[Senate Hearing 117-584]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 117-584
 
                        HONORING OUR PROMISE TO
                ADDRESS COMPREHENSIVE TOXICS ACT OF 2021

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 29, 2022

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
       
       
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                          ______

             U.S. GOVERNMENT PUBLISHING OFFICE 
50-956               WASHINGTON : 2023
         
        
        
        
        
        
                     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

                              ----------                              

                             MARCH 29, 2022

                                SENATORS

                                                                   Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     2
Sanders, Hon. Bernard, U.S. Senator from Vermont.................    10
Boozman, Hon. John, U.S. Senator from Arkansas...................    12
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    14
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    16
Murray, Hon. Patty, U.S. Senator from Washington.................    18
Tuberville, Hon. Tommy, U.S. Senator from Alabama................    20
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    22
Blackburn, Hon. Marsha, U.S. Senator from Tennessee..............    23
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    25
Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire......    27
Manchin III, Hon. Joe, U.S. Senator from West Virginia...........    29

                               WITNESSES
                                Panel I

The Honorable Denis McDonough, Secretary of Veterans Affairs.....     4

                                Panel II

Shane Liermann, Deputy National Legislative Director, Disabled 
  American Veterans..............................................    32
Christopher Slawinski, National Executive Director, Fleet Reserve 
  Association....................................................    33
Kristina Keenan, Associate Director, National Legislative 
  Service, Veterans of Foreign Wars..............................    35

                                APPENDIX
                          Prepared Statements

The Honorable Denis McDonough, Secretary of Veterans Affairs.....    45
Shane Liermann, Deputy National Legislative Director, Disabled 
  American Veterans..............................................    78
Christopher Slawinski, National Executive Director, Fleet Reserve 
  Association....................................................    88
Kristina Keenan, Associate Director, National Legislative 
  Service, Veterans of Foreign Wars..............................    96

                              Pre-Hearing
                        Questions for the Record

The National Academies of Sciences, Engineering, and Medicine 
  (NASEM) response to pre-hearing questions submitted by:
  Hon. Jerry Moran...............................................   103

                        Questions for the Record

Disabled American Veterans response to questions submitted by:
  Hon. Kyrsten Sinema............................................   113

Department of Veterans Affairs response to questions submitted 
  by:
  Hon. Jerry Moran...............................................   116
  Hon. Kyrsten Sinema............................................   124

                       Statements for the Record

The National Academies of Sciences, Engineering, and Medicine 
  (NASEM) cover letter and 2008 Disability Decision-Making 
  Summary........................................................   131
The American Legion..............................................   181
U.S. Department of Defense.......................................   184
Tragedy Assistance Program for Survivors (TAPS)..................   186
Wounded Warrior Project..........................................   196


                    HONORING OUR PROMISE TO ADDRESS



                    COMPREHENSIVE TOXICS ACT OF 2021

                              ----------                              


                        TUESDAY, MARCH 29, 2022

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:33 p.m., in 
Room SR-418, Russell Senate Office Building, Hon. Jon Tester, 
Chairman of the Committee, presiding.
    Present: Senators Tester, Murray, Sanders, Brown, 
Blumenthal, Hirono, Manchin, Sinema, Hassan, Moran, Boozman, 
Cassidy, Rounds, Tillis, Sullivan, Blackburn, and Tuberville.

              OPENING STATEMENT OF CHAIRMAN TESTER

    Chairman Tester. I want to call the Senate Veterans' 
Affairs Committee meeting to order, and I want to thank you all 
for joining us today to discuss the Honoring Our Promise to 
Address Comprehensive Toxics Act of 2021, which is also known 
as the PACT Act.
    Before I get started, I want to recognize a veteran who 
testified before this Committee this time last year about his 
experience with burn pit exposure. That gentleman's name, as 
you might remember, was Will Thompson.
    Will, sadly, passed away in December. He served his country 
for 23 years in the Army on active duty and as a West Virginia 
National Guardsman. After Will's second tour in Iraq, he 
developed pulmonary fibrosis from his exposure to burn pits, 
which eventually led to a double lung transplant.
    In his remaining years, Will spent much of his time 
advocating for his fellow veterans who were exposed to burn 
pits. Our country owes Will Thompson and his family a debt of 
gratitude, a debt that can never be repaid. We should keep his 
service and his sacrifice in mind today and every day.
    When I introduced the COST of War Act last year, I knew we 
were laying down a marker for what comprehensive toxic exposure 
legislation should look like in order to take care of veterans 
like Will. Since then, we have seen a lot of progress. VA 
created a new process that has added a dozen new presumptives. 
And, Mr. Secretary, I want to thank you for that.
    To put that in perspective, over the previous eight years, 
only four conditions were added, and three of those--bladder 
cancer, hypothyroidism, and Parkinsonism--were added because of 
an amendment that I had on the 2021 National Defense 
Authorization Act which forced the previous administration to 
do so.
    So it is my view that we cannot just rely on the Executive 
Branch. I believe Congress has to have a responsibility to do 
its job on behalf of our veterans. And that is why I am 
thankful that following the introduction of the COST of War Act 
our House colleagues introduced similar legislation with the 
introduction of the PACT Act. That legislation achieved a 
historic bipartisan vote of 256 to 174 and elicited a strong 
statement of support from the Biden administration. This proves 
that we have bipartisan support for comprehensive reform, and 
it is reflective of the hard work of Chairman Takano and all 
the VSOs and the many improvements that Chairman Takano made to 
that bill prior to its passage.
    Now as we consider the reforms in this bill, we should be 
very clear about our goals. We are here to right the wrongs of 
decades of inattentiveness, inaction, and failure by the U.S. 
Government.
    And as I said in the outset, our comprehensive approach to 
reform I believe is the only way to get this right. That 
approach must include an expansion of health care to more 
toxic-exposed veterans. It must include the establishment of a 
new process at VA for determining additional presumptive 
conditions, a process that is more transparent, timely, and 
more fair to our veterans. And it should provide long overdue 
benefits to the thousands of veterans who have been living with 
the effects of toxic exposure for way too long despite their 
nation's failure to acknowledge that reality.
    Yes, there is no one on the Committee that does not know 
that this is going to cost some money, but today, right now, 
our veterans are the ones that are paying that cost. I do not 
believe they can wait any longer.
    Today, we are going to hear testimony from Secretary 
McDonough and veterans service organizations about how we can 
do just that and do it in a way that does not punish the nearly 
10 million veterans that are already in the VA system. Look, by 
working together, we can get this done. And after gathering the 
feedback and technical assistance from our witnesses today, we 
will have what we need to move forward without further delay.
    With that, I turn it over to my friend and Ranking Member, 
Senator Moran.

