[Senate Hearing 117-]
[From the U.S. Government Publishing Office]




 
     MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2022
                  

                              ----------                              


                        WEDNESDAY, JUNE 23, 2021

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:00 a.m. in room SD-138, Dirksen 
Senate Office Building, Hon. Martin Heinrich, chairman of the 
subcommittee, presiding.
    Present: Senators Heinrich, Schatz, Tester, Baldwin, 
Boozman, and Hoeven.

                     DEPARTMENT OF VETERANS AFFAIRS

STATEMENT OF HON. DENIS R. MCDONOUGH, SECRETARY OF 
            VETERANS AFFAIRS

              OPENING STATEMENT OF SENATOR MARTIN HEINRICH

    Senator Heinrich. This hearing of the Military 
Construction, Veterans Affairs, and Related Agencies 
Appropriation Subcommittee is now called order.
    Today, we are going to be discussing the Department of 
Veterans Affairs' fiscal year 2022 Budget and fiscal year 2023 
Advanced Appropriations Requests. Veterans deserve more than 
just words of gratitude for their sacrifice when they return 
home. They deserve the quality care and benefits that they have 
earned. This budget strives to do that and requests a mandatory 
appropriation of $153 billion, and a discretionary 
appropriation of $113 billion. That is an 8.2 percent increase 
over fiscal year 2021.
    It also requests 156 billion mandatory advanced 
appropriation, as well as 111 billion discretionary advanced 
appropriation just to support its medical programs in fiscal 
year 2023. The cost of medical care continues to grow, and 
there are a lot of issues that we want to discuss this morning.
    We understand that VA's budget request is a bit complicated 
this year. The Department's request reflects the direct and 
indirect costs of the pandemic, including addressing the 
increases in the disability claims backlog, as well as the 
provision of deferred care, and increased mental health 
services. Funding provided in the Families First Act, the CARES 
Act, and the American Rescue Plan demonstrate congressional 
support for veterans during this challenging time, and much of 
the funding remains available for use in fiscal year 2022.
    In addition, this is the first year VA is allowed to use 
flexibility provided by Congress in the Recurring Expenses 
Transformational Fund, and VA plans to use $820 million of 
expired funds to support information technology and minor 
construction projects. While this is a robust request, 
especially considering all of the additional funding recently 
provided to the Department, VA must have what is necessary to 
respond to veteran demand.
    VA's requests for fiscal year 2023 shows a decrease in this 
program without supplemental funding. I hope that the need has 
subsided by then, but VA must plan effectively to avoid service 
cliffs relative to demand in these programs.
    This budget was developed prior to your undertaking a 
strategic review of the Electronic Health Record Modernization 
Program. We look forward to receiving more information on the 
results of the review, how the findings will affect the 
remainder of VA's ten-year plan, and how VHA's infrastructure 
costs will be incorporated into the total cost of the effort. 
The budget reflects VA's need to invest in physical 
infrastructure. As veterans come back to receive care at the 
VA, they deserve to be treated in facilities that are up to 
date and modernized. This year VA is planning to invest in its 
infrastructure through base funding, the Transformational Fund, 
and the American Rescue Plan funding.
    I look forward to working together to provide veterans with 
the services and the benefits that they have earned and 
deserve.
    And with that, I would recognize the Ranking Member for his 
opening statements.

                   STATEMENT OF SENATOR JOHN BOOZMAN

    Senator Boozman. Thank you, Mr. Chairman. And thank you, 
Mr. Secretary, for being here to discuss the Veteran's Affairs 
fiscal year 2022 and 2023 budget request. The budget request of 
$271 billion in fiscal year 2022 for the Department of Veterans 
Affairs, including medical care, collections, and the new 
Transformation Fund, represents a 10.4 percent increase over 
fiscal year 2021 enacted levels.
    This includes $118 billion in discretionary funds, a 10.4 
billion or 9.7 percent increase over fiscal year 2021. The 
budget also requests a total of $272 billion in advanced 
appropriations for fiscal year 2023. The large fiscal year 2022 
increase highlights the continued importance of programs for 
veterans. It also reflects the continued growth and popularity 
of the Veterans Community Care Program, which consolidated 
multiple community care programs through the MISSION Act.
    In fact, in this request the only dollars requested as part 
of the second bite to supplement last year's advance 
appropriations are for community care. Members of the 
subcommittee remain committed to providing VA with the 
resources needed to care for our veterans. However, continued 
growth of 8, 9 and 10 percent gets really difficult, and 
probably is unsustainable.
    Mr. Secretary, we need to work together to make certain we 
are prioritizing resources where they need to go, and to make 
sure Congress does not mandate costly initiatives without 
thoroughly considering the associated cost implications. Over 
the last year VA received roughly $37 billion in emergency 
funding to address COVID.
    I have to say that, overall, VA performed admirably 
throughout the crisis, and deserves praise and recognition for 
that. There is no doubt that most of these funds were 
absolutely necessary, and the obligation reports for the CARES 
Act funding demonstrates this. I had the opportunity to be in a 
number of facilities during that time, and again, the 
Department, all of those on the frontlines, and just all of the 
different areas really do deserve a big pat on the back.
    I hope to hear more about the future needs of the VA, 
especially after this large influx of emergency dollars; we 
don't want to find ourselves in a situation where CARES and the 
American Rescue Plan have reset the baseline for VA spending.
    The budget requests $2.6 billion for electronic health 
modernization, and many of us on this committee have long 
advocated for single, joint medical record that will follow a 
service member throughout their careers in the military and 
into their time as a veteran. We understand that this strategic 
review is nearing completion and we look forward to hearing the 
new path forward for the program. In particular, we look 
forward to receiving a revised deployment schedule as directed 
in last year's Omnibus.
    In addition to updates on those programs, we look forward 
to hearing details about the Department's request for mental 
health services, including efforts to combat opioid use 
disorder, and prevent veteran suicide. These initiatives to 
prevent veterans' homelessness also are very, very important, 
and efforts to improve care for our rural veterans, including 
through the greatly expanded telehealth program which, again, 
we can be so proud that the VA has been a leader.
    We look forward to discussing these and other issues this 
morning. And with that, I yield back, Mr. Chairman.
    Senator Heinrich. Well, I want to thank our witnesses for 
participating today. We have Secretary of Veterans Affairs 
Denis McDonough; and Assistant Secretary for Management and 
Chief Financial Officer, Jon Rychalski.
    Did I get that right, sir?
    Mr. Rychalski. That is correct.
    Senator Heinrich. Great, fantastic. We are going to start 
with questions, and I will recognize myself for five minutes 
first and then head to the--I apologize.
    With that, we will go to each of you for your opening 
statement.

               SUMMARY STATEMENT OF HON. DENIS MCDONOUGH

    Secretary McDonough. Thank you, Mr. Chairman, very much.
    Let me start by just offering my deep condolences to the 
family of Senator Warner, who will be laid to rest today, a 
Navy and Marine Corps vet of World War II and Korea, Secretary 
of the Navy for 30 years, and an outstanding senator. He was a 
true patriot, an iconic statesman, who always did what he felt 
was right for his constituents and for America. We will, 
obviously, all miss him.
    Chairman Heinrich, Ranking Member Boozman, Senators Schatz 
and Tester, thank you for the opportunity to testify today in 
support of the President's fiscal year 2022 and fiscal year 
2023 Budget Request, and for your steadfast support for 
veterans; I am accompanied today, as the chairman just said, by 
our assistant Secretary for Management and Chief Financial 
Officer, and proud Montanan, Jon Rychalski. Let me also 
acknowledge the Veteran Service Organizations, and our union 
partners, all of whom make us a stronger agency.
    Some good news: First, we have taken steps to reduce the 
backlog log of claims caused by the pandemic. We ramped up 
scanning efforts to digitize Federal records for claims 
processing, and temporarily assigned VA personnel to the 
National Personnel Records Center to pull records for claims 
processing. Now most of VA's requests for records are answered 
in two to three days. The number of pending VA-related record 
requests has dropped by 90 percent to pre-pandemic levels.
    Second, VBA rated our one-millionth veteran disability 
claim two weeks ago, hitting this important milestone faster 
than in all but 1 year in VA history, notwithstanding the 
challenge posed by COVID.
    Third, VA has now vaccinated 3.4 million people with at 
least one dose, including veterans, family members, caregivers, 
employees, and members of other Federal agencies.
    Last, and most importantly, on May 24th, just a month ago, 
there were no, that is to say no COVID-related deaths in any VA 
facility for the first time in 448 days, since March 18, 2020.
    These positive outcomes are a direct result of two factors: 
resources, which you have been critical in providing, and 
caring, compassionate people. Let me tell you about one such 
outcome. At the height of the pandemic Marine Veteran, Michael 
Novielli, developed fatigue, aches, and a fever. He never, 
``Felt this sick in his whole life,'' and his diagnosis was 
exactly what he feared. Like millions of other Americans, he 
had contracted COVID-19.
    After four days at Northport VA Medical Center, Michael was 
well enough to be discharged, but we placed him on our VA 
telehealth program to monitor his symptoms. That decision 
likely saved his life. He shared his temperature, oxygen 
levels, and heart rate every day for two weeks via telehealth. 
Then his VA nurse, Marjorie Rogers, noticed something unusual 
in his heart rate. She called him and told him to go to the 
emergency room immediately, where he was diagnosed with 
pneumonia, admitted--and admitted for another two weeks.
    ''Marjorie saved my life.'' he said. ``If I wasn't on 
telehealth, I would have stayed home with pneumonia.'' And 
Michael would be the first to tell you that that would have 
been, or could have been disastrous. Now that is the kind of 
experience every single veteran deserves at VA. VA people are 
the ones who cared for Michael, they are the ones who risked 
their lives to serve veterans during the pandemic, and they are 
the ones who made zero COVID deaths on May 24th possible.
    But VA employees will also tell you that their life-saving 
work is not possible without the resources they need; that is 
why this budget request is critical. The fiscal year 2022 
budget request will ensure VA can provide care and services to 
veterans, their families, caregivers, and survivors, and to 
other Americans such as the 488 non-veterans treated at VA 
facilities as pandemic-related humanitarian missions, including 
citizens from Arkansas, Arizona, and Texas, among others.
    These resources will be put to good use, empowering our 
Department to fulfill President Biden's charter for me to fight 
like hell for our vets. The budget ensures we can continue the 
growth and success of our Caregiver Support Program by fully 
integrating families and caregivers into the care plans of the 
veterans they love, continuing to implement MISSION Act 
expansion of our Program of Comprehensive Assistance to all 
generations of eligible veterans, and supporting the power--the 
training of over 1,900 field-based staff.
    The budget provides needed funding for women veterans. The 
number of women using VA health care has more than tripled 
since 2001. And this budget funds recruiting and hiring for 
women's health care providers, improving access to reproductive 
health services, and emergency services. The budget allows us 
to continue our success in reducing veteran's homelessness, 
building on the success of the last decade during which we 
decreased veteran homelessness by 50 percent. And this budget 
allows us to provide strong, sustainable, high quality direct 
care to our veterans at a time when they need it most.
    Community care, as Senator Boozman said, and direct care 
are both important, and care in both contexts is rising 
dramatically as the pandemic ebbs, and veterans returned to VA 
for care. And while both are growing, care in the community is 
rising at a faster rate than direct care. Veterans need deserve 
a thriving direct care system for generations to come, because 
it provides high quality, evidence-based, integrated care 
tailored to their unique needs.
    Beyond that, our Nation depends on the research, 
innovation, and medical education components of VA direct care. 
As well as an effective backstop to our country's health care 
system, VA's Fourth Mission has been critically important 
during this pandemic, as well as multiple other national 
disasters.
    That is not all these budget resources will do: they will 
fund mental health and suicide prevention initiatives, address 
major deficits in construction, physical information technology 
infrastructure, continue our electronic health record 
modernization, address issues of veterans environmental 
exposures, and continue to ensure VA is always a place where 
diversity is--diversity, equity, and inclusion are valued and 
sought.
    In short, this proposed budget allows us to deliver high-
quality whole health care and benefits to our veterans, and it 
does so, in large part, by enabling the work of great people, 
like those who cared for Michael Novielli. I commit to using 
these appropriated resources responsibly and transparently in 
close consultation with you, and getting greatest value out of 
every dollar.
    Mr. Chairman, Ranking Member Boozman, other members of the 
committee, I thank you for the opportunity to appear before you 
today. And I look forward to your questions.
    [The statement follows:]
               Prepared Statement of Hon. Denis McDonough
    Chairman Heinrich, Senator Boozman, and distinguished Members of 
the Subcommittee. Thank you for the opportunity to testify today in 
support of the President's Fiscal Year 2022 Budget and Fiscal Year 2023 
Advance Appropriations Request for the Department of Veterans Affairs 
(VA), and for your longstanding support of Veterans and their families. 
I am accompanied by Mr. Jon Rychalski, Assistant Secretary for 
Management and Chief Financial Officer.
    President Biden defined our country's most sacred obligation as 
preparing and equipping the troops we send into harm's way and then 
caring for them and their families when they return. It is the honor of 
my lifetime to join the dedicated, highly skilled professionals who 
constitute the VA workforce-many of them Veterans themselves. VA 
employees are committed to serving Veterans, their families, caregivers 
and survivors. The President's FY 2022 Budget Request reflects this 
commitment. This budget request will ensure VA is moving swiftly and 
smartly into the future, with much- needed monetary investments in our 
most successful and vital programs. This Budget ensures all Veterans, 
including women Veterans, Veterans of color, and LGBTQ+ Veterans, 
receive the care and benefits they have earned and prioritizes Veteran 
homelessness, suicide prevention outreach and caregiver support.
    VA faces critical challenges, many of them made even more complex 
by the COVID-19 pandemic. Getting our Veterans through this pandemic 
continues to be one of our department's highest priorities. As our 
country re-opens after 14 months of closures and necessary restrictions 
on some activities, all of us at VA remain focused on the robust 
clinical response to COVID-19. Our efforts include expanding COVID-19 
vaccinations; ensuring Veterans stay connected to longitudinal care 
through telehealth and in person care where necessary; keeping 
employees safe; and, planning how to address the pandemic's future 
impacts on Veterans and our workforce in the health care, benefits and 
cemetery systems. VA has demonstrated resiliency through this crisis by 
providing continuous services in line with national policy, and we 
continue to update our safety guidelines in accordance with Centers for 
Disease Control and Prevention (CDC) guidance. We encourage every 
Veteran to be vaccinated as soon as possible. That is why we thank 
Congress for providing additional authorities and we have expanded our 
efforts to include vaccinations for all Veterans, regardless of whether 
they are enrolled or eligible to enroll in VA health care, for 
Veterans' spouses, and for Veterans' caregivers, and, most recently, 
for some 12- to 17-year-olds, including those serving as Veteran 
caregivers and those who qualify as beneficiaries under VA's Civilian 
Health and Medical Program.
    As of June 11, VA has fully vaccinated more than 3 million 
Veterans, family members, caregivers, employees, and federal partners. 
We are seeing the positive results of those efforts. I am honored and 
delighted to report that VA recorded zero deaths from COVID-19 in our 
facilities on May 24 for the first time in more than a year. That is a 
critically important indicator of significant progress in fighting this 
pandemic. As we prepared for Memorial Day, a time of special 
significance for us and our Veteran communities, we followed CDC 
guidance and relaxed restrictions at our National Cemeteries which 
allowed us to remember our fallen heroes in person again this year.
    We are seeking input from VA employees about how we can safely and 
confidently bring our teams back to work in a manner consistent with 
CDC guidance and data- driven facts. We look forward to our continued 
return to normal operations, while recognizing that this pandemic has 
had an impact on every aspect of daily life for Veterans, their 
families, and all Americans.
        fiscal year 2022 budget and 2023 advance appropriations
    The President's FY 2022 Budget Request includes $269.9 billion 
(with medical collections), a 10.0% increase above 2021. This includes 
a discretionary budget request of $117.2 billion (with medical 
collections). The request includes $101.5 billion (with collections) 
for VA medical care, $8.7 billion or 9.4% above the 2021 enacted level. 
The 2022 mandatory funding request totals $152.7 billion, an increase 
of $14.9 billion or 10.8% above 2021. This funding is in addition to 
the substantial resources provided in the American Rescue Plan Act of 
2021.
    The 2023 Medical Care Advance Appropriations Request includes a 
discretionary funding request of $115.5 billion (with medical care 
collections). The 2023 mandatory Advance Appropriations request is 
$156.6 billion for Veterans benefits programs (Compensation and 
Pensions, Readjustment Benefits, and Veterans Insurance and 
Indemnities).
                            strategic focus
    To fulfill our country's most sacred obligation, every decision I 
make will be determined by whether it increases Veterans' access to 
care and benefits and improves outcomes for them. I will work 
tirelessly to rebuild trust and restore VA as the premier agency for 
ensuring the well-being of America's Veterans through a persistent 
focus on the three core responsibilities of the Department:

1. Providing our Veterans with timely world-class health care;

2. Ensuring our Veterans and their families have timely access to their 
    benefits; and

3. Honoring our Veterans with their final resting place and lasting 
    tributes to their service.

    Under my leadership, the Department will make it a priority to 
implement management reforms to improve accountability and ensure 
Veterans receive the care and benefits they have earned. In addition to 
the funding for medical care, this Budget includes $3.4 billion for the 
General Operating Expenses--Veterans Benefits Administration (VBA) 
account, including funds to hire 429 new disability compensation claims 
processors, and $394 million for the National Cemetery Administration 
(NCA). The Budget fully funds operation of the largest integrated 
health care system in the United States, with over 9.2 million enrolled 
Veterans, provides disability compensation benefits to nearly 6 million 
Veterans and their survivors and administers pension benefits for over 
350,000 Veterans and their survivors.
    In addition to focusing on these three core responsibilities, 
President Biden also tasked me with:

1. Getting our Veterans through this COVID-19 pandemic;

2. Helping our Veterans build civilian lives of opportunity with the 
    education and jobs worthy of their skills and talents;

3. Ensuring VA welcomes all our Veterans, including women Veterans, 
    Veterans of color, and LGBTQ+ Veterans; and Diversity, Equity and 
    Inclusion are woven into the fabric of the Department;

4. Working to eliminate Veteran homelessness and prevent suicide; and

5. Keeping faith with our families and caregivers.


Key Challenges:

