[Senate Hearing 117-218]
[From the U.S. Government Publishing Office]


                                                       S. Hrg. 117-218

                     REVIEW OF THE FISCAL YEAR 2022
                        BUDGET AND 2023 ADVANCE
                       APPROPRIATIONS REQUEST FOR
                   THE DEPARTMENT OF VETERANS AFFAIRS

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                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        WEDNESDAY, JUNE 16, 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
        
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
47-108 PDF                 WASHINGTON : 2022                     
          
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                     COMMITTEE ON VETERANS' AFFAIRS

                     Jon Tester, Montana, Chairman
Patty Murray, Washington             Jerry Moran, Kansas, Ranking 
Bernard Sanders, 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, Staff Director
                 Jon Towers, Republican Staff Director
                            
                            
                            C O N T E N T S

                              ----------                              

                             JUNE 16, 2021

                                SENATORS

                                                                   Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     3
Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire......     9
Boozman, Hon. John, U.S. Senator from Arkansas...................    11
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    12
Murray, Hon. Patty, U.S. Senator from Washington.................    13
Rounds, Hon. Mike, U.S. Senator from South Dakota................    15
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    16
Hirono, Hon. Mazie, U.S. Senator from Hawaii.....................    24
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    26

                               WITNESSES
                               Panel One

The Hon. Denis McDonough, Secretary of Veterans Affairs 
  Accompanied By: The Hon. Jon Rychalski, Assistant Secretary for 
  Management and Chief Financial Officer.........................     4

                               Panel Two

Mr. Shane Liermann, Deputy National Legislative Director, 
  Disabled American Veterans, Mr. Patrick Murray, Director, 
  National Legislative Service, Veterans of Foreign Wars and Mr. 
  Roscoe Butler, Associate Legislative Director, Government 
  Relations, Paralyzed Veterans of America.......................    19

                                APPENDIX
                          Prepared statements

The Hon. Denis McDonough, Secretary of Veterans Affairs..........    30
Joint Testimony of The Independent Budget Veterans Service 
  Organizations, Disabled American Veterans, Paralyzed Veterans 
  of America and Veterans of Foreign Wars........................    47

                        Questions for the Record

Prehearing Questions submitted by:
  Hon. Moran.....................................................    56

Post-hearing Questions submitted by:
  Hon. Moran.....................................................    80
  Hon. Blumenthal................................................   108
  Hon. Sinema....................................................   111
  Hon. Tillis....................................................   118
  Hon. Blackburn.................................................   119
  Hon. Tuberville................................................   122

                Additional Documentation for the Record

The Independent Budget FY 2022 and FY 2023 for the Department of 
  Veterans Affairs...............................................   125

 
                     REVIEW OF THE FISCAL YEAR 2022
                        BUDGET AND 2023 ADVANCE
                      APPROPRIATIONS REQUESTS FOR
                   THE DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                        WEDNESDAY, JUNE 16, 2021

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 3 p.m., in room 
418, Russell Senate Office Building, Hon. Jon Tester, Chairman 
of the committee, presiding.
    Present: Tester, Murray, Brown, Hirono, Hassan, Moran, 
Boozman, Cassidy, Rounds, Tillis, Sullivan, and Blackburn.

              OPENING STATEMENT OF CHAIRMAN TESTER

    Chairman Tester. I call this hearing to order. Good 
afternoon. I want to thank Secretary McDonough and my favorite 
Montanan, Jon Rychalski, for being here today. I appreciate you 
guys taking the time to take a closer look at the President's 
Fiscal Year 2022 budget for the Department of Veterans Affairs.
    Most everyone would agree that the VA handled the COVID-19 
pandemic incredibly well. We also know that the ripple effects 
of this pandemic is going to be felt for years to come. The 
VA's budget needs to account for this, and we have to do 
everything possible to ensure that no veteran is left behind or 
negatively impacted because of COVID-19.
    The current proposal in front of us is the largest request 
we have ever seen from the VA. I am pleased to see increases in 
funding for suicide prevention, including the implementation of 
the Scott Hannon Act, and funding to help VA speed up claims 
decisions for veterans with one of three Agent Orange-related 
conditions added by Congress just last year. It is a step in 
the right direction.
    I am also glad to see a renewed effort to address veteran 
homelessness in this budget request. However, the VA still has 
a ways to go to address deficiencies in other areas.
    Just last week, VA released its quarterly staffing numbers. 
The Veterans Health Administration has 30,000 vacant positions, 
with the majority of these being medical care providers. Look, 
we cannot deliver on its promises to veterans if we do not have 
the work force to do so. This is particularly concerning given 
the rate the department is sending veterans into the community 
for care. We need to talk about the balance between in-house 
care and community care, and VA staffing is critical in that 
conversation.
    Though we talk a lot about health care, we need to ensure 
VA's other missions are not left on the back burner. As I said 
during our May hearing on VA compensation and pension, I am 
concerned about the hundreds of thousands of backlogged VBA 
claims. The pandemic threw a wrench in the claims processing 
and the VA needs to address this backlog with the proper 
balance of speed and quality.
    This committee, as evidenced by our unanimous passage of a 
framework for comprehensive toxic exposure reform will continue 
to work to ensure that exposed veterans have access to earned 
care and benefits. We need the VA's cooperation in this 
endeavor, and I appreciate the Secretary's efforts to provide 
official views on that legislation.
    Finally, as we discussed in our hearing last week, VA has 
almost $70 billion in unmet infrastructure needs. Simply put, I 
do not see how the VA achieves any of its missions without the 
foundation of a modern, efficient, infrastructure. At the end 
of the day, these are all bipartisan issues, and this committee 
is going to address them in that fashion.
    Mr. Secretary, I know that having more of your leadership 
team in place will help ensure VA is better delivering for 
veterans across the board. So hopefully folks up here will stop 
playing games so we can get the four pending VA nominees 
confirmed and on the job, working for veterans. Because, quite 
frankly, the last thing I want to do is bring you up here in 6 
months and wring you up for something that we are the problem, 
not yours.
    I look forward to hearing from everyone today, especially 
the veteran groups here representing the Independent Budget, 
and how we can support our nation's veterans and their families 
in next year's budget.
    Senator Moran is not here, so I will turn to his right-hand 
man and say, can we go to the testimony of the good Secretary 
or do you want me to idle?
    Senator Rounds. He is en route. Could you idle for 2 
minutes?
    Chairman Tester. We are going to idle for 2 minutes. 
Rounds, you have got to have better control of Moran, I am just 
telling you.
    [Laughter.]
    [Pause.]
    Chairman Tester. So just so you guys know, we have got 
three votes starting at 3:15. Is that correct? Three votes 
starting at 3:15, so people are going to be shuffling in and 
out, and it is no disrespect to the VA. Schumer scheduled votes 
at the wrong damn time.
    So that is what we will be doing, and we have got a couple 
of panels today. We have not only got Secretary McDonough and 
Jon Rychalski, Assistant Secretary for Management and Chief 
Financial Officer, we have another panel too, which is equally 
important, with the Deputy National Legislative Director of the 
Disabled American Veterans, that would be Shane Liermann; with 
the Director of National Legislative Services of Veterans of 
Foreign Wars, that is Patrick Murray; and with the Associate 
Legislative Director of Government Relations of the Paralyzed 
Veterans of America, that would be Roscoe Butler.
    So we have got a lot of stuff to do, and here is the 
challenge that we have, so that everybody else knows. At 4:30 
the Ranking Member has a hard stop, and quite frankly, I am 
supposed to have a hard stop at 4, but that is probably not 
going to happen. So we are where we are.
    Man, I am glad we do not have to do push-ups for this 2 
minutes, I am telling you.
    We are going to recess briefly.
    [Recess.]
    Chairman Tester. All right. We will call the meeting back 
to order, and we will hear from the illustrious Ranking Member, 
the great Senator from Kansas, Senator Jerry Moran.

               OPENING STATEMENT OF SENATOR MORAN

    Senator Moran. Chairman Tester, thank you for that kind 
introduction, and I will be expecting something that you want 
from me once again, as a result. Mr. Secretary, nice to see 
you. I apologize. I assume that your opening statement would 
have been given in my absence, and I was hoping not to miss 
that.
    Chairman Tester. We did not do that. He is yet to go, so 
you are good.
    Senator Moran. Very good. Secretary McDonough, and to our 
VSO witnesses that will join us in our second panel, I am 
pleased that you are here. I am eager to hear from all of you 
your thoughts regarding the VA's proposed budget for the Fiscal 
Year 2022. These hearings, while sometimes tedious, are very 
important. We need, in my view, particularly at this point in 
time, greater transparency and an understanding of the VA's, in 
this case, funding sources. There have been so many things 
related to COVID-19 and the infrastructure plan, there are just 
a lot of things now that are out there for us to figure out, in 
my view, how it all fits together. And, of course, it is always 
important for this process to be as transparent as we can make 
it.
    Mr. Secretary, you have helped in the cause today by 
responding to our April inquiries. I would shorten my paragraph 
here again to encourage you to insist the VA respond more 
quickly to this committee. I think that even the pre-hearing 
questions for today's hearing have only been answered in a 
small portion. And so in this effort for transparency we still 
need a better, quicker, more thorough response from your team.
    The rest of that page is about criticizing you, and I saw 
you nod with me so I will assume that means that things will 
get better.
    Turning to the budget request, the VA is seeking another 
record budget that has grown from roughly $200 billion in 2019, 
to a proposed $300 billion in 2022, when combined with the 
American Rescue Plan spending and proposed Jobs Plan spending. 
Congress has worked hard to deliver VA the funding and 
resources it needs, and sometimes there is a suggestion that 
the VA needs resources and I am for that when demonstrated. But 
I need to make certain that what we are providing is being 
responsibly spent and that you have the capability of doing so 
effectively and efficiently.
    That budget of the Department of Veterans Affairs has grown 
significantly, while most budgets in the federal government, 
our agencies and departments, have remained pretty flat, and 
some have seen reductions. That is a testament to the priority 
that veterans have within the larger debate on spending 
deficits and debt, a priority that spans administrations and 
whichever party happens to have the majority. But that does not 
alleviate our responsibility to taxpayers and veterans to make 
sure that every dollar requested is adequately justified.
    Here is where I think I mostly need answers. The VA is 
asking for a 15 percent increase in medical care spending this 
year--15 percent increase in medical spending--which is a 63 
percent increase since 2018. VHA staffing is projected to be up 
17 percent since 2018 to nearly 370,000 employees, but 
outpatient visits are only up 5.9 percent since 2018. The 
average daily inpatient census is down 4.5 percent since 2018, 
and the number of unique veteran patients seen is only up 2.4 
percent since that year.
    In short, how do these many sources of funding--the base 
budget request, CARES, the American Rescue Plan--how do they 
marry up with actual caseload, actual patient care at the 
department?
    Secretary McDonough, I am hopeful that your testimony will 
untangle some of these questions so we have a clear 
understanding of how the VA expects its workload to change and 
why, and I believe that if we have the full picture, based upon 
data and sound modeling, then together we can make certain that 
the VA has the tools it needs to deliver good outcomes for 
veterans.
    Mr. Chairman, thank you for pausing to allow me to make my 
opening statement, and I welcome the Secretary and look forward 
to his testimony.
    Chairman Tester. Thank you for your words, Senator Moran. 
Now we will go to our first panel. Be as concise as possible, 
Secretary McDonough. Your entire written document will be a 
part of the record. You may proceed.

