[Senate Hearing 117-567]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-567

                 AN END-OF-YEAR LOOK AT THE STATE OF VA

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               ----------                              

                            DECEMBER 1, 2021

                               ----------                              

       Printed for the use of the Committee on Veterans' Affairs


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

                 AN END-OF-YEAR LOOK AT THE STATE OF VA
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 




                         


                                                        S. Hrg. 117-567
 
                 AN END-OF-YEAR LOOK AT THE STATE OF VA

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            DECEMBER 1, 2021

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
       
 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]      
       
       


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

             U.S. GOVERNMENT PUBLISHING OFFICE 
50-550              WASHINGTON : 2024       
        
        
        
        
        
        
        
        
                 SENATE 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

                              ----------                              

                            December 1, 2021

                                SENATORS

                                                                   Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     2
Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire......    10
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    12
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    14
Blackburn, Hon. Marsha, U.S. Senator from Tennessee..............    16
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    18
Tuberville, Hon. Tommy, U.S. Senator from Alabama................    20
Murray, Hon. Patty, U.S. Senator from Washington.................    22
Rounds, Hon. Mike, U.S. Senator from South Dakota................    24
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    26
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    28
Manchin III, Hon. Joe, U.S. Senator from West Virginia...........    30
Cramer, Hon. Kevin, U.S. Senator from North Dakota...............    33
Sinema, Hon. Kyrsten, U.S. Senator from Arizona..................    36

                                WITNESS

The Honorable Denis McDonough, Secretary of Veterans Affairs.....     3

                                APPENDIX
                           Prepared Statement

The Honorable Denis McDonough, Secretary of Veterans Affairs.....    45

                        Questions for the Record

Department of Veterans Affairs response to questions submitted 
  by:

  Hon. Sherrod Brown.............................................    59
  Hon. Richard Blumenthal........................................    61
  Hon. Mazie K. Hirono...........................................    68
  Hon. Jerry Moran...............................................    75
  Hon. Marsha Blackburn..........................................    92
  Hon. Tommy Tuberville..........................................    93
  
  

                       Submissions for the Record

Labat-Anderson Incorporated, Palomares Nuclear Weapons Accident, 
  Revised Dose Evaluation Report, April 2001.....................    97

U.S. Air Force Safety Center, 2020 Topical Issues for Assessment 
  of Dose to Palomares Accident Recovery Workers (1966)..........   234


                 AN END-OF-YEAR LOOK AT THE STATE OF VA

                              ----------                              


                      WEDNESDAY, DECEMBER 1, 2021

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3 p.m., via Webex 
and in Room SR-418, Russell Senate Office Building, Hon. Jon 
Tester, Chairman of the Committee, presiding.
    Present: Tester, Murray, Brown, Blumenthal, Hirono, 
Manchin, Sinema, Hassan, Moran, Boozman, Cassidy, Rounds, 
Tillis, Sullivan, Blackburn, Cramer, and Tuberville.

            OPENING STATEMENT OF CHAIRMAN JON TESTER

    Chairman Tester. I want to call this Senate Veterans' 
Affairs Committee meeting together. Today we are here to take 
stock on how the VA is doing and where it is headed in 2022. I 
want to welcome our only witness today, the Honorable Secretary 
Denis McDonough, for today's discussion.
    Mr. Secretary, you have been a great partner and I 
appreciate your leadership and your transparency and your 
candor. You initially assumed your role in the middle of a 
pandemic, and we all commend your team's efforts to care for 
and vaccinate as many veterans as possible in the fight against 
COVID-19. Today more than 3.7 million veterans have been fully 
vaccinated by the VA and more than 105,000 veteran spouses and 
caregivers have been vaccinated by the VA through our 
bipartisan Saves Lives Act, which was enacted earlier this 
year.
    Running VA is a challenge, not just because it is the 
Nation's largest integrated health care system but because of 
the unique role it plays in all of our communities. VA provides 
veterans with wraparound services and coordinated care, makes 
huge investments in training our Nation's health workforce. It 
also serves as a national backstop to overwhelmed hospitals and 
health systems through its Fourth Mission.
    And unlike the private sector, the VA has the benefit of 
watchdogs organizations like the Office of Inspector General 
and Government Accountability Office that point out 
deficiencies and opportunities in VA care and programs. This 
helps us, the Senate, ensure that the VA is doing all it can to 
provide veterans with holistic, high quality, and timely care, 
something that we are not fully ensured when veterans go into 
the community for their care.
    As we look to the year ahead, I know that there is a shared 
commitment, of this Committee and of yours, on toxic exposure. 
Veterans cannot afford to wait any longer for the care and 
benefits that they have earned and deserve. I look forward to 
working with you and Ranking Member Moran and other members to 
ensure that these veterans are not left behind.
    Another issue I want to highlight here today is the 
caregiver program. The MISSION Act required VA to expand the 
program to veterans of all areas by October 2021. The VA has 
delayed full implementation until October of next year. By 
missing this deadline, veterans and their caregivers have to 
wait even longer for the support and resources that they are 
due. I would like to get your assurance that the VA will work 
to expedite this timeline while also ensuring veterans are not 
unfairly denied. I know you share this commitment to do right 
by our veterans because you always have.
    I look forward to hearing more about your nearly first year 
on the job and where the VA is headed.
    And now I want to hand it over to my friend and Ranking 
Member, Senator Jerry Moran.

            OPENING STATEMENT OF SENATOR JERRY MORAN

    Senator Moran. Mr. Chairman, thank you, and Mr. Secretary, 
thank you for your service. Thank you for your service 
specifically as the Secretary of the Department of Veterans 
Affairs. The Kansan in me has to give you a compliment. I 
appreciate the way you have conducted yourself before I provide 
some criticism here momentarily. And while we are smiling about 
that criticism, it is sincerely offered. I do not want to make 
light of it.
    Congress determined that the most effective way for 
veterans to receive health care is to provide them with a 
choice of where they receive that care, in the VA or from a 
provider that is in their community. Under the MISSION Act the 
law is clear. Through the access standards or through a 
veteran's own consultation with his or her clinician, VA must 
provide that choice.
    Despite what the law says, I continue to hear, my staff 
continues to hear about veterans, through the press, through 
disclosures to my office, of those people who have not been 
able to fully exercise their choice because the VA 
administrators are discouraging the use of community care and 
even overruling clinicians who seek community care for their 
patients.
    I had planned to comment on your inability, the 
Department's inability to provide me with answers to what 
should be a routine oversight request as we investigate these 
reports and these disclosures. However, the Department provided 
us with your responses to a request that stretches back to 
October 4th yesterday afternoon. Should I have been provided 
this information in a more timely manner we could have had a 
more robust conversation today. I might have been better able 
to analyze your answers to my concerns on a topic that is 
critical to me, and, in my view, critical to the health of our 
business.
    Unfortunately, requests related to community care are not 
the only outstanding oversight request. We still have not 
received a response to our letter from October 27th, seeking 
information and data related to the coronavirus vaccine 
mandate. Although the vaccination deadline has passed for all 
VA employees, the Committee has had very little information on 
what impact the mandate has had on the workforce.
    This is the positive point. I appreciate the views we 
received from the Department on the Cost of War Act. These 
views and cost estimates will help determine how best to 
provide health care and benefits to veterans who were exposed 
to toxic substances. I applaud the VA's recent efforts to 
establish presumptive decisions related to toxic exposure. 
However, we have yet to be briefed on the findings of the VA's 
end-to-end internal review that resulted in the VA's 
presumptive decision-making pilot program. The result of that 
review is important from an oversight perspective. It also can 
help us better understand the mechanics of the VA's process as 
we draft legislation on this important topic.
    I expect us to continue working closely together to 
identify the remaining gaps in the VA's authority, refine 
operational impacts on estimates, and develop legislation to 
address veterans sickened by exposure to toxic substances.
    Mr. Secretary, I look forward to your testimony and I thank 
you for your service.
    Mr. Chairman, I yield.
    Senator Tester. Thank you, Senator Moran.
    I would like to welcome our first and only panelist of the 
day, the Honorable Denis McDonough, Secretary of Veterans 
Affairs.
    Secretary McDonough, the floor is yours.

             STATEMENT OF THE HON. DENIS MCDONOUGH

    Secretary McDonough. Chairman, thank you very much, Ranking 
Member Moran, distinguished members of the Committee, thank you 
for your support of veterans and for the opportunity to testify 
before you today.
    Our mission at VA is very simple and it goes back to what I 
first said when I testified before you back in January. We must 
serve veterans, their families, caregivers, and survivors as 
well as they have served us. That is the promise we make at VA, 
and between the pandemic and everything else that has happened 
this year, keeping that promise to vets has never been more 
important than it is right now.
    Fortunately, throughout the past year, VA employees, many 
of whom are vets themselves, have stepped up across the country 
to fulfill that obligation. Employees like Bobie Smith in 
Tennessee, who helped a veteran who had been struggling with 
alcohol and substance use find a purpose again through our 
compensated work program. Like Lindsay Daly, a call center 
supervisor in Arizona who spoke at length with a veteran in 
need, found out that he was teetering on the brink of 
homelessness and got him housing assistance before it was too 
late. Or like Herman Watkins, Michael Foster, and Brian Hudson 
of the Alabama National Cemetery, who saw a surviving spouse 
grieving at her husband's gravesite, discovered that she was 
struggling with suicidal thoughts, got her the help she needed, 
and, as she describes it, saved her life that day.
    I tell those stories because those public servants are not 
the exception at VA. They are the rule. And the work they have 
done during the pandemic has not only helped us respond to 
COVID but forged us into a stronger, better Department for our 
Nation's veterans.
    We have seen more patients via direct and, I underscore, 
community care, processed more claims, and held more benefits 
hearings than in any previous year in VA's history. We have 
massively ramped up telehealth and tele-appeals, allowing us to 
meet vets where they want, when they want, in unprecedented 
ways. Our outpatient trust scores among vets rose to 90 
percent, above 90 percent, the highest in years, and we 
vaccinated, as you said, more than 4 million vets and others, 
and led the charge in Federal Government on the employee 
vaccine requirements.
    We have cared for non-vets as part of our Fourth Mission, 
deploying staff to hotspots and providing beds for hundreds of 
COVID patients in need. And our cemeteries have not only stayed 
open during the pandemic but expanded to six new locations.
    So the state of VA is that we are now providing more care, 
more services, and more benefits to more veterans than ever 
before, and we are doing it by driving toward four fundamental 
principles: advocacy, access, outcomes, and excellence.
    Advocacy. Advocating for vets is a team effort, from the 
White House to VA to Congress to vet service organizations, and 
this year that team effort has resulted in lifesaving 
legislation like the American Rescue Plan and the Save Lives 
Act. It also resulted in a fiscal year 2022 budget that 
delivers for veterans and for which I ask Congress to 
appropriate funds as soon as possible to avoid a year-long 
continuing resolution that would directly harm our Nation's 
vets. And it has resulted in real progress and new presumptives 
on environmental exposures, making President Biden the first 
President to proactively provide benefits to vets who have 
fought our wars in the Middle East and South Asia for the past 
30 years, and, more importantly, ensuring that thousands of 
those vets are finally getting the benefits they deserve.
    Second, access. We are making sure that veterans have 
access to the best care and services, at home, in the 
community, and at VA. That means supporting caregivers. It 
means finding the right balance between direct care and 
community care, because veterans deserve a thriving and 
sustainable direct care system, one that ensures that future 
generations of veterans will enjoy the same great VA health 
care that past generations have.
    I underscore here in the letter, Senator Moran, I was 
responding to a letter of November 12, so it may be that I 
missed an earlier letter. But in any case I wanted to get that 
in the briefing we gave to your staff to you, so we could have 
that kind of conversation today and continue what I have 
considered a very rich conversation in private as well.
    It means reaching out to every vet who deferred care during 
the pandemic, which we are doing through VHA's Moving Forward 
Together campaign, to let vets know that we are here for them, 
ready to offer timely, face-to-face, world-class care. And it 
means deploying an electronic health record system that 
improves access outcomes for vets wherever they get the care.
    Third, on outcomes, which drive everything we do because 
vets, not us, are the ultimately judges of our success. Two 
important outcomes are addressing veteran suicide and veteran 
homelessness, two phrases that simply should not exist in the 
English language.
    On preventing veteran suicide, we have held more telehealth 
sessions than ever before, massively ramped up our lethal means 
safety efforts, and reached out to every single veteran in our 
network to let them know that they are not alone, especially in 
the aftermath of Afghanistan.
    And on ending veteran homelessness, we are making progress 
in Los Angeles, where there are more homeless vets than 
anywhere else in America, therefore building momentum toward 
housing every one of the more than 40,000 homeless vets in the 
country. Addressing these issues is a top priority because one 
veteran who dies by suicide or who is homeless is one too many.
    Finally, on excellence, I can just underscore one more time 
that in this Administration nobody is going to have to fight to 
get the quality care, benefits, and services they have earned, 
no matter who they are, where they come from, or who they love.
    So that the VA right now, delivering more care, more 
benefits, more services to more vets than ever before. But the 
state of VA is not just where we are now. It is about looking 
around the corner to where we are going. Let's be honest--there 
are some real challenges.
    Looking ahead to this winter, we are going to be releasing 
the AIR Commission recommendations, and I again encourage each 
of you and your staffs to get the briefings from our teams now 
on the market assessments in your States. Because we are on the 
verge of some very big decisions here, and you should 
understand the analytic basis for those decisions.
    At the same time, we may be facing an increase in COVID, 
which is already brewing across the country with the Delta 
variant, even as we seek greater clarity on Omicron.
    But I promise you this. We will learn from everything we 
have done over the past 20 months to meet this moment. We are 
already doing that in a place like Michigan, where we have more 
than 35 beds at the ready for vets and non-vets alike, and in 
places like Nebraska and Washington, where we have deployed 
staff to State veteran homes to make sure they have the 
capacity and training they need to help keep vets through this 
coming surge.
    The bottom line is that we will learn from last year to 
prepare for next year. We will see veterans through this surge 
and all of those coming challenges. We will work with this 
Committee and keep you informed every step of the way as we do 
it, because vets, their families, caregivers, and survivors 
deserve our very best. And with your continued help and 
partnership we will never settle for anything less.
    Thanks for the opportunity to be here today. I look very 
much forward to the conversation and your questions.

