steam 
engineers to come back and talk to us about what----
    Senator Blumenthal. But you were aware of prior reports 
about potential problems that were unaddressed?
    Dr. Stone. No, I was not.
    Senator Blumenthal. Would you be surprised to learn that 
employees actually complained about the life-threatening safety 
issues in maintenance of that facility?
    Dr. Stone. When I spoke to the VISN director and the 
medical center director, they did not relate to me any life-
threatening maintenance issues that had not been addressed.
    Senator Blumenthal. Let me ask you about that facility, 
because I think we would agree that it is aging and aged and 
needs to be, in effect, rebuilt. Would you agree?
    Dr. Stone. Yes.
    Senator Blumenthal. And would you agree also that this 
incident should lift that construction to the very top of 
priorities for the VA in its capital projects?
    Dr. Stone. I will tell you that managing 6,000 buildings, 
the average age of which is over 50 years, I believe that we 
are absolutely committed to the West Haven community, to our 
partnership with the universities that are there and our staff 
that come from those universities, and to the robust number of 
veterans that we serve there. You have my commitment that that 
will be at the top of the list as we move forward. As you are 
aware, we have $350 million worth of construction scheduled for 
that site in the 24 months. If we can possibly move that 
forward or accelerate that you have my commitment to do it.
    Senator Blumenthal. I appreciate that. I would like to 
followup with you and make sure that those very encouraging 
words are turned into reality, because I think that this tragic 
explosion is a sign that we simply cannot allow this facility 
to continue to age and threaten the employees who work there, 
and as I said, the day of this disaster, in no way does the age 
of that facility reflect the first-rate, world-class care that 
VA personnel are providing to veterans. They are doing their 
jobs, day in and day out, with supreme excellence and caring. 
And so I commend your very dedicated workers, employees, 
doctors, nurses, clinicians, all of the staff at that facility, 
because they are working under very difficult circumstances.
    One last question for you. Among the sites that have been 
indicated for either the Pfizer or the Moderna vaccines, is 
there a public list?
    Dr. Stone. Yes, there is, and we will make sure that your 
staff has it.
    Senator Blumenthal. Can you tell me whether Connecticut is 
one of those sites?
    Dr. Stone. I do not believe it is on the initial list, but 
in your catchment area there are two sites that will receive 
the Pfizer vaccine. The question is, is it in the State of 
Connecticut? I do not believe the initial five sites are within 
the State of Connecticut.
    Senator Blumenthal. Where is the nearest to Connecticut?
    Dr. Stone. Massachusetts.
    Senator Blumenthal. In which part?
    Dr. Stone. I think in Boston.
    Senator Blumenthal. And that is the nearest to Connecticut 
for any vaccine?
    Dr. Stone. I think that will be the initial delivery. But I 
would have to really--we have executed 83 contracts for dry ice 
to enhance our ability to distribute this around the system. I 
just do not know, until this weekend, when we get final 
distribution criteria from CDC and FDA.
    Senator Blumenthal. Well, I am going to ask that 
Connecticut be included as one of the sites that the dry ice be 
provided, and my staff will be in touch with you about this 
issue. Thank you very much.
    Chairman Moran. Senator Blumenthal, thank you. With the 
gracious cooperation of Senator Tillis I am going to recognize 
Senator Manchin. We are not going by presence. We are going by 
seniority, because of the nature of the Senators who are 
distantly participating. Senator Manchin.

                      SENATOR JOE MANCHIN

    Senator Manchin. I want to thank my dear friend from North 
Carolina. I appreciate you, buddy.
    Anyway, Dr. Stone, the VA has set, in the Infrastructure 
Review Act, AIR, something I strenuously opposed--I think you 
all know that--it creates a commission in 2022 to close down VA 
facilities across the country. I am very supportive of reducing 
waste and other inefficiencies in the VA system, but I have 
been against Washington cutting back on health care access to 
veterans, especially in rural areas, in rural areas like my 
State of West Virginia, which is entirely rural, in the 
Appalachian, and fear that may happen.
    That is why I introduced a bill with Senator Rounds, also 
from the very rural State of South Dakota, to eliminate the AIR 
Act commission. I am hearing worrying reports of efforts to 
accelerate the AIR Act timeline, which is alarming, given that 
we are in the middle of a pandemic, and that would not be the 
right time to do it.
    So my question would be, the pandemic has made it clear the 
valuable role of the medical centers, the VA medical centers, 
not only for our veterans but for national stockpile of 
emergency supplies and responses, in other words, our national 
security. Do you all see the harm that might be shortsighted if 
they would start closing, or even going down that pathway?
    Dr. Stone. Senator, I am unaware of any effort to 
accelerate the AIR Commission, but I do believe that we need a 
fundamental recapitalization of the VA system. I mentioned 
previously to Senator Blumenthal that our average age of our 
facilities is over 50 years. We need to be recapitalized, and 
that includes acknowledging the lessons learned of this 
pandemic. And the lessons of this pandemic is we are the safety 
net to this system and we must acknowledge the fact that rural 
hospitals in America are not stable, are going out of business 
at unprecedented rates, and we must be that safety net.
    Therefore, what I thought was a review looking at where 
veterans truly were, has expanded now to acknowledge the fact 
that we will need small facilities in remote areas of this 
country in order to serve a potential future pandemic as well 
as to serve America's veterans.
    Senator Manchin. Either one of you could answer this, or 
both of you answer. The Pfizer and Moderna vaccines need to be 
transported and stored in extremely cold temperatures. I think 
we are all concerned about how we are going to get into the 
most rural areas. Having a State that is entirely rural, and my 
friend from North Carolina, his State is extremely rural in 
certain areas, we are thinking that we might not have the 
facilities to do that, and to be able to do that, and get the 
vaccines transported in a safe manner. What precautions, and 
how are you all working with that to make sure that basically 
when these vaccines are distributed that we are able to handle 
those in these rural areas if we do not have the 
accommodations? So either one. Dr. Stone?
    Dr. Stone. So as I mentioned previously, we have sandboxed 
the entire process to make sure we can handle them safely. 