STATEMENT OF THE HONORABLE DENIS McDONOUGH, ACCOMPANIED BY THE 
HONORABLE JON RYCHALSKI, ASSISTANT SECRETARY FOR MANAGEMENT AND 
                    CHIEF FINANCIAL OFFICER

    Secretary McDonough. Chairman, thanks very much. It is an 
honor to be here, and Ranking Member Moran, thank you very 
much. Let me just also acknowledge the veteran service 
organizations who will appear after us and our union partners, 
who I believe make VA stronger.
    I am going to take one sentence from my prepared remarks 
and then just ask that the rest of them be added to the record, 
and then straight to questions, out of deference to your time 
and deference to the second panel.
    Chairman Tester. Okay.
    Secretary McDonough. The most important sentence is this 
one. I commit to using these appropriated resources 
responsibly, being fully transparent with you, and getting the 
greatest value out of every dollar.
    I will submit the rest of the statement for the record, and 
I look forward to your questions.
    [The prepared statement of Secretary McDonough follows:]

    Chairman Tester, Ranking Member Moran, distinguished Members of the 
committee-thank you for the opportunity to testify today in support of 
the President's Fiscal Year 2022 Budget Request and fiscal year Advance 
Appropriation Request for VA, and for your steadfast support of 
Veterans. I'm accompanied today by Jon Rychalski, our Assistant 
Secretary for Management and Chief Financial Officer.
    Let me also acknowledge the Veterans service organizations and our 
Union partners who make VA better and stronger.
    We have some great news. First, our goal is, by the end of July, to 
provide more care than we did before the pandemic. I don't want to call 
this ``reopening,'' because VA never closed-but I do want to make sure 
that we're offering in-person programs like residential mental health 
and substance abuse programs that are currently operating at 50 percent 
capacity.
    We will learn and improve from our pandemic experience-to ensure 
we're establishing a new, improved version of what VA looks like, a VA 
that doesn't just go back to how we operated before COVID, but one that 
we've forged into a stronger department as a result of pandemic 
challenges.
    Second, we've taken steps to reduce the backlog of claims caused by 
the pandemic. We ramped up scanning efforts to digitize federal records 
for claims processing, and temporarily assigned VA employees to the 
National Personnel Records Center to pull records necessary for claims 
processing. Now, most of VA's requests for records are answered in 2 to 
3 days, and the number of pending VA-related records requests dropped 
by 90 percent to pre-pandemic levels.
    Third, VBA rated our one millionth Veterans disability claim last 
week, hitting this important milestone faster than in all but 1 year in 
VA history-despite the challenges of COVID.
    Fourth, VA has now vaccinated 3.3 million people with at least one 
dose-Veterans, family members, caregivers, employees, and members of 
other federal agencies.
    Last, and most importantly, on May 24, just 3 weeks ago, there were 
no COVID-related deaths in any VA facility for the first time in 441 
days-since March 18, 2020.
    These positive outcomes are a direct result of two factors: 
resources, and caring, compassionate people. And as always, our efforts 
will ultimately be judged by the outcomes we produce for Veterans and 
their families. Let me tell you about one such outcome and the feedback 
we received from the Veteran's family.
    Last month, I received an e-mail from a Veteran's daughter, Dr. 
Jennifer Bendiske [BEN-disc]. Jennifer's father, a Navy Veteran of 
Vietnam, is receiving care at the VA Medical Center in Charleston, SC., 
for both Parkinson's disease and stage IV non-small cell lung cancer.
    She wrote:
    ``Everyone who my parents or I have encountered at the Medical 
Center, from those who work in the canteen to those who provide medical 
care seem to genuinely care . . . the care that has been directed 
toward my parents is a comfort to them, my sister, [me], and our 
families. In addition to the genuine concern shown by the medical 
staff, the treatments that have been proposed are in line with current 
best practices for this type and stage of disease . . . I know this 
because I am in clinical drug development, working toward new treatment 
for non-small cell lung cancer . . . I suspect that much of the 
feedback that you receive relates to that which is not working; I 
wanted to provide an example of care that meets the expectations of the 
Veteran and his family.''
    That's the kind of experience every Veteran and every family member 
deserves to experience at VA. And let's remember who makes that happen: 
VA clinicians and staff.
    They are the ones who are caring for Jennifer's father.
    They are the ones who have spent the pandemic risking their lives 
to serve the Veterans who served us.
    And they are the ones who made zero COVID deaths on May 24th 
possible.
    But those employees will also be the first to tell you that their 
life-saving work isn't possible without the resources they need.
    That's why this budget is so important. The fiscal year budget 
request will ensure VA can provide care and services for Veterans, 
their families, caregivers, and survivors-and to other Americans, such 
as the 488 non-Veterans treated at VA facilities as pandemic related 
humanitarian admissions-including citizens from Arkansas, Arizona, and 
Texas, among others.
    These resources will be put to good use, empowering our department 
to fulfill the mission that President Biden charged me with when he 
nominated me to lead VA: to fight like hell for our Veterans.
    This budget ensures we can continue the growth and success of our 
Caregiver Support Program by fully integrating families and caregivers 
into the care plans of the Veterans they love, continuing to implement 
MISSION Act expansion of our Program of Comprehensive Assistance to all 
generations of eligible Veterans. And this budget supports the training 
of over 1,900 field-based staff to improve consistency across the 
country and increase support of all family caregivers.
    The budget provides needed funding for Women Veterans, at a time 
when the number of women using VA health care has more than tripled 
since 2001, by funding recruiting and hiring for women's health 
providers, improved access to reproductive health services, and 
emergency services.
    The budget allows us to continue our success in reducing Veteran 
homelessness-building on the good work of the last decade, during which 
we decreased Veteran homelessness by 50 percent.
    This budget allows us to provide strong, sustainable, and high-
quality direct care to our Veterans at a time when they need it most. 
Community care and direct care are both important, and care in both 
contexts is rising, as we knew it would-Veterans are returning to care 
as we manage the pandemic. And while both are growing, care in the 
community is rising at a faster rate than direct care.
    Veterans need and deserve a thriving direct care system that they 
can depend upon for generations to come, because it provides higher 
quality, evidence-based, integrated care-and is tailored for Veterans 
and their unique needs. Beyond that, our nation depends on the 
research, innovation, and medical education components of VA direct 
care-as well as an effective backstop to our country's health care 
system, VA's 4th mission, that has been critically important during the 
COVID pandemic.
    And that's not all these budget resources will do. They will also 
fund mental health and suicide prevention initiatives, address major 
deficits in construction, physical and information technology (IT) 
infrastructure, continue our electronic health record (EHR) 
modernization, address issues of environmental exposures among 
generations of Veterans, and continue to ensure VA is always a place 
where diversity, equity, and inclusion are valued and sought.
    In short, this proposed budget allows us to deliver high quality 
whole health care and benefits to our Veterans at a time when they need 
it the most. And it does so, in large part, by enabling the heroic work 
of great people like those who care for Jennifer Bendiske's father.
    I commit to using these appropriated resources responsibly, being 
fully transparent with you, and getting the greatest value out of every 
dollar.
    Mr. Chairman, Ranking Member Moran, thank you for the opportunity 
to appear today.
    I look forward to your questions.

