[Senate Hearing 117-085]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-085

                VACCINES FOR VETS: OUR BEST SHOT AT ENDING 
                          THE COVID-19 PANDEMIC

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS


                             FIRST SESSION

                               __________

                           FEBRUARY 24, 2021

                               __________

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

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
45-822 PDF                 WASHINGTON : 2021                     
          
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                 SENATE COMMITTEE ON VETERANS' AFFAIRS

                     Jon Tester, Montana, Chairman
Patty Murray, Washington             Jerry Moran, Kansas, Ranking 
Bernard Sanders, (I) Vermont             Member
Sherrod Brown, Ohio		     John Boozman, Arkansas
Richard Blumenthal, Connecticut	     Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii		     Mike Rounds, South Dakota
Joe Manchin III, West Virginia       Thom Tillis, North Carolina
Kyrsten Sinema, Arizona		     Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire  Marsha Blackburn, Tennessee
			 	     Kevin Cramer, North Dakota
                                     Tommy Tuberville, Alabama 

                Tony McClain, Democratic Staff Director
                 Jon Towers, Republican Staff Director
                            
                            C O N T E N T S

                              ----------                              

                           February 24, 2021

                                SENATORS

                                                                   Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     2
Manchin III, Hon. Joe, U.S. Senator from West Virginia...........     9
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    11
Murray, Hon. Patty, U.S. Senator from Washington.................    13
Boozman, Hon. John, U.S. Senator from Arkansas...................    15
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    17
Tuberville, Hon. Tommy., U.S. Senator from Alabama...............    19
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    20
Sinema, Hon. Kyrsten, U.S. Senator from Arizona..................    22
Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire......    24

                               WITNESSES

Richard A. Stone, MD, Acting Under Secretary for Health, Veterans 
  Health Administration, Department of Veterans Affairs, 
  Accompanied By: Jane Kim, MD, MPH, Chief Consultant for 
  Preventive Medicine, Ralph T. Gigliotti, FACHE, Network 
  Director, VISN 19: VA Rocky Mountain Network, William P. 
  Patterson, MD, Network Director, VISN 15: VA Heartland Network.     4

                                APPENDIX

Richard A. Stone, MD, Acting Under Secretary for Health, Veterans 
  Health Administration, Department of Veterans Affairs, prepared 
  statement......................................................    32

                       Statements for the Record

Moderna, Inc.....................................................    36
Pfizer...........................................................    44
Dr. Richard Nettles, M.D. Vice President of U.S. Medical Affairs, 
  Janssen Infectious Diseases and Vaccines. Johnson and Johnson..    48

                        Questions for the Record

Response to Questions for the Record submitted by:
  Hon. Jerry Moran...............................................    54
  Hon. Sherrod Brown.............................................    59
  Hon. Kyrsten Sinema............................................    61

 
    VACCINES FOR VETS: OUR BEST SHOT AT ENDING THE COVID-19 PANDEMIC

                              ----------                              


                      WEDNESDAY, FEBRUARY 24, 2021

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 4:12 p.m., in 
room G50, Dirksen Senate Office Building, Hon. Jon Tester, 
Chairman of the Committee, presiding.
    Present: Tester, Murray, Brown, Blumenthal, Hirono, 
Manchin, Sinema, Hassan, Moran, Boozman, Rounds, Tillis, 
Blackburn, and Tuberville.

              OPENING STATEMENT OF CHAIRMAN TESTER

    Chairman Tester. I call the hearing to order. Dr. Stone, I 
want to thank you for being here with your team once again. We 
appreciate what you do, and thank you for being here.
    Today, with two vaccines authorized for emergency use and 
being distributed across the country, we will take stock of how 
VA is doing in terms of reaching its work force and the 
millions of veterans that the VA serves. It is my focus to 
bolster the vaccine supply chain and ensure there is a system 
to distribute the vaccine quickly and efficiently to all 
veterans, regardless of where they may live, and I know this is 
a goal shared by Senator Moran also.
    From what I understand, the Department is excelling in 
getting shots into arms in a safe and timely manner once doses 
are received from the Department of Health and Human Services. 
I want to commend you in your efforts to administer more than 
two million doses to veterans and employees so far, outpacing 
the private sector.
    Yesterday, Senator Moran and I had a productive 
conversation with Dr. Kessler and General Perna, the Biden 
administration officials responsible for development, 
manufacture, and distribution of coronavirus vaccines. We told 
them that the VA has proven its ability to quickly deliver 
vaccines where they are most needed, and that the Department 
already has the capacity to deliver above and beyond its 
current allotment. Moving forward, we will continue to press 
them for a larger allotment for the VA, and we will expect you 
to do the same.
    To date, the Department has only received about 2.3 million 
doses. That means we still need about 17 million more doses to 
get veterans and staff fully vaccinated.
    Beyond concerns with the overall supply chain, which are 
being addressed, I remain mostly focused on how we can better 
reach veterans in rural, remote, and underserved areas. The VA 
has piloted a vaccine fly in program for rural areas of 
Montana, like Havre and Kalispell, and to communities in 
Alaska, which I think is an innovative way to reach rural vets.
    However, we know that barriers remain to getting our rural 
veterans vaccinated in Montana and across the country. That is 
why we wanted Ralph Gigliotti from VISN 19 and Dr. Patterson 
from VISN 15 with us here today, and thank you folks for coming 
to this hearing.
    I look forward to hearing more about how you, Dr. Stone, 
are allocating vaccines to different VISNs, and then how you, 
Ralph and Dr. Patterson, are allocating them to the different 
medical facilities within your VISN. Whether a veteran lives 
next door to a VA medical center or hundreds of miles away from 
the nearest one, all veterans must have equitable access to 
getting this vaccine.
    I know that reaching areas, particularly highly rural and 
frontier areas, brings both logistical challenges and 
potentially higher refusal rates than elsewhere, but we have to 
get this right. And we have to do a better job of communicating 
with veterans, setting their expectations, and giving them a 
better idea of when, how, and where to get a vaccine when it is 
their turn. Addressing these issues of both supply and demand 
are truly our best shot at ending this pandemic and getting our 
economy back on track.
    I want to thank you all for being here today, and I look 
forward to the conversation ahead.
    Senator Moran, you have the floor.

               OPENING STATEMENT OF SENATOR MORAN

    Senator Moran. Chairman Tester, thank you very much, and 
thank you for the conversation we had with the general and the 
doctor yesterday. Good afternoon to everyone here today. I am 
pleased, Mr. Chairman, that we are conducting this hearing on 
this important topic. A shot in the arm is perhaps the most 
important thing we can do to improve our country's well-being, 
both economically and health-wise, and we certainly want to 
make certain that veterans are vaccinated as quickly and as 
time-efficiently as possible.
    I give special welcome this afternoon to VISN director, Dr. 
William Patterson. Thank you for your leadership. Thank you for 
the relationship that we have and your good works with my 
staff. I am very grateful for that.
    Throughout these past 11 months, our Nation has faced 
nearly an overwhelming challenge of responding to coronavirus. 
We have all been impacted by the loss of lives, strain on our 
health care system, upheaval in education structures, and 
economic disruptions. Through the hard work and determination 
of our country's scientific and medical communities, we now 
have two promising and available vaccines for COVID-19. With 
millions of Americans getting their doses each week, we are 
getting closer and closer to beating the virus.
    In addition to our individual actions to help keep our 
neighbors and ourselves safe and healthy, those of us on this 
Committee have a special responsibility to America's veterans. 
Through cooperation with and oversight of the VA, it is our job 
to make certain that American veterans are best served and best 
taken care of through these extraordinary times.
    The VA's dedicated work force has answered the call, and we 
honor and thank those who report to work every day to care for 
our heroes on the front lines of this pandemic. Remember 
especially those that have died in the course of their work, 
many of them veterans themselves, serving their brothers and 
sisters in uniform.
    I think we can all agree that the VA has stepped up during 
this pandemic, making themselves available to veterans far and 
wide, and executing numerous fourth-mission assignments. I want 
to highlight that earlier this month employees at the Kansas 
City VA, faced with cancellations at a mass vaccination event, 
conducted rapid outreach to eligible veterans to get shots in 
arms, and kept working until nearly midnight to make certain no 
doses went to waste. I commend and congratulate those who were 
responsible for that and those who made certain that the shots 
occurred.
    As we move closer toward the home stretch--hopefully to a 
home stretch--with each passing week, I seen immunization 
numbers continue to rise and ICU admissions numbers fall. It is 
critical that we not lose sight of our core mission: taking 
care of our veterans.
    I want to make certain that the VA is doing its best work 
in taking care of veterans and seeing that this vaccination 
rollout is working in the most efficient and expeditious manner 
possible. My staff has been having weekly calls with the 
Department, but despite that we continue to learn things 
through news articles and veterans that we did not otherwise 
know. This leads to a time-consuming process of requesting a 
call, facing scheduling delays to connect with proper people at 
the VA, and finding out weeks later things we should have 
known, could have known, much earlier had we been informed 
directly.
    One example of this is the use of algorithms to determine 
the vaccine eligibility prioritization. We are hearing now that 
veterans who should be at high risk, based on disability or 
injuries, are not being prioritized properly in the program, 
and I look forward to hearing from Dr. Stone and others in 
regard to this topic.
    At the same time, we are learning that the VA is 
continuing, perhaps even expanding, vaccination efforts for 
elements of the Federal work force from other departments and 
for caregivers. A concern is that the VA could be overextending 
itself without enough oversight to ensure smooth processes or 
make certain its primary patient population is getting 
vaccinated. I look forward to the assurance that that is not a 
problem.
    The VA's unique mission needs to be managed in accordance 
with the population it serves, and existing system and 
infrastructure in place to execute it. Congress, in recent 
years, has legislated significant reforms to put veterans at 
the center of their care decisions, and we must make certain 
that even in times of great strain veterans do not fall through 
any gaps.
    Particularly, I want to make certain that veterans in rural 
and highly rural areas, similar to what Senator Tester, 
Chairman Tester, said, that those veterans in that part of the 
country are not overlooked. My staff and I have received 
multiple assurances from VHA officials that rural vaccination 
efforts would have access to a fair share of allotment and at a 
pace equal to their urban counterparts.
    I visited the Colmery O'Neil Hospital in Topeka on Monday, 
on my return to Washington, DC, and I was pleased to see the 
efforts that are underway to make sure that rural veterans are 
not left behind, that CBOCs are being utilized, and I raised 
the topic, although I do not think the answer was the one I 
would hope to hear, that even our Community Care providers are 
capable of providing vaccinations to veterans through the VA.
    I am concerned that the Department lacks a standard 
communication strategy for outreach to veterans, and that the 
decisions are largely VISN dependent. VISNs are also delegated 
authority to draft their own vaccination plans, which could 
lead to inequities across VHA, and while I am generally for 
local control and decisions being made locally, I want to make 
sure that veterans across the country receive what they are 
entitled to and what they are eligible for.
    I have some concerns about the VA's plan to direct veterans 
to pharmacies in the community for vaccines and from what 
allotments those doses would be coming. So while I think it 
could very well be a good idea, I want to know what it is 
detracting from and utilization of those local pharmacies could 
be very helpful in vaccinating rural veterans.
    I want to make sure it is the best course of action to 
optimize vaccine rollout in the ways that reach veterans 
quickly, efficiently, and in a way that bolsters public health 
rather than placing unintended strains on vaccine supplies in 
communities or risking surplus at a VA site. This process is 
something we ought to get right, and the details matter.
    Mr. Chairman, I look forward to a robust conversation today 
as we look to find ways to improve upon the process in place 
and make certain that those who serve in uniform are best 
served by the department created to care for them. And with 
that, Mr. Chairman, I yield back.
    Chairman Tester. Ranking Member Moran, thank you for your 
Statement. Dr. Stone, I understand you are going to be the 
point person here to testify and the others will be here for 
questions. You have 5 minutes. Please know that your entire 
written testimony will be a part of the record. You may 
proceed.