Please remember, Senator, that we are in the midst of our 
influenza vaccine distribution and have given over 1 million 
doses of the influenza vaccine. So our ability to move these 
around the system is well tested as part of our pharmacy 
program.
    The difficulty here is refrigeration, and that is what I 
talked about in -20 and -70 degree freezers, to move these 
around. This morning, before we began here, I had a 
conversation about our ability to obtain a short-runway 
aircraft to go into rural areas, that we could bring small 
amounts of vaccine into those rural areas where there are 20, 
30, 50, or 100 veterans. I believe we are going to need to have 
that kind of creativity and innovation in order to deliver this 
effectively and quickly.
    Senator Manchin. The last question, very quickly, is 
internet access. You know, telehealth, all of that has been 
hard to come by in rural areas because we have no internet 
service, and then also getting reimbursement for travel. That 
has been a big thing with our veterans in rural areas. Has that 
been looked into and how they can basically be able to access 
that or expedite that, as far as access to the travel expenses?
    Dr. Stone. Let me answer the first portion of that, the 
internet. There are really some weaknesses in the internet 
system in America----
    Senator Manchin. We are working on it.
    Dr. Stone [continuing]. and we have been trying hard. We 
worked hard in Kansas with some of the small providers to see 
what we could do to enhance that. It has been a pretty 
frustrating area, but we are hoping for the help from FCC to 
really work that, and hoping for your help.
    Senator Manchin. We have a COVID package, with more help 
for that too, and it specifically spells out, in veterans, how 
we can help them in those vulnerable areas. How about on 
expenses. Are there other ways, since internet is not able to 
get their reimbursement, or get their expenses?
    Dr. Stone. And yes, we are examining that, and I have been 
assured that we have put methods in place to get people's 
reimbursement for travel and to make sure that is being done 
properly.
    Senator Manchin. Very helpful. Thank you.
    Dr. Stone. Thank you, sir.
    Chairman Moran. Senator Tillis. Thank you.

                      SENATOR THOM TILLIS

    Senator Tillis. Thank you, Mr. Chairman. Gentlemen, thank 
you for being here. Thank you for your past and current 
service.
    If we could go back to the vaccines, you said there are 37 
sites, you are going to plus up 36 more for 73. I am kind of 
curious. I am curious--did the original 36 sites already have 
the ultracold storage, or did you pre-position them? What was 
the rationale for the geographic location for the first 37 
sites?
    Dr. Stone. We moved them around. Most of those are used in 
the research community. Some of that research is not being done 
where there are large numbers of veterans.
    Senator Tillis. So are you all creating like a hub-and-
spoke sort of framework to where we should be concerned less 
with where they are physically and more with whether or not 
they are optimized for distribution out to other facilities? 
Was that the underlying strategy?
    Dr. Stone. That is exactly the strategy, Senator.
    Senator Tillis. Okay. So the 36 would plug any holes or 
create more--or the 36 additional, to create more hubs.
    Logistically, after the vaccine goes to the hub, how long 
does it--mechanically, so in Senator Blumenthal's case, 
Boston--I used to live in Boston. It is not too far from 
Connecticut. You have a need in Connecticut, so how does that 
work? First you have got the prioritization. You have 
stratified at-risk VA employees, at-risk veterans. You are 
going to determine that you need to surge a certain amount of 
vaccines to Connecticut. So logistically, have you all worked 
out how long it is going to take from the time that you have a 
stockpile in Boston to the time that you can get it to any part 
of Connecticut, if that is the priority need?
    Dr. Stone. CDC has not approved secondary transportation 
beyond the initial delivery site.
    Senator Tillis. Okay.
    Dr. Stone. Once we have that, that can be moved using dry 
ice that should last for a number of days for transportation.
    Senator Tillis. Okay.
    Dr. Stone. Once that is then unfrozen, it then has to be 
diluted, and once that is done it has to be used within 6 
hours.
    Senator Tillis. Okay. Do you think that--are there any 
areas of concern with the 37 hubs that are in place, the 36--
over what timeframe will the 36 hubs be put into place?
    Dr. Stone. Within the next 2 weeks.
    Senator Tillis. Okay. So you are going to be--that 
underlying infrastructure is going to be tracking roughly to 
what we hope is the availability of the Pfizer vaccine. So I 
guess the thing I am--with that 73 hubs, are there any areas 
where we are serving veterans where you are concerned that 
logistically you do not have geographic coverage for the points 
of distribution, or do you think that those 73 sites cover the 
points of distribution?
    Dr. Stone. No, I do not think it is going to cover the 
entire nation in the way that it should, and I think I am going 
to need the Moderna vaccine and the 200 sites that I will have 
from the Moderna in order to reach the rural veteran.
    Senator Tillis. I think it would be very helpful for the 
members if you could report back, as a question for the record, 
what areas of vulnerability we have. And it is not for a desire 
to serve them. It is because of the logistical challenges. But 
I think that would be helpful so that we are tracking that, 
more or less a coverage map for the distribution of the 
vaccine, and then Moderna, which is still cold storage but not 
super-cold storage.
    You know, you mentioned how--I watched both of your opening 
Statements in my office, and, Dr. Stone, I think you mentioned 
how, you know, things that seemed extraordinary decisions that 
you made over the course of the challenge of COVID has now 
become standard operating procedure, you know, in terms of the 
ways you are doing things differently. How many of those are 
authorized under emergency conditions that we need to make sure 
stay in place, because they should become part of standard 
operating procedure?
    And because I am running out of time, Dr. Lawrence as well, 
I guess what I would like to hear from you all is what more 
does Congress need to do, either through authorities or through 
resources, to make sure you can continue to sustain what I 
think is a remarkable success story in the way that you all 
have dealt with it. You are not perfect, but if I were to match 
you up against most major health care systems I would say you 
are doing as well or better than the vast majority of them, and 
I appreciate you doing that.
    So if you could just maybe, for the purposes of the 
Committee, talk about what more we need to do, as followup 
authorities or followup resources, to backfill maybe depletion 
of accounts, just because of what you have had to do to respond 
to COVID. That will be my last question.