    Chairman Tester. Thank you, Secretary McDonough. That may 
be the quickest opening statement on a budget that I have ever 
heard in my life, but that is fine. That is good, because we 
will get down to the meat of it.
    Secretary McDonough. I anticipate that.
    Chairman Tester. Yep. Look, we are coming out of a global 
pandemic, as I said in my opening statement, in which more than 
600,000 Americans have lost their lives, including 12,000 
veterans in the VA health care system, and likely a whole lot 
more than that outside the system. VA facilities were filled to 
the brim, forcing VA leadership to bring mobile medical units 
and pop-up hospitals to care for sick veterans. VA clinicians 
worked day-in, day-out, risking exposure to the virus, to take 
care of every veteran in need, as well as hundreds of non-
veterans, because civilian hospitals were stretched to their 
breaking point.
    We know the statistics related to the claims backlogs and 
wait times at VA facilities were negatively impacted. It was a 
global pandemic, after all, so that does not come as a 
surprised to anyone, or at least it should not.
    So, Mr. Secretary, as the VA emerges out of this pandemic, 
can you highlight some of your efforts to address the claims 
backlog and VA wait times?
    Secretary McDonough. Yes. Thank you very much, Chairman, 
and this is obviously an issue that has come up in discussions 
with many of you since I have come into this job. And I think 
it is important to highlight some collaborative efforts that we 
have undertaken to reduce the backlog of claims.
    We have revved up significantly scanning efforts to 
digitize federal records for claims processing. We have 
temporarily assigned VBA personnel to the National Personnel 
Records Center in St. Louis to pull records necessary for 
claims processing.
    Now, most of VA's requests for records are answered in two 
to 3 days, and the number of pending VA-related record requests 
at that facility have dropped by 90 percent, getting back to 
pre-pandemic levels.
    Importantly, that is happening as we are bringing the debt 
backlog down. It was about 220,000 cases when I got there. It 
is about 180,000 cases now. The staffing enhancements that are 
envisioned in the President's budget request will allow us to 
bring it down further still, so that we get it entirely 
accounted for by the end of next fiscal year.
    Importantly, this is all happening while we are managing 
existing claims, and last week VBA rated our one-millionth 
veteran benefit claim this year at record pace. There has only 
been one other year that we have rated that many cases, a 
million, that quickly, and by the way, we did that during the 
pandemic.
    So we have significant investments here, Mr. Chairman, to 
allow us to continue that performance, and we have anticipated 
increases in the backlog from, for example, Blue Water Navy, 
coming in August. But we have a plan to account for that, and 
more.
    Chairman Tester. Also, can you speak to the urgency of 
having more of your leadership team on the job and confirmed, 
and what would it mean for veterans, particularly distressed 
veterans?
    Secretary McDonough. Well, I thank you very much, Chairman, 
on that. We have an unbelievable team, a very effective, 
capable team at VA. I am very proud to be--in fact, honored to 
be associated with the team. That millionth claim rated as of 
last week is a perfect example of that. I have just had an 
opportunity to talk with one of your committee members. I 
appreciate it very much that she made time for me in that 
conversation.
    The main thing we need is a Deputy Secretary confirmed with 
your imprimatur, responsive to your concerns, but also in a 
position to help me staff the commission to find an Under 
Secretary for Claims. That is supposed to meet next Monday and 
Tuesday. We really need him in the seat for that job, because 
we really need a confirmed Under Secretary for the first time 
in several years on this important thing, including on issues 
related to the backlog.
    Chairman Tester. Thank you. I will turn it over to Senator 
Moran.
    Senator Moran. Chairman, thank you. Mr. Secretary, I noted 
in my opening statement that--incidentally, your opening 
statement was more popular than mine--I noted in my opening 
statement VA spending on medical care and staffing for VHA is 
increasing at a much faster rate than patient visits. Some 
measures of VHA workload, such as the number of inpatients 
treated and the average daily count of inpatients is actually 
dropping.
    If less than 5 percent of the cost increases are due to 
health care trends, like inflation and costlier care, then what 
is driving the rest of the sharp increases we are seeing?
    Secretary McDonough. Yes, very fair question. I appreciate 
it. I want to focus on two things. One is something that we 
have been anticipating and we are now experiencing, which is a 
significant increase in the demand for care coming out of 
foregone care during the pandemic, something that we are 
seeing, incidentally, across the care, for veterans and non-
veterans alike.
    As an example of that, I will just tell you that from March 
to May of this year, in the direct care system, we had 16.5 
million appointments. In the community care system we had 1.25 
million appointments. Compared to the same period last year we 
had 9 million appointments in the direct care system, less than 
700,000 in the community care system. So that is about an 80 
percent increase in each--81 in the first, 79 in the second.
    Part of our staffing request for this year recognizes that 
bow wave of care will continue into next year. So that is 
obviously very important.
    Now next--and we have been working with your teams on 
this--how we calculate care is in virtual care units rather 
than in FTEs or rather than in people, clinicians to provide 
the care. And what we know about virtual care units is that our 
vets generally are bigger consumers of health care, have more 
complex cases. So individual appointments may be not the best, 
most comprehensive way, especially as you are thinking about 
cost, to calculate what we are delivering in terms of value.
    And so this is something that obviously we have developed 
over time, through several Secretaries, in a model, by the way, 
that has held up pretty well, when you look back at it.
    So big bow wave of care, generally more demanding patients, 
relatively sicker, and so that means more complex cases, which 
means greater cost.
    Senator Moran. Let me see--is there anything that you said 
that answers this question. What portion of the 2022-2023 
medical care request funds are a result of increasing costs due 
to deferred care during the pandemic? You may have said that.
    Secretary McDonough. Yes. Rather than Jon whispering it to 
me, why doesn't he----
    Mr. Rychalski. It is really a health care projection model. 
Due to COVID, it was about 7.9 percent is the estimate.
    Senator Moran. 7.9 percent of the increase?
    Mr. Rychalski. Yes. And to your point about 5 percent, 4.9 
percent is attributable to intensity, inflation, reliance, and 
then there is another 2 percent for demographic changes, 
population changes.
    Senator Moran. OK. Thank you for that. Let me ask a 
question about community care. Your budget submission notes the 
department's desire to place veterans at the center of their 
own care. It also prioritizes a rebalance of direct and 
community care. I do not know if the department told us in 
detail what a rebalance would entail in this budget submission. 
What specific factors and data is the department taking into 
consideration for a rebalance, and how does this influence your 
budget and advanced appropriation request?
    Secretary McDonough. Great. Thanks very much for that. I 
think the numbers are roughly about--we anticipate about $25 to 
$26 billion in community care in this coming year, and in the 
advanced appropriation we are asking for, it is slightly over 
$24 billion. The first and most important thing is we are 
trying to understand precisely what the vets want, right. If we 
are going to put them at the center of their care, the way we 
do that is we ask them. So the Veterans Experience Office is 
out in the field with a very aggressive effort to understand 
from them what it is that they want, specifically what have we 
learned from the experience of the pandemic, where vets have 
demonstrated a much greater intensity and interest in, for 
example, video and telehealth than I would have anticipated, 
and then any conventional model had been anticipated 
heretofore.
    The second thing relates to making sure that we recognize 
vets in our care do better in terms of outcomes. And I have 
committed to you that everything I decide here will be decided 
on access and outcomes. And so one of the things we know about 
outcomes is the fact that we have integrated care with the full 
range of specialties that vets have come to rely on, 
particularly given their particular challenges of care. One of 
the things I will be looking at very closely, Senator, is our 
ability over time, understanding that we will be under budget 
pressure and we will not see these kinds of record budgets, is 
maintaining the system and its integrated nature with the full 
range of specialties that our veterans demand.
    And so one of the indicators that you see in our budget is 
making sure that we can recruit and keep specialists in the 
system, so we can address those in-house, rather than being at 
the risk of weakening that if we become over-reliant on the 
community.
    Senator Moran. I will have a couple of followup questions 
if I have the chance later. Otherwise, I will submit them to 
you in writing and we can have a conversation.
    I am going to go vote, so Senator Tester can go vote.

                  SENATOR MARGARET WOOD HASSAN

    Chairman Tester. Senator Hassan?
    Senator Hassan. Well, thank you, Mr. Chair and Ranking 
Member Moran, and thank you Secretary McDonough and all of our 
other witnesses for testifying today. Mr. Secretary, I was not 
on the committee yet when you were confirmed so this is my 
first hearing where you are appearing. I am really looking 
forward to working with you to help veterans across the country 
and in New Hampshire get the benefits they earned and deserve.
    New Hampshire is one of three states, along with Alaska and 
Hawaii, that lacks a full-service VA hospital, something am 
working to change. As my colleagues have pointed out, the VA's 
budget is insufficient to meet the agency's dire infrastructure 
needs.
    In your prepared testimony you noted that the President's 
proposed funding in the American Jobs Plan for VA 
infrastructure--and that is something I strongly support as 
well--but we need to make sure that VA funding that goes toward 
infrastructure adequately addressed the need of Granite state 
veterans.
    So does the agency take into account the lack of full-
service VA hospitals in certain states when developing your 
budget plan and priorities?
    Secretary McDonough. We do.
    Senator Hassan. That is helpful to know, and I would love 
to continue to work with you to make sure that, especially as 
we deal with the needs for community care and improved 
infrastructure at the resources we do have in New Hampshire, 
that they are attended to.
    Secretary McDonough. You can count on that.
    Senator Hassan. Thank you. The National Cemetery 
Administration has made increased access to burial benefits a 
strategic goal. This includes providing additional grant 
funding to state and tribal organizations. Unfortunately, as a 
condition of receiving VA money for improvements, state veteran 
cemeteries are barred from interring many National Guard 
members and reservists. Today I joined Senator Shaheen, Cramer, 
and Hoeven in introducing a bipartisan, bicameral bill that 
addresses this issue.
    So Secretary, will you and your team consider this bill and 
provide us with feedback, and will you work with my office to 
increase access to burial benefits, including for National 
Guard members and reservists? It is a matter just incredibly 
important to Granite state veterans.
    Secretary McDonough. Yes, I will say three things about 
this. I do not want to eat up your time. One is the budget 
request in the President's budget for this year continues a 
strategic expansion of our cemetery footprint to ensure that 
everybody has access. I am very proud of that service. I think 
this is really an important investment.
    Second is it came to my attention very early in my tenure 
here that we have a discrepancy whereby New Hampshire has asked 
for one way to use its state grant from us for its cemetery. It 
is inconsistent with current reg.
    Senator Hassan. Right.
    Chairman Tester. But there is North Dakota, who is 
currently using VA-provided funding in that same way.
    We have gone out with a Request for Information to the 
field, to all 50 states, to say hey, how should we do this.
    Senator Hassan. Okay.
    Secretary McDonough. Then we will have a conversation with 
you about it. In all cases, I will look at your bill.
    Senator Hassan. Well, I appreciate that very much and I 
know Granite state veterans would too.
    Last question. In this year's budget, the Veterans Benefits 
Administration lists two organizational priorities: benefits 
delivery and suicide prevention. The veteran suicide rate is 
highest among those 18 to 34 years old. This age group also 
accounts for 75 percent of transitioning servicemembers.
    You and I have discussed the Solid Start program, an 
initiative that aims to contact every veteran multiple times by 
phone in the first year after they leave active duty, to check 
in and help connect them to VA programs and benefits. I have a 
bipartisan bill with Senators Cramer and Cassidy to strengthen 
and make permanent this important program, which the committee 
will consider further, I hope during our legislative hearing 
next week.
    Secretary McDonough, can you please speak to how the Solid 
Start program aligns with the Veterans Benefits 
Administration's priorities, and will you work with us to 
support and build on this program?
    Secretary McDonough. So often the benefits package is the 
introduction to VA service for our vets, and we want to make 
sure that the introduction is not only professional, 
transparent, based on the customer service, and a positive 
experience, but that it also opens the door to the full range 
of services we have. So being in touch with our vets, including 
about introducing them to all of our services, including, when 
necessary, mental health services, is really important, and it 
is consistent with what we are doing through our program called 
REACH VET, which is a fundamental tenet of our suicide 
prevention programming.
    Senator Hassan. Well, thank you. I would love to continue 
to work on this and the Solid Start program with you. What I am 
hearing from veterans is just there is so much transition going 
on in that first period after they leave active service that 
they could really use that kind of steady outreach, and it may 
take multiple attempts. And I think it really benefits all our 
veterans and the country. So thank you.
    Secretary McDonough. Might be a good way for us to get more 
enrollees too.
    Senator Hassan. Yes. Yes. Thank you. Thank you, Mr. Chair.
    Chairman Tester. Senator Boozman?