STATEMENT OF RICHARD A. STONE ACCOMPANIED BY JANE KIM, RALPH T. 
               GIGLIOTTI AND WILLIAM P. PATTERSON

    Dr. Stone. Thank you, Chairman Tester, Ranking Member 
Moran, and distinguished members of the Committee. Thank you 
for the opportunity to testify today about the Department's 
response to the COVID-19 vaccine rollout. You have already 
recognized a number of the team members to my left, but Dr. 
Jane Kim is our Chief Consultant for Preventative Medicine, and 
I am accompanied also by Dr. William Patterson, Director of 
VISN 15, and Mr. Ralph Gigliotti, Director of VISN 19.
    I would like to acknowledge the somber milestone achieved 
this week of 500,000 deaths of our fellow Americans due to 
COVID-19. Of that number, just over 10,000 are veterans, and 
131 are VA employees. We collectively mourn all of those lost 
and continue our pledge to save every possible life that comes 
into the VA for care.
    Throughout this pandemic, VHA employees have stood on the 
front lines, courageously delivering care to America's 
veterans, and for the American population broadly. That heroic 
effort has now turned to distributing and administering as many 
vaccine doses as possible. It has been an emotional time for 
many in health care, as teams who fought this disease on the 
front lines have begun to have hope that relief is coming.
    We are absolutely committed to get as many veterans 
vaccinated as quickly as we can. The logistics and the delivery 
of these vaccines is very complex and requires new and unique 
processes. We are reaching out to veterans when they are 
eligible, and we encourage veterans to use our Web-based ``Keep 
Me Informed'' tool to get updates about VA vaccinations.
    Yesterday, as of February 23d, VA had administered well 
over 2.1 million doses of the vaccines. These include over 1.1 
million first doses to veterans and 484,000 doses, first and 
second doses, to VA employees, which have inoculated well over 
90 percent of our clinical staff. VA is currently providing 
vaccine at more than 215 sites nationally, and we are using 
virtually all the doses that we receive as soon as they arrive 
each week. And we have the capacity to deliver between 300,000 
and 600,000 doses weekly.
    More than 6 million veterans depend on us for their health 
care, and CDC plans to provide us with first and second doses 
for each of those 6 million, as well as our 400,000 employees. 
And we are focusing our efforts on enrolled, eligible veterans 
who are listed in the highest-risk categories. Veterans who are 
not yet receiving care through the VA health care system are 
encouraged to enroll now.
    We remain committed to health care equity across multiple 
dimensions, and that also applies to our vaccination efforts. 
We are working hard to reach our most rural veterans and those 
communities hit hardest by the pandemic. For rural veterans, we 
have developed distribution guidance to facilitate safe 
transportation of vaccines to rural areas. Our planning has 
ensured equitable access and distribution of vaccines to racial 
and ethnic minorities disproportionately affected by the COVID-
19 pandemic. We are very pleased that we are seeing relatively 
comparable outcomes across race once veterans are enrolled in 
our care.
    In preparation for the vaccine rollout, our teams wanted to 
ensure that wherever possible every veteran felt confident 
about receiving their shot. We recognize that the most trusted 
voice in making health care decisions is a patient's health 
care provider. Therefore, our outreach plan features VA staff 
and providers proactively calling the veteran. They serve to 
provide information, answering questions, and scheduling 
appointments for vaccination. This has helped to overcome 
barriers such as vaccine hesitancy. In fact, enrolled veterans 
over age 75, the group currently prioritized for vaccination, 
25 percent of white, 28 percent of Hispanic, and 30 percent of 
black veterans have been vaccinated.
    I am incredibly proud of our teams who are doing outreach, 
responding to questions and dedicating themselves to this 
effort. While we have not seen racial or ethnic disparities in 
vaccinations so far, we will continue to actively manage equity 
in our system.
    I would like to specifically address our support to those 
caregivers of veterans participating in the Program of 
Comprehensive Assistance for Family Caregivers. VA offers 
testing and vaccinations to eligible family caregivers, and so 
far more than 2,000 caregivers and 12,700 veterans involved in 
this program have received at least their first dose of 
vaccine.
    Before I close, I would like to thank this Committee for 
your support in passing the CARES Act, and I am pleased to 
report that we are on track to fully execute the remaining 
CARES Act funding in the coming months. Those funds have 
facilitated the agility VHA has demonstrated over this 
pandemic.
    The Biden administration's American Rescue Plan will 
sustain our response and ensure that we can respond to the 
inevitable wave of delayed and deferred care. Your support 
remains essential to our continuing effort to provide excellent 
care for veterans and their families, and I am grateful to this 
Committee and its leadership for your partnership.
    My team and I look forward to answering your questions.
    Chairman Tester. Thank you, Dr. Stone. I appreciate the 
testimony. We will start with the questions now.
    I understand, and correct me if I am wrong, Dr. Stone, the 
VA is receiving about 125,000 doses per week, and the VA is 
getting those administered within a week, for the most part, 
all of them. Dr. Stone, you said that the VA has capacity to 
administer 300,000 to 600,000 per week, and I know this is 
contingent upon national supply. But what is your ideal weekly 
allocation of doses?
    Dr. Stone. Between 300,000 and 600,000 a week. I am quite 
pleased, sir, that we just received a call before we came over 
here that we will, next week, receive almost 600,000 doses.
    Chairman Tester. That is good news, Moran. Look what 
happens. That is good. That is really good.
    So then the question is, now you have got some vaccines to 
work with, at least in the short term, and hopefully that will 
continue in the long term. How do you decide how those vaccines 
are distributed to the VISNs?
    Dr. Stone. I am going to defer to Dr. Kim for the answer to 
that.
    Chairman Tester. Okay.
    Dr. Kim. Hi. I will be happy to speak to that. So my name 
is Jane Kim. I am a general internist and preventive medicine 
physician, and since September 2020, I have been leading the 
COVID national vaccine planning team for VA.
    So in terms of vaccine allocation, our strategy really 
flows out of the Health and Human Services strategy, which uses 
a pro rata approach to determine vaccine allocations for the 
country. So for each State jurisdiction or Federal entity, the 
allocation of vaccines is determined by population, using a pro 
rata approach.
    We, in VA, follow a similar methodology using pro rata, but 
primarily base it on the CDC priority phase that we are 
currently in. So we are currently in Phase 1b, which is mainly 
75 and older veterans. So for each VISN we take the number of 
veterans in that VISN who are 75 and older, and the denominator 
is the number of veterans in our system who are veterans 75 and 
older. And that is all of our veteran users of our health care 
system.
    Chairman Tester. Can you have those--you have got those 
metrics lined out so you are comfortable that you have the 
metrics for veterans in each VISN that are 75 years and older?
    Dr. Kim. Yes.
    Chairman Tester. Okay.
    Dr. Kim. Before we started this we did a population 
enumeration and got those numbers nailed down.
    Chairman Tester. Okay. So that is fine. Thank you. And 
then, Ralph Gigliotti, at the VISN level, how do you decide 
vaccines that go to each VA medical center within your VISN, or 
each State? Is it done the same way?
    Mr. Gigliotti. Sorry. Yes, Mr. Chairman. It is done the 
same way. We base it on the 75-plus age with patients, patients 
that may be on hemodialysis, organ transplant, chemotherapy, 
that type of thing.
    Chairman Tester. Okay. So I know you have got your boss 
sitting here, just to your right a couple of paces down, or 
maybe right next to you, as far as that goes. The question is, 
do you feel like VISN 19 is getting the adequate number of 
doses?
    Mr. Gigliotti. We are using the formula that is being used. 
We look forward to when the volume increases and we have 
detailed plans at all eight of our health care systems to roll 
out more vaccine.
    Chairman Tester. How much lead time are you able to give 
the veterans to know when they can be vaccinated?
    Mr. Gigliotti. So we do scheduling in advance. We trust the 
weekly supply that we have been getting. We get excellent 
communication from Dr. Kim, from Dr. Stone, so we know in the 
upcoming weeks what we are projected for, and we go ahead and 
schedule out for that.
    Chairman Tester. So the 600,000 doses aside, that you got 
today, because that is good news, are you able to give the 
veteran 2 weeks' notice? One week notice? Two days' notice?
    Mr. Gigliotti. So yes to all of that. We are able to 
schedule in advance, 2 weeks to 4 weeks is the norm. However, 
there are some situations where we are able to call veterans in 
on a day or two's notice, because when we reach out to the 
veteran we ask what type of lead time do you need to come in 
for a vaccine. And so if we have an extra supply for a 
particular week we are able to bring somebody in on a day or 
two notice also.
    Chairman Tester. Thank you. I have got some more questions 
but there will probably be another round. Senator Moran.
    Senator Moran. Mr. Chairman, thank you, and thanks again to 
Dr. Stone and his colleagues for joining us today. I am perhaps 
exploring some of the things that Senator Tester just did, but 
I want to see if I can be specific or get a specific answer.
    Dr. Stone, in your written testimony you provided the 
insight that the VA's allocation process to VISNs is similar to 
how HHS allocates the vaccines to the States, and that is, 
again, this population issue that Senator Tester just raised. 
Are the VISNs bound to this pro rata allocation formula when 
reallocating to the network of facilities they have within the 
VISN? So does the veteran population coming to the VISN, is 
that then translated into, in my case, Wichita and Topeka as 
the same number, based upon veteran population?
    Dr. Stone. We have given discretion to the regional leaders 
to distribute to their health care centers, based on 
refrigeration capacity and labor capacity, to deliver vaccine. 
And, therefore, that discretion has included the kind of thing 
you described in your opening Statement, sir, that sometimes we 
find that we have got some extra doses and we may reach below a 
risk population to even a younger veteran.
    We know that the major risk of death and serious illness is 
based on age, and of all the variables, age seems to be the 
thing that stands out. And, therefore, we have followed the CDC 
guidance, but there is the flexibility, at the local medical 
center level, to reach to a lower group of risk should have 
vaccine available, because the transport of these vaccines is 
very difficult, especially the Pfizer vaccine.
    Now, in your State, the nearly 20,000 doses that have come 
into your State, have been mainly in Moderna, and I am sure Dr. 
Patterson can correct me if I am wrong on that.
    Senator Moran. Dr. Patterson, let me ask this question to 
see, again, if I can get this answer. So does Wichita and 
Topeka get allocated based upon changes in conditions of VISN 
decision, or is it specific to we have this many doses, based 
upon population, and based upon the number of veterans that 
utilize Wichita and the number of veterans that utilize Topeka, 
Topeka Leavenworth, that is how we allocate them?
    Dr. Patterson. It is a little bit in that way, Senator. Of 
course, we prioritize according to the guidelines we get from 
VA Central Office in terms of scheduling veterans to come in. 
But we do not have enough vaccine each week to do that entire 
broad population at one time. So what we have done is we 
allocated a minimum amount to each medical center.
    So for instance, Topeka and Eastern Kansas, Kansas City, 
Marion, Poplar Bluff, will all get a minimum of 600 doses each 
week. That is the minimum. Now, if they have the ability to do 
more, or if they have scheduled an event, if we have an amount 
above that, which we generally do, then we supplement that. So 
they are prioritizing based upon the age group, over 75, and 
then if they get all those done, well, first the CLC patients, 
then the over 75. If they need to go between 65 and 75, they do 
that.
    But as you referenced in your earlier comments about the 
event in Kansas City, we had 200 people not show up one night 
for vaccines. So we have standby lists ready to go, and we 
start calling those veterans. And I was out there that night, 
at 8 that night, and stayed until about 10, and it was amazing 
to watch the parking lot of people just pulling in, flipping 
off their lights, and running into the building, even carrying 
their kids in pajamas sometimes, to be sure that they could get 
a vaccine.
    Senator Moran. Again, thank you for that response, that 
response to supply.
    The conversation that we just had, Dr. Stone and Dr. 
Patterson, lends itself to my next question. My staff has been 
informed that the VA's risk stratification framework includes 
vaccinating veterans based upon occupation, starting in Phase 
1b with frontline and essential workers. So another way to 
allocate will be based upon what a veteran's occupation is--are 
they an essential worker. Can you clarify whether it is VACO's 
guidance for VISNs and facilities to vaccinate based upon 
occupation?
    Dr. Stone. I can. Certainly in 1b, frontline essential 
workers are identified by the CDC, so that is where that came 
from. As we have identified it, I think Ralph Gigliotti 
probably has the best story when it comes to that, of how they 
approached frontline essential workers. Mr. Gigliotti, do you 
want to go ahead?
    Mr. Gigliotti. Sure. What we did was identify the various 
caregivers across all eight of our health care systems, and 
then using the employee stratification, offer it to employees 
in order to ensure those that came in contact with veterans 
were eligible, able to receive the vaccine. And it has gone 
really well, and we have right now 76 percent of our employees 
have received a first dose, and many of them have also received 
a second dose.
    Senator Moran. I think I am talking about the veteran's 
occupation, not the staff member's occupation, right?
    Dr. Stone. Right. What I was referring to, and I apologize 
for catching Mr. Gigliotti on this one, was that they had 
identified and called veterans who were part of the local 
police department and had reached out to them and said, ``Look, 
all the police officers in this community who are veterans, we 
have got vaccine for you, as part of the 1b allocation,'' thus 
unloading the community to it provides. And please clarify.
    Mr. Gigliotti. Yes. That was with the Havre fight that we 
did in Montana, and that was with first responders from the 
Rocky Boy Native American Nation.
    Senator Moran. My time has expired, but I would ask this 
followup question. You can answer it later. Is there a way to 
verify a veteran's occupation to make sure that they are in the 
occupation that they say they are?
    Chairman Tester. Good enough. Thank you, Senator.
    Senator Moran. Apparently, you do not have time to answer.
    Chairman Tester. I am interested to know that too, 
actually.
    We will go to Senator Brown, virtually, if he is there. 
Going once. Going twice.
    Okay. Manchin is up.