    Dr. Stone. Senator, thank you, and I appreciate this 
question because I think we will need more resources. I think 
under the CARES Act you gave us $17.4 billion for the health 
administration. We have committed right about $8 billion of 
that. I think we will consume the rest of it through the 
remainder of this fiscal year.
    But I do believe there is a lot we cannot see about vaccine 
distribution, and I think we are still probably three to 4 
weeks ahead of the peak of what we are going to see in this 
escalation of cases across the Nation.
    One of the authorities that has been absolutely essential 
to us is the fact that the Office of Personnel Management gave 
us authority to waive many administrative requirements that 
have allowed us to hire over 66,000 employees. Should we expire 
in those authorities, it will make it very difficult for us to 
sustain this work force in the manner that we have. So that is 
one area where I would ask you to think about as we go forward.
    And, Dr. Lawrence, I will leave it to you.
    Mr. Lawrence. Yes, Mr. Chairman, if I might have a minute 
here. I know we are at time.
    We need to provide better service to our GI Bill students, 
the changes in the conditions and the laws. We put forward a 
request for $240 million to give them more modern systems so 
that when they call we know who they are, when they ask for 
computations of information we do it instantly, and we have all 
the data to not only service them but as well as to do 
oversight. So we put forward a pretty clear request to get 
better IT systems for our education service business.
    Senator Tillis. Thank you.
    Chairman Moran. Senator Tillis, thank you. Senator Hirono.

                      SENATOR MAZIE HIRONO

    Senator Hirono. We are having some technical difficulties 
and so the questioners and the responses are frozen, so I will 
do my best to proceed. I see that I--yes, I just froze.
    So let me start with Dr. Stone. You have been asked a 
number of questions. I see that I just got--Okay. You have been 
asked a number of questions regarding the vaccine distribution. 
I would like to know whether, at a time when transparency and 
communication with regard to vaccine distribution is critical 
to the hundreds of thousands of veterans all across our country 
and our territories, is your current vaccine distribution plan, 
including where the sites are, what the priorities are, are 
those on a website? And also, is there information on 
frequently asked questions on a website right now, and if not, 
are you going to put together such a website so that the 
veterans can understand what kind of distribution program they 
are going to need to follow?
    Dr. Stone. Yes. We did post our frequently asked questions, 
and we have not posted our sites for distribution yet until we 
get approval from the CDC, and I anticipate that this weekend. 
But I do have, in front of me, and I am happy to leave with the 
staff the listing of all 23 VISNs and what the locations are, 
as we anticipate it at this time. But I will firm that up over 
the weekend and they will be posted on our websites, where 
those sites are.
    We did also communicate via text to over 20 million 
distribution of the fact that we will be contacting veterans as 
we go forward and as the vaccine is made available.
    Senator Hirono. Well, I am hearing you say that you will 
put together a very user-friendly website that will explain the 
priorities for the vaccinations, with as much specificity as 
you can, because the communication and transparency of your 
program, your vaccine distribution, is going to be critical. So 
I am very interested to see what your website looks like.
    I know that, again, Dr. Stone, you are very familiar with 
what happened at the Yukio Okutsu State Veterans Home, and I do 
appreciate VA sending a team out there to help with the 
situation, the tragedy there, where 27 people who lived there 
lost their lives. And you made some recommendations as to how 
this home should proceed. Are you ensuring compliance with the 
recommendations made in the report that was generated by your 
team?
    Dr. Stone. Yes, we are.
    Senator Hirono. Are they in compliance?
    Dr. Stone. I would have to get an update at this point 
about that site, but it is my understanding that they were very 
cooperative and very supportive of coming into compliance. As 
you know, for a number of weeks we put personnel into that 
State veterans home in order to assure that, and every report 
that I got while they were there was that they were in 
compliance. I cannot comment, as I sit here today. I just have 
not had a report in the last few weeks.
    Senator Hirono. Are you also engaged in proactive 
communication with other VA facilities so that something like 
what happened at Okutsu is not repeated in other facilities 
that take care of veterans?
    Dr. Stone. Unfortunately, Senator, as you know, this has 
been repeated in other areas around the country. In every 
single site, now more than 100 of the 157 State veterans homes 
owned and operated by the States, they have welcomed us into 
those homes, and we have actively worked to make sure that 
veterans' health and safety is assured to the best of our 
ability.
    We have also been in hundreds of private nursing homes 
around the Nation, that have invited us in to provide training 
for their personnel as well as to comment on how to operate 
COVID-positive and COVID-negative----
    Senator Hirono. I am sorry, Doctor. Your response got 
frozen, but I just have one more question.
    Telehealth has really been in increasing use in the VA 
system. Are there any authorities that you need to enable you 
to expand your telehealth capabilities? Do we need to take 
further Federal action to enable you to do that?
    Dr. Stone. We just posted some regulations that will allow 
us to mimic what is done in the Department of Defense with 
Federal supremacy. What we do recognize is that the State 
licensure of some of our health care professionals is causing 
some difficulties in our current authorities when we distribute 
personnel as part of an emergency DEMPS deployment or deliver 
using your analogy across States.
    Senator Hirono. I am sorry. Your response just froze so I 
could not hear what you said. We will need to followup with 
you, because if there are any barriers to--sorry. We are having 
technical difficulties, so we will have to get back to you with 
regard to any barriers to your ability to have telehealth be a 
way to respond to the veterans' needs. Thank you, Mr. Chairman.
    Chairman Moran. Senator Hirono, thank you. Your 
difficulties exhibit the difficulties we have with technology. 
Senator Sullivan.

                      SENATOR DAN SULLIVAN

    Senator Sullivan. Thank you, Mr. Chairman, and thanks for 
your leadership on this Committee. I appreciate it and all that 
we are getting done here.
    Dr. Stone, Dr. Lawrence, I am going to ask some questions 
for the benefit of veterans listening who may not have caught 
you full opening Statements. I know the VA is working with the 
CDC on finalizing plans for distribution of the COVID-19 
vaccine, and I understand that the vaccines will be distributed 
at two site locations per region, as determined by that VISN 
regional office.