                      SENATOR JOHN BOOZMAN

    Senator Boozman. Thank you, Mr. Chairman, and thank you, 
Mr. Secretary, for being here. I want to be quick because 
Senator Tillis and I have to go vote. That is the only thing we 
have got to do around here.
    But I appreciate your transparency and I appreciate your 
willingness to work with us. We had a good talk about Chairman 
Tester's Cost of War Act, again going further so we can get 
good information. We are all really interested in doing that 
and get some really good legislation passed.
    The Senator mentioned suicide, and I am pleased that the 
John Scott Hannon bill, you know, we got that done and we are 
starting to implement that. Can you briefly discuss how the 
program is progressing? Do you have any more updates, 
particularly about the effort with the grant program? 
Everything tells us once they get in the VA they are going to 
do better than being on the outside.
    Secretary McDonough. Yes, we have had an extended 
conversation, now going back a couple of months, on this. 
Obviously the Hannon Act, as a general matter, offers us a lot 
of new, additional, very helpful authorities. One in particular 
is the Sergeant Fox--I think the Sergeant Fox Grant Act. We 
have been in the field now, seeking public comment on that. We 
want ideas from the actual service providers we want to fund.
    We are aggregating that. We are now in a position that we 
will be able to invite competition for grants come next spring, 
and we believe that will be in the field with the funding by 
next fall. I am thinking October-ish. The President's budget 
anticipates that. The funding for that program is in the 
President's budget. It is part of the increase in funding for 
suicide prevention that the Chairman talked about in his 
opening comments, and we think it is really important.
    Senator Boozman. Good. I have got an additional question I 
will put in the record concerning the medical records, you 
know, the process there.
    Thank you, Mr. Chairman.
    Chairman Tester. Thank you, Senator Boozman. Senator 
Tillis?

                      SENATOR THOM TILLIS

    Senator Tillis. Thank you, Mr. Chairman, and thank you, 
Senator Boozman. Secretary McDonough, it is good to see you.
    I want to go back. You know, we had the recent addition of 
three new diseases for the Agent Orange presumptive list, and 
that could be another potential bow wave if you have seen how 
the VA has dealt with this in the past. I do not think they 
were quite prepared for the influx of claims, not under your 
watch but under a prior administration. Now we have the TEAM 
Act, and the Cost of War Act, which is far more expansive than 
that, potentially.
    To this point we have not received from the department a 
position on either the Cost of War Act or the TEAM Act. The 
puzzle pieces that we have had, had them refer to the 
legislation that came together under the Cost of War Act.
    At some point we are going to need definitive stance on 
whether or not the legislation is workable and whether or not a 
budget request would take into account something that is 
likely, I believe, going to pass out of the Senate and 
potentially enjoy support on the House side.
    So I think I can make an assumption that your current 
budget request does not in any way account for that additional 
influx of claims?
    Secretary McDonough. That is correct. So we have several 
lines of effort going at the moment. You mentioned the three 
Agent Orange claims. We have just started those presumptive 
claims. We announced, ourselves, the initiation of rulemaking 
on three conditions that may be included, related to service in 
Iraq, Afghanistan, and Uzbekistan. We are continuing to work 
that.
    Our budget anticipates the Agent Orange pieces. Anything 
beyond that it does not yet anticipate, because I think those 
would be outside this fiscal year. But you have my commitment, 
as I have given the Chairman, as I have given Senator 
Blackburn, as I have given Senator Moran, and I have testified 
in the House, that we owe you--entirely fair question--we owe 
you what our estimates are for cost, discretionary, mandatory, 
what we believe will be required in terms of people, and what 
we believe will happen as it relates to the backlog.
    We are trying to get that accurately, you know, under the 
theory, you want it bad, you get it bad. I want it good, and I 
want to be able to stand by it. So I have said we can get that 
to you while you are still in session, in this summer. If I 
give it to you now it just would not be accurate, and I do not 
want to give you something I cannot stand by.
    Senator Tillis. Yes, we need that as quickly as possible, 
and I think some of your internal reviews on how you may be 
able to provide a solution to the problem under the current 
authorities.
    I also wanted to talk about your $2.7 billion for the VA 
health record account and $4.8 billion in total services for 
the Office of Information Technology. This represents about, I 
think, a $100 million cut under the 2021 appropriation for 
OI&T. So I am trying to understand, as you grow, as you add 
resources there is typically an operational tell for 
information technology and support. What assumptions did you 
make to justify the $100 million reduction?
    Secretary McDonough. Yes, so I am going to let Jon do that, 
but the first thing I want to say is just on EHRM, generally. 
We have really appreciated your scratching in on that with us. 
I will be in a position before the end of this month to submit 
a series of reports to you all. We will talk with our VSO 
partners, with our staff about that, with our agency staff 
about that, and with you all. But we know we are on the hook to 
provide that, and I think we are going to be in a good position 
to do it. But in terms of the OI&T budget, Jon can talk about 
the assumptions.
    Mr. Rychalski. Sir, that $4.8 billion is part of our budget 
request, but we also have access to the transformational fund 
starting in 2022, which is access to our expiring 
appropriations that we can use for two purposes. One is for IT 
and one is for physical infrastructure. And so we are going to 
use about, I think, $600-and-some million of that 
transformation fund for IT, and that will bring the total 
funding to about $5.3, $5.4, which is about a 13 percent 
increase.
    Senator Tillis. So it is only a category cut----
    Mr. Rychalski. Source of funding. You do not see that in 
the budget, or in that table, yes.
    Senator Tillis. Very good. I am going to submit a question 
for the record about dental health services down in the VA 
facility. We are building it. We are standing up additional 
facilities, but I think there is a need down there, with the 
growing population, that may easily tap the additional facility 
that you all have in mind, but I will submit a question for the 
record on that. And I look forward to getting with you all on 
the progress of the program office for the HR. Thank you, Mr. 
Chair.
    Chairman Tester. Thank you, Senator Tillis. Senator Murray?