               OPENING STATEMENT OF SENATOR MORAN

    Senator Moran. Mr. Chairman, thank you, and I join you in 
expressing my condolences to Will Thompson's family and 
saddened by his passing.
    I would also like to recognize today that it is National 
Vietnam Veterans Day and to all of our Vietnam veterans, 
welcome home. No generation understands the challenges and 
hardships of toxic exposure better than our Vietnam veterans, 
and we greatly value your continued service in this area, 
particularly as Congress continues to respond to this challenge 
to fix our system on which so many veterans depend.
    Over the last 30 years, Congress and the VA have relied on 
the National Academy of Sciences, Engineering, and Medicine to 
review literature associated with toxic exposure. Within 29 
scientific reports--that is what this is--more than 473 
conditions have been reviewed, and only 35 conditions have been 
added to a list of presumed service-connected diseases by VA 
through the recommendations of the Academies.
    In the 20 years since 9/11, 3.5 million veterans have been 
potentially exposed to burn pits, but approximately 70 percent 
of the burn pit claims have been denied. In the past two years, 
nearly every veterans service organization has testified before 
this Committee and emphasized the importance of fixing the 
process the VA uses to provide health care and benefits to 
toxic-exposed veterans.
    In response, I have been working; me and my colleagues have 
been working with Senator Tester, the Chairman, stakeholders, 
and veterans across the country to build a transparent, 
comprehensive, and enduring solution. Senator Tester and I are 
working together to create a fair, transparent, and responsive 
process for toxic-exposed veterans beginning with the Health 
Care for Burn Pit Veterans Act, which passed unanimously out of 
the Senate. This was also co-sponsored by every member of this 
Committee. When the President signs this bill into law--and he 
has asked the House to also pass this legislation. When the 
President signs this bill into law, sick veterans who are 
suffering from the effects of toxic substances will be 
immediately eligible for lifesaving health care without any 
further delay.
    The House has chosen not to take up that piece of 
legislation, at least yet, and decided to send us the bill that 
we are reviewing today, the PACT Act. While the PACT Act 
includes the critical Health Care for Burn Pit Veterans Act, 
signaling again broad support for the legislation, it also 
includes provisions that perhaps will stretch the VA beyond its 
operational capacity, effectively providing no guarantee that 
veterans will be able to access the benefits promised.
    This bill needs to be amended. I think that is generally 
known and agreed to. I think stakeholders know that. I think 
Secretary McDonough has said as much in his testimony.
    As we work to improve this legislation to make certain the 
VA can--and let me point out that this piece of legislation, at 
least the Senate version of it, has passed this Committee 
unanimously with the agreement that we would take the time to 
work to make the changes that we believed were necessary.
    As we work to improve this legislation to make certain the 
VA can continue to meet the needs of veterans, I again would 
ask the House to pass the Health Care for Burn Pit Veterans Act 
so the VA can immediately provide more toxic-exposed veterans 
health care.
    Last Congress, this Committee approved the TEAM Act, which 
I co-sponsored, to provide a lasting presumptive framework. 
That bill was developed with more than 30 VSOs as a veteran-
centric solution. We must draw on that framework and the VSOs' 
collaborative commitment to get the policy right to improve the 
bill before us today.
    The VA developed a pilot program last year to evaluate and 
implement presumptions for service connections, resulting in 
the establishment of several presumptions for respiratory 
ailments. However, the VA has yet to provide this Committee 
with its methodology from this pilot that has led to 12 new 
presumptions. I look forward to examining in depth this program 
today to help inform this Committee on how to create a law that 
will withstand the test of time while mitigating disruptions in 
the VA's work for caring for all of our veterans. Whether 
statutory or regulatory, reform must establish a threshold for 
scientific evidence, and the decision-making process must be 
transparent for all who are involved in the care of veterans.
    For decades, for decades, the VA has relied upon a 
partnership with the National Academy of Sciences, Engineering, 
and Medicine to help make determinations within the presumption 
decision-making process. As a trusted source of scientific 
evidence, the Academies were charged with reviewing and 
describing how presumptions have been made in the past and 
making recommendations for an improved scientific framework 
that could be used in the future for determining if a 
presumption should be made.
    I requested that the Academies submit for the record their 
2008 report--it is entitled ``Improving the Presumptive 
Decision-Making Process for Veterans''--so this Committee can 
utilize those recommendations while addressing this 
legislation.

    [The requested information appears on page 131 of the 
Appendix.]

    As part of our discussion, Secretary McDonough, I look 
forward to hearing how the VA has utilized and built upon the 
nascent recommendations.
    I look forward to today's testimony and exchanges and as 
well as our continued partnership with the Chairman and with 
members of this Committee, each stakeholder as well, to craft a 
responsive and enduring system that will work for veterans both 
today and tomorrow.
    Mr. Chairman, I thank you, and I yield back.
    Chairman Tester. Thank you. Today's hearing is going to 
consist of two panels. The second panel is going to be three 
VSOs. But first, we are going to hear from the first panel, 
which consists of Secretary Denis McDonough for the VA, and we 
are going to hear his views on the PACT Act and the impact this 
legislation would have on VA services if it is enacted as 
written.
    You have the floor, Secretary McDonough.