    As VA addresses the numerous challenges brought on or exacerbated 
by the COVID-19 pandemic, we also will need to tackle other 
longstanding issues that are essential to the Department's ability to 
sustainably and effectively execute its mission, including (1) 
establishing the right balance of direct care and purchased care, (2) 
delivering timely access to high-quality mental health care, including 
substance use disorder care, and preventing Veteran suicide, (3) 
increasing support to families and caregivers, (4) increasing support 
for the growing number of women Veterans who utilize VA services, (5) 
providing a whole of government solution to drive progress to eliminate 
Veteran homelessness, (6) improving support for transitioning 
servicemembers through improvements to the Transition Assistance 
Program (TAP), education and job training programs, and (7) addressing 
an aging medical infrastructure.
        establishing the right balance of va and community care
    Providing Veterans with timely access to high quality health care 
is essential. VA remains committed to a strong, thriving direct VA 
health care system, augmented by a robust and high-quality community 
care network. We will continue to expand access, innovate, and leverage 
our research and education missions to push the boundaries of what is 
possible in serving our Nation's Veterans. In short, we will lead--
empowering each Veteran with the confidence that their trusted system 
will lead with sustained excellence on their behalf and on behalf of 
future generations of Veterans. For the Veterans listening today: VA is 
here as a welcoming, steady force ready to help you grow your health 
and well-being with the excellence you expect from us.
             access to mental health and suicide prevention
    VA has made suicide prevention a top clinical priority and is 
implementing a comprehensive public health approach to reach all 
Veterans. The 2022 Budget Request includes $598 million, nearly $287 
million above the 2021 enacted level, for existing programs dedicated 
to suicide prevention outreach and related activities, including 
funding to increase the capacity of the Veterans Crisis Line. Funding 
for mental health in total grows to $13.5 billion in 2022, up from 
$12.0 billion in 2021. Our commitment to a proactive, Veteran-centered 
Whole Health approach is integral to our mental health care efforts and 
includes online and telehealth access strategies. Whole Health can help 
Veterans reconnect with their mission and purpose in life as part of 
our comprehensive approach to reducing risk. Suicide is a complex issue 
with no single cause. Maintaining the integrity of VA's mental health 
care system is vitally important, but it is not enough. We know some 
Veterans may not receive any health care services from VA, which 
highlights VA alone cannot end Veteran suicide. This requires a 
nationwide effort.
    VA developed the National Strategy for Preventing Veteran Suicide 
(2018),\1\ which laid the foundation for VA's approach to suicide. This 
national vision for preventing Veteran suicide is grounded in three 
major tenets in which we firmly believe: (1) suicide is preventable, 
(2) suicide requires a public health approach, combining community-
based and clinical approaches and (3) everyone has a role to play in 
suicide prevention. While the development of the National Strategy was 
groundbreaking in defining the vision of reaching and serving Veterans 
within and outside Veterans Health Administration (VHA) clinical care, 
VA moved to translate the vision of the 10-year National Strategy into 
operational plans of actions in: Suicide Prevention 2.0 (SP 2.0) 
combined with the Suicide Prevention Now initiative.
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs (2018). National Strategy for 
Preventing Veteran Suicide. Washington, DC. Available at https://
www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-
Health-and-Suicide-Prevention-National-Strategy-for-Preventing-
Veterans-Suicide.pdf.
---------------------------------------------------------------------------
    My promise to Veterans remains the same: (1) to promote, preserve 
and restore Veterans' health and well-being, (2) to empower and equip 
them to achieve their life goals using a whole health approach and (3) 
to provide state-of-the-art clinical treatments. We will continue to 
invest and share resources with community organizations in the fight 
against Veteran suicide. We understand Veterans possess unique 
characteristics and experiences related to their military service that 
may increase their risk of suicide. Additionally, Veterans also tend to 
possess skills and protective factors, like resilience and a strong 
sense of belonging to a group.
                         supporting caregivers
    The 2022 request includes $1.4 billion, an increase of $350 million 
above 2021, in funding dedicated to the Caregiver Support Program 
(CSP). The CSP empowers caregivers to provide care and support to 
Veterans with a wide range of resources through the Program of General 
Caregiver Support Services (PGCSS) and the Program of Comprehensive 
Assistance for Family Caregivers (PCAFC). As a result of the John S. 
McCain III, Daniel Akaka, and Samuel R. Johnson VA Maintaining Internal 
Systems and Strengthening Integrated Outside Networks Act of 2018, or 
the VA MISSION Act of 2018, VA began a major expansion of PCAFC.
    PCAFC expansion rolls out in two phases. The first phase, which 
began on October 1, 2020, expands PCAFC eligibility to include eligible 
Veterans who incurred or aggravated a serious injury in the line of 
duty on or before May 7, 1975. Effective October 1, 2022, the second 
phase will expand PCAFC eligibility to include eligible Veterans who 
incurred or aggravated a serious injury in the line of duty between May 
7, 1975, and September 11, 2001.
    Expansion of this Program was contingent upon the implementation 
and certification of the new IT system, Caregiver Record Management 
Application (CARMA). CARMA automates manual processes and integrates 
with other VA systems, increasing efficiencies and effectiveness, and 
allowing for more effective monitoring and management of the program 
for caregivers and VA staff.
    CARMA supports consistency through systematic calculations of 
monthly stipend payments and provides a mechanism for CARMA users to 
identify upcoming reassessments of PCAFC participants, among other key 
functions. A new digital version of VA FORM 10-10CG allows online PCAFC 
applications.
    VA also expedited the hiring of key staff with clinical 
qualifications and organizational skills to support program needs, 
provide a strong infrastructure and standardize application processing 
and adjudication, ensuring consistent eligibility decision-making. The 
expansion funded by this request will support providing training and 
education to over 1,900 field-based staff dedicated to the caregiver 
program. CSP has already expanded to approximately 1,800 staff. These 
changes will help ensure Veterans and caregivers receive timely, 
accurate assessments and eligibility determinations, as well as an 
improved customer experience.
                  improving support for women veterans
    As the number of women Veterans enrolling in VA health care 
continues to increase, VA must be prepared to meet their needs. Women 
make up 16.5% of today's Active Duty military forces and 19% of 
National Guard and Reserves. Based on the trend, the expected number of 
women Veterans using VA health care will rise rapidly. More women are 
choosing VA for their health care than ever before, with women 
accounting for over 30% of the increase in Veterans enrolled over the 
past 5 years. The number of women Veterans using VA health care 
services has more than tripled since 2001, growing from 159,810 to more 
than 550,000 today. To support the growing number of women Veterans, VA 
will increase total planned obligations from all funding sources for 
gender-specific care from $630 million in 2021 to $706 million in 2022, 
an increase of $76 million, or 12%.
    To address the needs of the growing number of women Veterans who 
are eligible for VA health care, VA is strategically enhancing services 
and access for women Veterans by hiring women's health personnel 
nationally to fill any gaps in capacity to provide gender specific 
care--this includes hiring primary care providers, gynecologists, 
mental health care providers and care coordinators across all VISNS so 
that VA is able to fulfill the mission of caring for those we serve. 
Funds also are available for programs such as pelvic floor physical 
therapy or lactation support. These efforts will be sustained by the 
2022 request, which includes $105 million for the Office of Women's 
Health.
    Each of the 171 VA medical centers across the United States now has 
a full-time Women Veterans Program Manager tasked with advocating for 
the health care needs of women Veterans. Mini residencies in women's 
health with didactic and practicum components have been implemented to 
enhance clinician proficiency. Since 2008, more than 7,600 health care 
providers and nurses have been trained in the local and national mini-
residency programs and even more have participated in monthly webinars 
and Talent Management System (TMS) trainings, not only developing 
women's health experts, but also enhancing competency of all clinicians 
across the system.
    Under a new collaboration with the Office of Rural Health, we 
established a pathway for accelerating access to women's health 
training for rural primary care providers. VHA actively recruits 
providers with experience in women's health care to join its care team. 
VHA has launched numerous initiatives to improve access to state-of-
the- art reproductive health services, mental health services and 
emergency services for women Veterans, as well as focusing on enhancing 
care coordination through technological innovations such as registries 
and mobile applications.
    To provide the highest quality of care to women Veterans, VA offers 
women Veterans trained and experienced designated Women's Health 
Primary Care Providers (WH-PCP). National VA satisfaction and quality 
data indicate women who are assigned to WH-PCPs have higher 
satisfaction and higher quality of gender specific care than those 
assigned to other providers. Importantly, we also find women assigned 
to WH- PCPs are twice as likely to choose to stay in VA health care 
over time. Designated WH- PCPs are available across all VA Health Care 
Systems, and VA is actively recruiting additional new providers with 
even more enhanced proficiency in women's health care. VA provides full 
services to meet specific needs of women Veterans, such as gynecology, 
maternity care, infertility services, reproductive mental health 
services and military sexual trauma assistance.
                    eliminating veteran homelessness
    VA remains committed to ending Veteran homelessness. The 2022 
Budget Request includes $2.2 billion for Veteran homelessness programs, 
an increase of 8.4% over the 2021 enacted level (base funding only). In 
addition, VA will obligate $486 million in ARP funding in 2022, for a 
total of $2.6 billion dedicated to reducing Veteran homelessness in 
2022. The goal is to ensure every Veteran has permanent, sustainable 
housing with access to high-quality health care and other supportive 
services to prevent Veteran homelessness. VA has partnered closely with 
other Federal agencies and with State and local programs across the 
country to:

  --Identify all Veterans experiencing homelessness;

  --Provide shelter immediately to any Veteran experiencing unsheltered 
        homelessness;

  --Provide service-intensive transitional housing to Veterans who 
        prefer and choose such a program;

  --Move Veterans swiftly into permanent housing; and

  --Have resources, plans, partnerships and system capacity in place 
        should any Veteran become homeless or be at risk of 
        homelessness.

    VA has made significant progress to prevent and end Veteran 
homelessness. The number of Veterans experiencing homelessness in the 
United States has declined by nearly half since 2010. On any given 
night in January 2020, an estimated 37,252 Veterans were experiencing 
homelessness. Since 2010, over 850,000 Veterans and their family 
members have been permanently housed or prevented from becoming 
homeless. Efforts to end Veteran homelessness have resulted in an 
expansion of services available to permanently house homeless Veterans 
and the implementation of new programs aimed at prevention, including 
low-threshold care/engagement strategies and monitoring homeless 
outcomes. VA offers a wide array of interventions designed to find 
Veterans experiencing homelessness, engage them in services, find 
pathways to permanent housing and prevent homelessness from 
reoccurring.
                          economic opportunity
    As an overall group, Veterans fare better economically than the 
average American. However, Veterans and their spouses still face 
economic challenges. Helping Veterans build civilian lives of 
opportunity with the education and jobs worthy of their skills and 
talents is a critical priority. The budget request supports this 
commitment by making key investments in VBA, including an increase of 
$81.5 million to support the Digital GI Bill Modernization effort, as 
well as an increase of $5 million for the Veterans' Clean Energy Job 
Training program in conjunction with the Department of Labor, and $3.6 
million for the VA Disability Employment Pilot Project to assist 
Veterans with service-connected disabilities seeking employment 
opportunities.
    VA military-to-civilian transition programs are designed to give 
transitioning Service members the best possible start to their post-
military lives. The VA Benefits and Services course, as part of the 
interagency Transition Assistance Program (TAP), helps Service members 
and their spouses understand how to access the VA benefits and services 
they have earned. VA TAP provides resources and tools Service members 
need to achieve emotional and physical health, attain economic 
stability in civilian life and become career ready. Although TAP has 
evolved significantly over the years, we continue to assess its 
effectiveness and evolve where appropriate to promote meaningful and 
economically enriching lives for Veterans and their families.
                   addressing an aging infrastructure
    The 2022 request includes $2.2 billion, a 26.8% increase over 2021, 
for Major and Minor Construction. The Major Construction request 
includes funding for 12 medical facility and two cemetery expansion 
projects. Additionally, the President requests $18 billion in mandatory 
funding in the American Jobs Plan (AJP) to modernize VA health care 
facilities with $3 billion to address immediate infrastructure needs 
within VA health care facilities and the remaining $15 billion to fully 
modernize or replace outdated medical centers with state-of-the-art 
facilities. We look forward to working with Congress to achieve our 
shared goal of addressing VA's aging infrastructure.
    VA operates the largest integrated health care, member benefits and 
cemetery system in the Nation, with more than 1,700 hospitals, clinics 
and other health care facilities; a variety of benefits and service 
locations; and national cemeteries. The VA infrastructure portfolio 
consists of approximately 184 million owned and leased square feet-one 
of the largest in the Federal Government. The median age of U.S. 
private sector hospitals is 11 years; however, the median age of VA's 
portfolio is 58 years, with 69% of VA hospitals over the age of 50. 
With aging infrastructure comes operational disruption, risk and cost. 
VA estimates that between $49 and $59 billion in short- and medium-term 
investments will be needed to maintain our infrastructure using our 
annual Strategic Capital Investment Planning process. However, any 
effort to fully address the aging infrastructure portfolio needs would 
likely far exceed those estimates and occur over a significant 
timeline.
    VA's market assessments have been on-going for nearly two years, 
allowing VA to gain significant insights into trends and needs in the 
VA health care delivery system--with enhancing Veteran access and 
outcomes at the core. The VA MISSION Act requires VA to continue 
construction, leasing, budgeting, and long-range capital planning 
activities while the market assessment and Asset and Infrastructure 
Review (AIR) Commission activities are occurring. The additional AJP 
investment would enable planning to start sooner to address facilities 
we know are not conducive to future health care delivery, while still 
being informed by outcomes of the AIR process.
    Health care innovation is occurring at an exponential pace and the 
comparative age between VA facilities and private sector facilities is 
informed by these trends. The architects who designed and constructed 
many VA facilities in the decades following World War II could not have 
anticipated the requirements of today's medical technology and the key 
role infrastructure-and technological infrastructure-now plays in 
delivering safe and high-quality health care. As a result, many of VA's 
facilities were not designed with these technology and infrastructure 
requirements, which limits our agility and ability to meet the evolving 
health care needs of Veterans.
    The experience of responding to the COVID-19 pandemic brought 
critical lessons. Uncertainty regarding the timing and location of the 
next surge or surges in cases across the country underscored the 
importance of portable capabilities (e.g., 24- bed Intensive Care Unit 
that can be transported) for VA health care's Fourth Mission role in 
future public health emergencies.
    Transforming VA health care to achieve a safer, sustainable, 
greener, person- centered national health care model requires VA to 
leverage innovations in medical technology and clinical procedures. As 
technology-enabled trends in U.S. medicine bring health care closer to 
individuals and communities, there is less demand for prodigious, 
sprawling campuses and more demand for emphasis on ambulatory 
facilities and virtual care. Many surgical, medical and diagnostic 
procedures that once required a hospital stay now are performed safely 
in the outpatient setting, and telehealth and tele-service delivery 
bring expertise to a patient's own home.
    This evolving landscape requires VA to rebalance and recapitalize 
its infrastructure to optimize the mix of traditional inpatient 
hospitals with outpatient hospitals, multi-specialty Community Based 
Outpatient Clinics, single specialty Community Based Outpatient Clinics 
and virtual care.
   leveraging technology to support service and medical care delivery
    VA is undergoing one of the most comprehensive information 
technology (IT) infrastructure modernizations in the Federal 
government, which will support seamless transition of health care 
information throughout an individual's journey from military service to 
Veteran status. The 2022 Budget Request includes $4.8 billion in 
appropriations for the Office of Information and Technology to pilot 
application transformation efforts, support cloud modernization, 
deliver efficient IT services and enhance customer service experience. 
Our three main transformative projects are the implementation of the 
Electronic Health Record Modernization (EHRM); the replacement of VA's 
multiple, aging systems to manage its inventory and assets with the 
enterprise-wide inventory management system used by the Department of 
Defense (DoD)-the Defense Medical Logistics Standard Support (DMLSS); 
and the adoption of a new financial and acquisition management system-
our Financial Management Business Transformation (FMBT).
                                  ehrm
    In October 2020, VA deployed a new electronic health record (EHR) 
system at the Mann-Grandstaff VA Medical Center in Spokane, Washington. 
This effort is one of the most complex and transformational enterprise-
wide endeavors in the Department's history. The Budget includes $2.7 
billion in FY 2022, which maintains a significant level of investment 
in FY 2022 and in future years and ensures necessary infrastructure 
upgrades are in place. This EHRM appropriation is in addition to the 
request for the central IT appropriation. The vision for the new EHR 
system is to empower Veterans, Service members and care teams with 
longitudinal health care information to enable the achievement of 
health and life goals from Service in the military to Veteran status. 
The new EHR system also presents the opportunity to achieve 
unprecedented interoperability with the DoD and functions as a catalyst 
for advancing VA's leadership of health care in the United States.
    In my first weeks in VA, I directed a 12-week strategic review of 
the EHRM program, which consists of a full assessment of ongoing 
activities in order to ensure the success of future EHR deployments. 
Based on opportunities identified at the first ``go- live'' site in 
Mann-Grandstaff, the strategic review is focused on ensuring patient 
safety, identifying areas for additional productivity and clinical 
workflow optimization, change management and team-based training; and 
driving enhanced rigor into VA's management of cost, schedule, and 
performance. Additionally, we are conducting a human-centered design 
initiative to optimize the patient portal experience. We intend not 
only to get this right but to drive the industry forward alongside DoD. 
Furthermore, establishing strong, effective management of the EHRM 
program sets the tone for our other key efforts: modernizing supply 
chain management and enhancing financial and business transactions.
                     va logistics redesign (valor)
    VA's response to COVID-19 highlighted the shortcomings of the 
software and business practices supporting VA procurement, logistics 
and infrastructure operations, including a 50-year-old inventory 
system, separate procurement system and multiple stand-alone systems to 
manage property accountability, distribution and transportation. VA 
also uses multiple, stand-alone systems for health care technology and 
facility management, which limit enterprise visibility of assets and 
their respective readiness conditions. VA is requesting $299 million in 
FY 2022, an increase of $103 million (53%) from FY 2021, to continue 
its efforts in replacing these systems.
    VHA is adopting DoD's proven software platform implementing the 
Defense Medical Logistics Standard Support (DMLSS) information 
technology system to modernize and standardize our supply chain, 
property, health care technology and facility management business 
lines. This improvement will allow us to manage the VHA supply chain 
and support functions and operate like other integrated medical 
systems. In doing so, we will ensure clinicians have the supplies and 
equipment where and when needed to provide safe and high-quality care 
to our Veterans. VA completed the first DMLSS deployment at the James 
A. Lovell Federal Health Care Center in Chicago, Illinois, on September 
21, 2020, and is continuing deployment on an accelerated schedule. We 
are grateful for the ARP funds that will help facilitate the continued 
modernization of VA's badly antiquated supply chain system.
    By implementing DMLSS and standardizing our business practices, 
leaders at every level will be able to leverage new capabilities and 
capitalize on enterprise data to drive insights into operations and 
enable evidence-based decision-making. This implementation, too, offers 
significant opportunity for cost avoidance.
              financial management business transformation
    In support of VA fiscal stewardship, the Financial Management 
Business Transformation (FMBT) program is increasing the transparency, 
accuracy, timeliness and reliability of financial and acquisition 
activities across the Department. The 2022 Budget includes $357 million 
for FMBT, a program that is improving fiscal accountability to 
taxpayers and enhancing mission outcomes for those who serve Veterans. 
Our recent roll-out of the new Integrated Financial and Acquisition 
Management System (iFAMS) at NCA and VBA has not been without 
challenges and has exposed the incredible complexities inherent in a 
financial and acquisition system implementation of this magnitude. We 
are learning from these early deployments and adjusting our strategy 
accordingly. Nonetheless, these implementations bring us one step 
closer to providing a modern, standardized and secure integrated 
solution that enables VA to meet its objectives and fully comply with 
financial management and acquisition legislation and directives. The 
next system rollout is Enterprise Acquisition for NCA, which is 
scheduled for April 2022. System rollouts will then continue across the 
remaining Administrations and Staff Offices until enterprise-wide 
implementation is complete.
     an evolving landscape will influence how va cares for veterans
    As VA addresses challenges and longstanding issues, several long-
term demographic and fiscal trends will shape VA's ability to serve 
Veterans in the future. Although the U.S. Veteran population is aging 
and shrinking and simultaneously becoming more diverse, demand for VA 
services continues to increase. As the Veteran population continues to 
evolve, it also continues to use VA more-most likely the result of 
nearly 20 years of sustained conflict, longer average terms of service 
for military personnel and rising health care and educational costs 
that will incentivize more Veterans to use the VA benefits they have 
earned. U.S. health care is changing, too, from a hospital-centric 
model of care to dispersed (and even virtual) care that can be 
delivered through networks of direct and purchased-care providers.
                         congressional support
    Over the past several years, Congress has generously supported VA's 
budget requests, which have enabled the Department to address new and 
growing challenges. More recently, Congress passed the ARP, which will, 
among other things:

    1. Help ensure health care access for the 9.2 million enrolled 
Veterans who may have delayed care or have more complex health care 
needs because of the COVID-19 pandemic;

    2. Forgive Veteran health care copayments and other cost shares and 
reimburse copays and other cost shares for care and prescriptions from 
April 6, 2020 through September 30, 2021;

    3. Fund construction grants and payments to State Veterans Homes to 
greatly improve the living conditions of our most vulnerable Veterans;

    4. Provide up to 12 months of training and employment assistance 
for unemployed Veterans to enter high demand occupations; and

    5. Help reduce the backlog of disability compensation and pension 
claims, which has grown from 73,000 in March 2020 to 188,000 in May 
2021.