    Can you go into detail about how those locations will be 
decided, what the prioritization is for receiving a vaccine 
among veteran population, and how do you plan to coordinate 
with States and other agencies to deliver to a wider 
population? I have, of course, a strong interest in Alaska, 
where we have a large veteran population, particularly in rural 
areas, where health care infrastructure is limited and 
traveling to major, you know, cities like Anchorage or 
Fairbanks is not always so easy.
    Dr. Stone. Senator, the initial distribution is dependent 
upon the presence of the refrigeration that will accommodate 
the vaccine.
    Senator Sullivan. I am sorry. Say that again.
    Dr. Stone. The initial distribution was based on the 
presence of refrigeration that would accommodate the vaccine at 
the appropriate temperature and then was matched to the 
concentration of veterans in that area.
    Senator Sullivan. So not to interrupt but that is kind of a 
0 for 2 for me, because in our rural areas we have a lot of 
veterans but it is pretty sparse, and we do not have--we have 
very limited refrigeration or even medical facilities. So I 
guess that is the challenge then, correct?
    Dr. Stone. So I would look for the distribution into the 
Alaska area with the Moderna vaccine. We have -20 degree 
freezers there. And then we are going to need to do a secondary 
distribution of that vaccine, and if you heard my earlier 
comments I think we are going to need aircraft to do that.
    Senator Sullivan. Okay. Well, it would be helpful. I am 
sure Alaska is not the only State similarly situated. I am sure 
there are other big rural States--we are the biggest rural 
State--and with so many veterans perhaps maybe offline, not as 
part of this hearing, my team and I can make sure we are 
coordinating well. I have been doing this with General Perna 
and others. We have so many unique challenges in Alaska that a 
lot of other States do not have, given the size and the weather 
and challenges like that.
    How about, how well do you think it is going in terms of 
your integration and coordination with other Federal agencies, 
say, DoD, and States? And I am not just talking Alaska. Of 
course I would be interested in Alaska, but whether it is 
Kansas or any other place, Arkansas, how do you think that is 
going?
    Dr. Stone. You know, early in this process and in this 
response the Secretary called every Governor in the Nation and 
spoke to, I think, more than 46 of them.
    Senator Sullivan. Good.
    Dr. Stone. That contact opened a methodology that we now 
have supported 47 different States in providing VHA services 
personnel or consultation, or even PPE, to support the States 
across the way. So I think that is going very well.
    I think that this is a herculean effort that nobody has 
done for 100 years, and even when the Sabin and Salk vaccines 
were released I think there is a--I can remember--I am old 
enough to remember my parents taking me and driving to get the 
vaccine. We are going to have some difficulties reaching rural 
areas, but you have our commitment that we will work diligently 
until every veteran is delivered this vaccine and we assure the 
safety of the population that is enrolled with us.
    Senator Sullivan. Good. I appreciate the hard work you guys 
are putting into this, you know, the Secretary on down.
    Let me ask one final question. How is the VA coordinating 
with IHS to make sure that the native veteran and non-native 
veteran populations served in those hospitals through the VA 
Tribal Sharing Agreements are accurately accounted for in the 
VA's vaccine distribution plan? You have some overlap there in 
some ways could be good. I think overlap is good, but falling 
through the cracks would be bad.
    Dr. Stone. Our allotment is not part of the IHS allotment.
    Senator Sullivan. Yes.
    Dr. Stone. We expect IHS to receive an allotment and we 
have expressed to their leadership that we are more than happy 
to come in and support them, should they need support-----
    Senator Sullivan. Good.
    Dr. Stone [continuing]. in providing this. We also have 
over 100 agreements with individual Tribes that operate their 
own systems, and we extend the same, and extend it today, we 
extend the same commitment that we will come and help if they 
need support. Every day my deputy, Steve Lieberman, sits with 
FEMA and HHS, looking at requests for support in an effort to 
assure, at the highest levels of VHA, we are responding 
appropriately and as agilely as possible.
    Senator Sullivan. Great. Thank you. Thanks for your hard 
work on this very important issue. Thank you, Mr. Chairman.
    Chairman Moran. You are welcome, Senator Sullivan. You are 
such a diligent advocate for Alaska and its unique nature. This 
is the first time, though, I ever heard you complain that you 
have lack of refrigeration.
    [Laughter.]
    Senator Sullivan. Well, you notice I mentioned Kansas too.
    Chairman Moran. Yes, I appreciate that as well. Thank you.
    Senator Sullivan. I did not mention North Carolina, though.
    Chairman Moran. Senator Sinema. Senator Loeffler?

                     SENATOR KELLY LOEFFLER

    Senator Loeffler. Thank you all for being part of this 
important hearing. I just wanted to followup on my colleague's 
question, particularly related to rural areas, and I apologize 
if this question has already been asked. So really it is along 
the lines of telehealth. Obviously, Congress has granted the VA 
the authority to form agreements with telecom companies to make 
sure that they can access tele-mental health services. As the 
pandemic forced people across the country into isolation, 
obviously it is so important that we assure the at-risk 
veterans receive the mental health care that they need. 
Obviously, connectivity and access in regard to telehealth is 
so important for every veteran, but particularly those in rural 
and otherwise underserved communities, that my colleague just 
mentioned.
    Dr. Stone, can you provide us an update on how the VHA is 
utilizing this important authority?
    Dr. Stone. Senator, I can, and I appreciate the question. 
At this time we are delivering mental health services at about 
exactly the same rate as we were before the pandemic began. 
What has changed is that the vast majority of that is being 
done using either video technology or telephone technology. The 
receipt of that has been extraordinary on behalf of veterans, 
with very high levels of satisfaction, being able to stay in 
their home and receive those services.
    The only change that we have seen is in group therapy, 
which the technology does not accommodate very well or maintain 
the level of privacy that veterans have wanted.
    We have also distributed over 80,000 iPads to veterans in 
remote areas, and we have worked to assure all of the major 
carriers now have signed on to allowing us to connect to 
veterans without it going against their monthly bill in the 
movement of data or text across their systems.