                            PANEL I

                              ----------                              


           STATEMENT OF THE HONORABLE DENIS MCDONOUGH

    Secretary McDonough. Mr. Chairman, Ranking Member Moran, 
and distinguished members of the Committee, good afternoon. I 
am grateful to be here this afternoon to testify on this 
important bill.
    We support the bill for many reasons, but the first is that 
it helps VA accomplish a priority goal, getting more veterans 
into VA care because study after study shows that vets in VA 
care do better.
    Addressing toxic exposure is also a top priority of this 
Administration, which is why we fundamentally changed how we 
address veterans' unique health and benefit needs. We have 
increased funding toward research, expanded our outreach and 
our training. We redesigned the presumptive decision-making 
process and leveraged our interagency partners to improve 
access and accelerate outcomes for veterans.
    President Biden is the first President to proactively 
address exposure for vets who have been fighting these wars in 
this region for 30 years. So it is no surprise that toxic 
exposure figures prominently in yesterday's budget submission, 
investing in toxic exposure medical research at $20 million 
more than in fiscal year '22, which is just the VA portion of 
the interagency effort, increasing funding of new disability 
claims related to three presumptives introduced last year, and 
among much more, funding new hires to process those claims.
    Today is, as Senator Moran said, National Vietnam War 
Veterans Day, a day to welcome home our courageous Vietnam era 
vets. Earlier, I walked the Wall with them and their families, 
and I am reminded that we honor them by fundamentally changing, 
improving, and expediting how we establish presumptions for 
vets who over the last three decades have fought wars in that 
geography from Somalia in the Southwest to Uzbekistan in the 
Northeast and all those difficult places in between, including 
Iraq and Afghanistan.
    Here is why. When someone signs up to serve our country in 
the military, we make them a simple promise that if they serve 
us we will serve them.
    While vets fought overseas, many breathed in toxic fumes 
and particulate matter. Some developed conditions that impacted 
or took their lives like, sadly, Will Thompson, long after the 
final shots were fired.
    Marine Veteran Sergeant Johnny Green fought in Desert 
Storm, inhaling fumes from diesel fires and burning wells, 
particulates and thick dust kicked up by dust storms. In 
country images of him are disconcerting, even alarming, 
obscured by smoke he and his sniper team operated in. When he 
got home, he was diagnosed with rhinitis, with nasal polyps, 
and suffered debilitating sinus infections, putting him down 
for weeks at a time.
    He is far from alone, and his condition is in many ways not 
as extreme as others. Toxic exposure is a life and death issue 
for too many vets, like Sergeant Green, who did their jobs for 
us. So now it is our turn to do our jobs for them.
    We have made progress, expediting the presumptive process, 
reevaluating the cumbersome model VA has traditionally used 
that Senator Moran just talked about, piloting a new model, 
taking all available science and vet claim data into account 
with one goal in mind, getting vets timely access to the 
benefits they have earned, and adding new presumptions of 
service connection for asthma, rhinitis, and sinusitis.
    When Sergeant Johnny Green heard about those, he filed a 
claim, and VA granted him a 30 percent disability rating. So 
far, nearly 12,000 vets and their survivors are getting 
benefits they are owed for these conditions.
    We are examining at the moment, constrictive bronchiolitis, 
lung cancer, brain cancer, and as you heard in the State of the 
Union, we have initiated rulemaking to add presumption for 
several rare respiratory cancers.
    And we are reshaping our airborne hazards and burn pit 
exposure registry to streamline the questionnaire, make the 
experience more veteran-centric, to encourage vets 
participation. We are going to make sure every vet 
participating in the registry who wants an in-person clinical 
evaluation will get it. We are leveraging this platform to do 
everything we can to learn as much as we can about their 
experience, both while serving and since.
    We have more to do. We need to ensure that the presumptive 
process created by this bill allows VA and future Secretaries 
to act with transparency, efficiency, and public participation 
for the benefit of veterans, not create additional 
administrative burdens that slow down presumptive decision-
making, which I believe Title II as currently drafted will do.
    We need our pilot program, our pilot model, to work so 
there is a sturdy, proven process that gets veterans and vets 
in the decades ahead the benefits they deserve as fast as 
possible.
    Finally, facility space is critical to caring for vets, and 
the PACT Act, thankfully, will bring millions more into our 
care. Yet, of 31 large medical facility leases in the proposed 
budget, 21 have been pending for years. Everybody on this 
Committee, most recently, Senator Hirono, has wrestled with 
this CBO-related problem. So in the PACT Act, we urge you to 
provide VA authority to move out on those 31 leases and on 
future leases so we can be genuinely responsive to vets' needs.
    So with President Biden leading the way and with your help, 
that is where we are headed because too many vets have waited 
too long for these benefits. Together, we will make sure that 
they do not have to wait any longer. And I look forward to your 
questions.