                      SENATOR JOE MANCHIN

    Senator Manchin. Okay. Thank you so much, Mr. Chairman, for 
being so kind.
    Dr. Stone, I am pleased that we have so many, 20, vaccine 
candidates reaching the final stages. I come from the State, 
the beautiful, beautiful State of West Virginia. Very, very 
patriotic and an awful lot of veterans. And I imagine when the 
vaccines are approved, some of them will need specific storage 
temperatures again. And I would hope you all would take into 
consideration, in some of the smaller rural areas, we do not 
have the ability to handle that. So when you are designing what 
vaccines are going to go to what area, will you make sure that 
basically it is matched up with the capabilities of handling 
the vaccine so it does not spoil, it is not wasted? Is that 
part of your----
    Dr. Stone. It is, Senator, and as you know, because of the 
rural nature of much of your State, we have shipped over 37,000 
doses to your State. It has all been Moderna, which has been 
easier to handle at a -20 degrees. None of it has been Pfizer. 
It is just too difficult to move that around.
    Senator Manchin. Absolutely.
    Dr. Stone. And it has given us the ability to actually 
immunize about 38 percent of the over-75-year-old veterans in 
your State.
    Senator Manchin. We are going to need a lot more, as you 
know. All the States do. We understand that. But in the rural 
States such as ours, as long as you make sure that you are 
identifying the type of facility it is going to take in order 
to handle that new vaccine when they come, whether it being J&J 
or other ones, I understand, are coming on quite rapidly.
    Dr. Stone. They are, and I will defer to Dr. Kim. It is not 
clear to us what the guidance is going to be from the FDA and 
the CDC on the utilization of the new vaccine that will come. 
That is the single-dose vaccine. And so I will defer to Dr. 
Kim.
    Dr. Kim. Yes, Senator, I am sure you know from previous 
people who have testified here that the FDA is meeting this 
Friday to discuss the Johnson & Johnson vaccine and possibly 
authorize it if data looks favorable this weekend. And we, you 
know, in the scientific community, really like that vaccine 
because it is one dose, refrigerated, and can last apparently 
up to 6 months in a refrigerator, which makes it a great option 
for places that only have a refrigerator, such as maybe some 
rural facilities, maybe in your State. So it is a nice 
versatile option from a storage standpoint, as well as it is 
only one dose, which some veterans may really like.
    Senator Manchin. Let me ask you this. In the weather 
conditions we have been having and some of the extreme weather 
around the country, have we lost, or has any of it spoiled, not 
being able to get to market or get to the end user?
    Dr. Stone. We have had minimum wastage, and, look, every 
dose is a tragedy. We had, up in VISN 1 in the Northeast, a 
contractor who was cleaning up after a broken pipe with a 
flooded area, inadvertently unplug one of our negative-70-
degree freezers and we lost a palette of the Pfizer vaccine, so 
we lost about 1,000 doses. And so that has been the largest 
loss that we have had.
    Frankly, the VISN leadership have done the same sort of 
thing that Dr. Patterson did, at 8 and 9 at night where we are 
calling veterans and we have got cancellation lists. That is 
true across the Nation.
    Senator Manchin. A lot of the people live in rural area. 
They do not have internet service. A lot of them are not on 
internet service. I know when you are contacting, trying to set 
your appointments up, what other, other than just a phone 
itself, how are you all able to communicate?
    Dr. Stone. I am going to defer to Dr. Patterson and Mr. 
Gigliotti about how they are doing their scheduling.
    Dr. Patterson. We do schedule as much as possible, but we 
also have some walk-in availability in a lot of places. But one 
of our big partners has been the veteran service organizations, 
so the Legion, the VFW. They have a lot of good connections in 
the community, and particularly in small communities where they 
are very strong. We set up events there and they help us get 
the word out. We may use social media and robocalls and the 
local clinics, but that community connection really goes a long 
way.
    Senator Manchin. I also was pleased to see the VA had been 
allowed to participate in the Defense Production Act committee 
and help determine the most effective ways to meet our Nation's 
needs. However, even with the great new developments we are 
seeing with vaccines, we need to be prepared to continue to 
deal with the COVID-19 on the long term, as we are seeing it, 
and if you are all prepared for that. So how has the VA's 
participation in the committee's decision on deploying the DPA 
helped you respond to the COVID-19 pandemic?
    Dr. Stone. Sir, I think it is too early to say what our 
participation with the DPA has been. At this point, we are 
still working and we have briefed our new Secretary on our 
desire to be at the table in the Defense Production Act. But 
how the Defense Production Act is utilized as well as our role 
and our voice as the largest provider of health care services 
in the Nation is one that I think still remains to be seen.
    Senator Manchin. Are you able to get all the equipment you 
need? Are you getting PPEs for your employees and everything?
    Dr. Stone. Yes, sir.
    Senator Manchin. And do you have your portable--in West 
Virginia we have a lot of the portable trailers that go around, 
trying to help people who live pretty far away from a facility 
or a clinic.
    Dr. Stone. Yes, sir. In comparison to where we were 6 
months ago, our supplies of PPE as well as our emergency stocks 
and our rolling stock is in much better shape than it was early 
in the pandemic, even a year ago.
    Senator Manchin. Are you able to spin shots out of your 
portable, out of your portables?
    Dr. Stone. We can, and we are.
    Senator Manchin. Yes.
    Dr. Stone. And we are using it mainly for transportation. 
We are finding, for efficiency sake, large open areas is a 
better place to go, and whether that is a parking lot----
    Senator Manchin. They will come. They will come, sir.
    Dr. Stone [continuing]. they will come. And so we are using 
that, but we are using the portable materials to transport and 
to assure the safety of the vaccine and the mixing of the 
vaccine when that is appropriate.
    Senator Manchin. Thank you very much.
    Chairman Tester. Senator?
    Senator Manchin. Mr. Chairman, I am indebted to you, being 
so kind.
    Chairman Tester. You can stick around for the second round 
too. Senator Tillis.