    [The prepared statement of Secretary McDonough appears on 
page 45 of the Appendix.]

    Senator Tester. Mr. Secretary, thank you for your 
statement. You have been on the job for almost a year. I do not 
need to tell you how important the job that you are doing is 
for our veterans, vitally important. So what has been the 
biggest challenge and what has been the biggest success for the 
Department during your tenure?
    Secretary McDonough. The biggest challenge is most 
definitely the pandemic. It has colored everything we do. It 
impacts our vets and it impacts our workforce. And so I, as I 
said in my opening remarks, take great pride in the fact that 
we have led the Nation on vaccination, both as it relates to 
veterans, and thanks to you all, veteran spouses and family 
members, as well as our workforce.
    I am equally proud of our work on toxic exposure.
    The biggest complication that we face is the flip side of 
the pandemic, which is our workforce is now 20 months into 
extraordinary efforts. And there is no mobile work options for 
clinicians in hospitals and clinics. They are working under 
constant challenge associated with contracting COVID. They are 
working in scenarios where their kids are, you know, over the 
course of the last year, at homeschooling.
    So I worry a great deal about ensuring that we keep that 
workforce supported and its morale is where it should be, given 
its high performance.
    Senator Tester. So if you could, quickly if you could, tell 
me what your top three priorities are going in for next year.
    Secretary McDonough. One is getting vets timely access to 
world-class health care. Two is getting vets timely access to 
world-class benefits. I consider those two things to be core 
course requirements. Anything else we do is extra credit, 
meaning if we do not perform on getting timely access to care, 
in the direct care system and in the community, and we do not 
get timely access to benefits, anything else we do will not 
matter.
    The third priority is what you hit at the end of your 
remarks. We are out of the gate, I would argue, strong on toxic 
exposure, but we are nowhere near where we need to be, and I am 
looking very much forward to continuing that progress, 
including working with you all.
    Senator Tester. I appreciate that. So right now it appears 
that we are going to be working on a continuing resolution at 
least until the end of January, maybe longer. I hope not but 
maybe--maybe for the full year, actually. Included in the 
Senate Appropriations Committee's passed 2022 is mandatory 
funding needed to pay veterans' benefits resulting from the 
Agent Orange presumptive, the new Agent Orange presumptive. 
There is also discretionary funding to hire hundreds of claims 
processors, additional processors.
    Can you discuss how the VA is going to pay these veterans 
their earned benefits and reduce the claim backlog if new 
funding is not made available?
    Secretary McDonough. Well I am very concerned about a year-
long continuing resolution. I think you just hit one of the big 
detriments, which would be a $259 million decrement from what 
we anticipated having to invest for toxic exposure at VBA, 
staffing, and advancements in, for example, the digital GI 
Bill. But there also would be a decrement of $941 million, for 
example, in Community Care. That is a substantial hit.
    Our challenge would be making do with a smaller allotment 
for people. You know, we are out in the market right now, 
hiring 2,000 people. We have about 900 already on board. They 
have begun training. Under that scenario, we could get those 
900 under a continuing resolution. We could get some of those 
900 in seats. So we could continue to process some claims, but 
it would inevitably lead to a longer backlog.
    Senator Tester. So my daughter is CEO of a hospital in the 
private sector. She has had a very difficult time getting 
nurses. There are not enough to begin with, and now with the 
traveling nurses getting paid big bucks, she is having a lot of 
the nurses leave.
    Could you just give me a quick update where the VA is as 
far as workforce and what you see as the challenges, and if 
there is anything we do to help you meet the challenges of a 
fully staffed VA? And I can do the same for docs if you want.
    Secretary McDonough. Yes. Look, first and foremost I just 
want to underscore one more time how proud I am of that 
workforce. Notwithstanding the huge challenges that they have 
confronted they are performing extraordinarily well, first and 
foremost.
    Second--and I talked with Senator Boozman in Arkansas about 
this last week--we have a series of OPM waivers that allow us, 
for example, to hire people in as quick as three days during 
the pandemic. Those are about five or six provisions that are 
tied to the national emergency associated with the pandemic. If 
that national emergency goes away we want to work with you to 
incorporate those hiring authorities into authorization, into 
statute. That is one place where we can work together. That 
includes finding nurses.
    Point three, we are asking the appropriators to give us 
some flexibility on what we call the Three R's--relocation, 
retention, and retraining--which would allow us, within the 
existing budget envelope, to compete more aggressively to keep 
our nurses, and to keep our docs, including our specialists.
    We will, as we finish a review of other authorities, come 
back to you with some requests--and this is basket four--where 
we might work together, with your forbearance, to see about 
doing away, for example, with the discrepancy between Title 5 
employees at VHA and Title 38 employees at VHA, because the 
multiple systems binds us up in unfortunate ways. But also 
Title 5 is a lot less workable, frankly, for us than Title 38, 
in a highly competitive market.
    So I appreciate the question. That is the start of what we 
are thinking. We will come back to you near the start of next 
year with some additional ideas of how we are thinking about 
nurse pay, doctor pay, importantly medical center director pay, 
which is one of the big challenges between Title 5 and Title 
38.
    Senator Tester. I appreciate that. Senator Moran.
    Senator Moran. Mr. Chairman, thank you.
    Chairman, first of all on the idea of a continuing 
resolution, there is absolutely no reason Congress cannot get 
its work done. A continuing resolution is damaging, as you 
described, to the Department of Veterans Affairs and most 
importantly the veterans it serves, and there is no legitimate 
reason that this Congress cannot resolve its differences on the 
appropriations process. And I pledge to you and to Senator 
Boozman, the Ranking Members of the Veteran Appropriations 
Subcommittee, MILCON VA, and all my colleagues that we ought to 
be all in on this, and we ought not let anybody have an 
explanation, an excuse for why this cannot be done.
    Senator Tester. Senator Moran, let's get 'er done.
    Senator Moran. Let's get 'er done.
    Let me start, Mr. Secretary, recently you were interviewed 
on a number of news programs, and you indicated that if a 
veteran is in need of urgent mental health services the VA will 
provide that veteran with a same-day mental health appointment. 
Is that correct, and could you walk me, the Committee through 
how that process works. That is a great development, and it is 
one of the things I worry about in rural America, where if you 
need mental health services, if you are suicidal, you need that 
attention immediately, and the VA, in some instances, is far 
removed.
    Secretary McDonough. Yep. So I want to distinguish between 
emergency care and urgent care. So if we have a veteran who is 
in emergency circumstances, a mental health requirement, for 
example, manifests, at an emergency department or manifests on 
the Veteran Crisis Line, we can get that veteran seen that day, 
telehealth or in person, depending on distance. But if you come 
to us through the Veteran Crisis Line, you come to us through 
an emergency department, or you happen to manifest somewhere 
else in a CBOC, community-based outpatient clinic, or in one of 
our hospitals, we can get you there.
    Urgent care, the word you used was ``urgent.'' Urgent care 
is a degree less emergent, and we have looked back and done an 
assessment over the course of the pandemic, and somebody 
manifesting urgent care needs, mental health or physical 
health, we are seeing an average of less than two days.
    Senator Moran. I think I used the word ``urgent''----
    Secretary McDonough. You did.
    Senator Moran [continuing]. In the more----
    Secretary McDonough. Well, that is why--I am not trying to 
parse here, but I want to make sure you understand what I mean.
    Senator Moran. I appreciate that distinction.
    Secretary McDonough. And emergency would mean suicidal 
ideation, for example, and this is why we have, and you guys 
have given us as many resources as you have given us, for the 
Veteran Crisis Line, for example.
    Senator Moran. Is this a new development?
    Secretary McDonough. Meaning the timeline?
    Senator Moran. The capability to timely provide that 
immediate care, that that-day care, is that something that is 
new?
    Secretary McDonough. It has always been our goal, 
obviously. That is the definition of an emergency. But the 
advancements at the Veteran Crisis Line, for example, allow us 
to do that. So what happens is a veteran calls in to the 
Veteran Crisis Line with suicidal ideation, we can locate where 
he is, and during the time of that communication can then be in 
touch with the emergency department where he closest to, to get 
him then linked up to the emergency department. So the 
technology has advanced to such a degree that it helps us to do 
that. When precisely it happened, I do not know.
    Senator Moran. Seven days a week, 365 days a year?
    Secretary McDonough. Correct.
    Senator Moran. Secretary, throughout the pandemic the 
Department has maintained that ATLAS telehealth sites have been 
a critical component to deliver care. I no longer remember--I 
think it was your predecessor who was always talking about the 
value of that ATLAS pod. I have been working with the VA and 
the American Legion for more than a year to secure ATLAS sites 
in Kansas, and you and I were in Emporia, where we discovered--
we did not discover but we knew that that was a site in which 
an ATLAS pod was being placed.
    My staff informed me today, as I came into this hearing, 
that they were informed, not by the VA but by the American 
Legion, that the Department's Office of Connected Care has 
decided to begin a strategic assessment of the ATLAS program 
which has paused delivery and planned clinical operations of 
the Emporia site. That was not communicated to me. And 
incidentally, the pod is developed. It has been made. And it is 
now sitting in a warehouse unable to be used.
    That ATLAS pod, again going back to suicide and mental 
health issues, is one of the ways that we can deliver that kind 
of care and meet those needs rapidly and in geographical 
locations in which it is a challenge. Something has happened. 
Your reactions suggest to me that you do not know what--I did 
not mean it the way that it sounds, but that you are unaware of 
this. I need your help in figuring out why this happened, and 
if it does not make sense, which it does not to me, why we 
would not complete this process.
    Secretary McDonough. You have my commitment to get to the 
bottom of it. In candor, I have heard--I have been in close 
touch with the Legion as well. I have heard indications of 
mixed success with some of the ATLAS pods. And we have been 
looking at it as a general matter. I was not aware of the 
decision on the Emporia pod, which you and I saw together, and 
I regret both that it happened and I also regret that it was 
not me who told you. So let me get to the bottom of it.
    Senator Moran. And I do not know whether this is an 
isolated instance or whether this is circumstances that are 
occurring across the country in other of my colleagues' States.
    My last question, for this round at least, Mr. Secretary. 
Your written statement notes that veterans made over 33 million 
visits to community care and over 78 million visits to VHA 
facilities last year. Community care represents, then, about a 
third of the total visits.
    Looking at fiscal year 2021 appropriation levels, roughly 
$18 billion was appropriated for community care and $76 billion 
for VA medical care. These are not apples to apples, I 
understand, but it would suggest that the cost of community 
care is less than the cost of care within the VHA. Tell me what 
I need to know about that.
    Secretary McDonough. Yes. I mean, I guess I want to say a 
series of things. One, I took to heart what you said. The last 
time I appeared before you, you were unimpressed with the speed 
with which we responded to one of your questions, one of your 
letters. So I got this letter on November 12, and I said if 
this is not signed out by the time I appear up there, somebody 
is going to get chewed out.
    Senator Moran. You know, before I leave here I am going to 
be apologizing to you. Now stop.
    [Laughter.]
    Secretary McDonough. So that is one. Two, I understand kind 
of the algebra that you are doing there, and on a certain level 
I would say community care does provide absolutely important 
opportunities and does so very competitively. For example, the 
average urgent care appointment in the community, $164. When 
you compare that to potential cost of an emergency room visit 
or potential elapsed time before you can get to see a primary 
care physician, even if we beat the 20-day target, that is an 
absolutely great deal.
    So if part of your question is, is community care a good 
deal for us, it is. Community care is also the law of the land, 
and we live by the law of the land. And the suggestion that 
anybody who works for me is willingly breaking the law is 
something I take really seriously.
    And so every one of those newspaper stories that have 
appeared I have been on the top of. Every one of the television 
ads which made the assertions, we get to the bottom of. We will 
continue to do it. But it is absolutely a critical tool for us.
    Last point is because we invest so heavily in education, 
training, research, and the coordination of care, it is really 
incumbent on us, if we are going to continue to make best use 
of care in the community that we get much better at 
coordinating that care. Part of that is the electronic health 
record, but part of that is our partners in the community and 
the third-party administrator getting more serious about 
running a professional network. And we are better now at paying 
our bills on time. They have got to be better at providing 
quality care on time, the way they promised, and at a cost that 
is competitive.
    And so that is what I would say to that. But again, A, it 
is the law; B, it is really good for our vets; and C, at the 
end of the day, it does not really matter what I think. It 
matters what the vet chooses.
    Senator Tester. Okay. Thank you. So I went over. Moran went 
over. We both apologize. Let's try to keep it as close to five 
as we can.
    Senator Moran. I do not apologize. I just did what you did.
    Senator Tester. I just did for you. Senator Hassan.