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

    Chairman Tester. Thank you, Mr. Secretary. As I said last 
year, this Committee thought it was critical to give VA time to 
design, implement, and test its pilot process for creating 
additional presumptive conditions. That internal analysis 
concludes in April. At the end of the day, any new presumptive 
process established in legislation needs to be proven and needs 
to work for both the veterans and the VA. With the VA's 
assistance, the House rewrote the process originally in the 
PACT Act to reflect the progress of the pilot.
    What lessons has the VA learned from this pilot process, 
and does the current language in the PACT Act successfully 
incorporate those lessons?
    Secretary McDonough. Thanks very much, Mr. Chairman. We 
have learned quite a bit. Most importantly, my commitment to 
you--and this is directly responsive to Senator Moran's 
question in his opening comments--is that, as you indicated, 
our internal pilot will conclude and come to me forthwith 
within days. We will take the following weeks to get--we are 
not going to grade our own homework. We are going to get a 
review of that from outside of the Department. Upon completion 
of that, which I anticipate is yet this spring, we will submit 
the whole thing to you to see, and you can see both what we 
have proposed and what the outside review of what we have 
proposed finds.
    The bottom line, in my view, about our presumptive--new 
presumptive process is that we have to put the veteran at the 
center of the process and we have to increase the sources of 
science available for us to make the decisions that we need to 
make.
    As to whether Title II reflects those lessons, I do not 
believe it does. I think Title II needs to be reworked. I have 
communicated as much to members of the House. I am not sure 
they agree, but you know, this would be one place where I think 
we could profitably do some work on the existing bill.
    Chairman Tester. So the internal analysis--well, let us 
start here. Do you have in mind who is going to review it?
    Secretary McDonough. Yes. I mean, so one group that should 
review it in my view is the Office of Science and Technology 
Policy in the White House. It has access to, and deep 
connections with, the kind of full academic, scientific 
community.
    Chairman Tester. And if you said this, maybe I missed it. 
When do you anticipate it being presented to the Committee?
    Secretary McDonough. I would say before the end of spring.
    Chairman Tester. Okay.
    Secretary McDonough. So now is the end of March.
    Chairman Tester. June 21, all right.
    Secretary McDonough. Well, yes. In Minnesota, we think 
spring goes till like August, but . . .
    Chairman Tester. All right. And then do you anticipate that 
the information in that analysis will be instructive on any of 
the work that needs to be done on Title II?
    Secretary McDonough. I do. The thing that concerns me about 
Title II is kind of the addition of--additional hurdles that we 
would have go to through. As I read Title II, and maybe as you 
read in our submission and the testimony, I think actually the 
steps that we have taken heretofore had Title II been the law 
of the land we would not have been able to have taken those.
    Chairman Tester. Yes.
    Secretary McDonough. I am not saying that we have done 
enough. I am just saying that what we have done would have been 
made more difficult by Title II if it were statute when we 
first arrived.
    Chairman Tester. Okay. I will ask you to be quick on this 
because you have only got about a minute. First of all, I want 
to thank you in making your staff available to Congress. We 
appreciate that very much.
    And as we have already said, your testimony reflects 
additional changes that need to be made. From your perspective, 
what are the two or three most critical improvements that can 
make this legislation better for our veterans?
    Secretary McDonough. Well, I stand by what I have said on 
Title II. And then I come back to the comment I made in the 
opening, which is that each of us--and I put in that all of you 
have wrestled with this leasing requirement that we have. We 
are the only agency in the Federal Government that requires 
full congressional authorization of each lease, and then how 
CBO scores those slows them way down. We are now 21 leases 
behind.
    Chairman Tester. Yes.
    Secretary McDonough. Take P.G. County right next to us or 
Beaufort, South Carolina, two facilities, each about 8,000 
square feet today. They have to go--demand for care in those 
communities requires a 75,000 square foot to 8,000 square foot 
facility. We have been waiting in one case since 2019 and in 
the other since 2020 for the authorization to go to those 
bigger facilities. We have got the people. We have got ideas 
about how to build, how to structure the site. We just cannot 
get into the building, and we have got to fix that.
    Chairman Tester. Okay. Thank you.
    Senator Moran.
    Senator Moran. Thank you, Chairman.
    Mr. Secretary, this is a bit of a follow-up on what 
Chairman Tester was asking you, but maybe I can get more 
definitive answers, and maybe I cannot because we are still 
waiting for the completion of the pilot program.
    Secretary McDonough. Yes.
    Senator Moran. Does your pilot include recommendations from 
NASEM's 2008 report, the one I mentioned in my opening 
comments?
    Secretary McDonough. I made note of that as I was listening 
to your report--to your opening comments. I do not know, but I 
will get you an answer by the end of the day today.
    Senator Moran. And does the PACT mirror what you were doing 
in the pilot, and where does it diverge? And perhaps that is 
again what you were answering for Chairman Tester.
    Secretary McDonough. I think in Title II of the PACT I 
think what--this is kind of classic balance of power stuff, I 
think. And I think that the House is trying to force our hand 
to try to do things. And I think they are trying to build 
institutional capacity around us to try to force us to be more 
transparent in what we do and then report to a new commission 
about what we are doing, get the commission to agree to what we 
are doing, and then proceed.
    So I get what they are trying to do in Title II, which is 
to try to get us to move quicker. But I think the tools they 
have used to try to force us to do that actually would slow us 
down in an instance where in this Administration the President 
is pushing pretty hard for us to move. And so that is the first 
thing on what they do there.
    I think, though, the spirit of what Title II intends is 
consistent with what I have read about what you and the 
Chairman are working in your process, which is let us get the 
veteran at the center of this presumptive process, let us be 
very clear and forthright about the process by which we make 
decisions so everybody's expectations can be clearly managed, 
and then let us communicate transparently when we make 
decisions pursuant to those agreements--to those efforts.
    So we have a way to do that. We are going to--as with all 
of this, while Congress deliberates, we are pressing forward. 
We will press forward with a plan that we have to put into the 
Federal Register everything we do under our process so that 
people can see, including in any given year what do we intend 
to review, what timeline, and what they should then expect, 
which is why, for example, we have made public that this year 
we are going to review not just constrictive bronchiolitis, 
which I talked about, but brain cancer and lung cancer. And we 
anticipate making those decisions and making them publically 
this year.
    Senator Moran. You said something that is forefront in my 
mind, and you said something about slowing down. One of my 
significant concerns about not getting this right is the 
consequence of slowing down services not only for toxic-exposed 
veterans----
    Secretary McDonough. Yes.
    Senator Moran [continuing]. But for other veterans as well. 
What does this Committee and this legislation need to be paying 
attention to that does not diminish the timeframe in which a 
toxic-exposed veteran will receive benefits and health care? 
And one of the things I might add is while we are doing this it 
would be useful to have those veterans receive health care, 
which is the legislation----
    Secretary McDonough. I agree with that.
    Senator Moran [continuing]. That this Committee--I will let 
you say that again.
    Secretary McDonough. I agree with that, and more 
importantly, the President agrees with that and has said that 
publically about your bill.
    Senator Moran. That, to me, is we want to do this in a way 
that does not prevent people who are toxic-exposed from getting 
the health care benefits that they need today. We want to make 
sure the legislation is written in a way that does not cause a 
veteran who is toxically exposed and entitled to benefits to be 
delayed in receiving those. But I also want to make certain we 
do not do things in this legislation that reduces the timeframe 
in which other veterans, unrelated to toxic exposure, can 
receive care and benefits from the VA.
    What would you--how would you respond to that, those 
concerns, and what would you suggest that needs to be done if 
you agree with my concerns----
    Secretary McDonough. Yes.
    Senator Moran [continuing]. To avoid that?
    Secretary McDonough. Yes. So I think they are legit 
concerns. I share the concerns.
    I think there is a couple of very near-term things we can 
do. One is get our two Under Secretaries, one for Health and 
one for Benefits, confirmed. And we are really grateful for how 
quickly you are moving on them.
    Two is enact the President's budget, and as I privately 
did, I publically thank you all again for the omnibus which 
gives us very important investments.
    The budget submission for this year includes opportunities 
to continue to modernize the presumptive making process, and I 
will come back to that in a second.
    What should you look at? Look, we have an estimate--and 
this is an estimate--that says under the PACT Act, over the 
next three fiscal years, there will be about 1.52 million 
claims filed if there is no inclusion of hypertension. If there 
is an inclusion of hypertension, we anticipate or we assess 2.5 
million claims filed. We process in any given year about a 
million and a half claims.
    So we have to--so just using those as rough estimates, and 
those are assessments, I will walk through like an algebra 
problem in a second.
    But, one thing to think about is we have experience now 
with these three presumptives that the President enacted last 
year as quickly as he could upon coming into office. We have 
some water under that dam--or over that dam, under that bridge. 
And that gives us at least a sense of how much--how many claims 
are being filed relative to how many we assessed. So that would 
be another thing to look at in the context of this assessment.
    Lastly, we think that there are prudent things we should do 
and we are doing, and I will lay out three of them in 
particular. One is we are hiring. We are hiring about 2,100 
extra people right now. And we have been--at VBA, we have been 
talking about this. Right now, we have hired about 70 percent 
of those people. Of those 70 percent are about 1,472-ish claims 
processors. That is about 90 percent of the claims processors 
we want for that number.
    So we are moving. There is still a bit of a training tail 
on that, but that will give you a sense of it. So that is one, 
is we should hire more, and we will probably have to hire more 
if this is enacted.
    Two, we should use the teams that we have more 
aggressively, which we are doing with mandatory overtime.
    Second, we should try to normalize this process in some 
way, shortening steps where we can prudently do so. So the 
requirement for, for example, additional exams I think is 
superfluous in many cases. So we should get that out.
    Third, we should also automate the process where we can. We 
have been updating you on this as well. There is technology 
that we can use to go get these records. You have invested in 
us, in our ability to digitize records, which we have done to 
the tune of a million additional records in the last year or 
so. So we should continue to prepare to do that, and we are 
developing the algorithms to allow us to do that. Our most 
recent addition to that is asthma late last week. We have now 
run five claims through that process. I am not saying that this 
is the be-all and end-all, but it is an important step.
    Those are the things we should look at, and I think there 
is meter sticks to measure this out there, both our assessed 
number of claims and then actual claims looking back on the 
three presumptives we have been working.
    Senator Moran. Mr. Secretary, thank you. In Kansas, we 
believe that spring can never come fast enough.
    Chairman Tester. Senator Sanders.