                      SENATOR THOM TILLIS

    Senator Tillis. Thank you, Mr. Chairman, and thanks to 
Senator Boozman for letting me go. I want to welcome you all 
here for the great work that you do. Dr. Kim, I want to--I feel 
like I have VISN 6 represented, to the extent that you are 
still doing work down at the Durham VA, so thank you for that 
work down there, one of several great facilities we have in 
North Carolina.
    Dr. Stone, I think in testimony before the House 
Appropriations Committee you talked about a mass vaccination 
down at the Salisbury facility as being successful. I would 
guess a lot of that depends on supplies as to whether or not 
you can replicate that. But do you see those mass vaccination 
programs as supply increases, maybe after we get another 
vaccine in the mix? Do you see that as being a key part of 
trying to step up the tempo on vaccinating veterans?
    Dr. Stone. I do. I think the mass vaccination events---in 
fact, on President's Day weekend, that 3 days, every single day 
we dispensed over 70,000 doses into veterans' arms. I think 
that Dr. Kim can go over what has actually been done at Durham 
and mass vaccination events, but we see that as the future, as 
we increase our supply of vaccines.
    Senator Tillis. Dr. Kim, I would like you to add to that, 
but I would also--I have been watching the final analysis of 
the Johnson & Johnson vaccine. We know logistically that makes 
everybody's life easier. We also know that it changes the way 
you may distribute them. So can you tell me a little bit on the 
mass vaccination strategy, but tell me to what extent are you 
already planning for the eventual availability of the one-shot, 
non-cold-storage vaccine that should enter the rotation? I know 
its efficacy is probably, for, I think, the more difficult 
cases about 10 percent lower, but certainly a highly effective 
vaccine.
    So tell me a little bit about how that plays in it and also 
maybe start with the mass vaccination strategy.
    Dr. Kim. Sure. I just will say that the mass vaccinations 
certainly are a really effective strategy to get shots in arms. 
You get a lot of vaccinators together and run a clinic all day, 
and you can do thousands. So I did one at Durham a few weeks 
ago and it was incredible. We had some frontline essential 
workers come through, a lot of older veterans. So I know those 
types of strategies are being used all across the country, 
including in North Carolina, and we will continue to do that. 
We are scaled up now to do that every weekend.
    I will say, for the Johnson & Johnson product, I am very 
curious to see how that product will be discussed at FDA's 
Advisory Committee on Friday. You are right about the efficacy 
looking to be lower than the two products currently available, 
Pfizer and Moderna. You know, but I think we do see, in the 
data, at least the paper that came out today, that we will 
brief the committee, the advisory committee, that the Johnson & 
Johnson product does appear to protect against severe illness 
and death from COVID-19, which certainly is really the goal. We 
might want to get moderately ill or just mildly ill, but we 
certainly do not want to be in the hospital or to die from 
COVID. So we will see how that kind of plays out in terms of 
the discussion on the data.
    In terms of how we would use this vaccine, we have talked 
about that a lot. You know, it is a great product because it is 
refrigerated, one dose, so it certainly could lend itself very 
well to mass vaccination. You would only need to go once, 
versus going back another time. But, you know, I think we will 
see how the efficacy plays into that discussion as well.
    Senator Tillis. I will ask my final two questions and try 
to keep within time. The first question, you were talking about 
you have instances where you may have surplus supply, and you 
may have veterans--you have spoken about the distribution to 
police officers. But is there some sort of an appeal process or 
waiting list for people with chronic underlying conditions that 
are below the age cut right now and an outreach to them to 
potentially get them ahead?
    Dr. Kim. Yes, Senator. In CDC's Phase 1c, which includes 
adults who are 65 to 74 years old, alongside of them are the 
younger adults who are 64 and younger who have a high-risk 
medical condition. And, you know, as we look at the phases of 
vaccination in VA, there are facilities, including Durham, who 
are at Phase 1c, and who are reaching out to some veterans in 
that age group who have a high-risk medical condition. So we 
are right there in terms of getting to that age group and that 
high-risk group.
    Senator Tillis. Okay. The final question has to do with 
moving forward with respect to the COVID relief package we are 
talking about, or funding that you already have in reserve. As 
your priorities either covered by the last phase of the COVID 
relief package or do you feel like that the funding priorities 
that are in the proposed COVID relief package are matched up 
with what you think your needs are?
    Dr. Stone. I think that the CARES Act covered us well for 
what we saw as the needs to confront this battle against the 
virus. What we did not get covered, what we did not even 
consider, was exactly what happened after the great influenza 
of 100 years ago. There is a tremendous amount of health care 
that comes in a population that has not come in for its health 
care for the last year. And as much as we have encouraged 
urgent care, there is a huge tail of deferred and delayed care 
that we are beginning to recognize and talk to your staffs 
about, as we look at what the needs of this system are for the 
future.
    In addition, the economic instability, where a veteran 
loses their health insurance, and then comes to us as the 
safety net, is resulting in our actuaries projecting very 
significant surge of care as we go into the remainder of this 
year and into the next few years.
    Senator Tillis. Thank you. Thank you all, and to the VISN 
directors, thank you. I am sure you are probably only behind 
VISN 6 in your performance. Thank you very much. You do a great 
job.
    Chairman Tester. Thank you, Senator Tillis. Senator Murray.

                      SENATOR PATTY MURRAY

    Senator Murray. Thank you very much, Mr. Chairman. Dr. 
Stone, Dr. Kim, welcome, and I appreciate you being here with 
us today.
    I want to start on the topic of how we promote vaccine 
confidence and fight disinformation and misinformation that can 
lead to vaccine hesitancy. We are seeing misinformation about 
vaccines spread really easily and widely across the internet, 
including through social media and messaging apps, coming from 
all kinds of sources and targeted to all kinds of people. And a 
lot of discussion around misinformation has been around 
communities of color. But we know that disinformation is a 
serious concern among all demographics. That can lead to our 
veterans, caregivers, family members refusing a vaccine, even 
when they are offered one.
    So I wanted to ask you, how is the VA and its Federal 
partners tackling this disinformation targeting all groups of 
veterans?
    Dr. Stone. Senator, thank you. In my opening Statement I 
discussed the fact that we are very proud of the fact that we 
are not seeing, in communities of color, a vaccine hesitancy 
resulting in disparities. What we are seeing, however, in rural 
America, is much more hesitancy to take this, and therefore we 
have had a very active campaign to communicate, especially with 
our primary care providers, recognizing the fact that the most 
trusted person is your doctor or your care team, in really 
dispelling the problems of vaccine hesitancy.
    I am going to defer to Dr. Kim, who has been close to this 
effort.
    Dr. Kim. Sure. Thank you. Senator, we have thought a lot 
about this issue, ever since the fall when we knew these COVID 
vaccines would become available, and thought about how to get 
information out to our veterans that was science-based. We did 
focus groups with our veterans, especially those of color, to 
find out what they needed to know to help them make a decision 
if they were hesitant. And they told us they wanted the 
science. They wanted to know if a vaccine was safe and if it 
was effective. And they, as Dr. Stone said, wanted to talk to 
someone they trusted on their health care team.
    So we combined all of that and have been working with CDC, 
who has a Vaccinate With Confidence campaign, to get science-
based information on the vaccines in the hands of our 
clinicians so they could have conversations with their veteran. 
You know, there really is no substitute for the hard work of 
calling somebody and having a conversation with them, and it is 
100 percent worth it when you can talk to one person and they 
figure out that they do want to get vaccinated. They tell their 
family. They tell other veterans. They tell their coworkers.
    And so there is no substitute for that hard work, and we 
prepared our staff in VA for those conversations, and I have 
heard many stories from around VA about how clinicians are 
getting on the phone, talking with their veteran, helping them 
make those decisions.
    Senator Murray. Well, thank you for that. And as we know, 
COVID-19 has had a disparate impact on communities of color. We 
know there has been a history of racism and medical 
mistreatment of people of color in this country, and those 
inequities have made the COVID crisis even more damaging for 
communities of color, and made it critical we do not let 
systemic racism block people of color from getting vaccinated.
    I was really glad to hear that the VA has been working with 
communities of color to answer questions about--any questions 
they have about vaccines, but even when those questions are 
answered there are still barriers to access, and often these 
facilities are not located in the same community, which may 
force veterans to take time off from work, or find child care, 
or find transportation to reach a VA facility where the vaccine 
is offered.
    So what is the VA doing to build trust within these 
communities and address those barriers to access?
    Dr. Stone. Senator, I am going to defer to our regional 
leaders, Dr. Patterson, because you have done a very aggressive 
outreach to these populations. And, Dr. Patterson, if you could 
also discuss just about the relative access of your veteran 
population, and then, Mr. Gigliotti, if you could follow that.
    Dr. Patterson. Right. Thank you for the question, Senator. 
If you look at VISN 15, and we cover the States of Kansas, 
Missouri, southern Illinois, some of southern Indiana, a little 
bit of northeast Arkansas and northwest Kentucky, within that 
area overall 95 percent of our veterans live within 60 minutes 
of a VA facility, whether it be a clinic or a hospital.
    Now that tells you one story for an entire six-State area. 
However, if you look at individual areas within there, most of 
our medical centers follow that same pattern. Some of them, for 
instance Wichita, only has 73 percent who live within the CBOCs 
in the rural areas that are within 60 minutes, and some are all 
rural and have a lot more contact.
    However, when you also talk about the way that our 
hospitals reach out to every ethnic group in order to get 
vaccinated, when we look at the large cities--St. Louis, Kansas 
City, even Wichita--our medical centers are located in the 
black communities. And so while Kansas City talks about a 
vaccine desert because there are no hospitals within a mile to 
five miles of the black communities, ours is in the middle of 
it.
    And so we are not seeing the equity problem with 
vaccination because physically we are close enough to the 
community for people to get there and get vaccinated.
    With our clinics, particularly in our metropolitan areas--
--
    Senator Murray. Okay. I am over time. So, Mr. Chairman, in 
respect to you, I have a few other questions that I would like 
to submit, and I want to make sure we continue to watch this 
very carefully.
    Chairman Tester. Absolutely. Thank you, Senator Murray. 
Senator Boozman.