                  SENATOR MARGARET WOOD HASSAN

    Senator Hassan. Thank you, Mr. Chair and Ranking Member for 
this hearing, and Mr. Secretary, thank you for being here today 
and it was good to see you yesterday.
    Just to the point of needing more personnel trained up fast 
I hope that the bill that the President signed into law 
yesterday, that Senator Braun and I did, will really get the VA 
much more proactive in recruiting health care workers from 
active-duty members who are in their last year of service who 
are already trained up by the United States military.
    Look, I want to talk a little bit about what is going on in 
New Hampshire. Obviously, support for our veterans is important 
in all of our States. In my State of New Hampshire, veterans 
make up more than 10 percent of our adult population, and the 
VA projects that the number of VA enrollees in New Hampshire 
will grow in the coming years.
    In previous testimony you noted the need to modernize VA 
health care facilities. It is especially true in underserved 
areas like New Hampshire, one of the only States that lacks a 
full-service VA hospital. As a VA New Hampshire Task Force 
found in 2018, we need to improve specialty care services and 
facilities, establish an ambulatory surgical center, build a 
community living center, and improve parking to access these 
facilities.
    So, Mr. Secretary, I understand that the VA has internal 
decision-making processes and you cannot get out ahead of that 
in terms of making final decisions. But will you commit to 
working with my office on finding a path forward for these 
kinds of critical projects at VA facilities in New Hampshire?
    Secretary McDonough. Yes, I will, and one, it was really 
good to see you yesterday too. I have to say I much prefer 
visiting the White House rather than working there. And it was 
also nice to be there for the signing into law of those bills, 
including yours, which is going to make a big difference for 
us. So that is one.
    Two, I make that commitment to you. Our teams have been 
working together on this, as we discussed yesterday. 
Importantly, if Build Back Better is enacted, there is $4.5 
billion extra dollars for infrastructure there. That will be 
managed through our internal processes, as you just talked 
about.
    I am also mindful of the fact that in the context of that, 
New Hampshire projects will be, obviously, considered. There 
are two projects currently in early stages of planning, both in 
the areas you talked about, ambulatory surgery and a parking 
garage. Analysis necessary to develop those projects is 
underway.
    The remaining two active minor constructions projects are 
further ahead. That is ones at the Manchester VAMC. It is 
currently developing a minor construction project for a 
dedicated women's health clinic. And this project is moving 
forward toward an early fiscal year 2023 construction contract 
award. Additionally, a specialty care building is currently in 
design, and is scheduled to be completed in the third quarter 
of 2022, and considered then in 2023 construction funding.
    So, we will stay on top of that. We will keep an open door 
with you on that, as we do with everybody here, of course. But 
it will be pursuant to our internal processes, but bottom line 
is we work with you. My commitment on this is as rock-solid as 
anything else on transparency and openness.
    Senator Hassan. I appreciate that, and for our veterans who 
do not have a full-service VA hospital in their State this is 
just really, really critical.
    Let me turn to another issue that I hear a lot about from 
New Hampshire veterans and particularly New Hampshire National 
Guardsmen and Reservists who swear to defend the Constitution 
and this country, just like their active-duty counterparts, and 
deserve the same respect and recognition.
    So I introduced bipartisan legislation with Senators 
Shaheen, Cramer, and Hoeven to reform the Veterans Cemetery 
Grants Program to ensure that all members of reserve components 
and the National Guard are eligible to be buried in State 
veteran cemeteries. Veterans in my State strongly support this 
bill, as do national veteran service organizations. The last 
time you testified before this Committee you committed to 
working with my office on this legislation, and we have had 
good conversations. We have worked extensively with the VA, and 
in particular the National Cemetery Administration, and I 
believe we have found a path forward.
    So just given the National Cemetery Administration's 
support for this legislation, will you commit to implementing 
it quickly once Congress is able to pass it into law?
    Secretary McDonough. Yes. I mean, you raised this issue 
with me. I took it for action. You know, Matt Quinn, who is the 
second-best Montanan I know, took this on board and he has 
worked it through. And so I think we are in a position--we have 
enunciated our support for the provision and we will make sure 
that it gets done.
    Senator Hassan. Okay. Thank you. And last thing, just 
because I am just about out of time, I had questions on toxic 
exposure legislation, the TEAM Act that Senator Tillis and I 
have introduced, and will follow up on the record. I will just 
suggest that one of the provisions in there was just that the 
VA could develop a questionnaire that would help them identify 
veterans who have been exposed as part of the primary care 
interaction. I think it could be something that the VA could 
implement without us necessarily passing it into law, and I 
think it would be a very important first step in really 
identifying those veterans who have been exposed, just 
integrating that into the quality care that you all are 
striving to provide.
    Secretary McDonough. A straightforward question. I think it 
does sound like something we could do, and I will get you an 
answer on that.
    Senator Hassan. Okay. Thank you very much. Thank you, Mr. 
Chairman.
    Senator Tester. Thank you, Senator Hassan. Senator Tillis.

                      SENATOR THOM TILLIS

    Senator Tillis. Thank you, Mr. Chair and Ranking Member, 
and Senator Hassan, thank you for bringing up the TEAM Act, and 
I look forward to us continuing to work on it.
    I wanted to thank you for reaching out to me and talking 
through the future governance structure and the management 
structure for the VA. I do not know if the other members have 
seen what I believe you announced formally today. The thing 
that I like most about it is that we are really creating what I 
would consider to be a classic program office for managing the 
EHRM project, and I look forward to onboarding the person who 
is going to lead that effort. It sounds like great experience 
from the DoD.
    I also hope that we can take what was a place on an org 
chart that is not yet functional and that joint team with DoD, 
because I do think that integration is going to be very 
important. We have a lot to learn from there. So thank you for 
sharing that information with me.
    I did want to quickly, you touched on veteran suicide in 
your opening comments, and I have introduced a bill called 
Expanding the Families of Veterans Access to Mental Health 
Services Act. It is a bill that I have introduced on my side. 
We have a companion bill in the House. I do not know if the 
Department has taken a position there but it is to recognize 
that in the aftermath of a veteran suicide you have got a 
family that could be in crisis, and we believe that having that 
available to spouses and family members are very important. 
Would you agree with that?
    Secretary McDonough. Yes, very much so.
    Senator Tillis. Thank you.
    Secretary McDonough. And I will take a look at the bill. I 
mean, among others, the assistance program for survivors, TAPS, 
does great postvention work. This is something we are spending 
a lot of time on through our Office of Mental Health and 
Suicide Prevention. And so, I think what I hear from you about 
the bill sounds like it is right on the same vector that we are 
operating.
    Senator Tillis. Yes, that would be really helpful as we 
move forward, because we would like--if we have concurrence 
from the Department it may be an expedient way to get that 
done.
    I do have a question about the integrated veteran care. I 
think you all introduced this concept back in October, and I 
have to say that when we are talking about trying to get timely 
access to health care, either in a VA facility or in community 
care, that we feel like we have hit some stumps or roadblocks. 
I know the goal is to provide a seamless sort of access to 
services and also working closely with the VSOs.
    But maybe not for the purposes of this hearing--I have got 
about two and a half minutes left--but I would really like to 
get a better understanding of how that is going to compress 
things, because it may just be the transition but we are 
hearing that it may be causing some delays to get community 
care or timely appointment.
    Secretary McDonough. Well, the short answer is, in the 
interest of time, we will stay close to you on this. Our whole 
goal is to reduce kind of the overhead around the decision-
makers. Before we began to bring these two offices together--
the Office of Community Care and then the office of care in the 
system; I forget what it is called precisely--we learned from 
veterans that it created a lot of confusion, it probably added 
to some of the time, but look, at the end of the day we own the 
time. We own the clock. We have got to get shorter on this, as 
a general matter.
    I think it stands to reason that having one stop where the 
vet does not have to make a choice which door he enters--he 
just goes in there and works through his particular access 
question and then ends up where he wants to end up, in the 
community or in the direct care system--is the better way to do 
this. I think it is unusual for us to start bringing down 
overhead and reducing kind of people working on an issue. The 
whole goal here is to make it a more streamlined process.
    Senator Tillis. You also mentioned your priorities on 
timely access to health care and timely access to VA benefits. 
I think we have seen--and I am always looking for silver 
linings in the COVID crisis--I think we saw that with 
telehealth, and I am glad to hear that we are going to 
institutionalize some of those things and move on. Of course, 
if any of the things you are doing on the health side require 
authority, we need to know that, whether or not it is within 
your authority.
    But I am also interested in whether or not you can apply 
the same things that we did on the health care side to the 
benefits side. Are you looking at how using a different 
outreach, using tele-outreach, for example, what could we do to 
expedite access to VA benefits?
    Secretary McDonough. Yes. So one perfect example of that--
there is surely more for us to learn. Some of the hiring 
authorities that have been so useful for VHA will be also 
helpful to VBA, the Benefits Administration. But tele-appeals 
have been extraordinarily effective at the Board of Veteran 
Appeals.
    Now, we are still pretty backlogged there, but to her great 
good credit, the Chairman at the Board of Veterans Appeals has 
gotten us in a position where we are doing many more tele-
appeals, meaning that it saves the vet a trip, it saves the 
judge, you know, a trip, and we are looking for additional ways 
to solidify that into practice.
    On the regular benefits operation, I will be happy to come 
back to you with some of our thoughts on that as well.
    Senator Tillis. Okay. Thank you. Thank you, Mr. Chair.
    Senator Tester. Thank you, Senator Tillis. Senator Hirono.