                    SENATOR BERNARD SANDERS

    Senator Sanders. Thank you very much, Mr. Chairman, and let 
me thank you for your important work on this legislation, as 
well as Senator Moran.
    Secretary McDonough, thank you for the great work that you 
have been doing, and we thank the President for the kind of 
budget that he is presenting to protect our veterans.
    It goes without saying that I will support the strongest 
possible legislation that we can come up with, but I wanted to 
ask the Secretary, maybe the members, a question here, 
something that I really do not understand. And I was through 
this with Agent Orange as well, and now we are dealing with 
burn pits.
    Hypothetically, let us say that Senator Brown and Senator 
Tester served in the same vicinity at the same time, and they 
both came down with the same illness. And after lengthy 
bureaucratic analysis, it was presumed that Senator Tester in 
fact was exposed to the toxin, Senator Brown was not, but they 
both were suffering from the same illness.
    So after spending thousands and thousands of dollars 
discussing both cases and whether or not they were exposed, we 
have concluded you will get the medical care you need, but you 
will not. You have the same illness. That does not make a whole 
lot of sense to me.
    At the end of the day--and I know not everybody in this 
room agrees with me--health care happens to be a human right 
for all Americans, in my view, and especially for people who 
put their lives on the line, such as our veterans. So I think 
that instead of spending a huge amount of money in the Federal 
bureaucracy to determine whether in fact somebody was exposed 
to toxins from a burn pit, exposed to Agent Orange, maybe we 
just say that if you were a veteran who put your life on the 
line to defend this country you are going to get all of the 
health care that you need.
    Will that cost more money? It will. Is it the right thing 
to do? Yes. But the money that we will be spending will go 
toward health care, not to a huge bureaucracy to determine 
whether or not you were exposed or not. If you got two guys who 
were ill, we want to take care of them as human beings and as 
veterans.
    Mr. Secretary, what do you think?
    Secretary McDonough. Look, I think that, as I said, one of 
the things that particularly attracts me to the bill and 
attracts this Administration to the bill before us is that it 
expands the number of veterans who could get care.
    Senator Sanders. Right.
    Secretary McDonough. Get into our care. So I think that is 
an attractive thing. We have that as a goal.
    I will say that we do spend a large number--we spend a 
large amount of money on health care. We are growing at a 
pretty rapid pace every year.
    Senator Sanders. But we spend money on health care, to be 
sure, but we also spend a huge amount of money on the 
bureaucracy to determine whether somebody is eligible or not.
    Secretary McDonough. Agree. Agree. And so this is why I 
think the President has put us--has directed us to make sure 
that we have the vet at the center of these determinations, 
that we are making sure that we are making the decisions in the 
interest of the veteran, and that we are setting up a--we are 
trying to design a presumptive process that gets to ``yes, 
if,'' rather than ``no.'' And that is what we are trying to 
build in this model.
    Senator Sanders. No, I appreciate that. But I think I would 
hope that we could all agree that if we are spending a dollar 
on VA health care spend it on health care, not a bureaucracy to 
determine whether or not the veteran, in fact, was exposed or 
not exposed. That seems to me a real waste of money.
    And in that regard, I just want to remind people I am going 
to--have introduced legislation which deals with another absurd 
issue. And that is, for example, if you live in San Francisco 
as opposed to Los Angeles, the eligibility requirement for VA 
health care is significant because San Francisco presumably has 
a higher cost of living than does L.A. And that exists in all 
of our zip codes. It exists in Montana. It exists in Vermont. 
You could live across the--you and I could live across the 
street from each other. I am eligible; you are not. Does that 
make real sense?
    So you have got a telephone book full of different 
eligibility requirements. We should simplify that and make 
sure, to quote the Secretary, the more veterans--I think the 
goal is to get more veterans into the VA. That is one way to do 
that.
    The other point I would like to make on a subject, a 
different subject, we will be holding a roundtable on Wednesday 
on dental care. I think all of the service organizations 
understand that dental care is health care, that we should 
expand VA health care to include dental care. That is going to 
be this Wednesday, and I would hope that members are able to 
attend.
    Thank you very much, Mr. Secretary.
    Secretary McDonough. Thank you, Senator.
    Chairman Tester. Senator Boozman.