                      SENATOR JOHN BOOZMAN

    Senator Boozman. Thank you, Mr. Chairman, for having the 
hearing, very much. First of all, I want to thank you all for 
being here, and I want to give a big shout-out to the folks at 
the VA in Arkansas that are doing such a tremendous job, and 
truly our frontline workers and heroes and we are certainly 
impressed with the dedication that they are using to serve 
their communities and their State.
    So, Dr. Patterson, thank you. A lot of people from 
northeast Arkansas use your services. I have been over to check 
it out and again, I really enjoyed the fact that you all are 
doing a great job.
    Dr. Stone, I have had the pleasure of working with you now 
very, very closely for the last few years and I appreciate all 
that you do. I would like to talk to you a little bit about 
funding. The CARES Act provided $19 billion. The most recent 
data shows that roughly $9 billion of that has been obligated. 
Congress recently provided VA with its full request for medical 
care in Fiscal Year 2021. In December, when Fiscal Year 2021 
appropriate bills, and most recent COVID-19 relief package 
passed, VA indicated it did not need any additional funds to 
assist with response to the pandemic.
    The current budget reconciliation package being considered 
in the House allocates $17 billion for VA to respond to the 
pandemic. I guess the question is, what has changed between 
December and today that leads the VA to require an additional 
$17 billion?
    Dr. Stone. Senator, first of all, thank you for your kind 
comments and I appreciate and I have enjoyed----
    Senator Boozman. We do appreciate you very much.
    Dr. Stone. Well, thank you, sir. I think there are two ways 
to think of this. First is the fight against the virus itself, 
and it was the foresight of this Committee, and frankly, all 
the oversight committees that got us the funding that allowed 
us to express the agility that we have had throughout this.
    But there is another piece of this, and the other piece, as 
we turn to the final mile of this pandemic, that we are 
beginning to recognize this tremendous toll on the American 
population and the American veteran. It is mainly deferred and 
delayed care that begins to generate what we have asked the 
Biden administration to consider, and that is that we have a 
very substantial need that will peak in late 2021 and 2022, as 
we go through. Now, you could say, well, make this part of the 
budget, but this is not a sustaining problem. This is a bow 
wave that is going to come and go. And, therefore, when I was 
in DoD doing wartime funding, we viewed this as what we called 
contingency operation funding, which I view the American Rescue 
Plan and the CARES Act as a contingency operation. Then, as 
part of the budget, you have got your base funding that is 
going to be ongoing. And I know since we have talked budget a 
fair amount over these last few years this is something you and 
I have discussed before.
    Senator Boozman. Right. So we are prefunding probably 
additional funds needed in 2021. Would that be fair? And 2022?
    Dr. Stone. I think a number of these funds will be needed 
in 2021, and especially----
    Senator Boozman. It is fair to say you have not--I guess I 
should ask, have we spent the dollars that we have allocated so 
far? Are we in good shape?
    Dr. Stone. We are still in good shape. We have obligated a 
little over $7.2 billion. But we will obligate the remaining 
$10 billion before the end of this fiscal year.
    Senator Boozman. Okay. I am sorry. I did not mean to 
interrupt. So 2021 and 2022, your concern is we are going to 
need additional funding, that is kind of a one-time thing.
    Dr. Stone. Yes, sir.
    Senator Boozman. Okay. Very good. One thing that has come 
up, I have heard from veterans in Arkansas who are eligible to 
get the vaccine and then their spouses were not, and maybe that 
veteran was pretty fragile and things, and then you still have 
the concern of the spouse coming in and out. Has there been any 
way of looking at eligibility for married couples?
    Dr. Stone. Not successfully. I will tell you----
    Senator Boozman. Is that just the dollars-and-cents factor, 
or----
    Dr. Stone. No. It has to do with the law that was written 
in the late 1990's.
    Senator Boozman. Okay. So you would need additional 
legislation.
    Dr. Stone. We need additional legislative relief in order 
to get there. Yes, sir.
    Senator Boozman. Well, maybe that is something that the 
Chairman and I can work on.
    Chairman Tester. I agree.
    Senator Boozman. Thank you very much.
    Senator Moran. What about the Ranking Member?
    Senator Boozman. And the Ranking Member also.
    Chairman Tester. Absolutely.
    Senator Boozman. We do not want to leave him out.
    Chairman Tester. Thank you, Senator Boozman. Senator 
Hirono?

                      SENATOR MAZIE HIRONO

    Senator Hirono. Thank you, Mr. Chairman. I am told that, 
Dr. Stone, you have not been asked this question yet. What is 
your targeted number of veterans to be vaccinated?
    Dr. Stone. We would like every veteran in America to be 
vaccinated, but right now, with the austere supply we have, we 
are targeting the 6 million active users of the system, 
Senator, and those 6 million active users are those that have 
depended upon us, and it is absolute that we must take care of 
those 6 million first before we look at any expanded 
population.
    Senator Hirono. When do you think you will be able to 
vaccinate those 6 million active users of the system?
    Dr. Stone. It entirely depends on the available vaccine. 
Our goal was within a 120-day period to be able to vaccinate. 
It remains to be seen whether we will have a sustained supply. 
It is not terribly difficult to figure out that if you getting 
125,000 doses a week, how many weeks it is going to take you to 
get to 6 million. If we receive a half a million this coming 
week and that is a sustained amount, we can move very quickly 
and meet our goal of vaccinating this high-risk population.
    Senator Hirono. So, Dr. Stone, you have a capacity to 
vaccinate a lot more people than the number of doses that you 
get. What is your capacity right now?
    Dr. Stone. Capacity right now is in excess of 300,000 a 
week. I mentioned that over the holiday weekend we were able to 
do over 70,000 a day. I think that is sustainable. And so, 
therefore, somewhere between 350,000 and 600,000 a week is 
certainly within the realm of possibility.
    This is one of the most effective vaccination programs 
ever, remembering that nobody has tried to do this since the 
Sabin and Salk vaccines of the 1960's in the polio epidemic in 
the children of America.
    Senator Hirono. Yes. So did you say that you get 125,000 
doses per week, that is currently what you are getting now?
    Dr. Stone. We were just called on the way over here to say 
that we would be getting about 500,000 doses this coming week. 
We have seen a gradual increase, and we are very hopeful with 
the new vaccine that is coming on the market that we will 
continue to see increases, and the problems that we are having 
with the amount of vaccine will resolve itself over these next 
number of weeks.
    Senator Hirono. So you are getting 500,000, and your 
current capacity is 300,000. Are you opening up other PODs 
outside of the VA system to provide these vaccines?
    Dr. Stone. We will expand our VA direct delivery system to 
accommodate this. We are very efficient at it. We also have, 
through our Community Care, offered through our urgent care 
system, vaccination if those are urgent cares were able to get 
vaccine. And so we will continue to increase our capacity as we 
receive additional supplies.
    Senator Hirono. So you can do this all within the VA 
system, is what you are saying.
    Dr. Stone. Yes.
    Senator Hirono. So you did indicate that you are 
vaccinating first the people who are in your system. So there 
must be a lot of veterans who have never utilized veteran 
services. But at some point you need to contact them, right?
    Dr. Stone. We are reaching out to veterans and asking 
veterans. We have had over 8 million contacts the last few 
weeks, where we have reached out to veterans and encouraged 
them to enroll in VA health care. Both Mr. Gigliotti and Dr. 
Patterson can discuss their efforts in enrolling veterans on 
the spot who come in for vaccination.
    Senator Hirono. I am running out of time, so I originally 
asked what is your target number and you did not give me the 
number. You said 6 million currently in the system. But how 
many veterans are out there?
    Dr. Stone. There are 18,500,000.
    Senator Hirono. And your goal should be to get every single 
one of them vaccinated, assuming that they are not going to 
object to getting a vaccine. So I know that you are doing 
everything you can to reach out to all of the veterans who are 
not within the system right now. Have you seen that during this 
COVID that there are veterans who have not utilized veteran 
services who are contacting you on their own because they want 
to be vaccinated?
    Dr. Stone. Yes.
    Senator Hirono. Good. You have been asked a number of 
questions about vaccine hesitancy, and I think you said that 
you have not seen that--I may have heard this incorrectly--you 
have not seen this in communities of color, vaccine hesitancy. 
Did I hear that correctly?
    Dr. Stone. You did. We are actually very proud of the jobs 
that the team has done to reach out to communities of color, to 
improve their trust and confidence in both the vaccination 
program and the VA.
    Senator Hirono. So there is just one more quick thing, if 
you do not mind, Mr. Chairman. I do appreciate that the VA is 
providing vaccines to veterans in Guam and American Samoa. I 
understand the rate of vaccination among these veterans is 
really low, with only a handful of veterans in these places 
being vaccinated so far. I hope that you are making concerted 
efforts to reach out to the veterans in Guam and American 
Samoa. They often have difficulty getting access to veteran 
services. That is my understanding. So there are logistical 
challenges to them getting the vaccines, that I hope you are 
addressing these challenges, Dr. Stone.
    Dr. Stone. Senator, I will tell you, this has been a very 
frustrating area. We have been working through the Departments 
of Health at each of these areas. We have agreed to bring in 
additional personnel to support those Departments of Health. We 
need the Departments of Health, primarily because of the 
refrigeration capacity, and we are looking forward to the newer 
vaccines as they come that do not require as complex handling, 
to expand our ability to reach each of these islands and areas.
    Senator Hirono. Thank you. Thank you for doing your very 
best. Thanks, Mr. Chairman.
    Chairman Tester. Thank you, Senator Hirono. I want to 
recognize one of the two new members to the Senate Veterans' 
Affairs Committee, next, Senator Tuberville. And we have all 
been waiting anxiously for your questions.