                    SENATOR MAZIE K. HIRONO

    Senator Hirono. Thank you, Mr. Chairman. Mr. Secretary, I 
know you are a can-do guy, and I really appreciate the fact 
that you took the time after your confirmation hearing to 
follow up with me regarding getting the ball rolling on a very 
long-delayed clinic on Oahu, soon to be named the Akaka Clinic, 
and we are actually going to be doing groundbreaking later this 
month.
    Secretary McDonough. I am really happy to hear that.
    Senator Hirono. So I really thank you for that because that 
is the kind of clinic that will provide community-based care 
for our veterans. And you may or may not know that Tripler, 
which is where part of their care occurs, there is no parking 
and all kinds of issues there.
    So at that time when we talked we had discussed making 
changes to the leasing process to help other States avoid the 
kind of delays that the ALOHA Project, which is the Akaka 
Clinic, faced. Can you provide an update on any changes that 
have been made?
    Secretary McDonough. Yes. Importantly, in the House-passed 
version of Build Back Better, there is a fix to the 
Congressional Budget Office procedure on scoring leases. So 
this will be not only important for Hawaii and for other very 
high-cost localities but, frankly, for every member on the 
Committee, given the slowness that we have had in fulfilling 
leases because of what I would argue is the antiquated way we 
score them for budget purposes. So, this would be another 
benefit of enactment of the BBB, if we can get that done.
    Senator Hirono. Yet another reason to pass BBB.
    Oh, hi, Joe. I am kidding.
    Mr. Manchin. No, you were not.
    [Laughter.]
    Senator Hirono. Of course not.
    You know, you cited in your testimony the ten key 
challenges areas, and it covers the gamut from suicide 
prevention, homelessness, et cetera. So as you are completing a 
year or so of your tenure, do you have any ongoing frustration 
with regard to meeting the challenges of these programmatic 
areas that you cited? Is there something overriding that we can 
help you with?
    Secretary McDonough. You know, I think there are two 
things. I am very focused on the fact that we have asked the 
workforce to do a lot in a relatively short time, and they have 
done it under extraordinarily demanding situations and 
pressures. And so that means I think it is time for us--that 
and the very tight health care labor market--means that I think 
it is time for us to take a step back to look at hiring 
authorities, training authorities. And I have committed to all 
of you on this Committee that we get back to you early in the 
new year with a stepped-back look at each of those things.
    That is our biggest challenge, frankly, is managing this 
workforce of 420,000 people, and doing it in a way that, as the 
market around them gets tighter, and therefore wages get much 
more competitive, how do we stay competitive there? The fact is 
we are pretty sticky with our health care professionals, in 
particular. Turnover in our system is somewhere around 9 
percent annually. It is a little less than that the two years 
of the pandemic, meaning that people are staying longer, people 
coming out of retirement to work in the context of the 
pandemic.
    So we have to figure out how we can amplify that so we can 
keep these people on board.
    Senator Hirono. I think we had already made some changes to 
help with filling some vacancies, because the VA had a pretty 
convoluted, kind of a lengthy process. So if there are other 
things that we ought to do to enable you to recruit and keep 
your staff, that would be good because they are providing the 
kind of direct services to our veterans.
    Just about every VA Secretary that I have worked with, and 
it has been quite a number, have put homelessness as a major 
priority, and I am wondering whether you are doing something 
different to reduce the number of homeless veterans that we 
have. Because at one point there was an effort to work with 
mayors, for example, all across the country, and the mayor of 
City and County of Honolulu was engaged. I mean, that is really 
getting down to it. But yet we have homeless veterans.
    So are you doing something different, unique, something to 
make a difference?
    Secretary McDonough. Yes. Well thank you very much. We have 
prioritized, in the first instance here, closing what was 
called Veterans Row in Los Angeles, which is what I thought a 
shameful scenario where between 40 or 50 of our vets every 
night were living homeless, just outside of our facility in 
West LA. Everybody who was on that facility is now in either 
transitional or sustainable housing. We also have a goal now 
where we are about 400 people into a 500-person goal of getting 
500 veterans between basically October 10th and the end of the 
year in LA County into housing for the holidays. We are at 
about 400. We set the goal of 500, and we are going to get to 
and through that 500.
    But we have also made a series of changes under the broad 
rubric of what we call Housing First, which is the most 
important thing is to get a vet into a house and then to take 
care of all the issues that led to homelessness in the first 
instance--joblessness, association with the justice system, 
substance use disorder, mental health challenges. We have made 
some changes there as well. For example, under some of our 
programming we have increased the amount of the subsidy that 
can be dedicated to rental assistance. We have extended the 
period during which somebody can stay in emergency housing.
    All of this is made possible by the fact that under the 
American Rescue Plan and the CARES Act, you all have made an 
unprecedented amount of assistance available for homelessness 
programming, which brings me to your last point. We have the 
resources from you all. We have established procedures that are 
proven to get vets into houses and keep them there. All that is 
missing now is will and execution, and we are going to bring 
that part of it, and our goal is to get the more than 40,000 
homeless veterans into houses.
    Senator Hirono. Thank you.
    Senator Tester. Thanks, Senator Hirono. Senator Blackburn.

                    SENATOR MARSHA BLACKBURN

    Senator Blackburn. Thank you, Mr. Chairman, and Mr. 
Secretary, thank you for your time.
    Secretary McDonough. Nice to see you, Senator.
    Senator Blackburn. It is good to see you. Let's talk about 
the VBA backlog.
    Secretary McDonough. Sure.
    Senator Blackburn. As you know, we hear a lot about the 
backlog.
    Secretary McDonough. I bet you do.
    Senator Blackburn. We hear a lot about wait times, and I do 
want to touch base with you on those. So talk to me about where 
you are, because right now my understanding is there is about 
250,000.
    Secretary McDonough. Yes.
    Senator Blackburn. So what is your timeline for bringing 
that up?
    Secretary McDonough. Yes. So I will just give you a quick 
snapshot of where we have been and where we are going.
    Senator Blackburn. That is great.
    Secretary McDonough. So when we came in we were at about 
215,000--220,000 cases in the backlog. That number had tripled 
in the context of the pandemic, importantly because early in 
the pandemic we stopped doing, for example, some exams because 
of concerns about safety for the veteran.
    So that led to a big spike up.
    We got that down to about 170,000. That bumped up again 
when Blue Water Navy cases, last August, came along. We worked 
that down to about 190,000. It then bumped back up to this 
roughly 250,000-260,000 case mark in October, when the three 
presumptives in last year's NDAA that you all were so critical 
in getting us access to, as those came due.
    So we are at about 260,000. Our plan is through the use of 
funding made available and the American Rescue Plan, through 
the hiring of 2,000 additional claims----
    Senator Blackburn. Adjudicators.
    Secretary McDonough [continuing]. Adjudicators, and 
through, ideally, increased automation of these processes, 
which I do not have news on yet but I hope we will----
    Senator Blackburn. Right. If I can jump in right there, I 
think that having staff willing--VA staff willing to do that 
training and using that technology is going to be crucial to 
this. If not, we are going to have the same problems we have 
had with the EHRs, and I think we want to be able to move past.
    Secretary McDonough. I am with you.
    Senator Blackburn. Okay.
    Secretary McDonough. Let me complete a thought, just so I 
do not miss answering your question. So under that process, 
which right now includes mandatory overtime, for example, by 
April 2024 we will have under 100,000 cases in the backlog.
    The last point is, just to your point about the team, we 
are hiring 2,000 people right now. We have already hired 900. 
Some portion of them--I do not have the exact number at the 
moment--are in training at the moment. We think we will have 
those, provided we get the funding through a regular 
appropriations bill, we will have those people in chairs, those 
2,000 in chairs, trained, at the end of the spring.
    Senator Blackburn. Okay. All right. And let me ask you 
about using community care, because what we are hearing, our 
caseworkers here, from veterans who call and complain about 
wait times, and then they will say, well, the option of 
community care was not offered to them on the front end. So I 
think this also speaks to training.
    So why is that not being offered at the outset, because 
that is a way to get that veteran to care more quickly?
    Secretary McDonough. Definitely.
    Senator Blackburn. And I think this is a missed 
opportunity. So the VA staff members need to be able to 
immediately offer that to them, to speed this process up. And 
the other part of that is that it looks like the way wait times 
are calculated, whether you are using the date that it is 
requested or, you know, the patient indicated date, so that we 
get a truer picture of what that wait time really is.
    Secretary McDonough. Yes. So two questions which is--let me 
work back.
    Senator Blackburn. Okay.
    Secretary McDonough. This question on calculation of the 
wait time, I am only now getting smart on this. I think we have 
been reporting it to you--I am under the impression that we 
have been reporting it to you all from the point that the 
referral is made, which is, as you say, the patient indicated.
    Senator Blackburn. And not requested?
    Secretary McDonough. No. Well, let me make sure that I 
understand it on my end. In any case, I guess what I am trying 
to do is to agree with you that if we need to rectify our 
reporting through, you know, public documents we will make sure 
we do.
    I think that what I understand, from our team and from 
their interactions with you all and your staffs, that we have 
been reporting it to you pretty straightforwardly on a regular 
basis now for many months--in fact, years. But let me get to 
the bottom of that and make sure that we are on the same page 
on that.
    On whether veterans are being made aware of their options, 
I guess what I would ask, Senator, is if there is something 
like that where one of your veterans finds that he or she has 
not been made aware of what their options are, please let us 
know. Our person who runs that office is up here on a monthly 
basis with your all's staff, going through every kind of comma, 
period, and semicolon of our reporting on this. I am not saying 
that the reporting is perfect, but I am saying that we are up 
here pretty regularly to try to get to the bottom of these 
cases.
    Senator Blackburn. We will communicate with you further on 
that because we have veterans on our staff who work with 
veterans, and it seems like this is a far-too-common 
occurrence, and we would like to help solve that problem.
    Secretary McDonough. Good. That is what we would like to 
do.
    Senator Blackburn. Thank you. Thank you, Mr. Chairman.
    Senator Tester. Thank you, Senator Blackburn. Senator 
Brown.

                     SENATOR SHERROD BROWN

    Senator Brown. Thank you, Mr. Chairman. And Mr. Secretary, 
nice to see you.
    Secretary McDonough. Nice to see you.
    Senator Brown. Thank you for your exemplary service in two 
administrations.
    A few months ago you were in this Committee about the 
electronic health record implementation. As you remember, your 
strategic review of that program, the OIG's report, new patient 
scheduling system needs improvement as VA expands its 
implementation. You remember all that? It was designed by 
Cerner.
    Secretary McDonough. I do.
    Senator Brown. Part of the broader HR. It is currently at 
the facility in Columbus, and the report outlined some pretty 
big issues that slowly timely care for veterans. The scheduling 
system left some clinics and appointments, their term, out, and 
lacked the tools to measure wait times, another serious area of 
concern.
    The new EHR will come to Columbus as soon as March, four 
months from now. My office talks to their staff regularly and 
will follow up with them as they prepare for the new system.
    You know how hard these VA workers are working everywhere 
in our States, and we have got to set them up for success with 
this new EHR. I am not sure we are doing that. I would like to 
ask your health record team, you and your health record team, 
to brief me and my staff soon so we can understand----
    Secretary McDonough. Absolutely.
    Senator Brown [continuing]. How the concerns raised will 
affect those workers and that implementation.
    Secretary McDonough. Absolutely.
    Senator Brown. Thank you for that.
    On Veterans Day I held a roundtable. I typically do not do 
big town halls. I do roundtables because it reminds me of 
Lincoln. Lincoln used to say, ``Go out and get your public 
opinion baths,'' and it is how you really learn from people, 
and it was a Zoom roundtable in this case. But a vet named 
Daniel shared a story and outlined his health complications. He 
said--and it was painful to watch. He is wheelchair-bound. He 
was very healthy when he entered the service. He was exposed to 
burn pits. He has immense pain, oxygen full-time from a rare 
lung disease. He shared that story, then he said he and his 
wife had been denied the higher tier for the caregivers 
program.
    What do you say to somebody like Daniel and his wife, who 
puts her whole heart into caregiving, other veterans like that 
who have been denied the expanded veteran caregivers benefits, 
or put into a lower tier? What do you say to them?
    Secretary McDonough. Well, look. It is obviously 
heartbreaking, one. Two, I have been talking to many of you all 
about the caregivers program, and my sense is that you did not 
pass the caregivers program so that 80 percent of applicants 
would be denied. And so I have given guidance to our team that 
that has got to change. So we are looking at regulation to 
figure out how we do that.
    And so what I would say to Daniel is I would say thank you, 
and I would say the same to his wife. And I would also say that 
we are looking, by virtue of our toxic exposure work, at rare 
respiratory cancers and rare lung diseases for our next round 
of presumptives. And then on the caregiver program, you know, I 
cannot say it better than some of your colleagues have said it, 
which you did not pass that program so that 80 percent of 
people would be denied.
    Senator Brown. And my understanding, from Ann, on my staff, 
who is really knowledgeable about this, is that an estimated 
6,700 legacy caregiver participants will be discharged from the 
program due to the new criteria. Does VA have the authority to 
make the necessary changes that they can remain in the program, 
or do we need to act?
    Secretary McDonough. So let's take a step back maybe on 
three things about the caregiver program, just real quick. On 
the legacy program, that expired basically at the end of last 
September, on October 1, because we are now expanding into the 
new program. So we are going back and we are looking at 
everybody who was eligible under the legacy program. That is 
19,000 people. We have communicated with about 2,000 of those 
people and begun the reassessments of their cases.
    I have seen the same estimation, which is that 6,700 people 
may not qualify for the new program. That is an estimation. We 
do not have hard data on that yet. In many ways, I hope that 
some of those people who do not qualify, do not qualify because 
they no longer need it, which would be a good-news story.
    Senator Brown. But you do not know that for sure.
    Secretary McDonough. I do not, but where we are then headed 
is--so that is what we are doing. We are working through those 
cases. In any case, if somebody is found to no longer qualify 
for the legacy program, the soonest their participation in the 
program, the enhanced program, would end would be 90 days after 
October 1, 2022. Okay? So more than a year from today. If they 
are found today to no longer qualify for the legacy program, it 
would be another year-plus before the support of the program 
would end. So that is the legacy program.
    Then the question is, are we ready for the new program? So 
we have hired about 1,900 people. We are going to hire another 
400 people for that program. We will be focused on consistency 
of decision-making for participation and authorization into the 
program, and we will be focused on making sure that the program 
is as Congress intended, and 8 in 10 people being denied is not 
as you intended. Right?
    But that brings me, third, to this question which is 
related to caregivers and is related to this question of the 
Beaudette case, where several people who have been denied 
access have asked for the right and have been granted it under 
an initial ruling to appeal that case in our Board of Veterans 
Appeals.
    We are contacting everybody who has been denied and making 
sure they know of their right to appeal. We are not seeking an 
injunction on that ruling. We will carry out those appeals. but 
we are also going to appeal the ruling itself to a higher 
court, or at least we have petitioned the solicitor general to 
allow us to appeal. I hope to hear from them soon about that, 
but I want to level with you, on this question of the Beaudette 
ruling, which will be meaningful to you and your team and to 
the caregivers. We will appeal that decision.
    Bottom line, though, is we are better positioned to carry 
out the expanded program. We are staffed up. We will carry out 
consistently and consistent with your intent.
    Senator Brown. Thank you, Mr. Chairman. A real quick 
comment. I appreciate your question about claims processing. I 
want to follow up on that. And also I will want to send you a 
letter on a question about the 90/10 loophole in the American 
Rescue Plan and what we are doing to prevent for-profit 
colleges from predatory behavior.
    Secretary McDonough. I look forward to that conversation.
    Senator Tester. Thank you, Senator Brown. Senator 
Tuberville.