    So I am really very pleased with the advances that we have 
made in this, and it is a reflection of the fact that the vast 
majority of mental health services are now using these 
technologies.
    Senator Loeffler. Well, that is great to hear, and in terms 
of your answer showing such effectiveness I would just be 
curious, as a followup, to hear what you might think, how that 
might change. Just once we get back to normal, does that allow 
you to kind of have a new way to address those underserved 
areas and keep that engagement going at a lower cost and more 
accessible basis? Are there some learnings going forward?
    Dr. Stone. There is, and I would suggest also that the 
partnership that we have with Philips, that has allowed us to 
develop the Project Atlas that is going into remote areas of 
the Nation which literally is a room that we can insert in 
facilities like our VSO partners, and has allowed us to deliver 
in remote areas where there is not even internet that is 
effective.
    We are also in partnership with organizations like the 
major retailers, like Walmart, where they have developed an 
infrastructure that we have been able to piggyback off of and 
to work. And we have been down in your State looking at some 
remote, what we would call health care deserts, looking at how 
we might partner with Walmart to deliver to veterans that just 
do not have access to internet ability.
    Senator Loeffler. Well, as someone who grew up on a farm 
and the family still struggles with that internet connectivity, 
I know that means so much to those in rural areas, and 
particularly this really urgent need for our veterans. So thank 
you for continuing to work on that and make sure--you know, our 
State is the fifth-largest for veteran populations and we have 
so many needs right now, so thanks for continuing your great 
work on that. And I will yield the balance of my time.
    Senator Tillis. [Presiding.] On behalf of the Chair, 
Senator Sinema will be next. After Senator Sinema we will take 
a brief recess pending the completion of votes and the return 
of the Chair. Senator Sinema?

                     SENATOR KYRSTEN SINEMA

    Senator Sinema. Thank you so much, Mr. Chair. I want to 
thank Chairman Moran and Ranking Member Tester for holding this 
hearing. At a time when coronavirus cases are spiking in 
Arizona and across the country, it is important for us to 
ensure the VA is well equipped to fulfill its mission. So I 
want to thank our witnesses for being here and for your 
continued efforts to provide care and support to veterans 
during this pandemic.
    It certainly has not been easy and there have been bumps in 
the road, but overall we have heard positive feedback from 
leaders in the Arizona veterans' community about the VA's 
response in the State.
    My first question is for Dr. Lawrence. Arizonans continue 
to express concerns that the VA has not taken any action to 
ensure that survivors of veterans who die from COVID will 
receive the benefits they have earned. I sent a letter, with 
Senator Tillis, in July, asking Secretary Wilkie to take 
action, and I still have not received an answer.
    Many of the illnesses that make individuals more 
susceptible to COVID-19 are widespread in the veteran 
population, but there are instances where a veteran's death 
certificate identifies COVID as the sole cause of death, even 
if the veteran had service-connected illnesses that could have 
made them more susceptible to the virus. In these cases where 
those illnesses are not listed as secondary causes of death, 
the survivor will not receive their earned VA benefit.
    So in my letter I asked Secretary Wilkie to provide 
guidance to VBA claims adjudicators to make this process more 
streamlined, including automatically seeking a second medical 
opinion in these instances. Given there is so much we are still 
learning about this virus, having an automatic second opinion 
would standardize the common-sense practice and take a huge 
burden off the survivor in an already difficult time.
    I have introduced the Ensuring Survivor Benefits During 
COVID-19 bill to require VA to do this. My question is, can the 
VA do this without legislation?
    Mr. Lawrence. So I am sorry to hear that your letter has 
not been responded to because I know this is something we take 
seriously. And like so much of what has happened during the 
pandemic, this is something that was not thought through. We 
rely on the death certificates to provide benefits, and I know 
that our folks--because others are identifying this too, the 
veteran service organizations have brought this to our 
attention, and I know that we are reviewing it.
    I will have to check in on where the review is, and I do 
not want to speak out of lack of knowledge of whether this is 
something we can implement through our rules or whether we will 
need legislation. I am thinking it is our rules, but let us get 
back to you on the do-out on that.
    Senator Sinema. Well, I would like us to get back with each 
other before the winter holiday, because, of course, I am 
concern now that we do not have a process streamlined for 
survivors, and if so, if there is not going to be a process 
from the VA I would like to get our legislation moved forward 
to give you that authority to do so.
    My next question is for you and then for Dr. Stone. In 
April, the VA announced a number of actions to help ease the 
financial burden on veterans during the pandemic by suspending 
all actions on veterans debt. The VA website announcing this 
action asks veterans to contact the VA to make arrangements. 
Other VA announcements suggest that debt relief was 
automatically granted.
    So I wanted to ask you, was debt relief automatic for both 
benefits and health-related debt?
    Mr. Lawrence. Let me start with benefits. So debt relief 
was automatic for new debts. For debts that were existing you 
were to call and arrange the payments you would like to 
continue on. We did not want to waive those for folks who 
continued to make their payments. So that is how that was done 
from a benefit perspective.
    Dr. Stone, why don't you answer that one?
    Dr. Stone. From a health perspective, Senator, we do not 
have authority to waive. We have delayed the collection of 
those debts until January, and it remains to be seen whether 
the economy will have been stabilized to the point that that is 
appropriate. But we do not have authority to waive the debt 
collection that will occur. In fact, we sent, this last 
weekend, notice to all veterans of what their current balances 
were.
    Senator Sinema. Well, given the case, the status of the 
pandemic right now, I think it is reasonable to assume that the 
financial situation in our country will not be significantly 
better in January than it is now. So I would like to followup 
on this, because I believe that the debt relief should be 
automatically granted, and again, some VA announcements have 
suggested it to be so. So I would like to get that clarified so 
we can provide certainty for our veterans.
    My final question is for both Dr. Lawrence and Dr. Stone. 