                    SENATOR TOMMY TUBERVILLE

    Senator Tuberville. Thank you very much, Mr. Chairman. 
Thank you for what you do. I am a military brat. Dad died on 
active duty. Huge. I spent a lot of time in the VA over the 
years with my dad. But as a representative of the State of 
Alabama we have 380,000 veterans. We are a military State. And 
I just recently went through most of our VAs through the State, 
and I am very proud of what they are doing. Obviously, we have 
got a lot of work to do in some areas. but we have got a lot of 
veterans, and with these wars that we have had we have got a 
lot more coming. And all veterans need a vaccine. They all need 
it. We all know that, and we are talking in circles in here, in 
some areas.
    There are a lot of new veterans in our State that have 
PTSD, underlying conditions. And I know that we want to get it 
to the older veterans, and rightly so, because they are more 
vulnerable. But nobody is any more vulnerable than our kids, 
our young men and women with PTSD, and we have got a lot of 
them. We are losing 22 veterans a day to suicide, and that has 
really increased since this virus, because stacking one problem 
on top of another creates more problems.
    And I really do not have a question. I just wanted to ask 
you, really, is there any priority to any of these young men 
and women that have recently come back, you know, with PTSD, 
with underlying conditions, with lost legs, lost arms, that 
have huge problems on top of problems, and scared to death that 
they are going to get this virus but they cannot get the 
vaccine. Is there any priority that we can look at that?
    Dr. Stone. There is, sir, and it is part of that 1c group 
that Dr. Kim was talking about, as we have looked at it. Now we 
have not seen an increased amount of virus sensitivity based on 
PTSD, but we have seen a lot of problems, and those problems 
primarily relate to the intense isolation that has occurred 
because of this pandemic and the fact that people have been 
locked in their homes.
    Therefore, we have converted about 75 percent of our 
behavioral health engagement to video-type visits that have 
reached into the veteran's home, and we have replaced face-to-
face visits with video visits that a veteran can interact with 
our psychiatrists and psychologists to make sure they remain 
stable.
    Our calls to our Veteran Crisis Line have gone up very 
significantly. Part of that is the 988 system that is being 
fielded around the Nation. But the rest of it is because of the 
really strain on this population that you so articulately laid 
out. This is an extraordinarily at-risk population that needs 
our engagement.
    Senator Tuberville. Thank you very much. Another thing that 
I noticed--and not just going through the VAs but also the 
hospitals all over Alabama--we are struggling, at times, even 
getting first responders to take the vaccine. They are a little 
leery about taking it. Marketing is a huge problem sometimes, 
in something new like this. I wish, you know, with the 
trillions of dollars, billions of dollars that we are spending 
on this, sometimes you need to market, you know, through public 
service of take the vaccine. We have got to get rid of this 
thing. I mean, and people do not take this if they are leery of 
it.
    Sometimes you even use football coaches. In our State we 
have got a pretty famous one in that State that probably could 
do a PSA to say, ``Take your vaccine. First responders, 
veterans, anybody that has an opportunity to take it.'' I think 
sometimes we forget to use the things that we have at our 
disposal to get people to understand that, you know, things do 
work, and we are not trying to trick anybody. We are just 
trying to make it work.
    But again, thank you for your service. Thank you for what 
you are doing. We truly--and I know our veterans appreciate it 
too. We truly thank you. Thank you very much.
    Thank you, Mr. Chairman.
    Dr. Stone. Senator, thank you. Let me just respond that 
anybody that a veteran trusts, that can talk about this 
vaccine, has value to making sure that we increase the amount 
of vaccination. Your State has some of the lowest acceptance 
rates of vaccine in the country, and part of that dates back to 
World War II era, where there were some egregious things done 
in various experiments. So that message needs to be overcome, 
and we would welcome participation in that, to get that message 
out.
    Chairman Tester. Thank you, Senator Tuberville, and I am 
sure the football coach you are referring to is the old Auburn 
Tiger himself, Coach Tuberville.
    Senator Blumenthal?

                   SENATOR RICHARD BLUMENTHAL

    Senator Blumenthal. Thanks, Mr. Chairman. I apologize if I 
cover ground you have already done, but I first want to say how 
proud I am to know that Connecticut, really, I think it is at 
the forefront of these efforts to vaccinate veterans. In 
Connecticut, 47 percent of our veterans have received a first 
dose, and 23 percent a second dose, which is far ahead of the 
national average. I am also pleased to say that 77 percent of 
our veteran employees have been vaccinated, and so they are 
protected.
    I think that this kind of record is due to real leadership. 
Obviously, you are trying to inspire that kind of leadership at 
the national level. But we need more aggressive leadership at 
the local level to counter the kind of misinformation and 
hesitancy that is found among certain populations, and, as 
well, to provide vaccinations to caregivers and spouses, family 
members, who live with our veterans, because I think one of the 
reasons why veterans may not come for a vaccine is that their 
spouse or caregiver is not going to get it as well, and either 
because they depend on that person for transportation and 
advice or for some other reason, they may be hesitant.
    I know you have answered the question about what can be 
done to provide the vaccine to those caregivers, the non-
veterans who provide for our veterans, and that you would need 
additional statutory authority to do so. Is that correct?
    Dr. Stone. For the most part, yes. It is a bit of a nuanced 
answer and I apologize for that. For those families that are 
engaged in our subsidized or reimbursed family caregiver 
program, that caregiver program we do have authority to give 
vaccine, and have vaccinated more than 2,000 family caregivers. 
What we do not have authority for is the rest of the population 
that are not on subsidies, and in those subsidies--and it is a 
nuanced, complex answer and it is not very satisfactory, sir. 
We need some additional authorities to get to the rest of that 
population.
    We have 200,000 elderly, frail veterans that we are helping 
in the home. About 20,000 we can vaccinate their caregiver, and 
180,000 we cannot. And that is the kind of discussion that we 
need to have of how we get those additional authorities in 
order to protect that veteran and their caregiver.
    Senator Blumenthal. Well, I offer my support and help. 
Whatever we can do to expand that authority, if necessary, I 
think there would be strong support for it.
    And as to the younger veterans, are they more hesitant? Are 
they less likely to take the vaccine? Do you notice any 
difference in age groupings as to that hesitancy?
    Dr. Stone. I am going to defer to Dr. Kim on this.
    Dr. Kim. Yes, I will maybe speak to the focus group that we 
did with veterans, that included veterans of younger and older 
age, and I think what we saw, you know, I think reflects maybe 
what we see in non-VA surveys from last year, is that hesitancy 
is at all age groups, unfortunately. I think it falls along 
racial and ethnic lines, actually, where blacks and African 
Americans and Hispanics had more hesitancy compared to whites, 
and that was played out by age. And I know it was a focus 
group, but I think it just really parallels what we see in 
larger national surveys.
    So I think our efforts to communicate really reach across 
ages, to make sure that we get the messaging across about the 
science, that we can trust these vaccines, that they are safe 
and effective.
    Senator Blumenthal. And then, finally, if you had to pick, 
out of a community, one person, one type of person to overcome 
that hesitancy, to recruit people to take the vaccine, would it 
be a faith leader? Would it be a coach? Who would you choose?
    Dr. Stone. It would be your provider, your nurse 
practitioner or your PA or your physician.
    Senator Blumenthal. So someone with medical credentials----
    Dr. Stone. Yes.
    Senator Blumenthal [continuing]. to talk about medicine. 
Makes a lot of sense, right?
    Dr. Stone. And, sir, that is exactly why we think we have 
done so well with this, is we have had this proactive outreach 
to our communities, especially our communities of color, and we 
think that is why we have erased the disparities in the 
population, that other parts of the American health care system 
are seeing. And we are trusted, because of what Dr. Patterson 
said. We are trusted because we are in those communities.
    Senator Blumenthal. And again, the people who are most 
persuasive and compelling on an issue of science or medicine 
are the people who have the credentials of medical doctors or 
nurses or scientists, who can attest to the efficacy and safety 
of the vaccine.
    Dr. Stone. Yes, sir.
    Senator Blumenthal. Thank you. Thanks, Mr. Chairman.
    Chairman Tester. Thank you, Senator Blumenthal. Senator 
Sinema.