                    SENATOR TOMMY TUBERVILLE

    Senator Tuberville. Thank you, Mr. Chairman. Thanks for the 
early Christmas present, this new desk you gave me. It took 
you, what, 11 months, but it is good. I am able to sit up at 
your level now.
    Senator Tester. That is very quick for the Senate to act, I 
just wanted you to know.
    Senator Tuberville. Thank you, Mr. Secretary. Good to see 
you.
    Secretary McDonough. Good to see you.
    Senator Tuberville. Thanks for your hard work.
    Secretary McDonough. Thank you.
    Senator Tuberville. Do you have a count, or who would we 
get a number from of how many vets we have lost to COVID this 
past year?
    Secretary McDonough. I could get you that number. I do not 
have it at my fingertips. I wish I did, but I do not.
    Senator Tuberville. I would not think you would. I think 
all of us would like to know of this year, how many we have 
lost.
    I am going to go back to my HBOT question, hyperbaric. I 
had success with them, being a lowly football coach, but we saw 
success using that with concussions over the years. Why can we 
not get some kind of feedback from people that have used it on 
their own, paying for it themselves? Does it actually help? You 
know, we are pumping drugs into these veterans every day, and 
we need to find some way to slow this suicide rate down.
    Secretary McDonough. Yes. So thanks very much. I would say 
a couple of things about this. One is we are under requirements 
because of statute to make sure that we are going through a 
series of processes. We are implementing those processes. We 
submitted a series of reports to you guys over the course of 
the last couple of months, and I think just yesterday or 
earlier this week, or maybe it was last week, sat down with 
your team and some of the other staff members about this 
question about what we are encountering at the moment, which is 
certain ethical limits on how we assess impact on individuals 
in the context not of a pilot, but in the context of actual 
treatment.
    And so I do not know the ins and outs of it, Coach, but 
what I gather is our ethics team, and then our team has come up 
and briefed your team about their concerns about precisely your 
question, which is how do we go and do some kind of valid 
testing while still maintaining fidelity of these ethical 
standards.
    And so the bottom line is, in answer to your question, is 
we are trying to work through these ethical limitations and we 
are in close touch with your team about it.
    Senator Tuberville. Thank you. Are you familiar with 
Operation Deep Dive, carried out by the University of Alabama, 
about looking into studies of veterans that have committed 
suicide? Are you familiar with that?
    Secretary McDonough. I do not think I am.
    Senator Tuberville. We need to find some way--you know, to 
me suicide is--of course it is very important to all of us, and 
we are losing, what, 17, 20 a day.
    Secretary McDonough. Yes.
    Senator Tuberville. And it is not getting any better. We 
need to find some way of, after the fact, of following up what 
happened at the VA, what were they on. We need to get some kind 
of structure, some kind of graph of how we get to the bottom of 
why. And I think that is where we all want to get to. But, I 
mean, it is not getting any better. And, you know, I have lost 
friends, and you think they are getting better. And they go to 
the VA, but something happens to them, and we have got to get 
to the bottom of that.
    But there is a group, like I said, at the University of 
Alabama, that does Operation Deep Dive. They look into why, 
what happened, put all the information together. I wish we 
would kind of do that from the VA ourselves instead of waiting 
on some other group to do it.
    Secretary McDonough. Yes. So we were just talking about 
this with Senator Tillis as well. He has got a bill on this. We 
do some work, we call postvention, rather than pre-
intervention, postvention, to make sure that we are working 
with families and understanding as best we can.
    I have an answer to your other question too, but the one 
thing I would add here, Coach, is importantly we did see 
improvements in 2018 to 2019, which is our most recently 
released numbers, and it is all backward-looking because of the 
way we aggregate the data. But we are making progress, by no 
means enough progress, but we are making progress. And we do 
believe that we know the steps that we need to take to continue 
that progress. It begins with the assistance and the resources 
that you are making available to us, but I would be more than 
happy to dig into Operation Deep Dive at University of Alabama.
    Senator Tuberville. Well they are telling me that they 
cannot get information from the VA of whether this person that 
committed suicide was actually connected with the VA. I mean, 
if we could get somebody in contact with us to where we can 
connect--all they are looking for is just as much information 
as possible, and again, I think it would be beneficial.
    Secretary McDonough. I will follow up with your team and we 
will get a name of somebody and we will make sure that our 
Office of Mental Health and Suicide Prevention is in touch with 
them.
    Senator Tuberville. Thank you. Thank you, Mr. Chairman.
    Senator Tester. Thank you, Senator Tuberville.
    Secretary McDonough. The number of veterans who have died 
from COVID last year--this is as of November 29th, the last 
time we reported it to the Committee--16,543.
    Senator Tester. Senator Murray.

                      SENATOR PATTY MURRAY

    Senator Murray. Thank you, Mr. Chairman, Secretary, good to 
see you again.
    Secretary McDonough. Nice to see you, Senator.
    Senator Murray. Thanks for being here.
    As you well know, this summer the VA completed its 
strategic review of the Electronic Health Record Modernization 
Program, and Deputy Secretary Remy made a virtual visit to 
Mann-Grandstaff VA Medical Center in Spokane last month, in 
November. I appreciate the senior leadership's continued 
engagement on this issue, but we really do need to see 
corrective actions to put this important program back on track 
and to get it right for veterans, families, and staff who are 
counting on it.
    For Spokane VA Medical Center and its clinics, what are 
VA's next steps for remedying the existing issues?
    Secretary McDonough. Yes. So the next steps are that we 
are--I last talked to Donald about this last night, Donald 
Remy--we are pressing on Cerner to enhance the presence on the 
ground in Spokane so that people can get more timely reaction.
    Senator Murray. What do you mean, pressing them? Saying you 
would like them to or telling them they have to?
    Secretary McDonough. Yes. We are telling them that they 
have to. And Donald reported to me last night he was in touch 
with Rob Fischer, who is the medical center director there in 
Spokane, and what Rob said to him is that as of last night, the 
kind of presence that Cerner was manifesting was not what he 
had been anticipating. And so Donald was going to tell Cerner 
today that is not good enough.
    Senator Murray. When do you expect to see that?
    Secretary McDonough. I do not know the answer to that 
question because he had that discussion today, but I will get 
you the answer. I have not talked to him since he had that 
discussion.
    Senator Murray. Any other steps that you are taking?
    Secretary McDonough. Well, we have regular engagement with, 
through our Office of Electronic Health Record Modernization, 
with the team in Spokane so that we, as an institution, are 
making sure that we are taking whatever corrective answer we 
need to take as well. And then we have obviously restructured 
the management and governance of the implementation of the 
project going forward.
    Senator Murray. Okay. Well in your testimony you mentioned 
that the VA plans to continue deployments to gain more 
experience while increasing future site readiness. That is a 
quote.
    Almost two years ago I cautioned the previous 
administration against deploying this new EHR until 
infrastructure and staffing issues were addressed. I do not 
want to see the new EHR deployed at other sites in Washington 
State until it is fixed and it is ready to go. So to avoid any 
confusion for future sites what indicators is the VA looking 
for to know when a site is ready and that the deployment will 
not disrupt a veteran's care or staff productivity or the 
morale that we have seen?
    Secretary McDonough. Yes, that is a fair question and maybe 
the way to answer this, Senator, is that inasmuch as Walla 
Walla would be the next site in Washington, why don't we come 
to you with our dashboard on what we intend to measure as it 
relates to Walla Walla, and then you can see our decision-
making on that.
    Senator Murray. Are you, at this time, moving forward on 
any other sites in Washington State?
    Secretary McDonough. What we have indicated is that as soon 
as March we will go to Columbus, and then shortly after that to 
Walla Walla.
    Senator Murray. Okay. And you will bring to me what your 
indicators are before you proceed on that?
    Secretary McDonough. Yes.
    Senator Murray. Great. I expect to see that. All right.
    You were asked about caregivers by Senator Brown. You know 
that is a passion of mine too.
    Secretary McDonough. Yes, and we have the program because 
of you.
    Senator Murray. Well, as you know, the previous 
administration finalized a rule for the caregivers program that 
restricted the eligibility criteria for veterans. I heard your 
answer to Senator Brown and I know what you are doing about 
those that have been denied, but he stated 88 percent of the 
applications were denied.
    So my question to you is a little different. How is the VA 
going to fix that unnecessarily restrictive eligibility 
criteria so we do not continue to see these denials?
    Secretary McDonough. Yes. I think there are two big movers 
in the decision. One is a statutory provision which says the 
condition the veteran suffers has to have been incurred in the 
line of duty. Our proxy for that is a 70 percent disability 
rating, and we cannot get around that. That is statutory. 
Right? We may, after looking at this, come back to you and say, 
hey, can we look at the statutory language.
    As I have discussed with several of you, the other mover is 
a determination of the percentage of activities of daily living 
that a veteran has to manifest problems with to qualify, having 
gotten over that first hurdle to the 70 percent disability. We 
do have some regulatory flexibility on that question of the 
percentage of activities of daily living that would be required 
once over that 70 percent hump. That is what we are looking at 
now.
    Senator Murray. So you are looking at changing some of that 
criteria?
    Secretary McDonough. We are.
    Senator Murray. All right. And what is your timeline on 
that?
    Secretary McDonough. ASAP.
    Senator Murray. Okay. All right.
    Secretary McDonough. We may have to do it through 
rulemaking. We may be able to do it through a clarification. 
That is a question really for general counsel. But I am working 
very closely with the caregiver office, with general counsel, 
to make sure that we do whatever we can, as quickly as we can, 
and surely in anticipation of the October 1 date.
    Senator Murray. Okay. Thank you very much.
    Secretary McDonough. You are welcome.
    Senator Tester. Thank you, Senator Murray. Senator Rounds.