                      SENATOR PATTY MURRAY

    Senator Murray. Thank you so much, Secretary McDonough. 
Good to see you here. Thank you for being with us today. You 
know, since the implementation of the expanded Caregiver 
Program last October, VA has reported receiving more than 
81,000 applications for the Caregiver Program, and 
unfortunately VA denied many of these applications because of 
the activities of daily living requirement and the 70 percent 
service connection requirement.
    Chairman Tester and I actually wrote to you in May about 
our concerns about how the program is being implemented. It is 
so critical for so many of our families. It is essential that 
veterans receive accurate decisions and do not experience 
delays in approval determinations.
    So I wanted to ask you today, what is the VA doing to 
implement the Caregiver Program, as Congress intended, 
including addressing these restrictive regulations? And also, 
what is the VA doing to respond to the Beaudette court 
decision?
    Secretary McDonough. Yes. Thanks so much. Let me talk about 
the Beaudette case first. We have submitted paperwork for an 
appeal of that to the next level court inside the Vet's Court 
of Appeals. We are working that. We are in direct touch with 
the litigants on the other side, to make sure that if there is 
something that we can do to work this out toward shared 
objectives that we do this, that we do not necessarily need to 
take an adversarial posture on this.
    Second, I do think it is a fair critique that perhaps some 
of these regulations have been overly restrictive and some of 
the decisions to date have been insufficiently explained to our 
applicants. That is why you see what you see in the President's 
budget request for the year going forward, to allow us not only 
to be prepared to implement the full expansion of the program 
at the end of next Fiscal Year but that we are in a position to 
also adequately staff across the country with 1,900 additional 
staff offices to address these concerns forthrightly with our 
vets and their caregivers.
    So this is a major priority for the President, as you know. 
I cannot tell you that we will resolve every question exactly, 
precisely, but I can tell you that it is a major priority, and 
the budget gives us some additional resources to make that the 
case.
    Senator Murray. Okay. I look forward to working with you to 
get that. This is just a huge priority for me. It has been for 
a long time. These families have been waiting, and it is just 
absolutely critical to them.
    Secretary McDonough. Absolutely.
    Senator Murray. You know, as VA has transitioned to the 
Community Care Network, my office has helped a lot of veterans 
as they adjust to this new system, and as clinics close in some 
locations and open in new ones across the state. In addition, 
the President's budget request includes funding for the Asset 
and Infrastructure Review Commission to review VA's 
recommendations in realigning the VHA facilities.
    How will VA take into account the challenges veterans face 
in navigating the new Community Care Network as well as 
existing geographical challenges that rural veterans face when 
making recommendations about the realignment?
    Secretary McDonough. You know, Access for our rural vets is 
a fundamental priority of the President. It also happens to be 
a fundamental priority of this committee, and I have been able 
to spend some time in your state and Senator Tester's state and 
Senator Moran's state, exploring exactly these questions.
    We do believe that Community Care is a key portion of that, 
but we also, as I said in response to Senator Moran's 
questions, want to make sure that we sustain the integrated and 
full-service nature of the VA system itself. If you look at now 
as that relates to the AIR Commission, if you look at the 
criteria on which we will make our decisions about 
infrastructure in that commission, we published it in the 
federal register about two and a half weeks ago, we put at the 
heart of that these questions of the integrated care system and 
the multiple roles that the VA plays, from education to 
training to research and to the provision of service across the 
entire country, to inform those decisionmaking opportunities 
that we will have in that commission.
    So my commitment to this committee is that we will handle 
all these decisions very publicly, very transparently, 
including, if necessary, an open session with you, to make sure 
that you understand the basis for our decisions and that we are 
able to get your feedback on them. It does not make any sense 
to me for us to conduct this review on such a critical issue 
behind closed doors. So that is my commitment to you, and I 
think you should be able to see that becoming evident in the 
next months on this.
    Senator Murray. Okay. Thank you very much. I appreciate it.
    Senator Brown. [Presiding.] Senator Rounds is recognized.

                      SENATOR MIKE ROUNDS

    Senator Rounds. Thank you, Mr. Chairman. Gentlemen, first 
of all, thank you for your service and thanks for appearing 
here before the committee today.
    Mr. Secretary, thank you for the phone call a couple of 
weeks ago with regard to housing, veterans' housing. I think it 
is something that we can work on together----
    Secretary McDonough. I agree.
    Senator Rounds [continuing]. and make some substantial 
improvements on. So I appreciate your attention to that.
    In addition, I will just share with you that I recognize 
that we have got veterans and we are making more veterans, and 
we have needed to. And as we do that, we owe them the 
commitment that we are going to honor our pledge to them with 
regard to the benefits that they have earned. And I know that 
there is a cost involved in that.
    I appreciate the comments that you made with regard to 
where the increases have been going and why they are there 
today. I look forward to working with you in the future. I just 
want to make sure that the resources that we put in, whatever 
they may need to do the appropriate job, that they are doing it 
in as efficient a way as possible but also one which clearly 
has that veteran first at heart. And I think you feel the same 
way that I do on that.
    I would also like to come back in on an item that is of 
real interest to me on a personal note, is the Hot Springs VA 
campus.
    Secretary McDonough. Yes.
    Senator Rounds. As you know, that particular campus, 
located in Hot Springs, South Dakota, is a critical part of the 
department's Black Hills Health Care System. Last October, 
former Secretary Wilkie rescinded a record of decision on the 
future of the campus, which provides vital health care 
services, not only to South Dakotans but residents of four 
other states. That record of decision would have significantly 
reduced the Hot Springs campus, and I am very happy that he 
worked with us to have it rescinded.
    In your confirmation hearing you recommitted to working 
closely on addressing the needs of the Hot Springs VA Medical 
Center. Has the department developed a long-term plan to 
modernize and expand this facility?
    Secretary McDonough. If the department has, Senator, 
candidly, I am not aware of it, but we are in the process, in 
the context of our infrastructure review and the context of the 
AIR Commission, and in the context of the annual budget 
process, continually looking at those questions. Included in 
this, and this is probably something I think you or your team 
would want to dig into, we have been conducting what we call 
market assessments pursuant to the Asset and Infrastructure 
Review Commission. My guess is that those market assessments 
speak a little bit to demand in that region in South Dakota, 
obviously, including, as you said, Nebraska and the other 
bordering states.
    So no specific plans that I am aware of, but my commitment 
to you remains, which is that as we do that, my commitment is 
to work with you closely on it.
    Senator Rounds. I understand that you are just getting on 
the ground and rowing through it, and that is what I would ask 
of you, sir, is that as you move forward in this that we not 
lose sight of the fact that you have got an absolutely 
beautiful facility, and you have got one that serves the needs 
of a large number of vets in a very rural area, and you have a 
community that clearly wants to continue to provide that 
service. So I would just ask that you keep us in the loop, and 
we will make contact and arrange for direct contact continuing 
in the future.
    Secretary McDonough. You can count on that.
    Senator Rounds. Thank you.
    Secretary McDonough. Thank you, Senator.
    Senator Rounds. Thank you, Mr. Chairman.
    Senator Moran. [Presiding.] Senator Rounds, thank you. 
Senator Brown?

                     SENATOR SHERROD BROWN

    Senator Brown. Thanks, Ranking Member Moran, and Secretary, 
nice to see you again. Our committee has made great strides 
getting veterans and their families vaccinated, making sure 
that homeless vets and veterans at risk of becoming homeless 
have additional resources through the ARP. Thank you for your 
efforts there. The $18 billion in VA funding to improve and 
modernize VA infrastructure, all of that is really important 
and it will help improve veterans' access to care, as you point 
out, and as I know Chairman Tester mentions over and over, 
getting the care where they want to receive it, that is at the 
VA, where most veterans want to go.
    When Senators Tester, Reed, and I raised concerns about the 
proposed rule for military borrowers, coming out of the last 
days of the last administration, you took action to ensure that 
veterans and servicemembers who struggled had the opportunity 
to get back on track with their payments and remain in their 
homes. Thank you for doing that. That was essential.
    I also encourage you to keep working with the CFPB's Office 
of Servicemember Affairs, which plays a critical role 
advocating for military customers, consumers, if you would be 
willing to continue to do that.
    Secretary McDonough. You can count on that.
    Senator Brown. Thank you. At last week's hearing, Senator 
Murray raised whether VA has a comprehensive plan to assess 
long-term care needs for veterans, whether it be at CLCs or 
state veterans homes or through home-based care options. 
Senator Murray and I will be following up with you on that 
topic, because investing in veterans' care is so important. I 
hope you will work with us to make sure VA has the right 
strategy and resources.
    Secretary McDonough. We will.
    Senator Brown. I know you are thinking about that. Thank 
you.
    Secretary McDonough. Yes.
    Senator Brown. We recently received a troubling OIG report 
about Chillicothe in southern Ohio, its facility. It lacks 
specific physical infrastructure to ensure veterans' physical 
well-being. That veteran should not have been admitted because, 
as the report stated, the patient's overall needs did not align 
with the services and capabilities available in the CLC. The 
veteran later died, as I think you know. You are aware of that 
report?
    Secretary McDonough. I am.
    Senator Brown. Okay. Thank you. I hope that VHA leaders 
review and implement OIG recommendations uniformly across VA's 
health system to ensure that all veterans at VA remain safe. My 
question, Mr. Secretary, has VA looked at its CLC facilities to 
see whether additional security features, like sure outdoor 
areas, two-door entry systems, might be appropriate to maintain 
patient safety? If so, could the American Jobs Plan 
infrastructure funding go toward those projects?
    Secretary McDonough. We are constantly reviewing the CLCs 
and, in particular, we have taken a deep look at performance in 
the CLCs during the pandemic, and have been able to apply those 
lessons learned in privately held facilities and state-run 
facilities, so I am proud of that.
    I will be very candid with you. I do not know whether we 
have looked at the specific security upgrades you have talked 
about, but I will find that out.
    Then as it relates to the infrastructure money anticipated 
in the Jobs Plan, of the $18 billion, $3 billion would be set 
aside for immediate needs. We have a list of those now. I will 
make sure that we have anticipated any specific security needs 
for that, and will come back to you on that. The other $15 
billion would be dedicated to the kinds of investments that, 
you know, are pretty evident across the system, and we would be 
more than happy to talk to you about that in additional detail. 
But on the specific questions around security upgrades, I do 
not have that with me. I have not looked into that, and I will.
    Senator Brown. Okay, if you would. Thank you.
    Mr. Secretary, last, we know the VA has a huge compensation 
and pension claims backlog, and exam backlog too. You have 
publicly discussed the VA using a mix of telehealth and in-
person exams at the VA and with contract and medical examiners.
    Secretary McDonough. Yes.
    Senator Brown. I know that you raised this when Senator 
Tester asked. Please keep us updated, because Ohio veterans 
raise that issue frequently with me.
    Secretary McDonough. And they are right to, and they are 
right to expect a fair call on that, and we are trying to turn 
up the volume on each of those channels, and we want to do it 
in a way where vets feel like they get a fair shake, and that 
is what we will intend to do. And, by the way, we have cranked 
up, thanks to interventions from many of you on this committee, 
the provision of C&P exams in the VHA system itself, from our 
providers. Now that comes at a cost to other services we 
provide, but we think it important, and Dr. Stone has been a 
great partner on this.
    Senator Brown. Thank you, Mr. Secretary.
    Chairman Tester. [Presiding.] Senator Moran, you have an 
important question.
    Senator Moran. Mr. Secretary, or Secretary Rychalski, I 
want to go back to what is driving increased requests for 
funding. In the budget document it talks about health care 
trends as the component that drives 5 percent of the increase, 
and I assume that is increased demand and inflation. And yet we 
are at a 15 percent increase. So what is the other 10 percent? 
Am I missing something here?
    Mr. Rychalski. So year to year, the greatest increase for 
us in health care, and I think in the commercial and Medicare/
Medicaid is, it is not the number of appointments. It is the 
inflation, but also intensity, and I guess the best way to 
describe intensity is the replacement of one treatment modality 
with a more expensive, like Hep C treatment or Alzheimer's 
treatment. And then there is the demographic changes, the 
population changes, more people come into the system. Their 
reliance is a big thing for us, how much people rely on the 
system. Historically, people have relied on the VA for about 30 
percent of their health care. That is increasing. And then in 
our 2022 budget, there is the COVID impact, which is about 7.9 
percent, and if you look in our budget and brief book, it 
breaks out those categories of the things that are major 
contributors to the 2022 budget request.
    Senator Moran. I think I understand that, and one of my 
takeaways from that answer is that when I look at increasing 
number of patients seen, that is an inadequate determiner of 
the necessary funding for their care.
    Mr. Rychalski. Right. The number of patients seen is not--
you know, our patients, our actuary had determined that our 
patients are about 30 percent, I don't want to say sicker, but 
have more serious conditions, about 30 percent, and that is 
going to be exacerbated by COVID. And so they tend to cost 
more. An emergency room visit costs more than, say, you know, a 
nurse practitioner visit.
    That is something else that we are seeing, is a lot of 
patients, our emergency room visits are sort of off the charts, 
so to speak. People are accessing emergency rooms at a rate 
that we have just not seen before. So it is things like that.
    Senator Moran. Did the urgent care clinics diminish 
emergency----
    Mr. Rychalski. No. They increased dramatically, and 
emergency room visits increased, doubled, dramatically.
    Senator Moran. OK. Thank you both.
    Mr. Rychalski. It is hard to know yet whether that is a 
fleeting thing, inasmuch as this is a tenet of the return to 
care, but we are very focused on it. I am quite concerned about 
it. The cost implications are significant. We have been talking 
to your teams and the appropriators, just in full candor, about 
whether we have the money to make it through this year, so we 
would continue to talk to you about that in terms of Community 
Care funding. So we will keep a very open line on that.
    Senator Moran. I think absent COVID, Mr. Secretary, with 
the increasing use of urgent care at the VA, I think I would 
expect a reduction in emergency room.
    Mr. Rychalski. You would think, and there are some of these 
trends that, on one level, are illogical. But, you know, the 
question is how much of the logic gets thrown out because of 
the pandemic.
    Senator Moran. Thank you very much. Thank you, Chairman.
    Chairman Tester. Thank you, Senator Moran. Thanks to both 
of you for being here today. I wish there could have been more 
of a grilling, but the votes kind of screwed that up.
    Secretary McDonough. We are not that disappointed.
    Chairman Tester. I bet you are not. That is good, but thank 
you, guys.
    Secretary McDonough. We are comfortable with the level of 
grilling.
    Chairman Tester. It will come later, okay, so thank you 
both for being here.
    Now while we get the panel set up, we are going to hear 
from three veteran service organizations who wrote this year's 
Independent Budget. I have said many times, and I believe this, 
that Congress needs to take its cues from veterans, and I am 
looking forward to hearing the veteran service organizations' 
views on this year's budget proposal.
    I want to introduce three people I guess should be just 
made part of the committee because they are here every 
committee meeting: Shane Liermann, Deputy National Legislative 
Director for DAV, the Disabled American Veterans; Patrick 
Murray, Director of National Legislative Service at the 
Veterans of Foreign Wars; and last but not least, Roscoe 
Butler, Associate Legislative Director for Paralyzed Veterans 
of America. These guys all know how important the VA is for 
health care, housing, and others, and we look forward to your 
words. Mr. Liermann, you may start.