    The Department is grateful for the ARP, which not only will enhance 
VA's ability to deliver world class services to Veterans and their 
families, but also will ease thousands of Veterans' worries by 
forgiving some debt, speed up VA disability compensation claims 
adjudication and provide much needed funding to retrain Veterans in 
high-demand occupations. We will work diligently to ensure these funds 
are effectively and efficiently used.
                       new statutory authorities
    Over the past 3 years, Congress has passed into law numerous, far-
reaching pieces of legislation, including the John S. McCain III, 
Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems 
and Strengthening Integrated Outside Networks Act of 2018 (VA MISSION 
Act of 2018), the Commander John Scott Hannon Veterans Mental Health 
Care Improvement Act of 2019, the Veterans Comprehensive Prevention, 
Access to Care, and Treatment Act of 2020 (Veterans COMPACT Act of 
2020), the Johnny Isakson and David P. Roe, M.D. Veterans Health Care 
and Benefits Improvement Act of 2020 and the National Defense 
Authorization Act (NDAA) for Fiscal Year 2021.
    The 2022 Budget Request includes over $500 million within VA's 
Medical Care accounts to begin implementing new and recently expanded 
health care programs for Veterans, including a new grant program for 
suicide prevention outreach, increased eligibility for emergency 
suicide prevention treatment, new investments in women's health 
programs, expansion of homeless programs, and military sexual trauma 
services. The funding also will further support the Department's 
efforts to address substance use disorders.
                        environmental exposures
    For some medical conditions that develop after military service, 
the information needed to connect these conditions to military service 
may be incomplete. Information may be needed about specific in-service 
exposures or there may be incomplete scientific or medical evidence as 
to whether an exposure causes a particular condition. These issues loom 
large for all Veterans, represented currently by post-9/11 Veterans, 
whose exposures to airborne and other environmental hazards may result 
in unknown long-term health impacts. I am committed to a full review of 
how VA provides health care and benefits to Veterans exposed to 
environmental hazards to be responsive to the Veterans we serve. I 
believe it is possible to strike a balance between the needs of 
Veterans and the need for an evidentiary scientific basis for action.
    In 2019, Congress passed legislation expanding benefits to tens of 
thousands of Blue Water Navy (BWN) Vietnam Veterans. As of May 1, 2021, 
VA has completed more than 54,000 BWN claims and paid out nearly 900 
million in retroactive benefits. More recently, VA added three new 
diseases to the Agent Orange presumptive conditions list in the FY 2021 
NDAA. VA will begin implementing these provisions so that Vietnam 
Veterans will no longer wait for these earned benefits. As the 
Department harnesses its resources to execute these new requirements 
and ensure Veterans receive the benefits they have earned, I have also 
recommended initiation of rulemaking to establish a presumption of 
service connection for respiratory conditions related to exposure to 
particulate matter and other airborne hazards, which may conclude such 
conditions as asthma, rhinitis, and sinusitis for Gulf War Veterans. 
This decision was based on the first iteration of a newly formed 
internal VA process to review scientific evidence relating to 
exposures. VA will conduct broad outreach efforts to reach impacted 
Veterans and encourages them to participate in the rulemaking process.
                                research
    The Budget includes $882 million, the largest year-over-year 
increase in recent history, for medical and prosthetic research. This 
historic investment will advance the Department's understanding of the 
impact of traumatic brain injury (TBI) and toxic exposure on long-term 
health outcomes while continuing to prioritize research focused on the 
needs of Veterans to include Mental Health and Suicide, Rare Cancers 
and Prosthetics as well as other disease areas.
    Increased TBI investment will enhance cutting-edge diagnostics and 
treatments such as investigating the role genomics plays in resilience 
and recovery from blast exposure, validating blast models, and studying 
the link between TBI and suicide. Further investment in environmental 
exposure includes the VA Military Exposures Research Program (MERP), 
capacity building with Federal partners, and expanding the workforce in 
military exposures research and training.
    VA will also invest additional resources, including from the 
American Rescue Plan, to advance the Department's understanding of 
coronavirus related research and impacts. To remain on the cutting edge 
of technology, VA will focus on software-as-a- service, cloud 
computing, and data security, and will continue to partner with the 
Department of Energy (DOE) to capitalize on DOE's computing power and 
technical expertise to put Veteran data to work.
                    diversity, equity and inclusion
    Diversity, equity, and inclusiveness are standards fundamental to 
everything we do. We will welcome all Veterans, including women 
Veterans, Veterans of color, and LGBTQ+ Veterans. Every person entering 
a VA facility must feel safe, free of harassment and discrimination, 
and we will never accept discrimination, harassment or assault at any 
VA facility. We will provide a safe, inclusive environment for Veterans 
and VA employees.
    Diversity is a strength, never a weakness, among Veterans, VA 
employees and all of America. Leveraging diversity, equity and 
inclusiveness will produce the excellence in all our interactions with 
Veterans. I recently instructed my team to establish a 120-day task 
force on diversity, equity and inclusion. The task force's goal is to 
offer concrete, actionable recommendations while building solidarity 
across the VA system on diversity, equity and inclusion. To support the 
Department's commitment to strengthening VA's diversity program and 
preventing and resolving discrimination at the early stages, the Office 
of Human Resources and Administration created the new Office of 
Resolution Management, Diversity, and Inclusion (ORMDI) by 
consolidating the Office of Diversity and Inclusion and with the Office 
of Resolution Management. The budget for this combined office will 
increase by $12.9 million and 74 FTE. These resources will also provide 
a robust harassment prevention program and counseling services while 
advancing equity for all who have been historically underserved.
    The Budget Request also furthers the commitment of the VHA Office 
of Health Equity to help eliminate health disparities based on race, 
gender, age, religion, socio- economic status or disability by 
improving health outcomes for underserved Veteran populations.
            empowering leaders to implement positive change
    I am mindful VA's capabilities have not always risen to the needs 
of our Veterans. Consistent throughout many of these past shortcomings 
has been a theme of leadership inconsistency and cultural challenges. 
To rebuild trust and restore VA as the premier agency for ensuring the 
well-being of America's Veterans, I am focusing on building a diverse 
team of professional, experienced leaders who bring a great breadth and 
depth of knowledge in government and Veterans issues. To that end, we 
recently stood up a commission to identify candidates to lead and 
manage VHA.
    At the same time, I also am working to retain the talented and 
hard-working leaders we currently have by empowering them to make 
decisions in a structure that allows them to do what's right for 
Veterans. As an initial step in support of that effort, I recently 
signed a memo for VA employees emphasizing my intent to lead with VA's 
ICARE Core Values-Integrity, Commitment, Advocacy, Respect and 
Excellence--and have been seeking opportunities to engage with leaders 
across the system to drive this point home. VA's success as a team-our 
ability to deliver world-class care for our Veterans-also depends on 
how employees treat one another and Veterans. Our respect for our 
fellow VA employees and the Veterans we serve is critical to everything 
we do.
    Essential to ensuring a healthy and accountable culture at VA is 
the Office of Inspector General's oversight. The 2022 Budget includes 
the OIG's request of $239 million for 1,100 FTE to support its programs 
and operations through independent audits, inspections, reviews, and 
investigations. The OIG's efforts have a significant impact on the 
services and benefits provided to Veterans. This funding level is 
prudent to safeguard the significant investments in VA and to help 
improve services and benefits for Veterans and their families.
    I take full responsibility to ensure VA employees have everything 
they need to carry out the important work before us and we operate in a 
culture that celebrates and draws strength from our country's great 
diversity. To ensure a welcoming environment for Veterans, we must 
foster fair and inclusive VA workplaces where the experiences and 
perspectives of our diverse employees are valued. The success of our 
mission depends on everyone being able to contribute their expertise, 
experience, talents, ideas and perspectives. I commit to advancing 
equity in VA and providing all employees with opportunities to reach 
their full potential. I commit to these principles and will make sure 
my senior leadership team reflects and embeds them in everything we do.
    At this moment when our country must come together, caring for our 
country's Veterans and their families is a mission that can unite us 
all, and I look forward to working with this Committee, Congress as a 
whole and our many other partners to embrace our collective 
responsibility to serve Veterans.
    Mr. Chairman, Ranking Member Boozman, I look forward to working 
with you and this Committee. Thank you for the opportunity to appear 
before you today to discuss my priorities for the Department and how 
the President's FY 2022 and FY 2023 Advance Appropriations Request will 
serve our Nation's Veterans.