                      SENATOR MIKE ROUNDS

    Senator Rounds. Thank you, Mr. Chairman. Secretary 
McDonough, it is good to see you, and I think this is a great 
opportunity to sit down and talk about what is going on in the 
VA and to learn from you, from your perspective, what is 
happening.
    I would like to talk about specifically the implementation 
of the MISSION Act, and about kind of what is going on with 
regard to referrals outside of the VA facilities themselves. I 
think the clarification that you could provide on the Referral 
Coordination Initiative, particularly how this initiative 
affects veterans' access to the community care. I think that is 
the area that I really want to focus on.
    You may have seen the results of the investigation 
conducted by USA Today that was released earlier this month. 
This report points out examples of VA actively denying access 
to community care. I presume you are familiar with the article.
    Secretary McDonough. I am, and we dug very deeply into each 
of the instance and obviously cannot talk about a lot of that. 
In fact, I am not even privy myself to each of those cases. But 
our team was up here yesterday talking about this. We dig into 
each of those cases to make sure that we understand what 
happened.
    Senator Rounds. Well, I think we have got a real problem 
and I think it goes back down to dollars and cents. I have 
concerns that these examples are not isolated and that they 
could be the result of the implementation of the RCI in a way 
that diminishes veterans' choice.
    Secretary McDonough. Yes, I do not agree with that, 
Senator.
    Senator Rounds. Well, let me share with you the reason why 
I am concerned. When a VA primary care provider refers a 
veteran to community care because they believe it is the 
veteran's best medical interest, does the referral coordination 
team have the power to override that decision?
    Secretary McDonough. No, and, in fact, it is not even the 
primary care provider's decision. It is the veteran's decision. 
And so our job is to make sure that the veteran is aware of his 
options and that we move with dispatch to execute his options, 
and that it is, in fact, best medical interest that determines 
that question.
    Senator Rounds. I think this may be where the problem is, 
because I think if the veteran actually makes the decision 
himself, that is one of the reasons why I challenged the 
MISSION Act in the first place was I did not read the law that 
way, and I am not sure that a lot of the folks that are 
implementing it read it that way either. And I will just give 
you an example.
    The Department's guidebook on the Referral Coordination 
Initiative features a call script, a framework, that members of 
the referral coordination team can use when speaking to a 
veteran who is eligible for community care. The call script 
framework recommends RCT members remind these veterans, and I 
quote, ``You should know, by choosing the VA we can better 
coordinate your overall care because we have the results of any 
services or tests in your health record.''
    It just seems to me that it--I am not sure it is 
appropriate for the RCT members to be suggesting, you know, 
that the VA might be a better option for a veteran, even after 
a veteran's primary care physician has determined community 
care is in the best medical interest. And I do not think that 
is the way it was sold to a lot of folks here, and I am not 
sure that is the way you would see it either.
    Secretary McDonough. Yes. Look, I mean, I do not. I mean, 
in effect--well, let me put it this way. GAO released a study 
last month wherein they found that care in the community is 
more difficult to coordinate. It is more difficult to get lab 
results, it is more difficult to get test results, and, 
therefore, more difficult, at the end of the day, to coordinate 
that care for that veteran. That is not my finding. That is not 
the Referral Coordination Initiative's finding. That is the 
GAO's finding.
    Senator Rounds. But either it is the----
    Secretary McDonough. At the end of the day, then----
    Senator Rounds [continuing]. Either it is veteran's choice 
or somebody else is making the final decision, and see, I 
really do think it should be the veteran's choice.
    Secretary McDonough. It is the veteran's choice. That is 
what the law says.
    Senator Rounds. And yet I think a lot of veterans feel that 
is not the way it is. And, in fact, within this article, there 
is one article that really was, I think, pointing to the fact, 
and the concern that I think Senator Blackburn had tried to 
address a little bit, and what I really feel strongly about. 
Part of the article says Dr. Kathleen Kim, who is the San Diego 
VA Chief of Staff, said physicians sometimes incorrectly try to 
relocate patients for treatments her hospital can offer, which 
would be internal, and administrators are regularly educating 
them to help keep veterans at the VA. And then the direct 
quote, ``Because of the nature of the MISSION Act, the VA is 
sending a lot of care in the community, and frankly, we are 
worried that we are not going to be able to pay the bills,'' 
end of quote.
    See, Mr. Secretary, I really think there is more of a 
driver here with regards to dollars and cents than what there 
is to making sure that the primary responsibility is to get 
that veteran the care that they want. And I would really like 
to explore this a bit more. My time has expired, but I think we 
have got a serious problem here that is not going to go away.
    Secretary McDonough. Yes, well, look. I mean, I am just 
looking at the month-by-month obligations for care in the 
community. So September, $2,067,412,193. So we had basically 
four months above $2 billion a month. That is a significant 
investment in the community.
    At the same time--so this is, by definition, outpatient 
care; correct--satisfaction ratings for outpatient care, north 
of 90 percent. That does not mean we are at 100, and I did not 
deal a lot in the 90 percentile myself, but 90 percentile is 
good. I am like a 70-percentile guy.
    But that is not to say that there are not problems. There 
are. It is a big system. You know, when I find a problem I 
snuff it out. But to suggest that, by design, we are breaking 
the law is an overstatement. That is what the article suggests. 
We took it very seriously, including with the team in San 
Diego, to get to the bottom of it, as you, I think, would 
expect us to do.
    What I believe is that we are giving best available care to 
our veterans, including historically high levels of care in the 
community. I think that ultimately reflects the veteran's 
interest. I want us to compete for access to that veteran.
    Senator Rounds. And I like the idea of competing, but I 
want it to be on a field that says we can provide equal or 
better care and the veteran makes the decision.
    Secretary McDonough. And we do, and that is what the GAO 
concluded.
    Senator Rounds. And I appreciate your thoughts on it, and I 
would like to pursue it further.
    Secretary McDonough. I look forward to that very much.
    Senator Rounds. Thank you. Thank you, Mr. Chairman.
    Senator Tester. Thank you, Senator Rounds. Senator 
Blumenthal.

                   SENATOR RICHARD BLUMENTHAL

    Senator Blumenthal. Thanks, Mr. Chairman. Thank you for 
your service, Mr. Secretary----
    Secretary McDonough. Thank you very much.
    Senator Blumenthal [continuing]. And your excellent work 
for the Administration. I want to talk a little bit about 
infrastructure. I hear you are planning a trip in 2022 to 
Connecticut. We will welcome you, and I will be delighted to 
show you the West Haven Hospital, which is in desperate need of 
rebuilding, as you and I have talked frequently, probably more 
often than you care to remember.
    Secretary McDonough. Oh, I remember every one.
    Senator Blumenthal. This stuff is pretty serious to all of 
us in the Congress and to the American people and I know to 
you.
    I am, frankly, disappointed that the Build Back Better 
program does not have more money for VA health care 
infrastructure. The way I read the Build Back Better program it 
has about $4.1 billion allocated to infrastructure-related 
expenditures in the VA, which is down from $18 billion--that is 
less than a quarter--which is a fraction of the $60 to $70 
billion that the VA has estimated that it needs, over a ten 
year horizon. So everybody on this dais, on both sides, should 
be aware we are shortchanging our VA, in my opinion. That may 
not be the way you view it, but this is literally bricks and 
mortar, and you say, in your testimony, that you are 
reassessing the pre-pandemic market assessment because, quote, 
``it may not have been expansive enough to identify emerging 
health care demands.'' In other words, it is bigger, not 
smaller.
    Secretary McDonough. Yes.
    Senator Blumenthal. I am not a good numbers guy. I am just 
a country lawyer from Connecticut. But what I take away from 
this assessment is in Connecticut, where we need a new hospital 
facility in at least ten other places, and probably the 
majority of VA health care facilities we have aging plans and 
we have great professionals performing yeoman first class 
medical work--we do in Connecticut--taking nothing away from 
the great people working in the VA health care. In fact, it is 
to their credit they are able to provide the gold standard of 
medical care, even under these difficult circumstances.
    What are we going to do?
    Secretary McDonough. That is an excellent question. I mean, 
the first thing is I do think that the investments in the Build 
Back Better Act will be meaningful. Second is we do have--you 
know, our average infrastructure, our average hospital is 59 
years old. You know, you have an example of this, but there is 
an example of a facility that is dated in everybody's State or 
an example of States like Alaska or New Hampshire where there 
is not a full-service hospital available. So that is definitely 
a major challenge.
    So we will do three things. One is we are looking at what 
we call an Asset and Infrastructure Review Commission, to take 
a kind of top-to-bottom look at our physical plant, what needs 
to be upgraded, what can we do without. The second thing we are 
doing is we have to get better at how we implement the projects 
that we do get funding for. Denver was an embarrassment.
    Senator Blumenthal. And I apologize for interrupting. I 
visited Aurora, and I am very familiar with the cost overruns, 
the delays, and I accept your point about doing it better. But 
there is no free lunch here.
    Secretary McDonough. No, which brings me to the third 
point, which is we will need increased investment in 
infrastructure. And so if it is not now it is going to have to 
be soon. And look, I want to underscore that we have to be good 
stewards of the taxpayer's dollars, and so we have to make 
better use of the money that we do get and then make better 
decisions around non-recurring maintenance, modernization, and 
making hard decisions when something is no longer needed.
    Senator Blumenthal. Well, I would love to explore this 
topic at greater length and greater depth, and it may be the 
topic for further conversation or maybe a roundtable we can do, 
depending on what the Chairman would like to do. But VA 
infrastructure, I think we are going to approach a crisis 
point.
    And I have run out of time but there are two other areas 
that I will pursue in writing. One of them is, you know, you 
were asked by Senator Brown what you would say to Daniel's 
caregiver. My question is, what would you say to Daniel about 
the burn pit exposure? What would you say to the other folks, 
Palomares and others who have--the Palomares veterans who have 
been exposed, whether it is to radiation or something else, 
about how we can cut through the time that it takes, as it did 
on Agent Orange, and the bureaucratic morass? And since it 
predates you I can say the bureaucratic resistance to doing 
fairly by our veterans.
    And that is one of the reasons why we have submitted the 
Cost of War Act. I hope you will support it, but it really is 
an urgent need.
    Secretary McDonough. I hear you. I could not agree more.
    Senator Tester. Thanks, Senator Blumenthal. Senator 
Sullivan.

                      SENATOR DAN SULLIVAN

    Senator Sullivan. Thank you, Mr. Chairman. Mr. Secretary, 
good to see you.
    Secretary McDonough. You too, Senator.
    Senator Sullivan. We are looking forward to having you in 
Alaska here soon.
    Secretary McDonough. There will be no sunlight.
    Senator Sullivan. What is that?
    Secretary McDonough. There is not going to be any sunlight.
    Senator Sullivan. It is cold right now in Alaska. It is 
cold. Twenty below in Fairbanks, so it is getting cold. 
Although you are from hardy----
    Secretary McDonough. I am from Minnesota. I get it, yes.
    Senator Sullivan. As I remind Senator Klobuchar, you guys 
are from the Land of 10,000. I think we have 4 million lakes 
but I never brag about that in front of her.
    Anyways, it is cold, though. You are tough.
    Let me follow on a couple of topics that seem to be a bit 
of a theme here. One is, you know, on talking about in--house 
versus community care, one of the topics we have had with a 
number of VA witnesses over the last couple months is the topic 
of VA-DoD integration, which you and I have talked about 
extensively. It is currently authorization in the NDAA that we 
are debating right now to do that, and we are trying to kind of 
reinforce that here in the Veterans' Affairs Committee. I think 
your agency is fully supportive of my legislation that is 
dealing with that.
    Can you talk to those issues? We just think it is a better 
way, efficiently, cost effectively, training with our docs, and 
cross kind of pollenization between our military and our VA 
members, both active-duty veterans but also the doctors on both 
sides.
    Secretary McDonough. Yes. Look, I mean, I will start where 
you ended, which is what I keep hearing from our providers and 
from vets is that vets like getting their care with active-
duty, and active-duty like getting their care with vets. And so 
I start there. It seems like it would be a big satisfaction 
increase.
    But then I think there are kind of standard economies of 
scale, training opportunities, affinity of maintaining cultural 
competence for care for active-duty and care for veterans. And, 
you know, I think this is one of the benefits of the EHR 
itself, the electronic health record, which is that we are 
going to have clinicians in both systems using the same 
backbone. So their closer clinical practice cannot help but, I 
think, improve outcomes for vets, which, at the end of the 
day--I have assured you all that I will make every decision 
based on whether it increases access for vets and whether it 
improves outcomes, and I think us making better use of shared 
infrastructure is an obvious step to take.
    Senator Sullivan. Good. Let me ask, one issue that I want 
to make sure we are able to do when you are up in Alaska is 
reaching out to the provider community as well. And one of the 
things that I unfortunately I am starting to see, just being 
back home last weekend, is that particularly in a community 
like ours where the VA footprint is very limited, the reliance 
on our community providers is an imperative.
    And as the MISSION Act is being rolled out, as we are 
undertaking the work with the local representatives from 
TriWest, I am hoping that we can make sure you are able to meet 
with a number of the community providers, and these are both 
community providers that are in the network, or have not yet 
joined the network, or--and I am starting to see more of this, 
and I do not know if it is happening around the country but it 
is happening in Alaska--have decided no longer to serve 
veterans under the MISSION Act. And I really want you to be 
able to meet with them to hear their concerns.
    Are you seeing this nationally? Anecdotally, I am seeing it 
back home. But what is your take on this right now, in terms of 
providers, they worry about rates, they worry about timely 
payments. What we do not want to do, in Alaska or anywhere 
else, is drive them out of the system.
    Secretary McDonough. Yes. I hear you. So, one, I would look 
forward to an opportunity to see whatever providers you think 
make sense, and so I would be happy to do that.
    Senator Sullivan. Great.
    Secretary McDonough. Two is, we have gotten much better as 
a partner, and I think the best way we can be a good partner, 
aside from the issues I was just talking with Senator Rounds 
about, is being a timely payer.
    Senator Sullivan. Yes. Really important.
    Secretary McDonough. Yes. And right now, on clean claims we 
rival Medicare on payment times. Okay? So on payment time we 
are beating industry standard, on clean claims.
    Senator Sullivan. What is a clean claim versus a non-clean?
    Secretary McDonough. That is a fair question. I think it 
has to do with kind of the complexity of the number of 
referrals and so forth.
    Senator Sullivan. Okay.
    Secretary McDonough. But on the apple to that apple, we are 
beating industry standard.
    Third, and I will take this for action, but I have not 
heard--I have spent a lot of time on community care--I have not 
heard dissatisfaction with providers driving network vitality.
    Fourth, I, to be honest with you, and I am really excited 
about the fact that we got the TriWest thing worked out for 
Alaska. It took some doing, but I am really glad we got there. 
I think we should be leaning on the third-party administrators 
now to help us get more vigorous about building those networks. 
So that is how I think about it.
    Senator Sullivan. All right.
    Secretary McDonough. And look, I am ready to be rebutted on 
this idea that there are providers, not providers walking from 
the system. I just have not heard it.
    Senator Sullivan. Okay. Good. Well, I appreciate your 
openness on this. It is an important topic, I think, for all of 
us, and I think it is going to be really a critical issue on 
the implementation of the MISSION Act.
    Secretary McDonough. Thank you.
    Senator Sullivan. Thank you, Mr. Chairman.
    Senator Tester. Thank you, Senator Sullivan.
    Secretary McDonough. I am sorry, Chairman. Can I just say 
one quick thing? What we are not seeing, by the way, is a lot 
of slack in the community system, meaning wait times in the 
community. Now we are really digging into this, by virtue of 
this requirement to come to you all with a report in June. We 
are trying to find out precisely what is the apple to the wait 
time in the direct care system to the wait time in the 
community.
    And the community system is really pressed. The pandemic 
really squeezed the community system, and so there is no slack. 
And a lot of times what we are seeing is that the apple to the 
apple, we are faster. And this, again, I think, should be a 
third-party administrator role, which is, hey, let's keep these 
networks vibrant for the care that our vets need. I saw this 
acutely in Montana and Kansas. I think that we have got to be a 
better partner, pay on time, most importantly. We need the 
third-party administrators to step up.
    Senator Sullivan. Good. Thank you, Mr. Chairman.
    Senator Tester. Senator Manchin.