                      SENATOR JOHN BOOZMAN

    Senator Boozman. Thank you very much for being here. I 
enjoyed visiting with you earlier today about the budget.
    And we also do want to give a big shout-out to our Vietnam 
vets and all that they represent on this day. And it is 
interesting, you know, that we have the hearing today. I do not 
know if it was designed that way, but certainly what we are 
dealing with now is much like Agent Orange and the difficulties 
that our veterans went through then and also the long period of 
time that it took to actually get that acknowledgment.
    What we do not want to do--and I have had the opportunity 
of serving on the House veterans committee and now the Senate 
veterans committee. What we do not want to do is repeat the 
same implementation. So I think as I look around the Committee 
I know that we are committed to getting this done. What we do 
not want to do is have a situation where we create a backlog 
that it literally took years and years and years, years, you 
know, to make it such that the veterans actually got their 
benefits.
    So I would like to ask, in the legislation, there is really 
no outline as to how you--in other words, we pass the 
legislation. You know, we are in good shape. We start dealing 
with the problem. As far as the implementation of the problem, 
it is really not in here.
    So right now, the veterans' backlog is what? 250,000 or so?
    Secretary McDonough. Yes. Right now, it is 243,000, down 
from its most recent peak of 264,000 last October.
    Senator Boozman. And it is safe to say right now you have 
got hardworking men and women that literally are working 
overtime to keep it at that level.
    Secretary McDonough. We do. In fact, we just earlier today 
passed the 800,000th claim adjudicated this year, this fiscal 
year, the earliest we have ever done that. By the same token, 
we have also received--so that is 17 percent higher than a year 
ago at this time.
    Senator Boozman. Right.
    Secretary McDonough. We have also received, you know, 1 
percent more claims this year than we did a year ago.
    Senator Boozman. Right.
    Secretary McDonough. So we are just barely keeping up.
    Senator Boozman. And the claims now are more complicated.
    Secretary McDonough. Some. Not always. But, yes, they can 
be for sure.
    Senator Boozman. Generally. And we anticipate working hard, 
getting this done, another 500,000 or so a year? Is that in the 
ballpark?
    Secretary McDonough. Yes. I mean, as I said, over three 
fiscal years we think a range of 1.5 to 2.5 million claims.
    Senator Boozman. Right. So, a lot of claims. And you 
mentioned that we are hiring more people. What kind of people 
do we need to hire, though? And again, I am not saying this in 
the sense of not--I just want to be prepared as we go down this 
path----
    Secretary McDonough. Yes.
    Senator Boozman [continuing]. That we make sure that we are 
able to deliver----
    Secretary McDonough. Yes.
    Senator Boozman [continuing]. What we are doing. Yes, I 
mean, that is what planning is all about.
    Secretary McDonough. I think it is a very--absolutely fair 
question. And so I talked through what I consider the prudent 
steps we are taking now to get ready. That does not mean that 
is all we would need. We do need to do more, but let me just 
talk for a minute about the hiring specifically.
    Senator Boozman. Okay.
    Secretary McDonough. A particular challenge--well, this is 
where the experience of those 2,000 hires I think is meaningful 
as you all think about your bill. We actually advertised those 
openings. We got very positive response in terms of number of 
applications per opening, meaning that they are highly sought 
after positions, that allow us to run a very competitive 
process to fill those positions. I think that is useful.
    I will get you the specifics in terms of how many 
applicants for the openings. Again, I think that will give you 
some----
    Senator Boozman. Right.
    Secretary McDonough. I hope it gives you some confidence 
that we are thinking about this clearly and carefully.
    The next question is identifying and hiring the person is 
step one. The training tail that comes with that person is step 
two. So there is probably--let us estimate a six- to eight-
month training tail on each individual person. So we believe 
that those hires we have in the chair now who are training will 
be profitably adding to our ability to crank out additional 
claims come the fall.
    So that underscores how complex it is, but I hope it gives 
you some confidence that we are thinking about it, soup to 
nuts.
    Senator Boozman. No, I understand. And yet, I think the 
reality is that kind of gets us out of the hole that we are 
currently in but does not do any for planning in the sense, you 
know, making the system where it works better.
    Secretary McDonough. Yes.
    Senator Boozman. But it really does not address the future.
    Secretary McDonough. I think that is particularly true 
about overtime.
    Senator Boozman. Right.
    Secretary McDonough. But I do not know that it is 
necessarily true about the hiring because we are adding a lot 
of fire power to the arsenal that will more than get us out of 
the hole.
    But then, yes, we will be adding more on top, which is then 
that is where the claims modernization process itself becomes 
really important. Automation becomes really important. And then 
the steps that we are taking now, for example, to digitize 
records so we do not have to go into some dusty closet and pull 
out paper----
    Senator Boozman. Right.
    Secretary McDonough [continuing]. Every time one of our 
veterans applies or files a claim. That is work we are doing 
now that will pay benefits in years ahead.
    Senator Boozman. Right. Well, we look forward to working 
with you so we can really, you know, hash out a system to make 
it such that it works. So thank you very much.
    Secretary McDonough. Thank you very much.
    Mr. Chairman, I just learned by virtue of modern 
communication that our lead researcher on the internal process 
did, in fact, use the 2008 NASEM report. We will get you 
specifics on what from the report we used as we implemented our 
proposed changes.
    Senator Tester. Thank you. Senator Brown.