    Senator Heinrich. Well, I want to thank you both. And, the 
fiscal year 2022 request and the fiscal year 2023 advanced 
appropriations request, Mr. Secretary, are record levels coming 
on top of a record fiscal year 2021 appropriation, and 
significant supplemental funding. The pandemic provided unique 
challenges to projecting where veterans will demand those 
services.
    For instance, through transfers, and the second bite, VA is 
significantly increasing resources to meet community care 
demand in fiscal year 2022, yet, this budget assumes a decrease 
in demand in fiscal year 2023. So, what is VA's vision for the 
right balance between in-house and community care going into 
the future; and is the medical community care request in 2023 
the right number?
    Secretary McDonough. Thank you very much. Thank you very 
much, chairman. We have been talking with all of you and with 
your teams, as well as within the agency about the right 
balance. We are driven first and foremost by the requirement in 
statute that we make decisions based on best outcome for 
veterans. That is also the commitment I have made to the Senate 
in the context of my confirmation, which is, every decision I 
make will be based on increasing access and improving outcomes 
for veterans.
    So first and foremost, we will make a determination based 
on what is medically best for our veterans. Second, I happen to 
believe, and I think the data shows, that veterans in our care 
do better than veterans not in our care. So, I think it is very 
important that we maintain a sustainably funded, whole health 
care system in VA, with the full range of specialties that our 
vets have demanded over time, and with care provided by 
providers who have particular understanding of the challenges 
facing vets.
    The fact is, however, that--and particularly in highly 
rural areas--our vets will continue to be dependent on the 
community as well. And this is something I have talked at 
length with many members of this body about, and traveled to 
see the impacts of our partnership with the community.
    And so, we will be working over the course of this year and 
next, as we manage this bow wave of care, our next year's 
appropriation, advanced appropriation request, recognizes that 
the expansion of provision of care is not as I think Senator 
Boozman fears it may be, or asked for clarity, that it not be a 
resetting of the baseline. But it is rather an ability to 
manage this bow wave of care now, and then over time as we get 
to post-pandemic, we will be in a position to right-size that 
care in the system and find where we need to augment that care 
in the community.
    Senator Heinrich. Mr. Secretary, I know the AIR Commission 
work is ongoing, but one of the concerns I have is that, to do 
a market assessment during a pandemic raises a lot of questions 
about the data that will go into those final decisions. We had 
enormous market distortions. We saw that in impacts to your 
budget, we saw it in the private sector. Will you provide that 
data to the committee, but also, do you have concerns about the 
quality of that data?
    Secretary McDonough. So, our teams have been looking at 
these market assessments now going back a couple of years. I 
have not dug into that data aggressively myself. I do have a 
belief. I do believe that it makes sense for us to relook that 
data in light of the pandemic, also in light of the fact that 
the U.S. Government has just gone through the decennial Census, 
for example. So, there may be data there, too, for us to 
prosecute as we do these market assessments.
    So, we will be augmenting the review that we have had to 
date. We are also committed, I have made this commitment in 
other public hearings, and I reiterate it here, to provide you 
that information for you to make your own decisions about this. 
I think it is only right that we make decisions like this with 
such import for the national interest in the light of public 
day--in public light. And that is what we intend to do. So, I 
would be more than happy to make sure that we get the committee 
information.
    Senator Heinrich. Great. I look forward to taking a look at 
that, and I have concerns given what a unique year it is to 
make very long-term impactful decisions based on data, in what 
may be a year that is a complete anomaly. With that, we will go 
to the Ranking Member for his questions.
    Senator Boozman. Thank you, Mr. Chairman. The CARES Act and 
the American Rescue Plan provided VA with $37 billion to 
respond to the pandemic. One of the conditions in the CARES Act 
was that any personnel hired using this money can only be 
temporary employees, so as to avoid building a ``budget tail'' 
in years to come. And you discussed a little bit about this in 
your previous question, but I want to follow up. The fiscal 
year 2023 medical care advance appropriations requests $111.3 
billion is an increase of $13.8 billion over fiscal year 2022 
revised request.
    So, I guess the question is, what is driving the 14 percent 
increase? Is the budget proposing to make the temporary hires 
permanent? Has the sudden influx of COVID-related funding reset 
the VA baseline significantly higher than it was before the 
pandemic?
    Secretary McDonough. Yeah, we don't--I will ask Jon to pile 
in with some additional specifics on this, Senator Boozman, but 
we don't seek to reset the baseline. We are seeking to manage 
both a strong pandemic response, which the CARES Act allows us 
to do, and then ARP really allows us to sustain that response, 
which is going to need to be sustained through this year, 
because of this bow wave of care, and supports recovery.
    But really what is happening, as we see care for our 
veterans, is a series of fairly substantial, big-moving pieces 
that include the fact that vets are living longer, that the 
pandemic has increased the complexity of care that our vets are 
facing. By the way, I think we have a better handle on that 
than anybody. We are doing--if you look in--you can't open a 
newspaper any morning now without seeing a story about VA-based 
research on Long COVID, and to be honest with you, no other 
system is doing that. We are doing that, thanks to your 
support.
    We have a particularly soft economy right now, and 
historically what we know in soft economies is that vets who 
were reliant on employer-provided care, until now, are relying 
on their care for us. Lastly, all those things contribute to a 
trend line towards complexity of care for our vets. That means 
that any incident of care is more complex and therefore more 
costly.
    That is coming at a time when, for example, the MISSION Act 
has increased what we call ``reliance on us.'' So, more vets 
are getting more services from us, as a result of some of the 
authorities in the MISSION Act, so what you see in that budget 
is our best assessment based on our model, and a model that has 
proven pretty decent over time, at what we anticipate in terms 
of complexity of care, and reliance on us for our services from 
our vets.
    Anything you want to add, Jon? Did I miss anything?
    Mr. Rychalski. Yeah, just one thing. I think when you look 
at our budget, there is a request--an increase in the requests, 
but when you compare how much we plan to spend in 2022, which 
includes ARP funding, and then you compare what we plan to 
spend in 2023, our budget actually goes down by about $4 
billion. And I think from a strategic standpoint, what you see 
is us hiring up, and then those FTEs staying on, but we are 
putting most of our requests in 2023 in the direct care system, 
and as the Secretary mentioned, we are betting that is going to 
be where people are going to want to get their care.
    And that this dramatic increase in community care is going 
to level off a bit. And you also see, going back to what I 
said, the $4 billion--sort of comes down about $4 billion in 
2023, because we think that the community care will level off, 
you know, that the demand for services in the direct care 
system will rise. But net-net, we actually have a lower planned 
expenditure in 2023 than 2022, because we don't have the same 
supplemental funding.
    Senator Boozman. So, what do you all feel, like is driving 
the increased demand for community care now? Because when you 
look at your modeling, and you look at the numbers that you are 
requesting, certainly, you know, there is a bunch of community 
care dollars now, but not in the future. And again, don't 
misunderstand, myself, the entire committee is committed to in-
house specialists, you know, the quality of care, you know, 
again, as good as anybody. And I think we can be very proud 
that the VA has achieved that. On the other hand, I think what 
we don't want are a bunch of surprises, going down the line, 
which we have really seen in the last year or two.
    Secretary McDonough. Look, I couldn't agree more Senator. 
And I would start on your last point, which is, I don't 
misunderstand you, and we couldn't misunderstand you because 
you have been regularly supportive of all of our efforts. So we 
are very grateful for that.
    I think that what is driving community care at the moment 
is that, by necessity, I think many providers in the community, 
open to full services sooner than many of our providers did. So 
that is one of the things that is driving this. The other is 
that we are experiencing now what we have been talking about 
for some months, which is that as the pandemic ebbs more of our 
vets are coming back to address care that they forewent during 
the pandemic. And that is also happening at a time when not all 
of our facilities are fully open. And so, we do think that what 
is driving the care in the community are the particulars of the 
pandemic, and less a stated desire of our veterans to get into 
the community.
    That said, partly to inform our going-forward process. We 
are in the field right now through our Veterans Experience 
Office, talking to veterans about what their experience in care 
during the pandemic was, and what that says about what they 
expect going forward.
    Senator Boozman. Good, very good. Thank you, Mr. Chairman.
    Senator Heinrich. Senator Schatz.
    Senator Schatz. Thank you, chairman; vice chairman.
    Secretary, Assistant Secretary, thank you for being here. 
Thank you for your service. I want to talk first about 
telehealth.
    Secretary McDonough. Yes.
    Senator Schatz. Obviously VA has made tremendous strides in 
telehealth as has the private sector, Medicare, Medicaid, DOD, 
it is happening everywhere. The specific question I have to 
start is: To what extent are any of the expansions of 
telehealth services, dependent on or precipitated by the 
pandemic, and likely to snap back to the Stone Ages when the 
pandemic is over? Or are there plans in place to not only 
institutionalize all these expansions of services, but to 
expand them?
    Secretary McDonough. Yes. So bottom line is that we have--
let me just give you some numbers around the expansion, 
basically, we estimated at about an 1,800 percent increase in 
video visits from VA to home, going from about 10,500 visits in 
the first week of March 2020, to 220,000, or almost 230,000 
visits at the end of February of this year. So, the numbers are 
a dramatic expansion.
    Another way to look at it is, halfway through this year, 
nearly two million vets--this fiscal year--have had one or more 
episodes of video care through our vets' Video Connect Program. 
So that tells us that there is massive demand. We are 
institutionalizing that as you say, we want to maintain it 
because it is ease of access for vets who don't need to be seen 
in person. We see a large degree of satisfaction from our vets. 
In full candor, our clinicians sometimes are less excited about 
it than our vets, but we are working that.
    Senator Schatz. That is kind of what I am trying to get at, 
is to what extent are any of these, at least currently 
temporary changes in clinical standards, or standards of care 
that need to be made permanent lest we go back to where 
something is more comfortable for either VA docs, or 
supervisors, or fiscal people.
    Secretary McDonough. Yeah.
    Senator Schatz. Do we need to institutionalize some of 
these. Like, are there specific places we need to burrow into 
the bureaucracy, or into the statutory law to make sure these 
things stick?
    Secretary McDonough. We are looking at exactly those 
questions. I think overwhelmingly there is going to continue to 
need to be things that are done in person, and we are looking--
we are developing those lists of what those are, working with 
VHA. But I think as a system, we recognize the huge efficiency 
gains and huge satisfaction gains, which come from the fact 
that vets are spending less time traveling to our facilities, 
while getting good care.
    And so, we have a bias toward institutionalizing, but we 
are going to let the data drive that too. So we will be more 
than happy to stay in close touch with you on that.
    Senator Schatz. Okay. I think I will send a QFR on this.
    Secretary McDonough. Good.
    Senator Schatz. So that we can get a little bit deeper 
fidelity on----
    Secretary McDonough. Fair enough.
    Senator Schatz [continuing].--what changes you need to make 
and how we can be supportive of it, because I have just seen in 
Private Pay and Medicare, you know, there is going to be a 
tendency to want to snap back to pre-pandemic time. And, I just 
think there is going to be a patient revolt if--you know, 10 
years ago if you told someone to interact with their clinician 
via their iPhone, it would be an insult. And now if you can't 
do that, it is an insult.
    And so, I just think we are underestimating the extent to 
which people are going to freak out in 18 months, if something 
that was fantastic and available is suddenly not. And we want 
to help you to make sure it is all permanent.
    Secretary McDonough. I agree with that. And I don't want to 
waste any more of your time, but I just make this point, which 
is, we have such demand for mental health care, like everybody 
else in our health care system, writ large, at such a position 
of competing for providers, we get not insignificant marginal 
gain of access through using video platforms, that it would be 
foolhardy to walk away from that.
    Senator Schatz. And there is at least anecdotal evidence 
among veterans that accessing mental health services via 
telemedicine can sort of overcome or circumvent the stigma.
    Secretary McDonough. No doubt.
    Senator Schatz. And so, it is all to the good, we just want 
to help you to make it permanent. Final question, when we spoke 
in January I mentioned the veterans on Hawaii Island are still 
waiting for VA to break ground on the new outpatient clinic in 
Hilo, Hawaii.
    Secretary McDonough. Yes.
    Senator Schatz. Can you please give me an update?
    Secretary McDonough. Yes, so we have an interim lease, fix 
in place, the permanent lease is taking far too long, both in 
Hilo, but across the board. So, we are looking at that 
systematically. The interim lease is in place, and I think we 
are in a position now to execute against that interim lease as 
we try to push on the permanent lease, which is now about 9 
months delayed. So, we are staying on top of it.
    Senator Schatz. Thank you.
    Senator Heinrich. Senator Hoeven
    Senator Hoeven. Thank you, Mr. Chairman.
    Secretary McDonough, it is good to see you again.
    Secretary McDonough. Nice to see you.
    Senator Hoeven. For all that work you did as chief of 
staff, and good to see you in your new role, congratulations on 
that.
    Secretary McDonough. Thank you.
    Senator Hoeven. Appreciate the opportunity to work with you 
again. Thanks for being here today, to both of you. One of the 
things that I have been working on for a long time is--and we 
have included language in a number of the bills, we passed the 
VA MISSION Act, and a number of the other veterans' bills that 
we passed.
    If a nursing home takes Medicaid or Medicare reimbursement, 
they have a set of standards and inspections that they have to 
meet. But if they take VA reimbursement, then they have 
additional standards they have to meet. So, they ended up with 
multiple inspections and additional regulations. As a result, 
only about 20 percent of the nursing homes in the country take 
VA reimbursement for long-term care.
    That makes a huge difference to our veterans because 
qualifying veterans can actually draw on the VA benefit without 
having to expand all our assets, unlike Medicaid, for example, 
where they would have to first dissipate their assets down to, 
you know, standard testing, varies a little bit by state. So, 
for qualifying veterans, this is a big deal.
    Now, about 20 percent of the nursing homes do take VA 
care--or VA reimbursement, but a lot don't for that reason. And 
so, we are trying to work with you, and with Labor, and with 
HHS to get these veteran care agreements simplified so that, 
you know, these nursing homes will take veterans with VA 
reimbursement, because like I say, the asset test.
    And so I would ask for your help. And we have just had a 
number of different challenges. Sometimes the VA tells us, 
``well, you know, those additional requirements, and those 
additional inspections are--we are just trying to take care of 
veterans,'' and ``we are just trying to protect the veterans.'' 
Well, I mean, that almost kind of makes the assumption that, 
you know, HHS and states are not taking care of other seniors.
    So, I mean, that does not really seem to fly. It really is 
a red-tape problem. And so, if we could work with you to 
streamline that, so that if a nursing home meets all the 
requirements for Medicare or Medicaid, then they should not 
have additional set of requirements for VA reimbursement. So 
that is the issue, and I would ask for your help on it.
    Secretary McDonough. Thank you, Senator. I confess that it 
is, and I know you have been working with us, I am not deep on 
this. I will just say the following, which is that our 
experience during the pandemic is that our clinicians far 
exceeded performance on reduction of COVID infection in our 
facilities, as related to other facilities, both state-run 
facilities, state-run veterans' facilities, and private 
privately-run facilities. So, I think there is a lot of work 
that we have done in this space, but I would be more than happy 
to take this and commit to work with you on it.
    Senator Hoeven. Yeah. And the key is access, you know, 
because you may have loved ones that have to travel a distance 
if they can't get their loved one in a nursing home close.
    Secretary McDonough. Yeah.
    Senator Hoeven. And this is not just a North Dakota 
problem, this is a nationwide--that stat I have cited is a 
nationwide stat.
    Hyperbaric Oxygen Therapy, HBOT: the veterans really feel 
that this is important to them, particularly for PTS. And we 
have got a pilot program going, there is a number of locations, 
including the VA center in Fargo, which is a high quality 
outstanding center, serves a lot of North Dakota, but a lot of 
Minnesota too. But are you committed to making sure that our 
veterans can get access to HBOT?
    Secretary McDonough. Yeah. Well, we are running that pilot 
currently. I just asked for an update on it yesterday. It runs, 
as you know, through this fiscal year, so we are absolutely 
committed to making sure that we run this through, we get high 
quality review of this, and then as we have assured you, we 
will make the decisions based on that. So, I will be more than 
happy to do that and stay in close touch with you.
    Senator Hoeven. Yeah. We would like to work with you on 
that too. We have talked to so many veterans that really, 
really swear by it, and so I think this is going to be 
something, and not just veterans, as you know, for concussions 
and other things as well.
    Secretary McDonough. Yeah.
    Senator Hoeven. You know, All-Star football players like 
John Boozman, and others, you know, sometimes--I think it has 
been very beneficial to them. I am sure you have seen the Joe 
Namath commercials, and he talks about it. The last thing I 
will bring up.
    Senator Boozman. The secretary played.
    Senator Hoeven. Oh, is that right?
    Senator Boozman. Yeah.
    Secretary McDonough. Yes, I did.
    Senator Hoeven. Where did you--where at, Minnesota 
somewhere?
    Secretary McDonough. I played at St. John's University.
    Senator Hoeven. Oh, you are a Johnny. Was that back when 
they had the fabulous teams? They had a long string of 
championships.
    Secretary McDonough. Yeah, they had a bad defensive back in 
me, but very good teams.
    Senator Hoeven. Good for you, fantastic.
    A last question, I will be quick. I am sorry, Mr. Chairman. 
It is just, ask for your help at the rural--we have the Rural 
Initiative (cemeteries), great program.
    Secretary McDonough. Yes.
    Senator Hoeven. Huge kudos to you. We have one now in 
eastern North Dakota. I just ask for your continued commitment 
as we add, you know, really important things, like restrooms, 
and storage, and wind walls, and things like that. Fabulous 
initiative in rural America, and I would just ask your strong 
support for it.
    Secretary McDonough. Yes. You got it.
    Senator Hoeven. Yes. Thank you. Thank you, Mr. Chairman.
    Senator Heinrich. Senator Tester.
    Senator Tester. Thank you, Mr. Chairman. A couple of 
housekeeping things, first of all: I want to thank Secretary 
McDonough for bringing up John Warner. John Warner gave me the 
best advice I have had since I got here. And I have seen this 
advice play out several times. His advice was, ``Don't stay 
here too long, kid'' which was, which is good advice.
    And then the other thing, Mr. Chairman, I just want to 
point out that you have possibly the best staff director of any 
of the appropriations committees, in Michelle Dominguez, she is 
absolutely the most competent staff member on the 
Appropriations Committee that I have ever been affiliated with. 
And she used to work for me.
    So, Mr. Secretary, you, or the VHA, brought on nearly 8,000 
employees under the Temporary Emergency Funding of COVID-19. 
What is your plan to keep those folks on board when the ARP 
money runs out?
    Secretary McDonough. Well, we are letting the demand for 
services inform that. We have a particular set of demands, and 
I know this is particularly important to you, around mental 
health. So, our first and biggest effort is to retain the 
excellent clinicians that we have, even as we approach a series 
of expected retirements.
    We are right in the middle of the annual Employee Survey at 
the moment, we will get data from that, which will give us a 
sense of what to expect coming in the new year. But the first 
and biggest challenge for us is to retain the people that we 
have. And then next is to make sure that we are not just out 
competing with other health care systems, but that we are 
adding to the available clinicians. And this is where our 
education component and our residency programs become so 
important to us. So, that is why we have the funding that we 
have requested in the budget. And we will continue to work with 
you guys on precisely that.
    Senator Tester. Thank you. Community care was brought up 
previously, but I just want to approach this from a little 
different angle. There has been a lot of talk about the wait 
time to see a doctor within the VA. And correct me if I am 
wrong, but I understand you are meeting the guidelines for wait 
time, is that correct?
    Secretary McDonough. We are. Yes.
    Senator Tester. Okay. Are you able to track the wait times 
in the private sector?
    Secretary McDonough. We are looking at that now to make 
sure that we have a good handle on this. You know, come a year 
from now, we have to make some decisions about our access 
standards. That is what the law requires us to do. I have 
implemented and started a process over the course of the last 
six weeks, or so, where we get the data to help us inform the 
decisionmaking that we have to make in consultation with you 
for a year from now.
    Among the data I am asking for is veteran satisfaction, 
health outcomes, wait times, and commensurate wait times for 
care in the community.
    Senator Tester. I think it is really, really important, 
because, the fact is wait times have been an issue which, by 
the way, why we have community care to begin with. And if we 
are not addressing that issue, the community care, then we need 
to go back and address it.
    Speaking of mental health, I was surprised in this year's 
budget that the VA projects treating 6,000 fewer vets via 
inpatient mental health care in 2022 than it did in 2021. Is 
that because of telehealth, or is there another reason here?
    Secretary McDonough. I think it is principally due to 
telehealth. But, Jon, am I missing anything on this?
    Mr. Rychalski. Don't have the answer to that.
    Secretary McDonough. Okay. Well, let me take that 
specifically, Chairman. But I think that is due to telehealth 
because frankly we will see our demand is up across the board.
    Senator Tester. Appreciate that. And I agree. Now I want to 
talk about something that is near and dear to both our hearts; 
and that is toxic exposure, and in a bill that Senator Boozman 
is very familiar with, as well as myself, and other folks that 
are on a VA committee. The budget supports about $7 million in 
new spending on toxic exposure research, to focus on 
collaboration between the VA, DOD, and the national academies, 
and other stakeholders. My question is: Do you think the VA 
should be the lead Federal agency on veteran toxic exposure 
research?
    Secretary McDonough. I do believe we should be. And I think 
that we are.
    Senator Tester. And do you feel that that increase of $7 
million establishes the VA as a leader on this research?
    Secretary McDonough. I think it does, but I also think, 
Chairman, as you are aware, we have also set up a process 
whereby we are getting the benefit of all the other science 
agencies, DOD, Department of Labor, HHS, and their attendant 
offices and capabilities on a very regular basis, in addition 
to the National Academy of Science. And my commitment to you 
all is to not only to continue to get that science, but to 
report to you on a quarterly basis what that science is telling 
us, including about whether we are in a position to connect 
other conditions to service in Southwest Asia.
    Senator Tester. I know that community care was talked about 
earlier, and the amount of money that is being spent on 
community care. And in some aspects, that is simply not 
sustainable, especially as it applies to emergency room 
treatment. I want to give you an example. And if I might, Mr. 
Chairman, of a story that was relayed to me just last week by a 
doctor that works for the VA, and is very proud to work for the 
VA. And a patient came in, I believe he had kidney stones, and 
he got to see him at about 4:30. And, of course the day ran out 
at 5:00.
    And the advice that was given to him by his superiors was: 
just send him to the private sector. The guy wanted to be 
treated by the VA and the easy way to do it--and maybe this is 
the problem--the easy way to do it was just get him to the 
private sector. I know you are concerned about this, and I 
appreciate your concern. And I just think that we need to be 
wise about how we utilize the private sector. It is the 
veteran's choice, it is not the VA's choice. Thank you.
    Secretary McDonough. Yeah. I would just say one thing about 
that is--two things about that. One, what the clinicians tell 
me is that to refer a vet to the community takes, in our 
current electronic system, two clicks. To refer somebody back 
into care in the system is something like 18 to 20 clicks. That 
does not seem right to me.
    That suggests, I think, as Senator Schatz was asking, a 
kind of an institutional direction. So, have asked us to look 
at that. The second is our facility in Ann Arbor is going 
through and running a pilot about access to emergency care, 
including access to mental health services. And this is 
anecdotal, this is why we are out getting some kind of 
statistically significant information from our vets.
    But the anecdote there was, our hospital administrator told 
me, is that when she invited vets back into care in the system, 
they all asked--three of them said to her: I am grateful that 
you ask, and I always wondered why he pushed me into the 
community in the first instance.
    And so, I don't know that that anecdote adds up to 
something statistically significant, but I want to make sure 
that we are giving the vet and the clinician the opportunity to 
make the best--what the statute requires, the best possible 
outcome for the vet deciding this. That requires us meeting our 
wait times, but it also requires us making sure that we don't 
tilt the--tilt the record.
    Senator Tester. Thank you.
    Senator Heinrich. Senator Baldwin.
    Senator Baldwin. Thank you, Mr. Chairman.
    And welcome, Secretary McDonough.
    Secretary McDonough. It is good to see you, too.
    Senator Baldwin. I know that when we spoke earlier this 
year that we talked a bit about bipartisan legislation that I 
had sponsored: the Jason Simcakoski Memorial and Promise Act.
    Secretary McDonough. Yes. Jason's Law.
    Senator Baldwin. Jason's Law. And, it was signed into law 
in 2016, and the law has been effective in strengthening 
oversight of the VA's opioid prescribing practices and 
providing safer care for our veterans. So, I thank you for the 
Department's support of Jason's Law in the fiscal year 2022 
budget. The progress that Jason's law is making to improve the 
care of veterans is, I think, really quite remarkable.
    And I remain committed to working with you to ensure 
delivery of the highest quality of care to our nation's 
veterans. But I also want to thank you for your commitment to 
meet with this Simcakoski family, to discuss implementation of 
the law that is named after their son, Jason. Can you give me 
any updates today on the VA's effort to reduce or right-size 
the prescribing of opioids, in addition to the latest VA-wide 
statistics on the rate of opioid and benzodiazepine 
prescribing?
    Secretary McDonough. I don't have those. I would be more 
than happy to provide those data to you, you know, when we 
leave here, I don't have those at my fingertips here. I believe 
informed both by the tumultuous experience--traumatic 
experience at Tomah, as well as, a national epidemic on 
substance use disorder.
    Our programming continues, as you suggest, to make good 
progress. This includes very aggressive recordkeeping about 
prescription practices, and that includes us working very hard 
to harmonize our records, for prescribing in the community, as 
well as for prescribing in the system. So, I think we are 
making good progress there. But the fact is that substance use 
disorder remains an epidemic in the country. And so, we will 
stay on top of this.
    Senator Baldwin. You know, on that note, the COVID-19 
pandemic has, I think, increased the severity of our opioid 
epidemic.
    Secretary McDonough. Yeah.
    Senator Baldwin. And I am wondering if there are any 
particular Departmental programs to address this within the 
veterans population, you know, pandemic-related, adverse mental 
health and opioid abuse, or is this----
    Secretary McDonough. There has been reporting on incidences 
of increased prescription of opioids for pain treatment in Long 
COVID. And overall, there has been reports, and across the 
health system, not the VA system, but across U.S. health 
system, of prescription of opioids for pain management in the 
context of COVID.
    In light--in reaction to those stories we went back in VHA 
to look at prescribing practices. We don't see that currently 
in our system. We have looked at that and we will stay on top 
of that for the obvious reasons. But it also goes to the point 
that I think the budget request also goes to, which is, the 
research capacity that you enable through the budget at VA is 
incredibly important.
    Nobody is doing as much research right now on Long COVID as 
we are. That is facilitated by how we aggregate data, and that 
will be improved even greater when we get this electronic 
health record on track. But it also speaks to the fact that 
that is a fundamental capacity we need in house, and that we 
need to make sure that we sustain over time. And we are using 
that expressly on substance use disorder and watching it very 
closely. And we will--obviously we know of your personal 
interest in this, and we will stay in close touch with you on 
it.
    Senator Baldwin. Thank you very much, Mr. Secretary. I have 
run out of time. I will submit two additional questions for the 
record, one pertaining to K2 veterans and exposures. And the 
other, dealing with, partnerships between the VA and, county or 
tribal veterans, service officers, to make veterans in local 
communities aware of the full array of services that they might 
be eligible for.
    Secretary McDonough. I would just--at the risk of going 
over, we have the Annual Tribal Nations Summit at the White 
House in this fall. This is one of the things that we will be--
we are trying to develop more robustly in anticipation of that. 
We are seeing really useful, collaboration between our national 
facilities, and local, and community facilities, and IHS 
facilities that build on some authorities you have given us. 
That might be something that we should follow up with.
    Senator Baldwin. Great. Thank you.
    Senator Heinrich. Mr. Secretary, I look forward to hearing 
more on that front. Actually, I think Senator Baldwin and I 
share an interest in, and that is a very complicated, 
coordinated care model that oftentimes our tribal veterans have 
to utilize.
    I want to ask you a question about compensation and pension 
exams. Under the previous administration, the Department 
indicated that it planned to contract out nearly all of the 
compensation and pension medical exams, and despite a number of 
VSOs, many senators raising concerns, the VA continues to, 
largely, privatize this component of its mission, and it is 
requesting funding for more staff to oversee those contracts. 
What is the financial basis, first off, for contracting out? 
And how does the cost of providing this service internally 
compare with providing it through these contracts?
    Secretary McDonough. Yeah. So first and--first and 
foremost, we have a significant backlog at the moment which--
so, I think part of the funding that you see reflected in the 
budget is our commitment to get that backlog down. That backlog 
springs from the pandemic. There is about a two-month period 
during which we did no exams, out of deference to the safety 
and health of our vets. That number is now at about 180,000 
[sic]. That is down from about a hundred--sorry, about 220,000.
    So, I don't have the dollar-for-dollar comparison, but I 
will get that for you and submit that. But I think you are 
right that we continue to rely a great deal on contracted C&MP 
exams, but we have cranked up volume on two other ways to 
administer the exams. One is in the system that is out of a 
collaboration among Dr. Stone at VHA and Tom Murphy at VBA, 
where VHA is now providing additional in-system C&MP exams. 
That does come at the expense of other, or at the cost of other 
services that VHA is providing. So, we are looking closely at 
that and tracking that closely to make sure that that does not 
tip in the wrong direction.
    And then we are providing C&MP exams through video 
telehealth, video and telehealth, and so that also increases 
demand on our in-house practitioners. But I think it is really 
important that we not--that we get that backlog down. So that 
is what is reflected in the budget. As to the specific dollar-
for-dollar comparison, to let us make that, and we will get 
that back to you unless you have that off the top of your head.
    Mr. Rychalski. No.
    Secretary McDonough. Okay.
    Senator Heinrich. Great. No, I appreciate that. We have 
talked a little bit about the unique challenges that rural 
veterans face but, you know, access to care in-person or via 
telehealth, it is just hard recruiting and retaining primary 
care and specialty providers. This budget requests $307 million 
to support rural health initiatives. It is a modest increase 
over prior years, especially in comparison to the overall 
budget growth, but can you talk to us just how is--how is VA 
developing and implementing enterprise-wide initiatives to make 
sure that we are serving veterans in those rural areas 
adequately?
    Secretary McDonough. Yeah, it is a great question. I mean, 
we have our Office of Rural Health, which is kind of the 
principal place where we are innovating on policy there. I will 
give you a couple of examples that I think are useful.
    And let me just correct the record on one thing. I looked 
at my notes after my answer, and what it says here as, as of 
June 21, the rating claims pending over 125 days is 190,000, 
not 180,000. So, I misspoke there.
    What we find is, a couple of different things about our 
primary care physicians in rural areas. One is, obviously, 
distances traveled. We have a relatively small number of 
practitioners covering a lot of different CBOCs over, as you 
know very well, over a wide expanse. We are trying to address 
that by increasing the number of practitioners.
    You have some isolation, professional isolation, where it 
may be a very vibrant, and I know it does not happen with my 
colleagues who work with me, but sometimes you work with a 
colleague who happens to be, or colleagues who happen to be 
very smart, very engaging, gives you opportunities to grow. 
When you are on the road all the time, you get less of that. 
So, we are trying to use, for example, telehealth 
opportunities--sorry--and video connect opportunities to 
increase that interaction.
    We are also using available authorities through that same 
Office of Rural Health to increase travel options for those 
practitioners, so they are getting to additional career 
development, specialty development options. Lastly, we are 
increasing the use of econ--sorry--educational partnerships to, 
again, enhance career building opportunities. So, none of these 
alone adds up to everything we need, but each innovation in 
that space I think is important. And we will continue, and this 
budget does continue, to invest in our ability to do that.
    Senator Heinrich. Yeah. I think all of us up here would 
agree that that is incredibly important. And I am running short 
on time, but I will just raise one more issue that is related 
to that, which is the VA's Highly Rural Transportation Grant 
Program. In fiscal year 2021, it was funded at less than $3 
million. You know, our discretionary budget this year is $113 
billion. I just think this is a place where we need to look to 
make sure we are actually meeting demand, and that number in 
fiscal year 2022 as it actually gets implemented, I think is a 
place we need to look at beefing things up.
    And with that, turn back to the ranking member.
    Senator Boozman. Thank you, Mr. Chairman. I just want to 
touch base on the Electronic Health Record Modernization 
Program.
    Secretary McDonough. Yes. Yes.
    Senator Boozman. It is such a huge, huge issue, a big 
expense, and just, you know, a gigantic project that is so, so 
very important. I know the budget requests $2.7 billion for 
fiscal year 2022, I understand there the review will reshape 
the program significantly in every facet and, again, its 
financial needs. The House is going to begin marking up their 
version of this bill on Friday without the benefits of the 
results of the strategic review.
    So, I know you can't go into it, you know, in the sense 
that it is not done, but can you just, kind of tell us how it 
is going and when we can expect the information to come out?
    Secretary McDonough. Yeah.
    Senator Boozman. And the deployments.
    Secretary McDonough. We don't anticipate changing the 
budget request, the shape of it may change, but the numbers 
themselves will not change as a result. You know, I am tempted 
to try to say: it will be reduced over time, but I am not, I am 
not going to say that.
    Senator Boozman. Sure.
    Secretary McDonough. But hopefully we can do that. We have 
identified that--we believe that the technology, basically, is 
sound. We think that we probably undervalued and underinvested 
in training and support to our team in the field. And as they 
are going through the change of this process, we also, I think, 
have identified some structural inefficiencies in headquarters 
in how we govern the project, so that--we will be changing 
that, too.
    We have not--the big question is, when we go to a next site 
to deploy the system and the next site, under current--under 
previous course and speed, we would be going next to Columbus, 
Ohio, in fairly short order. That decision, I have not yet made 
that, but that is a threshold decision. I anticipate making all 
those decisions and talking to you about the full shape of this 
by the middle of next week, by the 30th.
    We owe you some answers, as you laid out in your opening 
statement, pursuant to statute from last year. We are going to 
live up to that and make sure that we get you the information 
you need immediately on the 30th, but we will maintain a very 
fluid conversation with you on this.
    The last thing I would just say is, one of the reasons I 
really want our deputy who is, you know, still pending here, 
confirmed is, he is the person who will be overseeing this, 
given both the traditional, the deputy in our Department, and 
the statutory requirements that he personally oversee the 
budget. I would love to get him down there soon, so he and I 
can spend some time over the weekend, making sure that we are 
on the same page before we submit all this paperwork to you on 
Wednesday.
    Senator Boozman. Good. We appreciate that. And again, you 
know, the committee is very, very supportive of the project and 
understands how important it is. I think I can speak for all of 
us. And so, like I say, all of this is an effort to help you, 
you know, push forward and, you know, we certainly will do that 
any way we can.
    So thank you, Mr. Chairman.
    Senator Heinrich. No, thank you. And thanks to Secretary 
McDonough, and Mr. Rychalski, and all of our senators for 
participating in today's hearing. I think we all look forward 
to working together to make sure we provide the resources for 
the VA to be able to do its job, and do its job at the best 
possible quality.
    Finally, I will keep the hearing record open for a week. 
Any committee members who would like to submit written 
questions for the record should do so by 5:00 p.m., Wednesday, 
June the 30th. And we very much appreciate the Department 
responding to them in a reasonable period of time.
    Secretary McDonough. Thank you very much.