                      SENATOR JOE MANCHIN

    Senator Manchin. Oh, thank you, Mr. Chairman. Secretary, 
good to have you here.
    Secretary McDonough. Thank you for having me.
    Senator Manchin. I had to go down and get a little 
assistance in the medical and come back and I lost my turn, but 
I am glad you wrote me back in.
    Secretary McDonough. Are you okay?
    Senator Manchin. I am good. I got a couple of shots.
    Secretary McDonough. Okay.
    Senator Manchin. Anyway, Secretary, you and I talked a lot 
about the Clarksburg situation. It is horrific. And I know both 
the Senator and the Ranking Member have heard me talk about 
this before. But, you know, still the glaring thing that 
happened in our VA is that they were getting passing grades. 
They were Joint Commission which accredits the VA facilities 
were saying that everything was good, consistently passing, as 
you remember. And then we found out the OIG report was 
completely different.
    Give me a little update on what you have been able to do to 
change that from the Joint Commission versus the OIG, to see if 
they are in sync.
    Secretary McDonough. Well, so, you know, obviously we 
continue to be subject to that regular Joint Commission 
investigation, but we have also had, obviously, very aggressive 
IG participation on the ground in Clarksburg, including most 
recently, as you and I have discussed. And, importantly, we 
also have our Office of Accountability and Whistleblower 
Protection is taking a hard look at Clarksburg. So that is from 
the accountability side.
    Senator Manchin. Have you all look at some of the other VAs 
too? Is this inherently problematic throughout the VA system?
    Secretary McDonough. You know, you and I have talked at 
length about what are the lessons that we can apply from 
Clarksburg. Among the things we did, after I went up there and 
visited with you and then after the trial and everything, is 
VHA did a system-wide stand down on patient safety and 
accountability. So the entire enterprise dedicated time 
expressly to these questions raised by virtue of the experience 
in Clarksburg.
    So what I can tell you now is that we have looked across 
the system. We do not see this as endemic to the system. I 
think this was a particular challenge with this nurse and some 
of the oversight of performance in Clarksburg. But we are 
continuing to stay on top of it and we will apply whatever 
lessons we need to there.
    The last point. We also continue to apply new blood to the 
system, and I just got an update on Clarksburg last night. What 
I heard last night is that the contract teams that we have, 
including on the wards in question that you and I have 
discussed, report increased morale, improved performance, and 
improved outcomes.
    Senator Manchin. Have we been able to do anything--and I 
think we all talked about this--the people that basically would 
be under suspicion for allowing these types of egregious acts 
to happen, they retired and they are getting full pensions, 
full benefits, full everything, I understand. Were we able to 
reach back at all and find any of them negligent?
    Secretary McDonough. Not yet.
    Senator Manchin. Cannot do it. Okay.
    The assets cost of maintaining and updated critical 
infrastructure at the VA, you know a lot of money being talked 
about and how we are going to spend it. You have a Strategic 
Capital Investment Planning program from 2010.
    Secretary McDonough. The SCIP.
    Senator Manchin. SCIP, yep. And then you have the AIR, 
which is the Asset Infrastructure Review.
    Secretary McDonough. Yes.
    Senator Manchin. Are those two going to conflict with each 
other? Are they overlapping? Does one slow one down?
    Secretary McDonough. Yes. So they are completely different. 
The Asset Infrastructure Review Commission was enacted by 
statute, by you all. I have been saying, and I think our teams 
have talked, I have urged you all and your teams to look 
closely at what we call the market assessments.
    There have been market assessments going on since 2019, in 
96 markets around the country, where we are making some 
assessments about what are the care needs today and what will 
the care needs be for veterans in the future. And we will make 
then some recommendations. We will give those to the AIR 
Commission itself, which is an independent commission. The 
President appoints some members of that commission. Senator 
Schumer, Senator McConnell, Mr. McCarthy, and Speaker Pelosi 
make some recommendations to that commission. Right now we have 
seven commissioners ready to go. Two are still not done. So we 
do not even have a commission yet, and they still have to come 
before you to be confirmed. So you will be able to ask them 
some of these questions.
    So that is an aspirational look at our entire footprint, 
what is going to be needed, what, therefore, is not needed over 
the next two and a half decades.
    The SCIP process is the process through which we make 
decisions based on the resources we get from you all, on a 
year-to-year basis, and then where do we allocate those 
resources. So the SCIP process should surely inform what we are 
thinking about on AIR over time, and then AIR informs SCIP over 
time, but the SCIP is a much more nuts and bolts, dollars and 
cents. AIR Commission much more aspirational. And, by the way, 
right now I am kind of concerned, since we do not have the two 
remaining commissioners, we cannot even submit them for your 
consideration.
    Senator Manchin. Okay. Can I ask one more question? Senator 
Cramer would you mind if I--Mr. Chairman, would you indulge me?
    Senator Tester. We have only got a couple more to go so go 
ahead, Senator Manchin. Then I have got a question for you.
    Senator Manchin. Real quickly, the VA seems to do the best 
job as far as when it comes to pharmaceutical pricing.
    Secretary McDonough. Yes.
    Senator Manchin. Okay. Give me a little breakdown on that. 
Why can't we--why can't Medicare--why can't we copy yours? You 
are a single payer, right?
    Secretary McDonough. We are.
    Senator Manchin. Is there any way that we can integrate 
that into what we are trying to do with Medicare?
    Secretary McDonough. You know, so I would say a couple of 
different things. One is our ability to negotiate drug prices 
saves taxpayers billions of dollars and saves veterans----
    Senator Manchin. You are the lowest cost, basically, of any 
of the providers we have in the Federal Government. Medicaid is 
next, and then Medicare is just balls to the wall and get 
whatever they can.
    Secretary McDonough. And we are very proud of our 
pharmaceutical formulary. And I would be more than happy to 
have our team come up and brief you.
    Senator Manchin. Has anybody ever approached you from 
Medicare or Medicaid or any of our other agencies?
    Secretary McDonough. We have provided technical assistance 
to members of the Senate, of the House, over time, including in 
the context of the negotiations----
    Senator Manchin. I am talking about with the Medicare--you 
know, the Federal Government, Medicare.
    Secretary McDonough. Correct. And so what I understand----
    Senator Manchin. Is it possible--is it possible for us to 
integrate with your----
    Secretary McDonough. We think it is--we have demonstrated 
that it is sound medical and fiscal policy to negotiate drug 
prices, and we do it well. The question of should you use our 
formulary is more complicated. The way the House has done it is 
the House has said, as I read the bill, HHS should negotiate 
based off average international market price, and if there is 
not an average international market price--I would have to 
imagine that for every known pharmaceutical there is an 
international price--then you can look at VA and others.
    My view on that is the average international market price 
is the right way to go, and it gives you the leverage that you 
need to do the negotiation.
    We are very proud of the way we do it. I think we have 
demonstrated that negotiation actually saves dollars, and I 
think that is consistent with what the House has in its Build 
Back Better.
    Senator Manchin. Sounds like a winner to me.
    Senator Tester. I am with you.
    Senator Manchin. Thank you, Secretary. I appreciate it very 
much.
    Secretary McDonough. Thank you, Senator.
    Senator Tester. Senator Manchin, just because the Ranking 
Member and I are so concerned, did you get these medicinal 
shots delivered by needle or by some other method?
    Senator Manchin. Needle.
    Senator Tester. Okay. All right. Senator Cramer.

                      SENATOR KEVIN CRAMER

    Senator Cramer. I could not have done so well with those 
three minutes so I will let him keep----
    Do you know what the score of the Concordia-St. John's 
football game was this fall?
    Secretary McDonough. I do.
    Senator Cramer. I was hoping you would say no.
    Secretary McDonough. I am also aware of the way the 
Johnnies lost on Saturday to Linfield, Oregon, and so I am kind 
of bummed out.
    Senator Moran. Senator Cramer, I do not----
    Senator Cramer. Never mind. If he is not going to tell you 
I am sure as heck not going to tell you.
    Secretary McDonough. I know who sits where.
    Senator Cramer. By the way, I know that Senator Hassan 
expressed appreciation, and I want to join her in appreciation 
for the VA supporting our legislation to get these burial 
rights straightened out for our Guard members. Thanks for that. 
And General Quinn, as you probably know, was out in North 
Dakota last week and talked to some folks. So anyway, but thank 
you.
    Secretary McDonough. He told me it was really windy and 
cold.
    Senator Cramer. That hardly ever happens there. I do not 
know what he is talking about. He is from Montana, for crying 
out loud. How big a deal could it be?
    Secretary McDonough. I will just say, on that bill, Senator 
Cramer, I think that worked really well. You all raised this to 
my attention, we dug into it, and I think very transparently, 
straightforwardly, our staffs, our teams working together we 
came to a good outcome. I am really proud of that work.
    Senator Cramer. We just have to pass it.
    Secretary McDonough. Yes.
    Senator Cramer. We have a way of complicating simple things 
around here, however. You might have noticed.
    You might recall that one of my main focuses on the 
Committee, particularly last Congress but also this Congress, 
of course, is use of HBOT. And we were able to get some 
language into a bill last year, S. 785, that is now a law, of 
course. And I am just going to read a couple of lines from the 
bill so that we can then talk about it. You know it well.
    Secretary McDonough. Yep.
    Senator Cramer. The law will ``authorize the Secretary of 
the VA to enter into public-private partnerships to research 
the effectiveness of hyperbaric oxygen therapy; will require 
the VA to use an objective test to measure the effectiveness of 
hyperbaric oxygen therapy.'' ``It will commission a 
comprehensive review and study of HBOT, both within the VA and 
in outside organizations.'' ``The study would be completed with 
a recommendation from the VA about the effectiveness of 
hyperbaric oxygen therapy.''
    All right. So that was last Congress. You and I talked 
about it at the beginning of the year. You know, I know some 
days you may feel like you have been there for years and some 
days it may seem like last week. I do not know, but it has 
been----
    Secretary McDonough. Most days it feels like a long time.
    Senator Cramer. Yes, I bet it does, and time does fly. But 
maybe if you just give me a little bit of an update on where we 
might be on that.
    Secretary McDonough. So I am really glad you asked about 
this, and I knew you would. So we submitted our first report to 
you all in October. We have two remaining issues on the 
language that you just read, and so I want to read these two 
issues to make sure I get them right.
    Senator Cramer. Thank you.
    Secretary McDonough. Issue one, Section 702, subsection D, 
requires us to commence a study on, quote, ``all individuals 
receiving HBOT through the current pilot program,'' which you 
just read, to provide HBOT to veterans to, quote, ``determine 
the efficacy and effectiveness of HBOT for the treatment of PTS 
and TBI.''
    The program evaluation, i.e., the pilot program, is not 
considered a research study, and therefore commencing research 
activities with veterans who have agreed to participate in the 
program evaluation, i.e., the pilot program, poses an ethical 
risk, because they entered into the program, under a different 
pretense, according to our team.
    Issue number two, 702(D) requires VA to commence a study--
sorry. Outcomes related to the efficacy and effectiveness of 
HBOT are not assessed as part of the pilot program, and there 
is some necessary components of human subject clinical trials 
that are not included in the pilot program. So the point is we 
did the pilot program but it is not a sufficient or ethical 
basis on which to make the research conclusions. Do you see 
what I am saying?
    Senator Cramer. I do, but I think it is why we put in the 
law both within the VA and outside organizations, you know, so 
that we could put together a large enough sample.
    Secretary McDonough. Yes. So it now makes sense to me, more 
sense to me what Coach Tuberville was asking, because he made 
this point about outside participants. So let me take these two 
questions and make sure I understand and come back to you 
again.
    Senator Cramer. That would be great. I would appreciate 
that. And I know it is complicated, but I also know, and you 
and I have talked about this before you went into the job, and 
General Quinn and I talked about it, when I warned him about 
burial rights for Guard members I said, ``Because it sounds so 
easy until you get there and you bump up against that giant 
wall called bureaucracy.'' It is not mean-spirited. It is just 
bureaucracy, and it gets in the way.
    Secretary McDonough. Yes.
    Senator Cramer. And people that do not want to do certain 
things find it very easy to not do those things.
    So that would be great if you get that for me, and maybe it 
is a great opportunity just to renew the invitation to come out 
to Fargo.
    Secretary McDonough. I was saying to Quinn that I was 
jealous that he went, and I look forward to coming. I will 
come. I hope to come this year. I have just run out of real 
estate, but I definitely look forward to coming.
    Senator Cramer. You cannot be everywhere every week, for 
sure. But sometime on your way to Stillwater, you know, it is 
not that far. And as I know about you, February will not scare 
you. I mean, in fact it sounds like you are going to Alaska, it 
sounds like.
    Secretary McDonough. I am going to Alaska in two weeks. I 
do not know. I am actually going to have to get a new coat for 
that.
    Senator Cramer. Oh, good. Well, then you will be ready for 
Fargo.
    Secretary McDonough. Yes, definitely.
    Senator Cramer. Well, we would love to have you, of course.
    Secretary McDonough. Thank you so much.
    Senator Cramer. Yes. Thanks for your service.
    Secretary McDonough. Yes. Thank you.
    Senator Tester. Senator Cramer, could I just make a quick 
request? Could you tell us the score of the Concordia-St. 
John's game?
    Senator Cramer. No.
    Senator Tester. You can't?
    Senator Cramer. It was a lot to nothing.
    Senator Tester. Okay. We can make the assumption.
    Senator Cramer. You can assume from there.
    Senator Tester. Senator Moran.
    Senator Moran. Sinema.
    Senator Tester. Oh, you are right. Thank you very much. We 
have Senator Sinema online.