 STATEMENT OF SHANE LIERMANN, PATRICK MURRAY AND ROSCOE BUTLER

    Mr. Liermann. Thank you. Chairman Tester, Ranking Member 
Moran, and members of the committee, thank you for inviting the 
Independent Budget veteran service organizations--DAV, PVA, and 
VFW--to testify on VA's budget request.
    For more than 30 years, the IBVSOs have presented 
comprehensive budget and policy recommendations to ensure that 
VA is properly funded. Earlier this year, in February, we 
released the IB budget recommendations for Fiscal Year 2022 and 
Fiscal Year 2023 advanced appropriations, which detailed our 
best estimates at the time, and we ask that the full IB report 
be made part of the record.
    On behalf of my colleagues from PVA and the VFW, I am 
pleased to offer our highlights of the main IB budget 
recommendations and comment on the administration's request for 
VA funding.
    Mr. Chairman, overall the administration's proposed budget 
for Fiscal Year 2022, when combined with appropriated funding 
from the American Rescue Plan, available funding from VA's 
transformational fund, and proposed funding from the American 
Jobs Plan, would fully fund veterans' programs, benefits, and 
services for the first time in a generation. We commend the 
administration for this historic VA budget request, and now we 
call on this committee and Congress to ensure VA and veterans 
receive what they need and deserve.
    Mr. Chairman, for VA medical care the IB recommended a 
total of $81.5 billion for Fiscal Year 2022. By comparison, the 
administration has requested $78.1 billion in new 
appropriations. However, VA will also have an additional $12.5 
billion for medical care from the American Rescue Plan that was 
enacted in March.
    The administration also requested a significant increase 
for medical community care, plus $2 billion from the AARP. We 
would note that the primary reason for community care increases 
continues to be inadequate access to VA health care due to a 
lack of treatment space and health care providers. For this 
reason, the IBVSOs recommended filling at least 25 percent of 
pending VHA vacancies, and we are very pleased that the VA's 
budget request proposes 17,000 new FTEs for VHA.
    With more than half the veterans population over age 65, we 
recommended an additional $335 million to expand VA's long-term 
care programs. We also recommend that VA be provided sufficient 
funding to accelerate the Phase 2 expansion of VA's Caregiver 
Program.
    To ensure that VA has adequate IT capabilities, the IVBSOs 
recommended $5.2 billion to sustain all of VA's critical IT 
programs for VHA, VBA, and NCA. Within that IT budget, the 
IBVSOs call on VA to fund some specific needs, to include $42 
million to support VA research programs, $175 million to begin 
funding a portion of VBA's most critical pending IT projects, 
and $25 million for the Board to modernize its Case Flow 
program and AI needs.
    Mr. Chairman, the COVID-19 pandemic not only delayed VA 
health care for millions of veterans, it also created backlogs 
in the delivery of benefits by VBA and the Board. In February 
2020, there were approximately 70,000 benefits claims at VBA 
pending over 125 days. At the end of May of this year, there 
were more than twice that, almost 190,000 backlogged claims. 
There are also over 90,000 pending hearing requests with the 
Board, an increase of 15,000 pending hearings from a year ago.
    In order to address these backlogs, IBVSOs called for 
significant budget and FTE increases. We note that the 
administration proposed an additional 429 FTEs for VBA, whereas 
the IBVSOs recommended more than twice that amount to address 
the claims backlog, expand VA's call center capabilities, and 
address a growing volume of FOIA requests. The IBVSOs also 
recommended an additional 200 FTEs to address the hearing 
backlog, whereas the administration has requested roughly 
three-quarters that amount.
    Mr. Chairman, VA could not provide timely, quality care to 
enrolled veterans without having adequate and modern health 
care facilities. For Fiscal Year 2022, the IBVSOs recommended a 
total of $2.8 billion for major construction, which included $1 
billion for seismic deficiencies. Although the administration 
requested just $1.6 billion, it has also proposed that VA 
receive $15 billion for VA hospital construction as part of its 
infrastructure proposal in the American Jobs Plan. More 
importantly, the IBVSOs recommend that VA significantly 
increase its internal capacity to plan and manage 
infrastructure and construction projects by hiring additional 
personnel.
    As we await the recommendations of the upcoming AIR 
Commission, Congress and VA must not wait to conduct critical 
maintenance upgrades and modernizations and new construction of 
already necessary facilities. While the AIR process will inform 
the future of VA's health care infrastructure, there is already 
a $60-plus billion backlog that represents VA's needs right 
now.
    Finally, Mr. Chairman, the IBVSOs remain grateful for the 
continued bipartisanship support of VA and veterans programs by 
successive congresses and administrations of both parties. Like 
all of you, we are committed to ensuring that precious federal 
resources provided to VA for veterans care, benefits, and 
services are effectively and efficiently used, and that waste, 
fraud, and abuse are minimized. However, we must never forget 
that providing those who served with the health care and 
benefits they have earned is a part of the cost of our national 
defense.
    As Congress looks to expand benefits for veterans, 
including those exposed to burn pits and toxic substances, we 
must never ask veterans themselves to pay for these benefits by 
cutting veterans programs and services. And for those who would 
look at the size of VA's budget request and ask, ``When will VA 
be adequately funded?'' our answer is clear: when all enrolled 
veterans have timely access to quality care and all earned 
benefits are delivered accurately and on time.
    Mr. Chairman, we are confident that with the continued 
bipartisan work of this committee and Congress, we can achieve 
that goal for all the men and women who served.
    This includes the IB testimony on VA's budget. My 
colleagues and I look forward to any questions you and the 
committee may have.
    Chairman Tester. Thank you, Mr. Liermann. I have been 
informed that you did most of the talking and the others will 
answer all the questions. Is that true?
    Mr. Liermann. That is right.
    Chairman Tester. Okay. All right. We will start then.
    You spoke about this, Shane, in your remarks. Last week we 
had a hearing on what the VA needs to ensure its infrastructure 
is ready to support the veterans for years to come. One key 
component of this is construction. As the Independent Budget 
notes, VA has multiple sites that lack the funding to complete 
projects that are underway. The administration is requesting 
$1.6 billion for major construction. The Independent Budget 
estimates the need at $2.8 billion. You already pointed out 
that if we are able to get the infrastructure bill there is 
another $15 billion there, which would be incredibly 
significant.
    Can you all speak to why you think this account needs more 
funding, and what it means in terms of service that the VA 
provides to your members? I would just say this. I am part of 
the bipartisan team that is doing the negotiations on the $587 
billion package. The VA is not in that, OK. So tell me, using 
the potential infrastructure money, with and without, what the 
challenges are.
    Mr. Liermann. Mr. Chairman, thank you for bringing that up. 
Last week in the hearing, Kaiser mentioned that they go off 
about 3 percent operating costs. Three percent for VA would put 
them somewhere, anywhere from last year, this year, the 
upcoming year, anywhere from $6 to $8 billion. That would 
probably take care of VA's infrastructure needs.
    Currently they cannot do that work, though. They need more 
people to do the work. We talk about vacancies in VHA, the 
30,000 mostly doctors and nurses. That is also critical. But we 
need the buildings to do that. We need to not only fill the 
vacancies that are there for the construction jobs--the project 
managers, the engineers--we need to expand that cap as well. So 
we think that adding additional personnel to do that would 
help.
    Also a plan to actually knock down the backlog. The 
Secretary mentioned there were records and claims backlogs that 
are being addressed by adding VBA personnel, by adding staffing 
to take care of that. There is no plan to even meet the current 
backlog, never mind actually start to diminish it. So we think 
a plan to knock that down, a 10-year projection, whatever it 
might be, that is something critical in order to address 
infrastructure.
    Chairman Tester. Okay. So just to be clear, when you say if 
they build the construction they do not have the manpower, that 
is not necessary to build the physical infrastructure. That is 
to actually man the physical infrastructure once it is built.
    Mr. Liermann. No, it is to actually execute the contracts, 
specifically like NRM contracts. There are billions of dollars, 
about $22 billion worth of maintenance needed. If we gave them 
$22 billion in a year, they would not be able to execute that 
workload.
    Chairman Tester. I got you.
    Mr. Liermann. So that is the manpower that we need to 
actually execute the contracts, and oversee them as well.
    Chairman Tester. That is helpful because I read it a 
different direction, so thank you.
    Let's talk about mental health for a second. The 
department's request fully funds the Hannon Act, as has been 
pointed out by several on this panel today on this rostrum, to 
the previous panel. This is an important step for getting high-
quality mental health out to all veterans who need it, and we 
all know that COVID-19 has not helped the mental health status. 
But we know that staffing plays a major role in ensuring 
veterans have the mental health that they need, and make sure 
their needs are met.
    Are there any staffing-related challenges that your members 
are facing, and how would you suggest that the VA addresses 
them, or better yet, how would you suggest that we address the 
challenges so the VA can address them?
    Mr. Murray. Chairman, it is essential that VA implement the 
authorities that you have given them, the John Hannon Act, and 
so forth, and fully ensure that all the things that are in 
place are implemented, and veterans can receive the mental 
health services that they deserve. Right now, as you know, with 