                     ADDITIONAL COMMITTEE QUESTIONS

             Questions Submitted by Senator Martin Heinrich
    Question. The Department, and particularly the Veterans Health 
Administration, has struggled to address workforce vacancies. VA used 
administrative flexibilities and supplemental appropriations to hire 
staff, which VHA plans to maintain through FY 2023 with base funding.
    What is VA's personnel strategy to address clinical vacancies?
    Answer.As the Nation's largest integrated health care delivery 
system, the Veterans Health Administration's (VHA) workforce challenges 
mirror those of the private health care industry. Demand for clinical 
staff in all health care sectors exceeds the supply of appropriately-
trained health care professionals to meet projected Nation-wide health 
care needs. VHA's strategy is to prioritize clinical vacancies as they 
arise and use all the flexibilities authorized for recruitment and 
retention to attract top talent, including direct and non-competitive 
hiring authorities, competitive pay-setting, recruitment and retention 
incentives, and education loan repayment and scholarships. VA also 
utilizes a host of marketing efforts, including participation in 
recruiting events, award-winning digital and social media marketing 
campaigns and trainee recruitment events to transition VA Health 
Professions Trainees to permanent employment.
    At the end of fiscal year (FY) 2020, VA conducted a position 
validation review resulting in a reduction of vacant positions by more 
than 41%. As of March 31, 2021, there were 32,647 vacant total Full 
Time Equivalents (FTE).\1\ Of those, 16,965 were clinical vacancies in 
VHA. It is important to note that these vacancies do not represent 
staffing gaps or shortages, nor do they represent the true unfunded 
need of the organization or the number of positions that could possibly 
be filled at any given time; instead, they reflect the constantly-
occurring turnover of employees in the organization and funded levels 
of growth in FTE. For example, in response to the Coronavirus Disease 
2019 (COVID-19) pandemic, clinical occupations in VHA grew by 4.2% in 
FY 2020 and have continued to grow by another 1.2% in FY 2021 through 
March 31, 2021, reflecting a total net increase of more than 12,600 
additional clinical staff since the end of FY 2019.
---------------------------------------------------------------------------
    \1\ This count does not include more than 20,000 FTEs that are 
undergoing a position validation review.
---------------------------------------------------------------------------
    Question. How does VA plan to recruit, retain, and train staff in 
regions where they are needed the most, including rural areas?
    Answer. VA has taken great steps to increase access to care for 
rural Veterans. The workforce shortage occupations for rural VA 
facilities are comparable to those of non-rural VA facilities. The 2019 
All Employee Survey found no difference in responses for job 
satisfaction and burnout between employees at rural and non-rural 
facilities. The Office of Rural Health (ORH) and its partners in 
clinical program offices, Workforce Management and Consulting Office 
and the Office of Academic Affiliations (OAA) have created a number of 
initiatives designed to expand the rural workforce and to provide 
training to keep providers in rural health care. These initiatives 
include:

  --Rural Health Training Initiative provides rural clinical training 
        sites for health professions students and clinical residents. 
        Trainees include social workers, nurse practitioners, 
        pharmacists, psychiatrists, optometry students and dental and 
        family medicine residents. The focus is on training 
        professionals at rural sites with the goal of recruiting 
        graduates to rural-serving VA facilities.

  --Rural Interprofessional Faculty Development Initiative provides 
        training for residency proctors, enabling them to train, mentor 
        and monitor residents serving rural areas. Participants who 
        become professional faculty for academic partners have highly 
        regarded this professional development program. This evidence-
        based program impacts job satisfaction for participants, 
        educates trainees in the nuances of rural health care and 
        expands the workforce in participating VA medical centers. In 
        all, this program has provided training for more than 256 new 
        faculty to date. ORH and OAA are working on expanding the 
        program, creating a new cohort in FY 2022.

  --ORH Rural Scholars Fellowship Program provides professional 
        development opportunities for rural VA providers to develop the 
        skills and knowledge needed to lead innovation in rural health 
        care delivery, and ultimately improve recruitment and retention 
        of VA providers in rural facilities serving primary care. This 
        program allows providers to stay onsite in their rural 
        facilities and conduct research and process improvement 
        projects while receiving virtual mentoring from recognized 
        experts.

  --Rural Health Career Development Award Program supports early 
        investigators in developing a research program focused on 
        issues of relevance to rural Veterans and their health care. 
        This award provides protected time, research funding and 
        methodologic guidance to help recipients develop an innovative 
        program of research in rural Veterans' health and help support 
        their overall career development as an independently-funded 
        investigator.

  --Geriatric Scholars Program addresses the shortage of specialized 
        geriatric skills and knowledge in rural VA clinical settings by 
        training VA general clinicians in the treatment of older rural 
        Veterans.

  --Simulation Learning, Education and Research Network Rural 
        Coordinators develop simulation-based training infrastructure 
        to improve rural clinicians' technical skills without leaving 
        their home clinic.

  --Geriatric Research Education and Clinical Center Connect Program 
        trains VA providers to manage medically-complex cases through 
        case-based conferences, electronic consultations, virtual 
        meetings and clinical video telehealth.

  --Extension for Community Health Outcomes (ECHO) programs provide 
        training to VA and some non-VA rural providers in a variety of 
        different areas. Rural participant satisfaction data indicate 
        that this professional exchange of knowledge results in greater 
        job satisfaction among participants. ORH currently partners on 
        three ECHO programs across VHA, including:

    --VA-ECHO Expansion in Specialty Care uses telehealth to train 
            providers in a wide variety of specialties, including 
            treatment for chronic kidney disease, hepatitis C and pain 
            management.

    --National Mental Health and Suicide Prevention ECHO connects rural 
            providers to national mental specialists for regular 
            discussion of clinical cases and targeted skill-building 
            training on suicide prevention and substance use disorder 
            treatment.

    --COVID-19 VA ECHO focuses on COVID-19 care for patient care 
            providers from all disciplines in inpatient, outpatient and 
            residential care settings (also open to community 
            providers).

    Question. After making tremendous progress in reducing the claims 
backlog, it increased significantly over the past year due to the 
pandemic, including challenges in completing medical exams and 
accessing service records, and the inclusion of presumptive eligibility 
for three conditions related to Agent Orange Exposures. The Budget 
requests funding for an additional 429 FTE to address the increase in 
claims.
    What lessons from addressing the Blue Water Navy claims is VA 
applying to the current workload?
    Answer. VA recognizes the criticality of a robust and timely 
evidence supply chain to support qualifying service review, which is 
evident in the reviews of Blue Water Navy claims. VA has aggressive 
plans to digitize personnel and medical records supporting benefits 
determinations before a Veteran or survivor even files a claim. 
Congress provided VA with $150 million in the American Rescue Plan 
(ARP) Act of 2021 to proactively scan National Personnel Records Center 
records. VA and the National Archives and Records Administration (NARA) 
are collaborating to build an on-site scanning capability for this 
effort. VA will provide digital copies of all scanned records to NARA 
to help expedite future requests for records.
    Question. How long will it take VA to work through the backlog and 
return to a normal claims workload?
    Answer. The disability compensation claims backlog is impacted by 
two large claim groups. In April 2021, VA established more than 60,000 
claims for review pursuant to the Nehmer court order and claims 
remaining in the inventory from this group aged into backlog status, 
resulting in more than 42,000 claims entering the backlog in August 
2021. In June 2021, VA also established approximately 70,000 claims for 
review for three new disabilities presumptively linked to Agent Orange 
Exposure by the National Defense Authorization Act, and any unprocessed 
claims from this group were added to the current backlog as of the end 
of October 2021. As of November 4, 2021, there were 260,510 rating 
claims in the backlog.
    Increased receipts, fueled by the expansion of presumptive benefits 
for Gulf War Veterans (which VA began processing in August 2021) and 
typical annual receipt growth, will further impact backlog reduction. 
To mitigate backlog growth, VA is leveraging ARP grants to fund 
overtime to ensure timely claims processing, as well as aggressively 
hiring nearly 2,000 claims processors during FY 2022. Assuming 
continued improvement of the Veterans Benefits Administration's (VBA) 
evidence supply chain (Compensation & Pension examinations and Federal 
records), VA plans to reduce the current claims backlog to 100,000 
claims by mid-FY 2024.
    Any additional expansion in presumptive benefits, without 
commensurate resource increases in FTE, technology and other process 
improvement funding, as well as time to implement such changes, will 
increase the current claims backlog further and reduce timely claims 
decisions for all Veterans.




    Question. How many claims raters will be needed if toxic exposure 
legislation currently under consideration in the Senate is passed?
    Answer. As part of VA's enhanced technical assistance for the 
Comprehensive and Overdue Support for Troops (COST) of War Act of 2021, 
VBA has identified a need for 9,871 FTE in the first year and an 
average of approximately 8,000 FTE over 10 years, after passage. VA 
provided this estimate to the United States Senate on July 30, 2021.
    Question. VA provides for direct health care for tribal veterans 
through partnerships with the Indian Health Service and Tribal Health 
Programs, as well as through VA facilities. As veterans may need to go 
to different facilities for different types of services, coordination 
of care can be challenging. How does VA plan to improve access to care 
for veterans who live in Indian Country, including coordination of care 
with non-VA providers?
    Answer. VA operates the Indian Health Service/Tribal Health 
Programs (IHS/THP) Reimbursement Agreements Program (RAP) which 
improves access to care by reimbursing IHS/THP facilities for direct 
care provided to Veterans. To improve care coordination for Veterans 
who need services beyond what IHS/THP facilities directly provide and 
are referred back to VA, VA established the Healthcare Coordination 
Advisory Board to assist in developing a standardized care coordination 
process. Details of the approach can be found on the IHS/THP RAP 
website under the Care Coordination section. VA has made progress in 
implementing key elements of this effort. VA successfully partnered 
with IHS and THP facilities to expand reimbursement coverage to include 
telehealth through a modification signed by IHS and distributed to 
tribes in late September/early October 2020. VA is currently developing 
and implementing the Community Provider Orders/Standardized Request for 
Service Process, a Nation-wide effort to improve care coordination 
between community providers (including IHS/THP providers) and VA. This 
process and accompanying tools allow for community providers to 
electronically send referrals back to VA. Upon receipt of referrals, VA 
staff will then be able to coordinate the care needed by the Veteran--
either in a VA facility or by a community provider through VA's 
Community Care Network. VA is sharing information about this process 
during training sessions with IHS/THP held as of July 2021 to 
understand their interest in using this approach.
    Question. About half of the States have veterans living in highly 
rural areas, and main obstacles to veterans in these areas obtaining VA 
health care is distance and transportation. VA's Highly Rural 
Transportation Grant Program, which was funded at less than $3.0 
million in FY 2021, is one tool to improve these Veterans access to 
care. How does VA determine the demand for this program, and whether 
the Department is meeting the demand?
    Answer. VA establishes Highly-Rural Transportation Grant Program 
demand through a grant request process by issuing an annual Notice of 
Funding Availability (NOFA) letter. Eligible Veterans Service 
Organizations and state Veterans agencies are responsible for 
submitting grant requests. Demand for the program is gauged by the 
number of requests received in response to the annual NOFA, and future 
budget funding levels are informed by previous years' program demand 
balanced against total funds available for competing priorities.

                                 ______
                                 

              Questions Submitted by Senator Brian Schatz
                             va telehealth
    Question. Does VA's ability to make permanent any of the telehealth 
policies that it adopted during the COVID-19 pandemic rely on the 
current federal public health declaration?
    Answer. During the Coronavirus Disease 2019-declared public health 
emergency, VA providers are authorized to prescribe controlled 
substances following an audio-visual assessment of a Veteran using 
telehealth technologies in the home. Once the public health declaration 
is rescinded, VA will lose this authority. VA has advocated for this 
authority to become permanent through a special registration for 
telemedicine from the Drug Enforcement Administration. A special 
registration for telemedicine is already authorized under Federal law 
in the Controlled Substances Act but has not yet been established (21 
U.S.C. Sec. 831(h)).
    Question. What structural changes does VA need to make so that it 
can institutionalize and expand on the telehealth policies and services 
that it adopted during the COVID-19 pandemic, including with respect to 
the following:

  --Changes to the policies related to VA's electronic medical record 
        and appointment referral system;

  --Changes to the way VA contracts for community care;

  --Changes to the way VA contracts for internal medical care;

  --Changes to the way that VA provides pay retention or other 
        incentives to internal health care physicians and staff;

  --Changes to the way VA establishes standard of care models for its 
        patients;

  --Changes to the equipment and training that VA providers need to 
        deliver care through telehealth; and

  --Changes to the way VA ensures veterans have the ability to acquire 
        tablets or other devices to access telehealth care.