                     SENATOR KYRSTEN SINEMA

    Senator Sinema. Thank you, Chairman Tester, and thank you, 
Ranking Member Moran, for holding this hearing, and thank you, 
Secretary McDonough, for appearing before the Committee today.
    I appreciate the time you spent at the Phoenix VA Medical 
Center in August, and as we discussed the Arizona VA medical 
care system serves a large and growing population, and they 
have a number of construction needs to better serve the 
community. Among these projects is the need for a new bed tower 
and long-term care facility at the Phoenix VA, which is 
undergoing a feasibility study right now. The Tucson VA Medical 
Center also needs a new bed tower, and these are both major 
construction projects. I am looking forward to working with you 
and the Committee to move these projects forward so Arizona 
veterans can get the care that they have earned.
    I am grateful for the partnership between the American 
Legion, the VA, and Philips Healthcare that brought an ATLAS 
pod to Wickenburg, Arizona, and I also appreciate that the VA 
team is continuing to update my staff on this pilot. In these 
conversations we have been concerned that the VA is seeing low 
utilization of the pod, not just in Arizona but at other sites. 
So we have connected Arizona State University with the VA to 
explore how local community partnerships might help build 
success for these pods.
    Do you see these types of local collaborations beneficial 
to the pilot, and if so, what steps could the VA take 
nationally to build these kinds of collaborations?
    Secretary McDonough. Yes, that is a fair question and 
thanks very much, Senator. The bottom line is we have seen 
uneven use of the pods in the ATLAS program, so I think the 
kinds of things that we can do are the kinds of things that you 
are exploring, including these local partnerships, including 
with Arizona State, which has a significant veteran population.
    And so we believe that local partnership are useful. We 
also think that, you know, the ATLAS project, being in 
partnership with the Legion itself, makes it very attractive 
for further partnerships.
    But all of this is to say, too, that I have noticed 
underutilization of the pods in different places across the 
country. That is not isolated to Arizona. So we are looking at 
that to try to get to the bottom of it.
    Senator Sinema. Great. You know, veterans in Arizona 
consistently reach out to my office with questions and concerns 
about accessing dental care. Dental care is a critical aspect 
of whole health, and access to these services is important for 
veterans. In Arizona we have some wonderful programs that 
provide discount or free dental services to veterans, including 
participation by local dental schools, but the demand far 
outweighs the supply. And that is why I am particularly 
interested in the VETSmile pilot program that was started in 
New York and New Jersey in July, to help veterans access free 
or discounted dental services.
    Now I know it is early in the pilot launch, but are there 
any updates you can share about its progress?
    Secretary McDonough. No, but I have just taken note of it 
and I will get back to you concretely with that, because I 
agree with both kind of--I obviously agree with the thrust of 
the question, and I am embarrassed to confess that I do not 
know much about VETSmile pilot, so I will dig into it and I 
will get back to you on it.
    Senator Sinema. Great. As we get that information I would 
ask you to consider working with my office. As the VA is 
expanding the pilot program, we would like you to consider 
launching a pilot in Arizona.
    Secretary McDonough. Good. We will be happy to work with 
you.
    Senator Sinema. Great. You know, as we talk to our Arizona 
VA medical center homeless program offices and all the 
organizations that support veterans experiencing homelessness, 
we encountered two recurring issues. VA Medical Center HUD-VASH 
case managers are managing growing caseloads and their time is 
divided with other responsibilities. There is also a lack of 
housing that actually accept these vouchers. So while there are 
vouchers available for veterans, there is no housing to place 
them in.
    So how is the VA assessing the staffing levels and support 
for homelessness prevention efforts and what efforts are being 
taken to address the lack of housing, particularly in crowded 
urban areas like Phoenix, where landlords do not have an 
incentive to participate in HUD-VASH, or in more rural areas 
where there is just a lack of landlords and housing?
    Secretary McDonough. Yes, that is a good question. The 
bottom line is we have to get better about staffing up those 
offices. We are now operating under new authority in the Roe-
Isakson Act that said if by October 1 of this year we were not 
at full capacity with hired staff that we need to go out and 
contract staff. So our homeless program office is filling those 
vacant staff slots with contracted staff. So that the most 
important thing we can do, Senator, is actually get people in 
those chairs, because they should not be as pulled among 
multiple assignments as they currently are, and when they are 
not pulled among multiple assignments as they are currently, 
they can actually make a better case to the landlords.
    And so these two issues are related. We are seeing a lot of 
good progress in Los Angeles, and throughout California, 
frankly, by partnering with local nonprofit housing advocates, 
and I think that that has got to be part of the solution, in 
addition to these hiring contracted staff to the challenge in 
Arizona. But let me take that one too and come back to you with 
something more concrete on it.
    Senator Sinema. I appreciate it.
    Mr. Chairman, my time has expired. Thank you.
    Senator Tester. Yes, thank you, Senator Sinema. Senator 
Moran.
    Senator Moran. Chairman, thank you. I will do my best to be 
brief. You too, Mr. Secretary, be brief, for all of our 
benefits.
    You mentioned third-party administrators need to step up. 
What do you have in mind?
    Secretary McDonough. Well, I just think that they know 
these markets well. I think they can help us understand the 
full complexity of the market, range of providers in the 
market, and help market us to those providers. So that is what 
I mean. They are out in the market. We should empower them with 
timely payments, we should empower them with professional 
experience with us, and then we should expect of them that they 
help build robust networks for us.
    Does that make sense?
    Senator Moran. It does, and I am happy to try to encourage 
that as well. I would highlight for you a topic that I have had 
with you and with third-party administrators. Currently the 
third-party administrator contracts do not include the same 
standards, access standards as the law does. It is particularly 
true for one of the administrators because the contract was 
entered into before, and we have been encouraging you to make 
sure the standards that are in law are the standards they have 
to comply with under their contract, and we have not been 
successful in getting that accomplished.
    Secretary McDonough. You and I have talked about this, and 
I am smarter but not yet as smart as I need to be on this. But 
this is one of the things that we are looking at as we do this 
review in anticipation of the June report to you.
    So I think it is a very fair critique/question, as I have 
indicated to you before, and so let me try to make sure that we 
get a better answer to you.
    Senator Moran. I think we find that the networks are not as 
robust as they were previously, and you have veterans who are 
then accustomed to a provider that no longer can go to that 
provider. Maybe that is just the nature of changing third-party 
administrators, and it altered the network. At least the 
standards ought to be the same and the veteran ought to be able 
to rely upon those standards, day in and day out, year in and 
year out.
    Secretary McDonough. I mean, this is assessment, not hard 
intel, but we have seen, because of the pressures on providers 
in the community from the pandemic, a willingness to engage 
with us in certain markets. I do know if that is not the case 
in Kansas, but it would surprise me if it is not. But it ended 
up being such an important source of revenue for them in the 
context of the pandemic that it helped actually put us in a 
position of a kind of a buyer's position, which I thought 
would, therefore, translate into a more robust network. So I am 
surprised to hear you saying that is not the case.
    Senator Moran. Let me make clear, I think the challenge is 
not that the providers are not interested. The circumstance is 
the providers are interested but they are not being--they may 
not meet the criteria----
    Secretary McDonough. I see.
    Senator Moran [continuing]. And brought in. So the 
providers are interested, and so we share that same 
circumstance.
    I also would say that our third-party administrator, when 
we bring a provider to their attention, they have been very 
cooperative in trying to bring that provider in. But, I mean, 
we are happy to do the ad hoc thing, but if nobody is knocking 
at their door it does not happen.
    Secretary McDonough. My instinct is that we are paying 
these guys a lot to help us administer these networks, and I 
think they can do a better job. We are also in a market that is 
pretty thin so far. We really got opted in TriWest. We should 
be able to leverage a more active market there. We are surely 
spending enough.
    Senator Moran. My only follow-up that is left is to 
continue our back-and-forth, the letter--oh no, I have one more 
before I go to the back-and-forth.
    We had this conversation about trying to get folks to the 
AIR Commission, and nominated.
    Secretary McDonough. Yes.
    Senator Moran. What I know about that is that Senator 
McConnell made his nomination and Representative McCarthy did 
as well, and the one I believe is the most recent is 
Congressman McCarthy, and it was made four weeks ago. So I am 
not sure what holds this up.
    Secretary McDonough. I am happy to chat with you a little 
bit off--if we can, off-mic on that.
    Senator Moran. Not a problem.
    Now, only to continue our banter on community care, but in 
this case really about the responses from the VA, we only set 
the letter on November 12th because there was no response to 
the staff request on October 4th.
    Secretary McDonough. Okay. Well, I take really seriously 
what you said to me at the last hearing, which is like, ``Come 
on, man. Just answer our questions.'' And so when I saw this I 
was like, let's answer this darn thing. So I am sorry about the 
October 4th thing. We will make sure that we do a better job of 
it.
    I really think that this question about, as we have 
discussed, how we provide care, where we provide it, is one 
that benefits from our debate, and I wanted to make sure that 
we got you the information to inform this debate, so I 
apologize that did not----
    Senator Moran. No, I appreciate at least your statement and 
perhaps your belief that our circumstances benefit the cause. 
And I do not want to be the proverbial that you just decide to 
write off, never satisfied.
    Secretary McDonough. Well, actually, unfortunately I do not 
really have that option.
    Senator Moran. I do not like the way you say that.
    Secretary McDonough. Even if it were my predisposition.
    Senator Moran. Because it suggests you would like to do 
that. We will continue to work closely together to see if we 
cannot solve this circumstance.
    Secretary McDonough. Good.
    Senator Moran. Thank you, sir.
    Secretary McDonough. Thank you.
    Senator Tester. Thank you, Senator Moran. I would just say 
what I have said before in this regard, and that is that we can 
outsource the work, and we can, and we should when the veteran 
wants it, but we can never outsource the responsibility of 
taking care of our veterans.
    Secretary McDonough. That is exactly right.
    Senator Tester. And so I think that is very important.
    Secretary McDonough, thank you for being here today. I 
appreciate your service at the VA. I also want to express my 
appreciation for professionalism on both sides of the dais 
today. I think that the Committee members did well and I think 
you did well, and I want to thank you for that, because, after 
all, we are working for our Nation's veterans and their 
families.
    And so I know we have got a strong partner in you in making 
sure we are doing right by our veterans, that they get what 
they have earned, and I think that is really important. Thanks 
for being here, and I think this was a good Committee hearing.
    I will tell you that I think everybody showed up. There 
were only two that did not ask questions, because they had 
other conflicts. But I just want to say thank you to the 
Committee members for being here and thank you for being here.
    This record will be open for a week, and with that the 
hearing is adjourned.
    Secretary McDonough. Thank you very much.
    [Whereupon, at 5:07 p.m., the Committee was adjourned.]






                            A P P E N D I X




 




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                        Questions for the Record



     
    
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