the staffing challenges, a lot of the staffing challenges are 
clinical service-wise, and when you have those types of 
challenges, it creates burnout amongst the staff that are there 
doing the work.
    So VA needs to ensure that they have a sufficient staffing 
plan that they can share with you, to demonstrate how they are 
going to decrease the staffing shortages, but also ensure that 
the authorities that you have given them to help offset some of 
the services being provided in-house can also be provided 
through the other means made available to them.
    Chairman Tester. Thank you. Senator Moran?
    Senator Moran. Chairman, thank you. Gentlemen, thank you 
very much.
    The VA's budget for 2022 proposes spending from all sources 
for medical care that is $17.5 billion more than the IB's 
recommendation. That is a 17 percent difference. Where does 
that come from?
    Mr. Murray. Frankly, Senator, as the Secretary mentioned, 
COVID. There are a lot of details that we do not have as 
accurate information as the department does. But our 
recommendations come off of trends, come off of what we have 
seen, basically appointments, as was also discussed, 
appointments is not the most accurate way when you are talking 
about the complexity of the appointments. So that is some of 
the difference there, that we are basing ours off of 
appointments, which I am sure we would love to see more about 
their information. But that is the difference.
    Senator Moran. Okay. Thank you.
    Mr. Butler. Let me also add, VA released their budget---I 
mean, the IB released their budget in February. As Shane was 
saying, or Patrick was saying, Mr. Murray was saying, is that, 
you know, VA recently released their budget, and so additional 
information was made available to them that we did not have at 
the time that we released our budget. But our assessment was an 
independent assessment of, at that time, what we felt was the 
need.
    Senator Moran. Thank you both. The Independent Budget's 
estimate for community care assumes that the existing access 
standards remain in place. I did not say it quite right. Is 
that true? So you are estimating the need, the dollars 
necessary for community care, we have community care standard 
in place. I assume that your estimate would be based upon those 
community care standards staying in place as they are.
    Mr. Murray. Yes, sir, until the next period to review them 
would be, yes.
    Senator Moran. Okay. Thank you. You noted, in your 
testimony, the importance of a couple of economic programs that 
I consider important and have championed, such as the Veteran 
Rapid Retraining Program and then the VET TEC Act. Do you have 
any suggestion for how we make certain we have the right kind 
of data for these programs that would tell us how we can 
improve employability and mitigate loss of earnings, 
particularly for disabled veterans, going forward?
    Mr. Murray. Absolutely. Thank you for bringing those up. 
The VET TEC Program, we have seen great successes in so far. It 
is a newer program, and increasing the capacity, the number of 
slots available we think is very important. It originally 
started at about 15,000, doubled, now it is to 45,000. There is 
a bill to increase it to about 125,000. The demand is there. 
There are a lot of people looking to go back to work through 
that program.
    The Veteran Rapid Retraining Program, some of the last 
numbers there were about a few thousand applicants so far, so 
that is getting off the ground. We are very excited about that 
program. It takes some of the existing employment along with 
some of the BAH model payments that the GI Bill has, and kind 
of a hybrid, to get folks back to work.
    We are very encouraged by what we have seen so far, and I 
think transparent, regular reporting about those programs would 
really help, to let us know where we need to almost double 
down. If we are going to invest in programs that are going to 
put people back to work, you know, putting food on the table, 
paying taxes back into the system, that is important for us to 
know exactly how successful those are.
    Senator Moran. You said it very well. Thank you, Mr. 
Murray. Chairman, I will yield back my time.
    Chairman Tester. Senator Hirono?

                      SENATOR MAZIE HIRONO

    Senator Hirono. Thank you, Mr. Chairman. Thank you, all of 
you on the panel, for your advocacy on behalf of veterans.
    I want to get to the subject of reproductive health, so 
this is for Mr. Butler and Mr. Liermann. Am I pronouncing your 
name correctly? So increasing health services for women at VA 
facilities necessarily includes reproductive care. Would you 
agree?
    So does this budget, in your opinion, support reproductive 
care, especially as it relates to women veterans with service-
connected conditions that may impact their ability to have 
children? Any of you can respond to that.
    Mr. Butler. I think the Independent Budget recommendation 
support the necessary increase for IVF, and that we fully 
support that recommendation.
    Senator Hirono. So the question was specifically whether it 
is adequate to provide reproductive health services to women 
veterans. Have you been in contact with advocacy groups for 
women veterans on this point, whether they think it is enough 
funding?
    Mr. Butler. We have, and our contact at PVA has spoken with 
many advocates of women veterans, and they support PVA's budget 
recommendations.
    Senator Hirono. Good, because we are making progress, 
because at least now we are recognizing this is an important 
aspect of what should be made available, services to women 
veterans.
    Not too long ago eliminating homelessness among the 
veterans community was the No. 1 priority for the VA, and 
Secretary McDonough's statement notes that it still is among 
those, but it is no longer the top priority. Obviously with 
COVID there are even more veterans who are homeless. Correct?
    So are you satisfied that the VA is doing what is necessary 
or doing all that it can to eliminate homelessness among 
veterans, and if not, what should they be doing?
    Mr. Butler. Well, this predates back to Secretary 
Shinseki's statement about----
    Senator Hirono. Yes, I know. I was here then.
    Mr. Butler [continuing]. calling to eliminate homelessness 
and the initiative that he put forth. So over the past 
administration, since Secretary Shinseki left, there has been, 
in our opinion, a lack of increasing in eliminating 
homelessness. There are some examples of where they did not 
spend all of the money that they should have spent toward that 
initiative.
    So we would like to see the VA renew its efforts in 
eliminating homelessness across the nation.
    Senator Hirono. Well, you are nodding your head. Did you 
want to add something to this, Mr. Liermann?
    Mr. Liermann. No, I agree with Mr. Butler's comments. If 
you take a look at some of the legislation that has been 
introduced lately, talking about increasing grants and 
increasing more funding for other organizations that are able 
to provide those, we absolutely agree.
    Then when you try to think of what is the priority, right, 
homelessness, absolutely. Suicide, absolutely. Mental health 
services, providing women veterans with what they need. So we 
believe, and we are all committed, as part of the DAV, to find 
ways to eliminate and find the right balance of funding for all 
of these programs.
    I think trying to say that one should be a priority over 
another is very difficult do when they are all just as 
important as the other, but I do agree that we do need to 
increase that commitment and renew it. Veterans should not be 
homeless when there is a means to get them the help they need.
    Senator Hirono. I think we need to become a lot more 
creative about our approaches, because homelessness among 
veterans, it is not a monolithic issue. There is a lot that you 
have to delve into to figure out, you know, how we can house 
the veterans, how can we provide them with the training they 
need, if they need training to get jobs, all of that. It is 
interconnected. So when we talk about mental health needs, that 
also relates to homelessness, I would say. Suicide also.
    So there is an interconnectedness, and I do not know if the 
VA has really embarked on much more of an interconnected 
approach to eliminating homelessness among veterans, but what 
could be--I can't say more important, I knowledge all these 
things are important. This has been just a perennial issue, and 
it is very troubling.
    Cemetery maintenance. The National Memorial Center of the 
Pacific, Punchbowl--have you all been there? It is quite the 
facility, yes--anyway, currently has a number of deferred 
maintenance projects, some of which have been on the books for 
nearly 10 years. Now your testimony applauded VA's budget 
request for the National Cemetery Administration. So knowing 
that, for example, the Punchbowl facility has been waiting for 
over 10 years for some needed improvements, do you still think 
that the funding for the National Cemetery Administration is 
adequate?
    Mr. Murray. Ma'am, one of the things that we would really 
like to see happen is to almost clear the deck of some of these 
outstanding projects, much the same way that state veterans 
homes recently, there was about $500 million given to kind of 
take out that priority list. We think that especially projects 
like Punchbowl, as you mentioned, and cemeteries around the 
country that have very similar challenges--you know, space, 
they need to actually just put in the right facilities in order 
to place our nation's heroes. That facility mirrors other 
challenges around the country, and we think that those are ways 
that we can just clear that deck, by adding infrastructure 
moneys to actually address some of these longstanding project 
issues.
    Senator Hirono. Well, that is the thing--and I am sorry, 
Mr. Chairman--but I would love to clear the decks on all of 
these things. You know that we are on the page with you all, 
but obviously the need exceeds the funds available, not to 
mention that there are communities of veterans still waiting 
for, for example, CBOCs to be built. And, you know, we have had 
situations on Oahu, for example, where the community has been 
waiting for like 5, 6, 7, 8 years. So, you know, those need to 
be cleared too.
    So I would just like to see the VA, especially under 
Secretary McDonough's leadership, have a sense of urgency, and 
let's get on with all of these things. So I got that off my 
chest, Mr. Chairman.
    Chairman Tester. That's good. Senator Sullivan?