    Answer. The Veterans Health Administration's (VHA) Connected Care 
Strategic Vision builds on VA's strong foundation in virtual care 
delivery and will contribute significantly to enhancing the exceptional 
care that VHA already delivers. Solidifying connected care foundations 
is one of three goals in the strategic vision.
    Connected care foundations are the policies, legal authorities, 
technical infrastructure, equipment and processes on top of which 
connected care services operate. Key foundational goals have already 
been achieved as part of VA's ongoing Anywhere to Anywhere telehealth 
initiative, begun in 2017. These include license portability under 
Federal law for VA health care professionals (VA Maintaining Internal 
Systems and Strengthening Integrated Outside Networks Act of 2018, P.L. 
115-182) and for health professions trainees and other qualified health 
care professionals (National Defense Authorization Act of 2021, P.L. 
116-283). These also include modernization of bandwidth infrastructure 
at community-based outpatient clinics, development of a standard 
platform for telehealth delivery to Veteran homes (i.e., VA Video 
Connect), a system to efficiently grant providers access to one or 
multiple facility medical records, a systematic process to help 
Veterans overcome the digital divide and publication of VA policy for 
cross-facility clinical resource sharing and telework-telehealth.
    As part of its next phase of solidifying connected care 
foundations, VA is focused on:

  --Integrating VA Video Connect scheduling into its front-line 
        Veterans Health Information Systems and Technology Architecture 
        scheduling application and increasing appointment flexibility;

  --Establishing policy authorizing national health care professional 
        telehealth privileging;

  --Enhancing cross-facility scheduling applications to facilitate 
        additional clinical resource sharing from telehealth hubs;

  --Resolving legal barriers to controlled substance prescribing 
        including for substance abuse treatment;

  --Developing a certification program for telehealth support staff 
        inside and outside VA;

  --Enhancing accessibility options in telehealth applications;

  --Integrating required components of VA connected care into Cerner;

  --Developing systems to support provider collaboration across 
        facilities;

  --Adding options to assist Veterans with overcoming the digital 
        divide; and

  --Modernizing and simplifying telehealth equipment.

    As part of its efforts to modernize care delivery, all options to 
enhance VA's connected care foundations, and therefore VA services, are 
being considered. While VA has not yet identified the need for specific 
changes to community care policy, provider pay incentives, standards of 
care or changes to the way Veterans obtain tablets from VA, these could 
become future focus areas.
    Question. Does VA require any new statutory authority to make any 
of the structural changes identified above?
    Answer. Legislative changes are needed to resolve barriers to 
controlled substance prescribing, including for substance abuse 
treatment. VA would appreciate engagement with Congress regarding 
authorities for prescribing controlled substance(s) via telehealth.

                                 ______
                                 

              Questions Submitted by Senator John Boozman
    Question. Since Congress passed the 21st Century IDEA [Integrated 
Digital Experience Act], the nature of how individuals engage with 
government has fundamentally changed-in large part because of the 
coronavirus pandemic. These changes underscore an even stronger need to 
implement the 21st Century IDEA and allow federal agencies to deliver 
an excellent customer experience from anywhere, to anyone, on any 
device.
    Has the Department of Veterans Affairs fully implemented the 21st 
Century IDEA Act (Public Law No: 115-336)?
    Answer. The breadth of services, transactions and content available 
to Veterans on VA.gov is extremely large, and despite not fully 
implementing the 21st Century Integrated Digital Experience Act (IDEA), 
we have made great progress. VA has been working to modernize and 
consolidate various tools into an enterprise-wide self-service platform 
accessible from a single place: VA.gov. The new VA.gov launched in 
November 2018, and it now serves as the primary front door to VA.
    The site-wide navigation, on VA.gov web pages, allows users to sign 
in or search VA.gov, and just below that on the homepage are the top 
tasks Veterans told VA are the most important to them--representing 
over 80% of the tasks users visited VA.gov to accomplish. The 
modernized pages are all compliant with section 508 of the Americans 
with Disabilities Act. Since relaunch, the Customer Satisfaction Score 
for all VA.gov websites (including both modernized and legacy pages) 
rose from 52.9% to 67.9 % (a 28% increase).
    In order to continue to align VA's digital experience with our 
users' expectations--and to meet the goals put forth by the 21st 
Century IDEA--VA has placed a major focus on modernizing our digital 
experience. Our Agency digital strategy has three primary goals: 1) 
increase the use of self-service tools; 2) enable faster access to care 
and more timely delivery of services; and 3) improve customer 
experience and reliability on VA's online services. VA has continued to 
make progress on these goals throughout 2021, even as we continue to 
create new digital experience capabilities to support VA's Coronavirus 
Disease 2019 pandemic response that began in March 2020.
    Question. What barriers has the VA faced in implementing this law 
and modernizing its digital services?
    Answer. The process to modernize VA's inventory of forms and 
digital services is driven by the demands and priorities of the Office 
of Information and Technology's business partners. The Department 
provides hundreds of benefits, with forms to enable Veterans to apply 
for each and in many cases, online tools to help track and manage both 
the application as well as the benefit itself.
    Question. The final FY21 MilConVA Appropriations bill included 
report language and funding direction for the VA to implement Section 4 
of PL 115-336 ``21st Century IDEA,'' which required that no later than 
two years after the date of enactment, each executive agency was 
required to digitize and ensure any paper-based form was made available 
to the public in a fully usable mobile friendly option.
    Who is responsible inside VA for ensuring the agency fully 
implements PL 115-336?
    Answer. The Digital Experience product line, within the Office of 
the Chief Technology Officer, is charged with executing VA's Digital 
Modernization Strategy. This includes initial and ongoing efforts to 
implement the 21st Century IDEA.
    Question. Where does the VA stand in ensuring its forms can be 
filled out and submitted electronically on all common, digital devices?
    Answer. Currently, there are approximately 500 public-facing forms 
available on VA's web properties. This number varies as forms are 
added, removed or expire. Additionally, many VA medical centers create 
and manage their own forms in a decentralized fashion, adding to and/or 
subtracting from that overall total. All public-facing customer VA 
forms are currently accessible online as fillable Portable Document 
File forms. Those can be completed digitally, printed and then 
submitted to VA by mail, fax or in-person. Approximately 20 of VA's 
most used forms can be completed and submitted through an online 
wizard. These comprise about 350,000 submissions per month. All of VA's 
digital online experiences are compliant with section 508 and conform 
to both the Privacy Act and the Paperwork Reduction Act. VA is working 
to ensure that all digitized forms meet these standards.
    VA is also working to identify and prioritize the digitization of 
paper forms and non-digital services that are highly utilized by 
Veterans. On VA.gov today, over 40% of traffic comes from mobile users, 
so introducing new forms and services that are secure and mobile-
responsive will not only allow us to better connect with our users and 
have a greater impact on their lives, but it will also help VA achieve 
cost savings and workflow efficiencies.
    Question. For more than ten years, VA has successfully provided 
timely access to high quality dialysis services through community 
providers under the Nationwide Dialysis Services contracts when VA 
cannot directly provide such care. What factors have changed to trigger 
consideration of changing contracts which has been successful in 
providing care to these vulnerable veterans?
    Answer. VA's Office of Community Care implemented the next 
generation of Veteran Community Care in fiscal year 2020 with the 
Community Care Network (CCN) roll out. As of today, CCN is operational 
across the United States and will soon be operational in the Outer 
Pacific Islands. With this implementation, previous Community Care 
contracts began to sunset. The National Dialysis Services Contract 
(NDSC), which had been VA's previous community Dialysis Program, also 
began the sunset process for some contracts. However, nine NDSC 
contracts will be renewed for another year. NDSC was a successful 
program, but it did not encompass the full spectrum of dialysis care--
for example, nephrologist oversight and Acute Kidney Injury (AKI) were 
not covered. Under the new CCN contracts, End Stage Renal Disease, 
nephrologist oversight and AKI can be managed by the same Contractor's 
in-network provider base.

                                 ______
                                 

        Questions Submitted by Questions Senator Mitch McConnell
                  louisville va medical center (vamc)
    Question. As you know, Kentucky veterans have been waiting for a 
new VA medical facility in Louisville since 2006. Please provide an 
update on the new Robley Rex Louisville VAMC, including the expected 
timeline for construction and when the hospital will begin serving the 
region's veterans.
    Answer. On August 17, 2021, the United States Army Corps of 
Engineers awarded the base construction contract to Walsh Turner Joint 
Venture II (located in Chicago, Illinois) for construction of the new 
Robley Rex Louisville VA Medical Center. At this time, construction 
completion is scheduled for winter 2025, with the Beneficial Occupancy 
Date of winter 2026.
    Question. The VA's budget includes an additional $93 million for 
this project to address increased costs stemming from project delays. 
Please provide an explanation of these costs, as well as the potential 
for additional funding needed to complete the project.
    Answer. Of the budgeted $93 million requested for fiscal year (FY) 
2022, $51 million is for cost escalation associated with a 2-year 
solicitation delay (at approximately 3.8% per year) due to the lawsuit 
by the Crossgate community over VA's compliance with the National 
Environmental Policy Act. VA prevailed in spring 2021. The remaining 
$42 million of the $93 million is for cost escalation and additional 
contingency funds associated with executing contract options that will 
not be awarded for 12-18 months after the base contract award.
    Question. Can you please detail how the new Louisville VAMC will be 
specifically equipped to provide state-of-the-art health services to 
female veterans?
    Answer. To specifically address the needs of our women Veterans, 
the new hospital will include a Women's Health Clinic with four Patient 
Aligned Care Teams (PACT). The clinic will include a dedicated 
reception and waiting area, gynecology examination rooms with private 
restrooms, general examination rooms, telehealth examination rooms, 
PharmD consultation/examination, behavioral health consultation, 
nutritional consultation, phlebotomy laboratory, procedure room with a 
private restroom and an imaging suite. The imaging suite will include 
equipment for comprehensive women's health care including Ultrasound, 
Bone Densitometry and Mammography. In addition, the Women's Health 
Clinic will have dedicated support space for all assigned staff. For 
cases in which a woman Veteran would like to see a provider not 
specifically assigned to the Women's Health Clinic, all other PACT 
modules include gynecology examination rooms with private restrooms.
                              rural health
    Question. Will you provide information on the VA's plans to improve 
access to health care for Kentucky's rural veterans?
    Answer. The Office of Rural Health, in collaboration with other VA 
program offices, plans to maximize high-quality virtual care options 
for Kentucky's rural Veterans by continuing its efforts to increase 
access to health care by providing opportunities for the delivery of 
health care services to rural Veterans through funding the following 
initiatives: Telehealth Clinical Resource Hubs, Pharmacist Providers 
for Rural Veterans with Opioid Use Disorder, VA Maintaining Internal 
Systems and Strengthening Integrated Outside Networks Act Emergency 
Room Specialty Care Scribe Program, Women Veteran Care Coordination and 
Management Program, Veteran Transportation Services and Telehealth 
Equipment Modernization efforts, all delivered via telehealth, in-home 
or in-clinic. VA will continue to expand our telehealth partnerships 
with community partners and create strong partnerships to utilize 
available facilities and resources to better serve rural Veterans, 
their families and the communities where they live. Additionally, VA's 
Community Care Network will provide a direct link with community 
providers when needed that will ensure VA provides the right care, at 
the right time, to Veterans.
    Question. What are the VA's plans to expand telehealth options for 
rural veterans who lack reliable access to the internet?
    Answer. VA has established a 5-year strategic vision for connected 
care which will enhance Veteran digital engagement, deliver health care 
without walls, sustain and increase capacity in rural and highly rural 
locations and solidify VA's connected care foundations. The strategy 
includes initiatives that will enhance the accessibility of VA health 
care in rural areas by delivering enhanced video telehealth care in the 
home using VA Video Connect and VA-provided examination peripherals 
(e.g., digital stethoscopes, blood pressure cuffs, pulse oximeters, 
thermometers, etc.). The strategy also includes continued focus on 
expanding the capacity of VA services in rural and underserved areas by 
distributing clinical resources using telehealth through clinical 
resource hubs and other virtual health care delivery initiatives. 
Services that will be distributed include inpatient services such as 
tele-critical care; high-volume outpatient services such primary care 
and mental health; and low volume, highly-specialized services such as 
stroke neurology. Additionally, the strategy supports expanding remote 
patient monitoring capabilities, allowing rural and highly-rural 
Veterans to attentively monitor and manage chronic health conditions, 
in partnership with VA, from their homes.
    As part of its vision to deliver trusted VA care, anytime and 
anywhere, VA will continue efforts to bridge the digital divide for 
Veterans who lack the technology or broadband internet connectivity 
required to participate in VA telehealth services irrespective of their 
location in the country. Central to this effort, VA has implemented a 
national digital divide consult process in the electronic medical 
record. Through this process, qualifying Veterans can obtain an 
internet-connected device from VA or assistance in applying for Federal 
Communications Commission (FCC)-administered internet subsidies. The 
FCC subsidies are available through the Lifeline and Emergency 
Broadband Benefit (EBB) programs. The Lifeline and EBB programs can 
combine to provide many qualifying Veterans up to $59.25 per month for 
their internet services. Veterans on tribal lands can receive up to 
$109.25 through these programs. VA has completed over 49,500 digital 
divide consultations since the beginning of FY 2021 and has distributed 
more than 84,000 internet connected tablets since the start of the 
pandemic. Additionally, VA has worked with major wireless carriers such 
as Verizon, T-Mobile, SafeLink by Tracfone and AT&T to support 
Veterans' access to VA telehealth services through Zero Rating the 
telehealth platform VA uses to deliver telehealth to the home. Zero 
Rating this platform allows Veterans, their families and caregivers to 
use VA Video Connect with fewer worries about data fees.
    VA will also continue enhancing existing telehealth infrastructure 
at community-based clinics serving rural and highly-rural parts of the 
country. Clinical video telehealth visits, with full remote examination 
capabilities, allow Veterans to receive specialty care services at 
their closest clinic, even if the specialist is elsewhere in the VA 
system. This supports care in rural areas, even where affordable 
broadband is not readily available in the community.
    VA is also evaluating the opportunity to leverage community-based 
telehealth access points through its Accessing Telehealth through Local 
Area Stations (ATLAS) pilot program. ATLAS is a pilot designed to 
bridge the digital divide and reach rural and underserved Veterans in 
areas with limited access to broadband and health care. Through this 
initiative, VA is teaming up with Philips, Walmart, Veterans of Foreign 
Wars and The American Legion to provide convenient locations within 
Veterans' communities equipped with the broadband and telehealth 
technology necessary to access VA health care. Walmart has provided 
space within their health services room as well as equipment, while 
Philips designed unique and private spaces equipped with state-of-the-
art telehealth equipment within Veterans Service Organizations. VA 
currently has 12 ATLAS locations nationally that are open and available 
for scheduling. By the end of 2021, it is anticipated that a total of 
13 ATLAS sites will offer clinical services by telehealth from VA 
providers.
                             mental health
    Question. Will you provide an update on the VA's efforts to improve 
veterans' access to mental health care services, including through the 
implementation of the President's Roadmap to Empower Veterans and End a 
National Tragedy of Suicide (PREVENTS) and the Commander John Scott 
Hannon Veterans Mental Health Care Improvement Act (P.L. 116-171)?
    Answer. The Veteran Wellness, Empowerment and Suicide Prevention 
Task Force under the President's Roadmap to Empower Veterans and End a 
National Tragedy of Suicide (PREVENTS) Task Force was formed as a 
result of Executive Order 13861, signed on March 5, 2019, with a call 
to action to amplify and accelerate the progress in addressing Veteran 
suicide in the United States. On June 17, 2020, the Task Force released 
PREVENTS, which contains recommendations for a federally-coordinated 
national public health strategy to address Veteran suicide.
    In FY 2021, the PREVENTS national public health campaign called 
Reach, Engage, Attend, Connect, Help (REACH), has garnered 
approximately 5.7 billion impressions since it was launched in July 
2020. The REACH website, https://www.reach.gov, has been visited more 
than 12 million times and PREVENTS-produced public service 
announcements have had nearly 1.3 million views. In March 2021, 
PREVENTS launched the How We R.E.A.C.H. Coaching Tool to teach people 
how to ``reach out'' to help someone in need. In 1 month, the Coaching 
Tool was downloaded more than 1,600 times and its accompanying 
application nearly 900 times. More than 16,000 individuals signed an 
online pledge to help increase awareness of mental health challenges 
and suicide prevention practices. These efforts demonstrate the 
efficacy of PREVENTS contributions to VA's collective efforts to 
improve Veterans' access to mental health care services.
    Paid media is a critical component of any national public health 
campaign. In FY 2021, paid media was implemented through a variety of 
media platforms, including social media, television, radio, digital 
content (such as news websites) and online media streaming services 
(e.g., Pandora and Spotify). Paid media also included running public 
service announcements in communities that have had high rates of 
Veteran suicide, and during programming that is watched, listened to or 
visited by targeted audiences as well as during events or activities 
attended by Veterans (e.g., the Army/Navy football game). In FY 2022, 
PREVENTS communications will continue to target Veterans at risk for 
suicide and people in their communities to get them the resources they 
need to prevent suicide with a goal of decreasing risk factors and 
increasing prevention factors, particularly lethal means safety. VA 
will also be evaluating the campaign to see what is effective in 
driving exposure, awareness and engagement, and we will adjust efforts 
as needed. All of this will be done in coordination with other VA 
suicide prevention initiatives and programs to ensure public health 
campaign communications are appropriately aligned and research is 
informed. VA will also collaborate with others to carry the public 
health campaign message forward when the PREVENTS Task Force terminates 
on June 17, 2022.
    Implementation of the Commander John Scott Hannon Veterans Mental 
Health Care Improvement Act (P.L. 116-171) continues to move forward. 
Prior to the President signing the legislation into law, VA established 
a team within the Office of Mental Health and Suicide Prevention to 
oversee implementation. Each section was assigned a primary Point of 
Contact who is responsible for ensuring all actions in that section are 
completed. All Congressionally-mandated reports due to date have been 
submitted on time. A series of White Papers on each section, along with 
responses to any questions or concerns needing clarification from 
Congress, have been provided to the staff of the House Committee on 
Veterans' Affairs (HVAC) and Senate Committee on Veterans' Affairs 
(SVAC). VA continues to brief HVAC and SVAC on a regular basis (last 
briefings were completed July 1 and July 6, respectively). Development 
and implementation of the Staff Sergeant Parker Gordon Fox Suicide 
Grant Program (section 201) and the Readjustment Counseling Service 
Scholarship Program (section 502) continue to make exceptional 
progress. Regarding section 502, the proposed regulation has been 
reviewed and approved by VA's Office of General Counsel (OGC). The 
Office Management and Budget (OMB) has determined that the Secretary 
can sign the proposed rule for publication in the Federal Register 
without full OMB review, which is anticipated to result in expediting 
the scholarship award cycle.
                            toxic exposures
    Question. I have heard from Kentucky veterans who were exposed to 
contaminated water while stationed at Marine Corps Base Camp Lejeune 
between 1953 and 1987. What steps has the VA taken to provide resources 
and information on benefit eligibility to veterans and their family 
members who may suffer from medical conditions caused by toxic exposure 
at Camp Lejeune?
    Answer. On March 14, 2017, VA effectuated 38 C.F.R. 
Sec. 3.307(a)(7) to address the presumption of service connection for 
certain conditions associated with exposure to contaminants in the 
water supply at Camp Lejeune. The rule allows Service members with 
records demonstrating no less than 30 days of service (either 
consecutive or cumulative) at Camp Lejeune during the specified 
timeframe, and who have been diagnosed with any of the eight 
presumptive diseases, to be presumed to have a service-connected 
disability for purposes of entitlement to VA benefits. The rule applies 
to all military Active Duty, Reserve and National Guard personnel who 
meet the requirements of the regulation. To address community concerns 
and provide information, VA has held joint community meetings, 
partnering with the Department of Defense (DoD), on Camp Lejeune. 
Further, VA provides resources and information to the public regarding 
benefit eligibility through its website at Camp Lejeune water 
contamination health issues. Veterans and survivors may also call the 
benefits toll-free hotline at 1-800-827-1000 to speak directly with a 
VA employee, who may assist with benefit eligibility questions.
    The Agency for Toxic Substances and Disease Registry held Community 
Assistance Panel (CAP) meetings for 15 years. These quarterly meetings 
included large public meetings and CAP board member meetings, and VA 
attended these meetings. These meetings were online and in person, as 
they were held before the onset of the Coronavirus Disease 2019 (COVID-
19) pandemic. VA discussed the programs available for both Veterans and 
family members. VA answered an average of 200 individual questions for 
these meetings. VA placed posters (electronic and/or paper when 
available) in VA medical centers and clinics. VA prepared and conducted 
training regarding Camp Lejeune exposures for its health care providers 
and Compensation and Pension examiners. This was also available to 
civilian providers via a platform called the TrainingFinder Real-time 
Affiliate Integrated Network, or better known as TRAIN. VA newsletters 
have featured articles about Camp Lejeune and benefits available to 
Veterans and family members.
    If one searches the term Camp Lejeune programs online, the first 
items to appear are VA's Public Health website at https://
www.publichealth.va.gov/exposures/camp-lejeune/index.asp, which covers 
Camp Lejeune questions and offers resources. VA's Community Care 
website also offers information regarding Camp Lejeune at: https://
www.va.gov/COMMUNITYCARE/programs/dependents/CLFMP.asp. There are many 
civilian, advocacy and law firm websites that reiterate VA benefits 
when searched. VA coordinates with DoD mailings to those on the DoD 
Camp Lejeune rosters about VA benefits. DoD has also placed full-page 
advertisements in newspapers across the country to discuss the benefits 
available.
    Question. What statutory limitations, if any, prevent the VA from 
efficiently accessing the Department of Defense records needed to 
provide benefits or establish service connections for diseases related 
to toxic exposures, both at Camp Lejeune and elsewhere?
    Answer. 38 U.S.C. Sec. 320 codified the VA-DoD Joint Executive 
Committee, which is, in part, tasked with providing recommendations to 
both Secretaries about the strategic direction for the joint 
coordination and sharing efforts between and within the two 
Departments.
    DoD and VA have worked together extensively since at least 2011 on 
exposure-related issues. Regarding Camp Lejeune drinking water 
contamination, the United States Marine Corps supported VA by providing 
computerization of millions of personnel and housing records of 
Veterans. Other efforts include the development of the Individual 
Longitudinal Exposure Record (ILER), a web-based application that will 
reference multiple data sources to create the exposure record for 
Service members. ILER will provide medical providers with an available 
exposure record, support VA clams processing for claims due to in-
service environmental exposures and have other functions and benefits.
    Question. Veterans dealing with health conditions due to service-
related toxic exposures need timely access to life-saving VA benefits. 
Once scientific research has identified a connection between a disease 
and a toxic exposure, what steps does the VA take to ensure decisions 
regarding service connections are made and implemented quickly?
    Answer. Once rulemaking is complete, VA will develop procedures and 
training curriculum to deploy to claims processors, as well as make any 
required system updates to allow for processing of the condition(s). 
This will include any needed updates to the Veterans Benefits 
Management System. The scope of training will be dependent on the 
number of impacted Veterans and scale of expected receipts; therefore, 
training may be deployed to a subset of claims processors at a limited 
number of sites or to all claims processors. Additionally, for efforts 
with larger numbers of expected receipts, VA is likely to request 
additional resources in future budgets or supplemental requests to 
ensure timely claims processing.
                          veteran homelessness
    Question. Will you provide an update on the permanent supportive 
housing project in Lexington, Kentucky, which became operational in 
fiscal year 2020? How many veterans are currently being served through 
this enhanced-use lease project?
    Answer. The Victory Point Apartments and Townhomes supportive 
housing enhanced use lease project in Lexington, Kentucky, received its 
first Certificate of Occupancy on May 6, 2020. The 50 units of 
permanent supportive housing currently have 26 Veteran and 24 non-
Veteran residents.
    Question. Will you provide an update on how the VA is meeting the 
specific needs of female veterans who are homeless or at risk of 
homelessness?
    Answer. The national VA Homeless Program Office (HPO) provides a 
full spectrum of services designed to meet the unique needs of all 
Veterans, including women Veterans who are at-risk of or who are 
experiencing homelessness. These services include clinical outreach, 
treatment, transitional housing, supportive services and permanent 
housing. VA's efforts are enhanced by harnessing the strength of 
community providers in coordination with VA health care and benefits. 
In FY 2020, including all homeless services provide under HPO, over 
32,700 unique women Veterans were served. In 2021, HPO conducted an 
analysis to identify potential gaps in services provided by VA homeless 
programs for women Veterans experiencing or who are at-risk for 
homelessness. Results from this analysis show that there are no 
significant gaps in service delivery, outcomes and Veteran 
satisfaction, and to the extent possible, VA is meeting the needs of 
homeless and at-risk women Veterans.\2\ Additionally, the Johnny 
Isakson and David P. Roe, M.D. Veterans Health Care and Benefits 
Improvement Act of 2020 (P.L. 116-315) provides VA homeless programs 
with flexibilities to address identified gaps, as detailed in the 
summary below.
---------------------------------------------------------------------------
    \2\ A detailed review of data for corresponding findings will be 
provided in a Congressionally Mandated Report (CMR) titled ``Gap 
Analysis of Department of Veterans Affairs Programs that provide 
assistance to women Veterans who are homeless.'' The CMR is currently 
in concurrence for clearance and pending submission to Congress.
---------------------------------------------------------------------------
    Population Comparison: As of FY 2020, women Veterans represented 
8.4% of the overall homeless Veteran population and 38.5% of women in 
the general homeless population. Since 2017, the number of homeless 
women Veterans decreased, while the number of homeless women in the 
general homeless population increased. Women were equally represented 
among the Veteran population (8.9%) and the homeless Veteran population 
(8.7%); however, women Veterans comprised 11.5% of all Veterans served 
by VA homeless programs. These data demonstrate that VA homeless 
programs successfully reach women Veterans experiencing or who are at-
risk for homelessness and are providing services designed to resolve 
their housing needs.
    Homeless and At-Risk Veterans Served by VA Homeless Programs: A 
demographic overview shows VA homeless programs provide a wide variety 
of services to meet the diverse needs of the homeless population. This 
analysis identified gender gaps in service engagement, which are 
attributed to the often unique service needs and family composition of 
women Veterans. Specifically, homeless and at-risk women Veterans are 
more likely than men Veterans to have children in their custody and 
require additional services and resources to accommodate dependents. 
Additionally, many congregate living settings, like VA's residential 
treatment programs, are mostly populated by men, with women as the 
extreme minority. These congregate settings have limited designated 
space available for women, such as separate living and bathroom 
facilities. Traditionally, women Veterans are more likely to utilize 
services that provide independent housing options such as housing 
subsidies for an apartment/house or temporary shelter in a private 
hotel. As a result, women Veterans have a higher rate of admission to 
the Department of Housing and Urban Development-VA Supportive Housing 
(HUD-VASH), Supportive Services for Veteran Families (SSVF) Prevention 
and SSVF Rapid Re-housing (RRH) programs than to programs more 
congregate in nature. VA's residential treatment Grant and Per Diem 
(GPD) program serves approximately 50% less women Veterans than HUD-
VASH, SSVF or RRH. It should be noted that the Johnny Isakson and David 
P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020 
(P.L. 116-315 Sec. 4204) provides that in cases of a homeless Veteran 
who has care of a minor dependent, GPD must pay, in addition to the 
daily cost of care of the eligible Veteran, an amount that equals 50% 
of the daily cost of care for each minor dependent.
    We expect that this ability to pay for care for dependents will 
make GPD a more viable option for women Veterans with minor dependents 
and should increase the percentage of women served in GPD as time goes 
on. Within HUD-VASH, there is a significant difference in service 
utilization when comparing rates of program entry among women and men 
Veterans with children, with close to 30% more women with children 
entering HUD-VASH compared to men with children. In SSVF and RRH, there 
are no significant differences in admission rates for this cohort. 
Beyond the specified limitations of programs offering congregate living 
settings, no significant gender gaps in homeless program service 
provision or access were identified in this analysis.
    VA Homeless Program Outreach: VA's Health Care for Homeless 
Veterans (HCHV) program provides outreach and case management services 
to at-risk and homeless Veterans. Women Veterans received more outreach 
contacts proportionally than what they represent in the homeless women 
Veteran population (10.9% of all outreach contacts were with women 
Veterans, compared to the 8.4% of women represented in the homeless 
Veteran population). This demonstrates that VA is actively reaching out 
to women Veterans experiencing homelessness to ensure equitable access 
to services. No significant gender gaps in outreach services were 
identified in this analysis.
    VA Homeless Program Referrals: VA homeless programs receive 
referrals from community partners, self-referrals from Veterans and 
other VA services. Self-referrals from Veterans can come through the 
National Call Center for Homeless Veterans (NCCHV), which provides a 
24-hour/7-day-a-week hotline for Veterans seeking housing services. 
There were no significant gaps in referrals generated through NCCHV 
when comparing men and women Veteran callers. While men represented 
higher numbers of calls to NCCHV, a slightly higher proportion of Women 
Veterans had a service provider visit within 90 days of reaching out to 
NCCHV. Veterans receiving care across VA health care settings complete 
an annual Homeless Screening Clinical Reminder (HSCR), which is a brief 
screening to determine if a Veteran needs assistance with housing. 
While men represented higher numbers of positive HSCRs, they also had a 
slightly higher proportion of subsequent visits with a VA service 
provider within 90 days of being screened. No significant gender gaps 
in referrals and service provision from these two main referral sources 
were identified in this analysis.
    SSVF has innovative features that allow its grantees to address the 
needs of women and in households where women were head of household. 
These features, described below, have allowed SSVF to serve 
significantly more women Veterans than would be expected as women 
currently represent 8.4% of the homeless Veteran population but 13% of 
Veterans served by SSVF in FY 2020.