The VHA is sending out information to veterans notifying them 
that these debt suspension actions expire at the end of the 
year. The VBA has told SVAC staff that the current debt relief 
policies will be in place until 60 days from the end of the 
national State of emergency, and yet VA's Debt Management 
Center has said the current debt relief provisions will end but 
that VA will announce a new plan shortly and notify veterans 
over a 7-month period.
    Is VA continuing these debt suspension actions, and how and 
when are you notifying veterans? They need to know now.
    Mr. Lawrence. Certainly, I agree. There is some confusion 
in the communication coming from the Debt Management Center. So 
both Statements are true. We are going to continue to suspend 
debts, but what the Debt Management Center is doing is writing 
letters to our veterans in January, telling them of their debt, 
and offering them three courses of action: one, pay 
immediately, if you will; two, talk to us about rearranging the 
schedule, and there is some flexibility in how long you can 
rearrange your debt; and three, ask for a waiver.
    So that is what they are doing in January, and, again, you 
can see it incorporates that.
    In terms of, you know, providing information to the debt 
services, that will not continue until October, at which point 
they will rearrange it. So we have talked to our debt 
management colleagues to clarify this. I know that they have 
been up to talk to your staff about this, to try to get the 
right information. But both Statements are true.
    Dr. Stone. So let me say, on behalf of the VHA, we did 
communicate this last weekend. We have received large numbers 
of phone calls from veterans stating that they wanted to use 
their flexible savings accounts and wanted to assure that we 
were informing them of any debt that they might have. In an 
effort to comply with that, we sent out the notice last 
weekend. We also, as part of that letter--and we would be happy 
to get your staff a copy of it--invited any veterans that 
needed special assistance to contact us and we would work with 
them. We also made personal contact with any veteran that had a 
balance of greater than $2,000, many of which occurred because 
of long-term care facility copayments.
    Senator Sinema. Thank you, gentlemen. Mr. Chair, I see that 
my time has expired. I yield back, and thank you.
    Senator Tillis. Thank you, Senator Sinema.
    Gentlemen, we are going to take a break. I do want to also 
extend my thanks to Secretary Wilkie. I think we should remind 
everybody of where the VA was just a couple of years ago, and 
17th out of 17 Federal organizations, as the least desirable 
places to work. Now you have move up, I think, into about the 
top 5 or top 6 category. I want to thank you for the work that 
you have done for the pandemic response. It is not perfect but 
I again would say it is probably about as good as any 
comprehensive health care system in the United States.
    And I am going to submit some questions for the record. I 
think it would be helpful to the members to understand the hub-
and-spoke strategy, where you do think you have vulnerabilities 
in the rural areas and potential remediation strategies for 
that. I think that will be helpful for the members. I do not 
want to question the underlying infrastructure that you are 
putting into place. What we do not want to do is have a hub 
move to an area that is suboptimized. What I think our members 
want is to make sure that their constituents are covered. So I 
appreciate you all getting that back to us. I will submit some 
other questions for the record.
    We are going to take a brief recess, subject to the call of 
the Chair, after the second and third votes are taken, which I 
expect to happen momentarily. So thank you all. We will be in 
recess.
    [Recess.]
    Chairman Moran. [Presiding.] The Committee hearing will 
reconvene, and thank you, both witnesses, for your willingness 
to allow my return from votes. And pleasing perhaps to you is 
that we have another vote in 5, 10 minutes. So my questioning 
will be brief and I will not expect you, nor do I want to run 
one more time from the floor back here. So thank you very much 
for your patience. Let me ask Dr. Lawrence a few questions and 
then Dr. Stone a few questions.
    Dr. Lawrence, although the VBA worked with its contract 
vendors to conduct as many telehealth and acceptable clinical 
evidence exams during suspension of in-person exams, there, of 
course, is still a backlog of exams and claims to be processed. 
What is the VBA's strategy going forward to continue enhancing 
and expanding access to telehealth and ACE exams to tackle this 
backlog? How do you foresee these virtual exams and the ACE 
exams will evolve the medical disability exam process?
    Mr. Lawrence. We think this is one of the things the 
pandemic has really opened our eyes to, is how much can be 
done. We want to continue that as much as possible, and we are 
working with VHA to expand the list of conditions by which 
tele-C&P exams can be done.
    We also want to encourage our veterans to get us acceptable 
medical evidence. We do not like when they go to a C&P exam and 
we could have looked in their records. We encourage them to get 
us their medical records. If they will sign a form, we will go 
get it in 5 days from their provider. We are very, very good at 
that. So we would like to do as much of that going forward as 
possible. We are working with the contract vendors to do that, 
and that is our plan.
    Chairman Moran. Is there any less accuracy related to the 
exam in this manner, and are there certain medical conditions 
or cases that would still--the preference would be to be seen 
in person?
    Mr. Lawrence. Yes. So what we do is we limit the expansion 
of C&P to make sure we do not have the problems you are 
describing about accuracy. Only if it meets the criteria that 
you can do it well, and the answer is yes, there are many, and 
that is why we have to coordinate with VHA in terms of the 
medical protocols, things you just cannot do virtually. You can 
understand touch measurement, things like that, but that is 
right.
    So we are trying to strike the right balance as much as 
possible, understanding it will never replace everything.
    Chairman Moran. And this discovery, this utilization of 
this technique will help in reducing the backlog, in the long 
term?
    Mr. Lawrence. Absolutely. We want to have more capacity of 
our vendors, you know, in-person as well as tele-C&P. So 
before, obviously, you would just reschedule, we would wait, 
you would reschedule, we would wait. Now if we could do it 
online that would be great.
    Chairman Moran. Dr. Lawrence, in addition to going through 
a name change and rebranding this year, your testimony 
illuminated a lot of good information regarding the Veteran 
Readiness and Employment, or the VR&E, program's response to 
COVID through increased telecommunications. However, in July, 
the VA Office of Inspector General issued a management advisory 
memorandum to request that VBA examine overpayments by the VR&E 
program that were made to schools covering veterans' tuition.
    Where is the VA on investigating on how to appropriately 
recover those overpayments? Has the VA provided the OIG with 
any updates on their efforts to examine and recover those 
overpayments?