                     SENATOR KYRSTEN SINEMA

    Senator Sinema. Thank you, Mr. Chairman, and thank you to 
Ranking Member Moran for holding this hearing, and thank you to 
all of our witnesses for being here.
    Dr. Stone, I appreciate that in addition to providing 
vaccine support for its work force, the VA has stepped in to 
support vaccine distribution for the Department of Homeland 
Security. This is an especially important program for Arizona's 
Customs and Border Protection employees.
    In Arizona, the VA should further identify ways to offer 
vaccines for CBP employees through VA community clinics and 
mobile vet centers, given the often long distances between 
where they work and the nearest VA medical center. You know, it 
is 3 hours from Yuma, on the border, to our medical centers in 
Phoenix or San Diego, and it is 3.5 from Yuma to Tucson. So I 
would appreciate you and your office keeping me updated as you 
work with DHS to expand this program, and share any challenges 
you experience.
    We have heard from a number of Arizona veterans with 
questions and concerns about the availability of the vaccine 
and scheduling appointments across the Arizona VA medical 
centers. I appreciate the responsiveness of the Arizona VA 
medical centers as my team works at the local level to address 
these concerns. So I will focus my questions on how these 
issues are being addressed nationally.
    Currently, the VA has 9.3 million enrolled veterans, 6 
million with an active status. We have received calls from 
veterans who enrolled with the VA, have an inactive status, and 
are scheduled and then canceled, presumably because of their 
inactive status. Should veterans with an inactive status have 
access to vaccination appointments, and if so, what clarifying 
guidance must be sent to the medical centers to make sure that 
they do?
    Dr. Stone. When we are no longer in an austere environment 
where we know that we are only going to get 6 million doses, I 
think will be able to expand to the rest of the enrolled but 
not active users.
    Senator Sinema. So there will be a point where the VA will 
be able to offer vaccines to inactive status veterans.
    Dr. Stone. That would be my absolute desire. You know, my 
view is that none of us are going to get our lives to turn back 
right-side up again until we get the American population 
vaccinated. So I share your desire to get vaccine into as many 
people as we can. And as soon as CDC and HHS can assure us that 
we will move beyond the 6 million doses, we will expand, and we 
are actively recruiting veterans to move to enrolled status so 
we can begin to interact with them.
    Mr. Gigliotti, I think, can discuss some of the efforts in 
his VISN, as can Dr. Patterson in his VISN, to really seek out 
those veterans and to bring them in.
    Senator Sinema. Well, thank you. My next question is, how 
is the VA tracking instances of canceled vaccination 
appointments to ensure that veterans are not losing access, and 
how are they identifying and fixing potential problems as they 
arise?
    Dr. Stone. Mr. Gigliotti or Dr. Patterson, do you want to 
take that?
    Dr. Patterson. Senator, what we do is reschedule them. So 
if they call in and cancel and cannot make the appointment we 
usually ask them why, just to be sure that, for instance, they 
are not ill and maybe they need to come to the clinic anyway. 
But we just put them back on the list and reschedule them.
    Senator Sinema. Okay. Do folks fall through the cracks when 
that occurs, or is that not something you have experienced?
    Dr. Patterson. You know, it is really interesting when I 
visit the medical centers and see the vaccination clinics, the 
incredible enthusiasm that the staff has. It is really 
rewarding to go and watch how eager they are to vaccinate 
people. So they have a list and they keep up with it. I cannot 
guarantee that nobody falls through the cracks, but clearly 
they want to get them vaccinated.
    Senator Sinema. Thank you. Moving on, the Northern Arizona 
VA Health Care System is piloting the use of a mobile vet 
center to bring vaccines to community clinics in an effort to 
expand distribution to more rural areas. This is very important 
for vaccinating Arizona veterans. What is the VA doing 
nationally to ensure that as efforts such as this expand access 
to rural and highly rural areas, how is the VA working to 
ensure that these are successful, that they are resourced 
appropriately across the VA network, so that rural and highly 
rural veterans can also access the vaccine?
    Dr. Stone. So Mr. Gigliotti, in his VISN, piloted an 
airborne delivery of vaccine. We have now expanded that to VISN 
20 in both Alaska and Oregon. We also are using mobile assets, 
as you referenced, and we are discussing these type of unique 
solutions on a daily basis, in what we call our health 
operations update, where each of the VISNs highlights what they 
are doing to get vaccine out.
    We have been having ongoing discussions with our emergency 
operations team to make sure we have maximum numbers of 
vehicles available and have been working with the White House 
team to assure that we are taking what I view as the most 
difficult area of inequity, which is the remote areas of this 
Nation where there are health care deserts, trying to get 
vaccine into areas.
    We are very proud that last week we flew an airplane into 
southern Alaska to an island where there were 50 veterans, and 
vaccinated virtually the entire veteran population. It is that 
kind of creativity and effort that I describe as part of the 
herculean effort that we are undergoing. Nobody has done this 
before, but one of the things we have recognized is these huge 
distances and remote areas, especially as you have described, 
in your State.
    Chairman Tester. Thank you, Senator Sinema.
    Senator Sinema. Thank you.
    Chairman Tester. Next up we have the second newest member, 
or one of the two newest members, I should say, from the great 
State of New Hampshire, Senator Hassan.