  --SSVF can offer families temporary child-care, thereby providing 
        opportunity for women Veterans with children to seek employment 
        and needed medical and mental health care.

  --SSVF offers additional assistance to those fleeing domestic 
        violence. This provision allows the full range of SSVF 
        services, including financial assistance, to be offered to 
        victims of domestic violence whether they are Veterans or the 
        victim of violence in a Veteran's household.

  --SSVF is unique in that it can directly serve all household members, 
        including dependent children, of homeless and at-risk Veterans. 
        As women are often the primary caretakers for a family's 
        dependent children, this feature of SSVF is critical to meeting 
        the needs of these women Veterans.

  --SSVF is currently working with communities across the country on a 
        national initiative that seeks to help at-risk Veteran families 
        avoid homelessness through family reunification. By training 
        staff on mediation techniques, supported by limited financial 
        assistance, SSVF seeks to work with families and friends to 
        prevent the trauma of homelessness.

  --If a Veteran is separated from their family for any reason 
        (including discord, hospitalization, incarceration or other 
        forms of institutionalization), services can be maintained and 
        provided to the Veteran's family members for up to 1 year.

    VA Homeless Programs Outcomes: There were no significant gender 
gaps in outcomes for women Veterans served in VA homeless programs, and 
overall, women had better outcomes compared to men. Across all 
programs, women had higher rates of permanent housing placements and 
lower rates of negative program exits. Women were more likely than men 
to exit HUD-VASH case management with a voucher at exit. Women Veterans 
were also more likely than men to have full or part-time employment at 
exit, except in the GPD program, where women and men were equally 
likely to have full or part-time employment at exit. Finally, apart 
from the Health Care for Homeless Veterans Contract Residential 
Services/Low Demand Safe Haven (HCHV CRS/LDSH) programs, women Veterans 
had higher rates of income and non-cash benefits at exit than men, with 
slightly lower proportions of women exiting HCHV CRS/LDSH having income 
and non-cash benefits at exit.
    Veteran Satisfaction: VA's two primary satisfaction surveys reveal 
that both women and men Veterans reported similarly high levels of 
satisfaction with VA services. Over 90% of women and men agreed that 
the services they received met their expectations and needs, and over 
95% of women and men were satisfied with the overall services they 
received. In 2019, three of the top five Veteran-met needs were the 
same for homeless women and men Veteran respondents: Medical Services, 
Medication Management and Tuberculosis Testing and Treatment. Of the 
unmet Veteran needs in 2019, three of the top five were the same for 
homeless women and men Veteran respondents: Legal Assistance to Expunge 
a Criminal Record, Legal Assistance for Credit Issues/Debt Collection 
and Tax Issues. It should be noted that under section 5105 of the 
Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits 
Improvement Act of 2020, VA must enter into one or more agreements with 
public or private entities to provide legal services to women Veterans. 
As of this report, HPO has identified communities with the most 
pronounced indications of unmet need for legal services among homeless 
women Veterans and is conferring with OGC regarding the potential for 
new or expanded partnerships with legal service providers in these 
communities as a result of this legislation. No significant gender gaps 
in reported satisfaction with VA homeless programs and services between 
men and women served were identified in this analysis.
    Question. Will you provide an update on how the VA is meeting the 
specific needs of rural veterans who are homeless or at risk of 
homelessness?
    Answer. The Veterans Benefits Administration's (VBA) Veterans 
Transportation Program (VTP) offers Veterans many travel solutions to 
and from their VA health care facilities at little or no cost to 
eligible Veterans. VTP provides safe and reliable transportation to 
Veterans who require assistance traveling to and from VA health care 
facilities and authorized non-VA health care appointments. In addition, 
the VHA Office of Connected Care's ATLAS service is part of VA's 
Anywhere to Anywhere telehealth initiative, which sets out to better 
serve the nearly 9 million Veterans who receive care through VA no 
matter where they are. ATLAS has teamed up with public and private 
organizations to enhance underserved Veterans' access to VA health care 
by offering them convenient locations to receive VA care closer to 
home. This new option reduces obstacles such as long travel times to 
appointments and poor internet connectivity at home.
    HPO provides a full spectrum of services designed to meet the 
unique needs of all Veterans, including the needs of rural Veterans who 
are homeless or at risk of homelessness. VA's efforts are enhanced by 
harnessing the strength of community providers in coordination with VA 
health care and benefits.

  --Grant and Per Diem: GPD's grant funding decisions consider a 
        variety of factors including geographic dispersion. When funds 
        are made available for a grant or per diem award under 38 
        C.F.R. part 61, VA will publish a Notice of Funding 
        Availability in the Federal Register. The notice will state any 
        priorities for or exclusions from funding to meet the statutory 
        mandate of 38 U.S.C. 2011, to ensure that awards do not result 
        in the duplication of ongoing services and to reflect to the 
        maximum extent practicable appropriate geographic dispersion 
        and an appropriate balance between urban and non-urban 
        locations. In this way, GPD promotes equity and is responsive 
        to the needs of communities. GPD continues to work to support 
        communities in need, such as rural communities, as they work to 
        end homelessness among Veterans by providing transitional 
        housing resources for use by Veterans experiencing or at risk 
        of homelessness.

  --Supportive Services for Veteran Families: Through the SSVF program, 
        generally, grantees may use a maximum of 40% of the temporary 
        financial assistance to provide homeless prevention assistance 
        to those most at risk of becoming homeless. However, this 
        requirement has been waived for the duration of the COVID-19 
        health emergency. SSVF recognizes that rural areas often lack 
        the shelter capacity to meet local needs and therefore, rural 
        Veterans are more likely to be in temporary housing 
        arrangements that qualify only as prevention. To address this 
        unique feature of rural communities, SSVF allows rural grantees 
        to apply for a waiver to this 40% prevention spending limit. 
        Additionally, when selecting applicants to receive supportive 
        services grants, VA will, ``[t]o the extent practicable, ensure 
        that supportive services grants are equitably distributed 
        across geographic regions, including rural communities and 
        tribal lands.'' 38 C.F.R. Sec. 62.23(d).

  --HUD-VA Supportive Housing: Approximately 9% of Veterans housed with 
        HUD-VASH vouchers live in rural or highly-rural areas. These 
        Veterans often require additional or modified case management 
        services to accommodate their remote locations. Even prior to 
        the challenges posed by the global COVID-19 pandemic, the 
        national HUD-VASH program office had encouraged facility-level 
        programs to adopt telehealth as a means to ensure Veterans were 
        able to access adequate case management supports.

  --Tribal HUD-VASH: Serves American Indian/Alaska Native Veterans (AI/
        AN) within the tribe's service area. HUD provides the grant 
        funding for rental assistance, administered by the tribe or 
        tribally-designated housing entity grantee, and VA provides the 
        case management and supportive services to enrolled AI/AN 
        Veterans. There are currently 26 tribes participating in the 
        program. Tribal HUD-VASH has case managers who travel to the 
        grantee's reservation or tribal areas to provide outreach to 
        homeless Veterans and Veterans at risk of homelessness. The 
        program has been developed to specifically address the unique 
        aspects of homelessness in tribal communities. Throughout the 
        pandemic, some of the tribal grantees have closed their borders 
        to non-tribal persons but made an exception for VA staff. These 
        tribes expressed their support for VA tribal HUD-VASH staff as 
        VA brings services to Veterans, instead of Veterans having to 
        travel to services. VA staff aided tribal members with 
        individual contacts, VA Video Connect (VVC) or other virtual 
        telehealth-type meetings, and through contactless delivery of 
        goods such as food, clothing and masks. VA was able to lend 
        smart phones with data plans to Veterans who did not have these 
        resources and assisted Veterans with use of the devices to 
        allow them to complete VVC meetings or to at least connect by 
        telephone if the Veteran was not comfortable using video 
        technology. Staff provided support and assistance to Veterans 
        who were experiencing significant losses of family, friends and 
        cultural connections due to the pandemic.

  --Homeless Patient Aligned Care Teams (HPACT): The HPACT program is 
        committed to addressing the physical, mental health and social 
        needs of all Veterans experiencing homelessness or at risk of 
        homelessness including those residing in rural and highly-rural 
        areas. Work is focused on the expansion of HPACT sites and 
        services to provide optimal health to rural Veterans through 
        utilization of extensive outreach, engagement and telehealth to 
        increase access to care. Many HPACTs offer some form of 
        outreach and engagement including health assessment, health 
        education, medication prescriptions and referrals to homeless 
        programs or other needed VA services. Additionally, telehealth 
        services, such as VVC, enhance access and allow Veterans to 
        receive additional services when indicated.