                      SENATOR DAN SULLIVAN

    Senator Sullivan. Thank you, Mr. Chairman. Gentlemen, 
thanks. Mr. Secretary, thanks. Sorry I missed the first panel. 
Man, that went fast. We had a bunch of votes, but maybe I will 
call you and give you kind of update on some of the issues I am 
focused on, one of which I was going to ask the Secretary but I 
want to ask our VSO leadership. It goes to this issue of VA-DoD 
integration. You know, we have that in Chicago. It is a good 
way to actually save money but expand services. You do not have 
a lot of those opportunities throughout the country, really 
throughout the federal government.
    In Alaska, over 40 percent of our residents are federal 
health care beneficiaries. That is VA or DoD kind of related, 
which is really pretty big. I think it is one of the biggest 
per capita, if not the biggest in the country. But we do not 
even have a full-service VA hospital, in the whole state. More 
vets per capita than any state in the country.
    What is the general view, from you guys' perspective, on 
those kind of opportunities--VA-DoD integration in terms of 
hospitals and health care?
    Mr. Murray. Senator, one of the things that we really think 
is critical for VA is flexibility. Hopefully the AIR Commission 
is going to provide a lot of answers. As you mentioned, 
Chicago. There are other places where they can have 
partnerships, the public-private partnerships.
    Senator Sullivan. I am pushing this in the NDAA this year. 
I think the VA is supportive. But Alaska, to me, I know Senator 
Hassan mentioned it a little bit ago, but I think we are kind 
of a pole position for that.
    Mr. Murray. But shared facilities is another flexible one. 
Reviewing the lease authority so that they can execute the 
leases that are different than the 10-year moneys needed up 
front. But also looking at areas like medical schools, so that 
they could partner with places that need a place to train. VA 
has been a training organization for years. Over 70 percent of 
physicians have been trained at VA facilities at one point in 
their career.
    Partnering with folks like that, with organizations like 
that, we think is important, and giving them the authority to 
start those sharing facilities from the ground up, not going 
into an existing one and trying to create an authority to share 
it once there is already an existing facility in place, but 
actually starting from, you know, digging the first shovel in 
the dirt. They do not have that right now. I think that would 
help add to the flexibility.
    Senator Sullivan. Good. I am glad you mentioned medical 
schools. We do not have a medical school in Alaska, 
unfortunately, but we did have legislation a couple of years 
ago that had VA residency programs with our Alaska Native 
health organizations. It was very popular. We are implementing 
it now, so that is another good example on flexibility. Shane, 
anyone else, gentlemen, you have views on that first question I 
asked?
    Mr. Liermann. Absolutely. Thank you, Senator. Evidence 
shows, and what we know is veterans do better with VA health 
care. They thrive. They have better preventative maintenance 
and they are just long term going to do better. So if we can 
find ways to provide that with these partnerships and with 
other facilities, other organizations, it is going to benefit 
veterans in the long run. It is hard to believe there is not a 
full hospital there, but providing that access is extremely 
important.
    I come from a very rural part of the country as well, 
Nebraska, and the nearest VA facility was over 3 hours from 
where I was living at the time. They have increased CBOCs in 
those areas, but again, to the point, when you cannot have 
access to the health care we need to find that flexibility, as 
Pat mentioned, to get them, because we know they do better with 
VA health care.
    Senator Sullivan. Okay. Mr. Butler, do you have a view, 
sir?
    Mr. Butler. Well, the Chicago facility has demonstrated to 
be a proven model. I have also been to Alaska and seen now the 
integration between DoD and the Alaskan health care system 
works together.
    So I think that there is opportunities for improvement in 
those areas, and expansion in those areas. So there should be 
serious concerns, and hopefully this administration will look 
to do more in those efforts.
    Senator Sullivan. Good. Thank you. Let me go back, Mr. 
Liermann, real quick, on the burn pit exposure. You know, my 
legislation with Senator Manchin, you have been really strong 
supporters of. You referenced in your opening statement 
challenges with the current claims backlog.
    What we are trying to do here, as you know, is get in front 
of this, not having an Agent Orange-type of situation, but also 
make sure the VA is getting the science right and making sure 
that we can afford this, so there is a balance. One issue that 
a lot of people forget, if you do massive amounts in this area 
you start to crowd out people who are already in the system.
    Can you kind of unpack a little bit more of the reference 
you made in your opening statement on the claims backlog and 
what you think, in addition to my legislation, needs to happen?
    Mr. Liermann. Thank you, Senator. With over roughly 190,000 
pending claims right now, and then we know that VA now has to 
add the newer implications, Blue Water Navy, Agent Orange 
cases, the three new presumptives that are starting, any new 
additional presumptive diseases that would be added, or new 
exposures, based on my experience in 2010, when VA added three 
additional exposures at that time, it really did create a 
significant amount of additional work, and it really did add to 
the backlog of pending claims throughout the VA.
    So going forward, we need to be mindful that if we are 
going to add additional presumptive disease and exposures that 
VA is very well prepared with the number of people in place, 
and a plan in place before they start, so we do not add an 
additional one-to 2-year wait on claims, as we have seen in the 
past.
    Senator Sullivan. Yes. It is a huge issue, and I think--I 
am not sure this committee is thinking through that well 
enough. We do not want to create a giant backlog by doing 
something we all think--and trust me, I have been, you know, on 
the front foot on this one for quite a while--what we think we 
are doing right, but then there are consequences that we are 
creating even more wait times for not just burn pit exposure 
veterans but Blue Water Navy, I mean, just the list gets long. 
Any thoughts on that?
    Mr. Murray. Yes. We agree with you that we need to be 
mindful of that. But this is not necessarily a new problem. The 
scope of what we are talking about is new. This might be larger 
than anything we have talked about, but in terms of an influx 
of new claims, we have seen that. In terms of it creating a 
backlog, we have seen that. So moving forward, when this 
passes, we want to see that there are resources dedicated up 
front, so we can do what we can to mitigate that, so we do not 
run into that problem again. It is the same problem we have 
seen. This will maybe be something a little bit more expansive, 
but we should be able to get ahead of it.
    Senator Sullivan. Yes. We have seen this movie before. The 
committee and the VA need to be ready for it, right? We know it 
is coming. We have just got to comprehensively look at how to 
address it. Mr. Butler, do you have any views on that?
    Mr. Butler. No.
    Senator Sullivan. [Presiding.] Okay. All right. I think I 
have been given the gavel here, and so I want to thank the 
Secretary and the VSOs, the leadership here. We make a promise 
to those who serve our country, and if the VA is going to 
deliver on them they need the resources to do it. I am 
supportive of that increase.
    I am not sure if I should raise it, but I am going to raise 
it anyways. This administration has put forward a budget that 
actually cuts the Department of Defense, adjusted for 
inflation. That is not good. That is not good. I know that is 
not you guys' area, but you guys care about it. My veterans 
back home in Alaska, they care about the VA budget. They care 
about the DoD budget too. We should not be cutting the DoD 
budget, but that's a whole other topic.
    We will keep the record open for a week. Mr. Secretary, I 
know there were a number of us who wanted to--I did not get 
here in time for your testimony. It was not at all disrespect. 
It was just the votes. So I am sure there are going to be 
questions submitted for the record for you, sir.
    Other than that, I want to thank the witnesses for their 
service, particularly to our great veterans, and this hearing 
is now adjourned.
    [Whereupon, at 4:29 p.m., the Committee was adjourned.]

                                APPENDIX

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