                     SENATOR SHERROD BROWN

    Senator Brown. Thank you, Mr. Chairman.
    Secretary, thanks for your terrific work as a public 
servant and what you said at the beginning, the promise, you 
serve us, we serve you. A whole lot of veterans, as you know, 
and as you have said to us personally, privately, and 
publically, do not think they always get the fair shot that 
they should. And I think none of us question--whether we are 
from South Dakota or Connecticut or Kansas, none of us question 
the public spiritedness of the great, great majority of VA 
employees in places like Chillicothe and Cincinnati and Dayton 
and Cleveland.
    But it just--when you think about--I mean, ever since I 
started, met the first Agent Orange veteran, I do not know how 
many decades ago. It is just hard not to believe that the 
military, and in those days the chemical companies, knew what 
Agent Orange was doing to the men and women exposed. And it is 
hard to believe that the military did not know more about what 
these burn pits were doing when they are burning batteries and 
tires and medical waste.
    We have with us today--there is a couple of people I want 
to--Heath Robinson's family is with us. Danielle and her 
daughter, Brielle, are here. Brielle's grandmother, Susan, who 
is one of the great activists in this country in bringing to 
our attention.
    And to yours, Mr. McDonough, you did not need a lot of--you 
already were there, Mr. Secretary. But the heartbreak and the 
sadness of all this.
    And they are joined by Tim Hauser today from--thank you for 
joining us. A Gulf War veteran from 30 years ago. He told me 
today he knew--from Twinsburg, Ohio. He knew within weeks of 
returning that something was different in his respiratory 
system.
    So it just does not seem--I mean, I know you want to make 
this clean and direct. I know this is going to be really 
expensive. I do not know the hearts of everybody on this 
Committee, but I do believe they all think that we have a duty, 
no matter the cost, to take care of this.
    So, a couple of questions. For Title I, you said it would 
cost about $534 million for personnel and equipment. Elaborate 
how that would be spent on medical professionals. I mean, I 
heard what Senator Sanders said. I do not disagree with that. 
But, IT systems, administrative support. How do you spend that, 
delivering service?
    Secretary McDonough. I think that is both just a people 
prospect, which is hiring clinicians and continuing to hire 
clinicians. You know, the subject of other hearings that we 
have had here and ongoing concerns and efforts, concerns you 
have about efforts that we are up to. So it is hiring people. 
It is also making sure that we have facilities into which we 
can make sure if we really do get a million and a half to two 
million additional enrollees who are coming to us for care, 
that we have facilities in which we can treat them.
    And so it is all straight medical account care management, 
right, which is if we have more patients we need more 
investment to care for those patients.
    Senator Brown. Thank you. Senator Boozman had--I am going 
to follow up on his question about the backlog. And we have 
all--I mean, I assume everybody on this Committee has done 
various kinds of listening sessions, roundtables, and veterans 
do not quite understand. If they were in a specific place and 
they have one of these conditions, shouldn't it be a more 
straightforward process? So walk us through why the backlog 
will jump so high.
    Secretary McDonough. Well, remember that the whole purpose 
of presumptives is to address one of the issues that Senator 
Sanders talked about, which is if Senator Brown and Senator 
Tester are both deployed in roughly similar areas, they both 
develop a similar condition, but somehow the process--the 
science is so difficult to prove, that one proves out--your 
case proves out differently than his. The idea of a presumptive 
is to sweep in or lower the threshold of evidence in places 
where the science in the aggregate is strong but the science in 
the particular is difficult.
    And so one of the reasons--so it is true that any veteran 
could file a claim about his or her condition today and that 
claim would get adjudicated, but we would have to work through 
each of the portions of the claim. If we establish--if having 
established, for example, presumption of service-connection for 
asthma, or for rhinitis in the case of the Marine I discussed, 
the evidentiary threshold for him reduces, but it does not go 
away, right, because we still have other things we need to 
prove out given the statute under which we operate.
    And so I think it can be--look, I think we can be 
frustrated. Look, our team is unbelievable, cranking through 
800,000 claims already this year. Our scientists, some of the 
best scientists in the country. They are trying to follow the 
statute, follow the law. They are trying to do the right thing. 
But as we do that, that can be frustrating for vets.
    And if we get to the presumptives, that does not erase the 
entire process. It erases one big piece of a three-part test. 
So working those other two parts ends up being time consuming.
    More importantly, though, the attention around the issue 
will remind people, like these great Ohioans that you just 
talked about, that, hey, they have a claim before the United 
States Government, so they will come forward.
    My last point on this is I do urge the Committee to take a 
look both here looking forward on the numbers, what we assess, 
but also let us look at the experience here back to last May 
2021, when the President announced the first three presumptives 
and how did that process track our assessments. You know, what 
can we learn about that for the newest--new presumptions going 
forward?
    I hope that is responsive to the question, Senator.
    Senator Brown. Good. Thank you. Thanks.
    Chairman Tester. Senator Tillis.