                  SENATOR MARGARET WOOD HASSAN

    Senator Hassan. Well, thank you very much, Senator Tester 
and Ranking Member Moran, for holding this hearing on what is a 
critical issue of vaccine distribution to veterans. And I just 
want to say I am really excited to be a member of this 
Committee and I am really looking forward to the work that we 
can do together to serve our veterans. And I want to thank the 
witnesses today for your work to serve our Nation's veterans 
too.
    Dr. Kim, I wanted to start with a question for you. First, 
thanks for working to get these vaccines out to veterans as 
quickly as possible. New Hampshire, as you probably know, does 
not have a full-service VA hospital, and as a result, Granite 
State veterans get some of their care across the border at the 
VA Medical Center in White River Junction, Vermont, or in 
Bedford, Massachusetts. That can create some challenges when 
the States are not fully aligned in terms of vaccine 
availability and protocols.
    So how does the VA determine the vaccine allocation for 
these kinds of facilities that serve veterans across State 
lines, and what steps is the VA taking to disseminate the 
information to veterans who may be crossing State lines to get 
their care?
    Dr. Kim. Sure. So I think, Senator, that the answer to that 
question is that we know for the veterans who receive care in a 
certain medical center who they are. We know their age, their 
demographics, et cetera. So whether they live in New Hampshire 
or whether they live in Massachusetts, if they are served by 
that medical center or clinic we know whether they are in a 
priority phase for vaccination.
    So we will reach out to them, regardless of where they 
live. I have patients who I see in North Carolina but they live 
in Virginia. To me that does not matter. They are served by me 
so I will reach out to them when it is their turn. And I think 
the same would apply to your veterans, as well, in your State.
    I wonder if, you know, the question is whether--you know, I 
know each State has their own phase where they are. Certainly 
each State has flexibility to do that. For the VA, you know, we 
do follow CDC, but there is flexibility, say, for your area of 
the country, for that particular VA to move into Phase 1a, 1b, 
or 1c, depending on how much supply they have. But it really 
depends on the veterans they serve in that facility as to, you 
know, when they are reaching out to them.
    Senator Hassan. Thank you. Another question for you, Dr. 
Kim. Many facilities are offering an online appointment 
registration system for veterans to sign up for the vaccine, 
and if this has been asked already forgive me. But the online 
portals are obviously a great tools. Some veterans may struggle 
with the technology, though, or they do not have the 
connectivity to access the system. And many veterans in my 
State live in rural areas, which, one, has less access to 
broadband. Also a lot of veterans in my State are older and 
have less exposure to online tools.
    So what alternatives is the VA offering veterans who may 
have limited internet access or technological know-how to 
register for appointments online?
    Dr. Kim. Sure. I will just say--and I will let Mr. 
Gigliotti and Dr. Patterson comment--we are using all 
modalities, especially those we know that are veterans in each 
medical center respond to.
    Senator Hassan. Thank you.
    Mr. Gigliotti. Senator, in that scenario, the partnership 
with American Legion, Disabled American Veterans, and other 
service organizations is critical to get the word out. One 
thing we have also had great success with are electronic town 
halls. They have really ramped up in the last year, due to the 
pandemic. The minimum attendance that we have had is 1,500, and 
in some cases up to 8,000. So veterans getting the word to 
other veterans has also really helped in that scenario.
    Dr. Patterson. Yes, Senator. The veteran service 
organizations are a great partner in this way. We reach out to 
them, ask them to contact their members, and they will also 
contact other people in the community, even if they are not a 
member of the VFW or the Legion. And we are using some of their 
facilities, because it is a great drawing point.
    Senator Hassan. Thank you. I will just echo what Senator 
Sinema was just speaking about, in terms of making sure we are 
getting to our rural veterans in remote areas. And it was great 
to hear the pilot programs you have up in Pittsburg, New 
Hampshire, which is on the Canadian border. It is one of our 
largest towns but it has 900 people total, and it is a 
beautiful spot but it takes 3 hours for people in wintry 
weather to get to Manchester. So I really appreciate those 
efforts and would like to work with you all on expanding them.
    Dr. Stone, I wanted to drill down a little bit on the data 
you have about veterans who are declining the vaccine. We have 
begun to see data on the rates of certain segments of the 
population declining to get the vaccine, including actively 
serving military members and first responders, something that 
you have heard about from other members of the Committee too.
    In your testimony you described listening sessions with 
minority veterans and other concrete steps that you are taking 
to help reduce vaccine hesitancy among the veteran population. 
Now that vaccines are being administered, are you gathering 
data on how many veterans have declined to receive the vaccine 
and whether their reasons match the concerns you were hearing 
about during your planning?
    Dr. Stone. I do not think our data is as clear as it should 
be, and it appears that about 15 percent of the population is 
declining. And then as time goes on much of that is just a 
hesitancy, that once their friend begins to get it, or a fellow 
veteran, or a family member does, they will then go ahead and 
get the vaccine. So the numbers are declining of hesitancy, but 
it requires very active listening sessions and engagement of 
that population in order to resolve it.
    I will tell you, I have worked the vaccine clinic that we 
have been operating in Washington, DC. Many of the people 
coming in, especially in the communities of color, want 
pictures taken so they can send it to their family members, 
say, ``Look, I got the vaccine.'' It has been a very emotional 
engagement, even as a provider with 40 years of experience. 
These are very emotional engagements for many of these 
families. But it is those kinds of things that we have been 
talking about that I think has made us successful in erasing a 
lot of the hesitancy.
    Now there is a portion of the population that will never 
get the vaccine, and we have seen that with vaccine, really, 
refusal across many areas of the country, over multiple types 
of vaccines. This is really unique, new types of vaccines that 
we are dealing with, and it is just going to take a lot of 
education and a lot of work and a lot of trust for us to get to 
where you and I would like to be one this.
    Senator Hassan. Thank you very much. Thank you, Mr. Chair, 
for your indulgence.
    Chairman Tester. Thank you, Senator Hassan. A couple more 
questions, really quick. First of all, just to followup to 
Senator Hassan's question, I think gathering that information 
as to why the veterans are hesitant is critically important. 
You are spot-on on rural veterans. I think the Ranking Member 
would concur that there is a lot of hesitancy in rural America 
and we have got to figure out how to break that down.
    Mr. Gigliotti, you are using fly ins to reach rural 
veterans, and you talked about expanding that to VISN 20, at 
least Dr. Stone did. I think it is really good. I think the fly 
ins can be incredibly effective, and they have been incredibly 
effective. The question is, are there other approaches you plan 
to use, because the fly ins are a bit limited.
    Mr. Gigliotti. Thank you, Mr. Chairman. We are using the 
fly ins, as you said. Today is our third one. Lewistown is 
having that. We are using dual-use vehicles and the medical 
mobile units, where we have them across our VISN, and those are 
part of the deployment strategy to reach the rural veterans, 
particularly in the rest of Montana, Wyoming, and we are 
looking at eastern Utah for that. So those are critical.
    Dr. Patterson made the point, in his VISN, which is 
accurate for mine, that 90 percent of our VISN population of 
veterans lives within 60 miles of a facility that can give out 
the vaccine, and a large chunk of that percentage is within 0 
to 30 minutes, and then 30 minutes to 60. So it is really going 
to be important for us, when the volume increases in the 
vaccine, to get the word out, to be able to come to those 
clinics themselves, and for those very rural areas using those 
two vehicles, the flights as well as the dual-use vehicles.
    Chairman Tester. Yes, and it all works together. You guys 
know that. I mean, the availability of the vaccine is No. 1, so 
you guys can plan for it and tell the folks where to go, to 
those CBOCs, or whether there is a mobile van going out and how 
to get to them. So I appreciate that.
    Dr. Stone, what percentage of the work force has refused 
the vaccine?
    Dr. Stone. I can tell you that 73 percent of the entire 
work force has received the vaccine, over 90 percent of our 
clinical personnel. Refusals of the vaccine have primarily 
occurred amongst some of our non-licensed personnel in our 
CLCs, and we are working hard to do educational programs for 
that in order to get those numbers up.
    Chairman Tester. As a last resort, do you have the 
authority to make the vaccines mandatory as a condition of 
employment, regardless of whether these are medical 
professionals or they are non-licensed personnel?
    Dr. Stone. Senator, I have that authority but I am not 
going to use it, and I am not going to use it under the 
Emergency Use Authorization. When there is full licensure of 
the vaccine we will revisit that decision, but as an Emergency 
Use Authorization, and the fact that our employees are 
dramatically taking the vaccine. This is much different than 
the commercial marketplace. Our employees are taking the 
vaccine, and I am very pleased. That has been reflected in the 
fact that prior to the vaccine we were running consistently 
6,000 employees that could not come to work because of either 
exposure or actual infection with COVID. That number this 
morning has dropped to under 1,100. So literally 5,000 more 
people are coming to work now than had.
    Chairman Tester. Senator Moran.
    Senator Moran. Senator Tester, thank you for the second 
round. I will try to be brief, as you were. I want to ask a few 
questions related to the $17 billion request for the VA making 
its way through Congress. In my view, unfortunately, it is 
coming through Congress in an expedited manner, that we will 
not have, as this Committee, the opportunity to debate and 
amend, or even understand that legislation.
    I want to visit with you about how the request is related 
to the $10.5 billion that is remaining in the CARES funding 
currently. Is it true--I think you said this, maybe in your 
opening Statement--is it true that the remaining $10.5 billion 
in CARES funding will met COVID-specific needs, such as PPE, 
testing equipment and supplies, increased health care costs, 
through the remainder of the fiscal year?
    Dr. Stone. It is my anticipation that it will meet the 
requirements primarily of health care. About $3.5 billion is 
needed for Community Care, and we have a request that is 
working its way through to repurpose $3.5 billion in Community 
Care. The majority of the rest will go into direct patient 
care, within our direct care system, for the care of patients 
with COVID.
    Senator Moran. So $10.5 billion, about $3 billion of it 
needs to be repurposed to meet Community Care opportunities, 
requests, and the other $7.5 billion is to provide care within 
the VA?
    Dr. Stone. The financial people are probably cringing at 
this point because I am sure there is a piece that I have 
missed. There are some pieces that are going into the homeless 
programs. We have taken the caps off of HUD-VASH vouchers to 
make sure that we are taking away insecurity in homes. But that 
is primarily what it is addressing.
    Senator Moran. And then the $17 billion that is in what I 
would call Phase 5, the legislation that the House is currently 
considering, those are targeted at needs that may occur in 
Fiscal Year 2022 and beyond, and in part, at least based upon 
pent-up demand for health care?
    Dr. Stone. I would not quite put it that way. I think it 
will be late 2021 that that occurs. I think probably the last 
quarter of 2021 we are going to see a bow wave.
    Let me give you an example of this. We are down by 12,000 
surgeries a month in our direct care system. They are not going 
out to the community. That is pent-up demand and it is surgery 
being done later. Think about putting off a knee replacement 
for a year. That is a tougher surgery. And so what our 
actuaries are telling us is that deferred and delayed care is 
going to create a bow wave that none of us anticipated a year 
ago, when we were looking at what was in the CARES Act.
    In addition, reliance on our system that is coming because 
people are losing insurance because of job loss is resulting in 
more veterans enrolled. We will enroll well over 300,000 
additional veterans this year. And so that sort of bow wave is 
what we are trying to take care of in this late 2021 and 2022 
timeframe. It is our hope, then, that that will stabilize once 
we have taken care of that, and we can come back here with a 
much more optimistic picture.
    Senator Moran. Dr. Stone, you would not expect me not to 
ask this question. The reason that I want to make sure I 
understand--you also said it is not occurring in the community, 
under Community Care, it is not occurring in the VA, the 
surgeries that you described. The fact that it is not occurring 
in Community Care is not a result of anything that the VA is 
doing to restrict that from occurring in the community. It is 
just that the patients are deciding to defer. Is that true?
    Dr. Stone. The best example of this is the fact that we 
have got a big problem in VBA, where we have got people that do 
not want to come in for their comp and pen exam. So we have got 
a lot of built-up comp and pen exams. Over 50,000 of those are 
veterans that just will not come in for a face-to-face visit. 
Well, if you will not come in for your comp and pen exam, you 
are not coming in for your knee replacement either.
    And so it is not because we are failing to refer to the 
community or have not built an adequate community environment 
for people to go to. This is exactly what happened after the 
great influenza of 100 years ago, that there was this bow wave 
of care that was necessary because it was delayed or deferred.
    Senator Moran. Dr. Patterson, anything unique about our 
VISN in regard to this topic?
    Dr. Patterson. No, Senator. There is not.
    Senator Moran. Okay. Thank you. Just to conclude, Mr. 
Chairman, first of all, Dr. Patterson, is there anything that 
you would--I do not know how many times you have testified 
before Congress, but welcome to this occurrence. Is there any 
request that you would have of me on behalf of the veterans in 
our VISN, that you would like for me to know?
    Dr. Patterson. Well, Senator, I know you visit every county 
every year, and I really appreciate it when you come visit our 
vaccine clinics, because it is great press for us. It hits the 
local news, and I think it just encourages veterans to come in 
and get vaccinated.
    We have a rally cry in our network called ``Reclaim the 
Summer,'' and you might have heard that when you were in Topeka 
earlier this week. But that is what we want to do. We want 
everyone vaccinated so we can have a summer again, play 
baseball.
    Senator Moran. I like that. In the absence of the Chiefs' 
victory maybe we will have a Royals victory.
    I would add to only confirm what Senator Blumenthal said, 
and that is the importance of spouses and caregivers. And 
yesterday Senator Tester and I, in our conversations with the 
general and the doctor, General Perna and Dr. Kessler, raised 
this issue with them, and they indicated a willingness to see 
if there was something they needed to do to make this possible.
    I did not understand your response to Senator Blumenthal. 
Is there something that prohibits the VA from vaccinating 
spouses, spouses who are not veterans?
    Dr. Stone. Yes.
    Senator Moran. Okay. And that could be corrected within 
this system that we have developed for distribution of 
vaccines, or takes something within the VA, within the 
Congress?
    Dr. Stone. Not within the authority of the Secretary to do 
non-veterans for providing any sort of health care, unless they 
are on the stipend program.
    Senator Moran. Maybe there is a way to get to it in the 
fourth mission. I will look for ways to be of help in 
accomplishing that.
    Dr. Stone. Sir, we are talking to a number of States about 
exactly that, and working with a number of States to try and 
get at it in that manner, and thus unload the rest of the State 
from the vaccine that is necessary and protect veterans at the 
same time, sir.
    Senator Moran. That is good news. Mr. Chairman, thank you.
    Chairman Tester. I will tell you this, Ranking Member 
Moran. Our staffs are going to get together and we are going to 
figure out what kind of language it needs to give them the 
temporary authority in this particular case of a pandemic, and 
then we are going to give all the credit to Boozman. That is 
just the way it works around here.
    I just want to thank you guys for your testimony. I am 
going to give you an example of exactly what you are talking 
about on pent-up demand. My brother, who is a few years older 
than I am, that has COPD, has not seen a doctor in a year. He 
just got his second shot. He is proceeding to set up doctor 
appointment after doctor appointment after doctor appointment 
right now. There is a lot of pent-up demand out there, and 
there will be. You guys being able to deal with that is going 
to be a challenge.
    The other thing we have not talked about here today, that 
we all know is a big deal, is mental health, and the fact that 
the isolation caused by this pandemic has only contributed, not 
only in the VA but across society, to increased mental health 
problems. I just met with a bunch of school personnel today 
that are talking about kids having increased mental health 
problems.
    I will just put a plug in for the John Scott Hannon bill, 
that the Ranking Member and myself got done last Congress. I 
think that can help, and, of course, telehealth can. But that 
is another expensive proposition that we have to deal with. 
Thank God you are there, Dr. Stone, and you have good people 
like the panel up here today, that can deal with that.
    Look, I cannot give you guys enough credit. The Ranking 
Member and myself were on the call yesterday with Dr. Kessler 
and General Perna, and, quite frankly, we just need to get more 
vaccines in your hands to get distributed. I think what 
happened today is a really good sign, and hopefully that will 
keep up. And they assured us that, by the way, it would come 
up, that it would ramp up more and more. And, in fact, in 3 
weeks it sounds like you guys may be really in full swing.
    So thank you for what you are doing. We are going to 
continue to push the administration in a bipartisan way to use 
all the authorities they have to get more doses allocated for 
the VA. It is important that we take care of our veterans. It 
is a cost of war.
    I would ask that any post-hearing questions be sent to the 
clerk no later than a week from today, and we will keep the 
record open for a week as well.
    This hearing is adjourned. Thank you all.
    [Whereupon, at 5:49 p.m., the Committee was adjourned.]

                                APPENDIX

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               Material Submitted for the Hearing Record
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