    Mr. Lawrence. I will have to check in on the last part of 
your question, how we work with OIG on this. I know we have a 
regular cadence with them. I meet with the inspector general 
every month and we talk through what is going on in both of our 
organizations.
    Overpayments and inaccurate payments is something we take 
very seriously. We spent the last year working on, you know, 
reducing our overpayments, and the last couple of years we 
reduced our improper payments by $400 million. I will also 
check in on the status of where they are in terms of running 
down the processes and tightening it up, and certainly 
recovering the monies. So we will take that as a do-out and 
talk to your staff about where we are.
    Chairman Moran. I welcome your followup on those questions. 
Thank you.
    Let me turn to Dr. Stone. Dr. Stone, the VA has undertaken 
civilian assistance missions in 49 States and territories, 
admitted 355 civilians to its hospitals, and provided over 
908,000 pieces of PPE to civilian health care facilities as 
part of its fourth mission. I say that because I want people to 
know that. You would be aware of it.
    My questions are, if a civilian hospital CEO or a county 
public health director visits with me, they think they need 
VA's help in responding to the pandemic in their community, 
what steps should they take to get that help?
    Dr. Stone. They would go through their State emergency 
operations, through their Governor, and then it would come to 
us through FEMA. That can be done in an agile manner in that we 
quite often will begin to support a local facility as we await 
this to come through the State approval from the Governor and 
then the FEMA approval.
    Chairman Moran. The numbers that I indicated, extended the 
involvement of the VA and its fourth mission to civilians. Has 
it changed since the facts I outlined? Is something more 
happening today with the result of the increase than what those 
numbers reflect?
    Dr. Stone. A couple of things have happened. No. 1, let me 
clarify. It is 908,000 pieces of equipment.
    Chairman Moran. I do not know what I said, but that is what 
my notes say, 908,000.
    Dr. Stone. All right. I appreciate that, sir, and I 
appreciate you outlining it. But we also just this week, in New 
York, gave ventilators to a private hospital on a lease basis 
or on a loan basis, that they were out of ventilators. We have 
a large amount of ventilators that we have secured throughout 
the pandemic. So we have equipment all over the Nation that we 
have given to private hospitals in order to respond to this.
    Chairman Moran. Dr. Stone, my conversations with Kansas 
hospital CEOs, chief nursing officers, with certainly press 
reports, probably the most prevalent COVID-19 story in our 
State, in addition to the number of deaths or the number of 
positive cases, the spread, is the lack of hospital 
capabilities, particularly ICU capabilities, to meet the 
demands of the patients, the demands of what now COVID presents 
a hospital. The ability, for example, of a small, rural 
hospital to find transfer for a patient that needs ICU care is 
limited. It takes a long time. There are some who are unable to 
be transferred and others it is where hospital personnel in 
small hospitals are spending their time trying to find a bed in 
Kansas or outside of our State.
    In exploring the challenges that those hospitals that have 
ICU beds generally available to patients in Kansas but do not 
now have the availability, in some instances, perhaps most, it 
is not a lack of beds. It is a lack of health care 
professionals, the necessary nursing and other staff. So the 
shortage is, in significant part, unstaffed beds, and that is 
due to those who work in the health care delivery system 
testing positive, being home, being isolated, have members of 
their family who are in that circumstance, students who are not 
in the classroom. There is a lack of professionals, the 
necessary people to work in the ICU.
    What role, if any, can VA play in providing professionals 
to better staff ICU units?
    Dr. Stone. Mr. Chairman, the sustainment of the medical 
work force across the Nation is the major weak point that we 
face today. That work force, as you know, in Italy and in 
Spain, as much of 15 percent of the work force went down from 
COVID and was unable to work.
    What we believe is that in no way can the VA's 175 
hospitals staff the 6,000 civilian hospitals in the Nation. Our 
best approach is to accept critically ill patients to be 
transferred into our facilities. And as you and I are speaking 
this morning, I have 1,100 ICU beds that are available across 
the Nation.
    Chairman Moran. Available as in available beds and staff?
    Dr. Stone. Yes. They are available and staffed. I also have 
mobile units that can be moved into areas of the Nation. We 
just moved from El Paso to Oklahoma City a 30-bed ICU that is 
mobile, that will allow us to take some of the strain off the 
Oklahoma City and surrounding area. I have multiple 25-bed 
modules that can help reduce the stress on civilian hospitals.
    But we cannot be a staffing agency. And although we have 
tried to do that in many areas, we are just not large enough, 
even with 400,000 personnel to care for America's veterans, to 
care for the challenge that we are having with now over 1,800 
veterans currently hospitalized in either acute or convalescent 
care in our facilities. We cannot sustain that operation and 
staff other facilities.
    Chairman Moran. So, Dr. Stone, let me see if I can put this 
in the way I would explain it to someone at home. The VA's 
capabilities are not to be a staffing agency, as you say. It is 
not to send personnel from the VA to a different hospital. But 
there are staffed beds available within the VA that patients 
could be transferred to, where they would be cared for in a VA 
hospital, with VA staff.
    Dr. Stone. That is absolutely correct. Let me just finish 
the story. We also, on a med-surg basis, or medical-surgical 
beds, I have 3,000 empty beds across the Nation today, and then 
the 1,000 that are ICU beds. About 4,000 beds are available 
today. And the Secretary, as I mentioned earlier to Senator 
Tillis, has reached out to Governors in areas that are really 
stressed, saying that we are available and we are more than 
happy to enter into discussions on how to get them help for 
critically ill citizens that need help, even if they are not 
veterans.
    Chairman Moran. I read in a press report today, in a small-
town paper not far from my hometown, about a patient who died 
with just the inability for that patient to be transferred 
someplace else. So it is a serious, acute circumstance. Would 
the process by which that can occur be what you described 
earlier, through FEMA, emergency preparedness, or is there a 
direct way to seek transfer to a VA hospital?
    Dr. Stone. Yes. It needs to go through the Governor, but 
any medical center leader who needs help, if they call their 
local VA director, we will work that, and we will work as 
agilely as we can in order to support critically ill Americans.