                                 ______
                                 

             Questions Submitted by Senator Lisa Murkowski
    Question. I appreciate that the Department is increasing its 
request for suicide prevention initiatives to $598 million dollars. A 
92% increase is an impressive ask and I believe that it indicates that 
you are making a serious commitment to provide support to our nations 
veterans who are facing desperate situations, and you have my 
wholehearted support in doing so. In 2019 and the wake of a tragic 
cluster of suicides, the U.S. Army at Fort Wainwright in Fairbanks, 
Alaska completed an in-depth Behavioral Health Epidemiological 
Consultation that identified several actions they could take to try and 
reduce suicide among active duty service members. Despite the Army's 
serious commitment to implementing these changes, we have not seen a 
significant decrease in suicides. I am worried that this may happen at 
the VA, where we continually appropriate money at the problem but don't 
see improvement in the situation.
    What is different about this year's suicide prevention portion of 
the budget request that will justify such a large ask?
    Answer. There are four primary programmatic areas that account for 
the suicide prevention budget increase: 1) Veterans Crisis Line's (VCL) 
implementation of 988; 2) Suicide Prevention 2.0 (SP 2.0); 3) 
President's Roadmap to Empower Veterans and End a National Tragedy of 
Suicide (PREVENTS); and 4) the Staff Sergeant Parker Gordon Fox Suicide 
Prevention Grant Program (SSG Fox SPGP).
    First, VCL accounts for 50% of the total increase, which is to 
support operational readiness in fulfillment of the National Suicide 
Hotline Designation Act of 2020, which requires the Federal 
Communications Commission (FCC) to designate 9-8-8 as the universal 
telephone number for the National Suicide Prevention Lifeline and VCL. 
A volume increase of 122% to 154% is anticipated for VCL, and the 
transition to 988 must be complete by July 16, 2022. Once activated, 
the 988 expansion will directly address the need for ease of access and 
clarity in times of crisis, both for Veterans and non-Veterans alike. 
By providing a universal, unique 3-digit dialing code, it will also 
give VA an opportunity to work in greater collaboration with the 
suicide prevention community across the United States and open the door 
to engage new individuals in life-saving care.
    Second, the increase for SP 2.0, which accounts for 12% of the 
total increase, is to further the implementation of our public health 
approach to suicide prevention. To accomplish its goal of reducing 
suicide among all 20 million U.S. Veterans, and to reach Veterans both 
inside and outside VA care, SP 2.0 is moving suicide prevention beyond 
a one-size-fits-all model to a blended model combining community 
prevention strategies and evidence-based clinical strategies that will 
empower action at the national, regional and local levels. This 
initiative is informed by the evidence supporting suicide prevention 
interventions and public health approaches. The Centers for Disease 
Control and Prevention, the Substance Abuse and Mental Health Services 
Administration and the National Action Alliance for Suicide Prevention 
have all moved toward a public health approach to suicide prevention. 
The model works to incorporate reaching both Veterans in the community 
as well as those we currently serve in VA with innovative community-
based prevention strategies combined with strategies with known 
outcomes for reducing suicide and suicide attempts based upon the 2019 
updated VA-DoD Clinical Practice Guideline (CPG) for the Assessment and 
Management of Patients at Risk for Suicide.
    Third, the increase for PREVENTS, which accounts for 18% of the 
total increase, is to support Roadmap implementation and completion to 
include an aggressive plan integrating Roadmap recommendation 1 with 
Roadmap recommendation 8 across fiscal year (FY) 2022.
    Fourth, SSG Fox SPGP accounts for 19% of the total increase. SSG 
Fox SPGP supports section 201 of the Commander John Scott Hannon 
Veterans Mental Health Care Improvement Act of 2019 (P.L. 116-171) and 
will enable VA to provide resources toward community-based suicide 
prevention efforts to meet the needs of Veterans and their families 
through outreach, suicide prevention services and connection to VA and 
community resources. In alignment with VA's National Strategy for 
Preventing Veteran Suicide (2018), this grant program will assist in 
further implementing a public health approach that blends community-
based prevention with evidence-based clinical strategies through 
community efforts.
    Question. Does this budget request have any points of focus on 
Veteran suicide prevention programs that target rural or remote 
communities like so many in Alaska?
    Answer. The Office of Rural Health (ORH), in collaboration with 
other VA program offices and research entities, have funded over 40 
mental health and suicide prevention initiatives targeted at rural or 
remote Veterans. The following programs have been established and are 
delivered in rural and highly-rural communities to Veterans in 
locations similar to those in Alaska: Telehealth Clinical Resource 
Hubs, Rural Access Network for Growth Enhancement, Pharmacist Providers 
for Rural Veterans with Opioid Use Disorder and Clinical Pharmacy 
Specialist Providers programs. In addition, ORH funds several 
initiatives in other rural communities such as the VA Farming and 
Recovery Mental Health Services, National Mental Health and Suicide 
Prevention Extension for Community Healthcare Outcomes, Community 
Clergy Training to Support Rural Veterans Mental Health and the Rural 
Suicide Prevention Program, just to name a few. These mental health and 
suicide prevention programs contribute to VA's continuing efforts to 
increase access to health care and to expand delivery of health care 
services to rural Veterans where they live. Active partnership with the 
Tribal Health Organizations in implementing these suicide prevention 
programs will be essential in highly-rural Alaska. In addition, 
providing postvention support when suicides happen and honoring those 
individuals in their communities would help them heal and assist them 
in being open to the resources.
    The budget includes expansion of our Community-Based Interventions 
for Suicide Prevention (CBI-SP) program to all Veterans Integrated 
Service Networks (VISN), including VISN 20. This program brings 
together the Governor's Challenge initiative (Alaska will be invited to 
join in FY 2022), the Together With Veterans peer led rural program and 
Veterans Health Administration (VHA) Community Engagement and 
Partnership Coordinators to facilitate community-led suicide prevention 
efforts. CBI-SP will facilitate the spread of the community suicide 
prevention efforts to all communities by deploying trained and 
dedicated VA staff who will help community coalitions organize, provide 
technical assistance and provide training all within a unifying model.
    Question. The VA is running a Native Veteran Suicide Prevention 
Project with the goal of addressing risk factors or enhancing known 
protective factors of suicide and developing Tribal partnerships. The 
program is in the process of establishing, or has already established, 
partnerships with 32 Tribes. Is the VA planning to expand this program 
to any Alaskan Tribes?
    Answer. The Tribal-VHA Partnerships for Suicide Prevention project 
is a demonstration project with three VA medical centers: VA Puget 
Sound Health Care System, Northern Arizona VA Health Care System and 
the Oscar G. Johnson VA Medical Center in Iron Mountain, Michigan. The 
tribal partnerships and outreach being conducted as part of this 
project are specific to tribes in these health care systems within the 
states of Washington, Arizona, Michigan and Wisconsin (which is served 
by the facility in Iron Mountain). The goal of this project is to 
develop and demonstrate a model for increasing partnership between VA 
suicide prevention and rural tribes. This initial project deliverable 
is due at the end of FY 2022, after which we expect to propose to roll 
the model out further in order to support additional VA health care 
systems that serve Native American Veterans.

                                 ______
                                 

               Questions Submitted by Senator John Hoeven
    Question. Section 102 of the VA MISSION Act called for the creation 
of Veterans Care Agreements (VCAs), a new type of contract between the 
VA and its community care providers. These types of contracts are 
intended to be used in areas where VA community care is either not 
provided or not sufficient to ensure that veterans can receive the care 
they need. For example, Bismarck--the second largest city in North 
Dakota--has zero nursing homes contracting with the VA, resulting in 
veterans having to pay out-of-pocket to receive the long-term care they 
need, or having to relocate away from family and friends.
    What is the current status of Veterans Care Agreements?
    Answer. Veterans Care Agreements (VCA) are currently being utilized 
to supply providers to support VA's ability to deliver timely care to 
Veterans to meet their medical needs. Pursuant to the legal standard 
for use of VCAs that is set forth in the VA Maintaining Internal 
Systems and Strengthening Integrated Outside Networks Act, a provider 
with a VCA is used to serve a Veteran when the hospital care, medical 
services and/or extended care services needed for that Veteran is not 
feasibly available from VA or through a conventional procurement 
contract or a sharing agreement (e.g., health care resource sharing 
agreement with the Department of Defense). There are 16,945 active VCAs 
as of October 13, 2021, according to the VA Provider Portal Management 
System.
    Generally, the use of VCAs has been gradually decreasing as the 
Community Care Network (CCN) has stabilized, and VA is less reliant on 
them as the implementation of the CCN becomes more robust. Some of the 
services VA is currently most reliant on utilization of VCAs to acquire 
are homemaker/home health, mental health and dental services.
    Question. Can you provide examples of where VA is currently using 
Veterans Care Agreements?
    Answer. A few examples of where VCAs are currently being used 
include CCN Regions 4 and 5 (Alaska/California/Arizona), where VA 
utilizes VCAs for mental health services, when necessary, to ensure 
Veterans have timely access to mental health care. Additionally, VCAs 
are currently VA's primary means of procuring family member Bowel and 
Bladder coverage.
    In many geographic areas, particularly rural areas, VCAs bridge the 
gap for providing specialties related to homemaker home health care, as 
well as for dental services in those areas where providers are still 
being recruited into the CCN. As of October 13, 2021, there are 
approximately 2,970 VCAs for Bowel and Bladder care, 3,300 VCAs for 
home health care and 8,300 VCAs for dental services.
    Question. Since 2019, the Fargo VA has carried out a hyperbaric 
oxygen therapy (HBOT) clinical demonstration project. Under the 
project, veterans who have yet to experience positive outcomes from two 
traditional post-traumatic stress disorder (PTSD) therapies can be 
referred for HBOT in the community.
    Do you agree that in order to put an end to veteran suicide, we 
need to address the problem with every possible option--including 
expanding access to innovative, alternative treatment options like 
HBOT?
    Answer. VA agrees with the importance of providing effective mental 
health care to address Veteran suicide and supports the use of 
promising practices along with evidence-based treatments for mental 
health. The effects of Hyperbaric Oxygen Therapy (HBOT) on suicidal 
thoughts and behaviors have not been tested; however, HBOT does not 
appear to be an effective treatment for mental health disorders. The 
evidence on HBOT for traumatic brain injury (TBI), with or without 
posttraumatic stress disorder (PTSD), that is based on the results of 
four randomized controlled trials is largely negative, with only one 
study showing some short-term benefit for PTSD. VA offers Veterans 
access to a range of promising practices through its Whole Health 
Program and will continue to monitor the evidence on HBOT and 
potentially innovative strategies for addressing Veteran suicide.
    Question. Given it is already July and the country is still 
recovering from the COVID-19 pandemic, do you anticipate extending the 
HBOT demonstration project beyond this fiscal year so that more 
veterans can access this treatment option?
    Answer. VA does not anticipate extending the HBOT clinical 
demonstration project (program evaluation) beyond this fiscal year. VA 
clinicians and Fargo VA Health Care System leadership will continue to 
make case-by-case, evidence-based determinations on clinical care and 
case management, including community care authorizations for HBOT for 
any medical indication, consistent with VA policy and with 
consideration for the unique needs, health factors and treatment 
history of individual Veterans.
    The clinical demonstration project was intended to identify 
administrative implications of administering this therapy within VA and 
has successfully accomplished that goal. It was never intended or 
designed to address efficacy of HBOT for these conditions or influence 
clinical care decisions, which are made by the provider in 
collaboration with the Veteran patient.
    On October 22, 2020, the Acting Under Secretary for Health agreed 
to increase the total number of Veterans who could enroll in the 
program evaluation across all five sites from 215 to 250, which 
facilitated consistent opportunity for Veteran participation at each 
location. At the end of fiscal year (FY) 2020, leadership at four of 
the sites concluded their participation in the program evaluation 
following the planned active period of approximately 24 months. Due to 
the impact of Coronavirus Disease 2019 and the later start date, VA 
leadership supported the continuation of the program evaluation at the 
Fargo VA Health Care System for an additional 12 months (through the 
end of FY 2021), which would be consistent with the 24-month active 
period of the other four program evaluation sites. To maintain 
consistency across sites, the program evaluation concluded at the end 
of FY 2021.

    Background:

  --A total of 56 Veterans have been referred across all five sites.

  --A total of 51% Veterans either dropped out or canceled before 
        beginning treatment across all sites.

  --As of June 23, 2021, Fargo VA Health Care System remains the only 
        site that continued to enroll Veterans for FY 2021.

  --A total of 23 Veterans have been referred to the Fargo site since 
        September 2019.

  --A total of 45% of all Veterans have either dropped out or canceled 
        before beginning treatment at Fargo.

  --Data indicate that the number of referrals for the first year (12 
        referrals) is similar to the second year (10 referrals over 10 
        months).

  --HBOT is not recognized as an evidence-based treatment for PTSD or 
        TBI; is not approved by the Food and Drug Administration (under 
        guidance by the Undersea and Hyperbaric Medicine Society); and 
        is not reimbursable by Medicare, Medicaid and insurance.

    Question. The National Cemetery Administration (NCA) has determined 
that additional infrastructure--such as restrooms, storage sheds, and 
wind walls--are necessary at Rural Initiative cemeteries in order to 
better serve veterans and their families. Can you provide my office an 
update on the pending design and construction of the infrastructure 
projects at Fargo National Cemetery?
    Answer. The infrastructure improvement project at Fargo National 
Cemetery is currently under design. We anticipate the design phase will 
be completed this fall. We also anticipate a construction contract will 
be awarded over the winter, and the work will be completed in the fall 
of next year.

                                 ______
                                 

            Questions Submitted by Senator Susan M. Collins
    Question. In December 2020 my legislation, the State Veterans Homes 
Domiciliary Care Flexibility Act, was enacted into law. This 
legislation requires the VA to implement regulations which allow the 
waiver of certain eligibility requirements for domiciliary care per 
diem payments when in the best interest of the veteran. This authority 
would ensure that vulnerable veterans do not fall through the cracks 
and receive the care they need, and I urge the VA to quickly complete 
its rulemaking and delegate this waiver authority to local VA hospitals 
and regional Veterans Integrated Service Networks (VISN). Can you 
please provide the committee with a status update on these efforts?
    Answer. The proposed changes to regulation 38 C.F.R. Sec. 51.51 are 
currently going through the VA regulatory concurrence process which 
follows the Administrative Procedures Act, which typically, though not 
always, requires two rulemaking stages. This process takes generally 18 
to 24 months and involves VA and the Office of Management and Budget. 
Following internal development, review and approval of the regulation, 
the Federal Register publishes VA's Notice of Proposed Rulemaking 
(NPRM). VA's NPRM invites the public to comment on the proposed 
amendments. VA considers and responds to all comments in the final 
rulemaking. The proposed regulations will address the new waiver 
authority in the Public Law.
    Question. A 24-bed Substance Use Disorder Residential 
Rehabilitation Treatment Program (SUD RRTP) facility was approved at 
the Togus VA in August 2020 as an out-of-cycle Strategic Capital 
Investment Plan project. Currently, veterans served by VA Maine are 
unable to get these services within the State, and Maine veterans 
waiting for admission to a SUD RRTP or unwilling to travel out-of-state 
utilize over 500 acute inpatient bed days of care per year at VA Maine. 
The establishment of a residential program at Togus would improve 
veteran continuity of care and accessibility to vitally important 
services for Maine veterans. My understanding is that a design was 
internally approved by VA for FY21 funding in December 2020. However, 
based on the Department's budget request submission, it does not appear 
the VA has adequately prioritized this project. When does the VA plan 
to construct this much needed facility?
    Answer. The following is the anticipated timeline for the Substance 
Use Disorder Residential Rehabilitation Treatment Program facility:

  --Design Award--September 28, 2021

  --Design Completion--February 2022 to June 2022

  --Construction Award--December 2022 to January 2023

  --Construction Completion--March 2024

  --Activation--April 2024

  --Occupancy--May 2024

    Question. New International Guidelines for the Prevention and 
Treatment of Pressure Injuries were made available in 2019. Hospital 
acquired pressure ulcers impact over 2.5 million and cost the health 
care system $26.8 billion annually. Following these guidelines could 
make significant improvements in wound care for veterans being treated 
at VA hospitals. When does VA anticipate adopting these guidelines as 
the VA's standard of care and implementing the Standardized Pressure 
Injury Prevention Protocol (SPIPP) Checklist to improve pressure injury 
prevention?
    Answer. VA is aware of the evolving evidence and research related 
to Pressure Injury (PI) prevention and wound care. Moreover, VA has 
adopted the 2019 International Prevention and Treatment of Pressure 
Ulcer/Injury: Clinical Practice Guidelines, as well as areas contained 
in the Standardized Pressure Injury Prevention Protocol Checklist, 
within the recently-released Veterans Health Administration (VHA) 
Directive 1352, Prevention and Management of Pressure Injuries. This 
directive provides policy and implementation procedures for the 
assessment, prevention and management of PIs across VHA clinical 
practice settings. The directive contains practice recommendations and 
is consistent with both national and international guidelines for PI 
prevention and management. Additionally, the national VA Approved 
Enterprise Standard Skin (VAAES) Inspection/Assessment electronic 
health record template was developed to ensure staff documentation of 
interventions were consistent with evidenced-based recommendations and 
guidelines for PI prevention and management. VAAES also includes the 
link to the 2019 International Prevention and Treatment of Pressure 
Ulcer/Injury: Clinical Practice Guidelines.

                                 ______
                                 

          Questions Submitted by Senator Shelley Moore Capito
    Question. I appreciated you meeting with me and my colleagues last 
month to update us on the actions that the Department is taking at the 
Louis A. Johnson VAMC in Clarksburg, West Virginia, in the wake of the 
horrific events that took place at the facility. As I know you observed 
during your time at the facility, both staff and patient morale is low. 
It is imperative that the VA continues to monitor the progress towards 
restoring trust at the medical center.
    During our visit, I brought up that there is still staff in 
leadership roles at the facility, who were in those positions when the 
murders took place. You told me that part of the issue is that the VA 
could not begin its internal investigation, until after the OIG and DOJ 
investigations concluded. While I understand that the internal 
investigation is probably still ongoing, can you provide me with an 
update on this and if the VA has found any new issues since our last 
meeting, that need to be addressed?
    Answer. The internal Administrative Investigation Board was 
completed on December 18, 2020. No actions were taken until the Office 
of Inspector General (OIG) report was published May 11, 2021. We were 
awaiting completion of the OIG report to implement disciplinary actions 
regarding this incident, all of which have since been effectuated.
    Question. Are there still employees waiting to have disciplinary 
action taken against them?
    Answer. VA has taken the necessary administrative actions against 
all identified employees. The administrative actions ranged from 
written counseling to removal. There were several VA staff members 
including the Medical Center Director, Chief of Staff and Associate 
Chief Nurse who retired from their respective positions before 
administrative action could be taken. Additionally, two staff members, 
a Hospitalist and a Quality Manager, resigned before administrative 
action could be taken.

                          SUBCOMMITTEE RECESS

    Senator Heinrich. And with that, we stand adjourned.
    [Whereupon, at 11:02 a.m., Wednesday, June 23, the hearing 
was adjourned, and the subcommittee was recessed, to reconvene 
at a time subject to the call of the Chair.]