    Chairman Moran. Dr. Stone, I appreciate that answer very 
much. I appreciate that you have the capability to respond in 
that way.
    Let me ask, because it may be the last time, at least, this 
year, that you and I have an opportunity for me, at least in a 
setting like this, to ask you a question. I want to go back to 
CCN contract modifications. You know, we held a hearing, as you 
know, in regard to the MISSION Act, in October. During the 
hearing, Optum and TriWest both testified that they are 
voluntarily building their respective networks to meet MISSION 
access standards. While that is something I support, the VA has 
a responsibility, in my view, to modify the contracts to ensure 
that third-party administrators continue to meet those 
standards.
    Dr. Stone, why is the VA either has been or it continues to 
be hesitant--I do not know which--to modify those contracts 
when the TPAs are already building out their networks to meet 
the standards?
    Dr. Stone. This has been one of the most frustrating areas 
in yours and my relationship. I promised you in August I would 
get this fixed. It is not fixed yet. I considered it a 
shortcoming and I actually spoke to Optum leadership 48 hours 
ago, because I anticipated that you might ask me about the fact 
that I have not done what I promised----
    Chairman Moran. I am sorry that you know me so well.
    Dr. Stone [continuing]. I would do. They are about ready to 
move forward with moving off of the 180-minute rule that we had 
previously. I have been promised by the Community Care 
leadership that that modification will go forward, and I am 
looking for a date that I can fulfill my promise to you from 
now more than 90 days ago.
    Chairman Moran. Let me again try to put that in words that 
I would understand. What you are telling me is that in the near 
future you want to see that the contracts are modified to meet 
the standards of the MISSION Act.
    Dr. Stone. That is correct. Now I am talking about the 180-
minute rule, the 120-minute rule. There is more than a million 
providers in this Nation, more than are participating in 
Medicare, that are part of our Community Care delivery network. 
I think it is a robust network and I look forward to seeing 
how, as we come out of this COVID pandemic, it really serves 
the needs of America's veterans.
    Chairman Moran. I am not sure whether I like that answer or 
not but I will take it under advisement, and we can continue 
our conversation about this topic.
    We sent a request for information to the VA, asking whether 
their Fiscal Year budget request included funding to modify the 
contracts. The VA responded that the budget did indeed include 
funding for modifications. However, we continue to receive 
mixed signals from the VA. Can you confirm whether or not 
funding for the CCN modifications, which we are talking about, 
were built into your budget request or not?
    Dr. Stone. I have been told the same thing you have, and 
that is that it was built into the budget.
    Chairman Moran. So I guess my takeaway from that is that 
when I'm told, or if I'm told that there is insufficient money 
for purposes of modifying the contract, if we were to provide 
the money requested, that would not be an accurate explanation 
for why the modifications could not occur.
    Dr. Stone. That is correct.
    Chairman Moran. Thank you. I am just almost done, but I 
want to bring a story to you, Dr. Stone, of a circumstance in 
Kansas, and indicate a desire for your help.
    So this is at least the second time, maybe this year, the 
second time this year in which the VA has announced the 
intention of closing a CBOC in Kansas. And we have tried to be 
very cooperative and not--I am trying to choose my words 
carefully--not stand in the way of making a good decision, if 
that is the best outcome for veterans.
    So I would think that a normal response by an elected 
official is when we hear something is closing it is an 
immediate reaction, ``Oh, you can't do that.'' I am of the view 
that if the MISSION Act is fully implemented, and Community 
Care is available, there are circumstances in which Community 
Care may provide better services to veterans than a CBOC, 
particularly a CBOC that struggles to have the necessary 
personnel, has a physician only 1 day a week, is only open 
several days a week.
    So my indication, without conceding any point, I guess, is 
that I am interested in cooperating with the VA to accomplish 
the goal of replacing a CBOC, or eliminating a CBOC but only if 
Community Care Network can be built up to meet the needs of 
those veterans who were utilizing the CBOC.
    And so I would ask just for your cooperation, your help, or 
suggestions of what I might do to make--I know the folks in 
this community have reached out to Optum, so those 
conversations have started. But it would be nice for me to be 
able, it would be useful for me to be able to assure the 
veterans in the area of Liberal, Kansas, southwest Kansas, that 
the Community Care Network will be fully capable of meeting 
their needs on perhaps a more continuing basis, on a more daily 
basis than what the CBOC was able to do.
    Does that make sense to you and is that something that you 
can help me achieve?
    Dr. Stone. Sir, you have my commitment. It makes sense to 
me and you have my commitment that we will work together to 
assure that the veterans of that area of Liberal, Kansas, are 
served well.
    Chairman Moran. Thank you.
    Let me see if anybody has anything else.
    And then my usual practice of allowing our witnesses to add 
or detract, take something away that you said that you wish you 
would not have. Anything that we should know before we conclude 
the hearing?
    Dr. Stone. We thank you for the courtesy of the Committee, 
and we again arrive here today really as representatives of the 
400,000 great employees of this agency who continue to do their 
work so beautifully throughout the pandemic.
    Chairman Moran. Doctors, you always, in your testimony, 
your presence before the Committee, make a point of recognizing 
those that work with you and for you, and I join you in 
expressing my gratitude for their ongoing care and concern for 
our veterans, and particularly during the times of COVID-19 
pandemic. They have lots of challenges themselves in their own 
families, in their own lives, and yet they are willing to try 
to help care and cure and heal those that have significant 
challenges.
    And I thank both of you once again for your service at the 
Department of Veterans Affairs. I look forward to continuing to 
work with you, and I thank you both for being here today and 
discussing the work that you and your Department has done 
during these unprecedented and challenging times. We are not 
out of the woods yet and we will continue to be your ally and 
help and try to provide constructive suggestions that would be 
valuable to you as we meet the needs of our veterans.
    I would ask unanimous consent that members have five 
legislative days to revise and extend their remarks and include 
any extraneous material. With that the hearing is now 
adjourned.
    [Whereupon, at 12:04 p.m., the Committee was adjourned.]

                                APPENDIX

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