                      SENATOR THOM TILLIS

    Senator Tillis. Thank you, Mr. Chairman.
    Secretary McDonough, thank you for being here and, as I 
have said before, thank you for being so responsive when I have 
reached out to you and you reaching out to me. I appreciate the 
working relationship.
    You know, I first got involved with toxic exposures 
probably six or eight months into my first term here back in 
2015, with the Camp Lejeune presumptions, and that was a 
constant battle in that case. And actually that battle 
transcended over administrations and a couple of VA 
Secretaries. It was a frustrating process. And a part of that 
was using data outside of the VA to get to a fair decision on 
presumptives.
    I have reintroduced the TEAM Act again because I think we 
have got to get it right and we have got to make sure that we 
do things that are, you know, that are scientific, transparent, 
and enduring with respect to how we go about moving forward, 
getting as many presumptions as possible. How important do you 
think it is to have that scientific, transparent, enduring 
framework in anything that we pass out of the Congress?
    Secretary McDonough. I think it is really important, 
Senator. Thanks. I echo your very generous comments about our 
working relationship. I appreciate that very much. People very 
important to me live in your State, too, by the way.
    It is very important for a lot of different reasons. This 
is why the President has stood up, first time ever, this 
interagency process in the White House. I happen to know a 
little bit about that. The best interagency processes are run 
from the White House, chaired by the White House, but they yank 
everybody to the table. So we have Labor, HHS, Defense, and 
many of the specialized subagencies in each of those around the 
table, sharing science from outside VA. We have met now seven 
times. That is increasing the aperture for additional 
information to us.
    And having that then, as you say in the TEAM Act, fall in 
on a well-established, transparent framework so people like 
many of the people in the room today, suffering as they are, 
can have some transparency around, and some expectations for, 
what is going to come out of a process. So I think it is really 
important.
    Senator Tillis. Thank you. The PACT Act, I believe at least 
in a couple of cases, would legislate a number of presumptions 
that may or may not have a factual basis for support. And I 
think there are somewhere on the order of 400 some diseases in 
addition to the 23 included diseases in the PACT Act.
    So is it wise for us to take that step or just to make sure 
that we have--that you all are enabled to have the processes 
that you can expedite. If these 23 are--maybe they should be 
viewed first. But does it make sense for us to legislate 
presumptions or just to provide a framework that we expect you 
all to work through on a timely basis?
    Secretary McDonough. Well, we--as the President has made 
very clear, we support the PACT Act. We think that a big piece 
of it is those presumptives. I think working through those--you 
know, I am not in a position to say, we think this makes sense, 
this does not. But I think as a group I think we should work 
through those consistent with the way we have been having those 
discussions. We have had those discussions with the House. We 
should continue to have them with you.
    I think that as a general matter, in the past--and I think 
this is particularly true with Agent Orange--congressional 
impetus as it were really forced action from VA. So I think 
there is historically--and maybe today of all days especially, 
as Senator Boozman underscored, is probably a day to recognize 
that legislated presumptions play an important role.
    That said, we are putting together a framework that I think 
works, I hope works. I hope we can convince you it works. And I 
think I would like to see that enacted as well.
    Senator Tillis. Yes, yes. I am just mainly concerned with 
the other diseases, some 400 diseases, that we do not either 
through resources or focus shift our attention away from these 
that may have merit in being moved ahead of the line.
    Secretary McDonough. Yes.
    Senator Tillis. So it is more managing the process and 
priorities to make sure we are helping as many veterans as 
possible as quickly as possible.
    Secretary McDonough. That is why we started where we did. 
We are starting on--you know, if you line up the presumptions 
we have done, we started with as wide a capture as we could. 
Sinusitis, rhinitis, asthma, these are not the most 
debilitating conditions. Many conditions, including some that 
people in the room today are suffering from, are much more 
heart-wrenching, but we try to cast a wide net.
    The question then is constrictive bronchiolitis, same, very 
broadly impactful across the force, and then these rare 
cancers, which are rare but they are extraordinarily 
devastating.
    So we are trying to mix how we get as many vets in our care 
as we can with who are the vets, as both Senator Sanders and 
Senator Moran have said, who need the most timely care. We are 
trying to balance both of those.
    Senator Tillis. The final question just relates to the 
presumptions in the PACT Act. Why not go ahead? We are going to 
take time. We are going to try and get to a consensus and get 
it passed.
    Secretary McDonough. Yes.
    Senator Tillis. But you have authority to implement all 
those presumptions now. Do you intend to do that before we 
actually move forward with the legislation?
    Secretary McDonough. Yes. So we have been very clear about 
what we intend to do this year. As I said, we have initiated 
rulemaking on the nine rare respiratory cancers. We are looking 
at brain cancer, lung cancer, and constrictive bronchiolitis. 
We published--we have talked about that publically. We have 
made clear what we are going to do this year. We have tried to 
put rough timelines around them. And then we will make those 
records of those decisions available to everybody through the 
Federal Register. So that is what we are going to do this year.
    As to whether we just go ahead and do all the ones that are 
in the PACT Act, you know, I want very much to work through all 
of those. My own view is the founders probably would have had a 
view on that, which is if we are going to expand--if I am going 
to expand our budget, basically $300 billion over the next 10, 
my guess is that there is a role for Article I in that and a 
role for Article II in that.
    And so I think we should keep working it down on our side 
of the street as you guys keep deliberating on your side of the 
street, and I think there is lessons learned in both, where I 
do not think anybody should wait. As we have all--you know, 
Camp Lejeune or North Carolinians, Minnesotans, Montanans, 
Kansans. There is a lot of suffering out there, and the 
President has been very clear to me what I need to do to make 
sure that we address that.
    Senator Tillis. Thank you.
    Chairman Tester. Senator Murray.

                      SENATOR PATTY MURRAY

    Senator Murray. Thank you, Mr. Chairman. And I just want to 
thank Senator Tester for his leadership on this issue. I know 
we are capable of tackling some really big challenges as a 
committee and that that includes making sure that our veterans 
that are harmed by toxic exposures in their service for our 
country get the care they deserve. I really hope that this 
hearing can bring us closer to resolving some of the open 
issues in order to pass the comprehensive legislation that 
veterans in my State of Washington and across the country 
really expect of us.
    Mr. Secretary, good to see you here today. As we continue 
to shape the legislation in front of us, what does VA still 
need to get this done?
    Secretary McDonough. That is a good question. So I think 
there is two things in particular and then one--well, let me 
make a general point, and then I will answer the specific 
question.
    Generally, I have appreciated the open channel that I have 
had with everybody around the room on this issue. As long as I 
have been Secretary, we have been having very spirited, 
straightforward, I think transparent conversations. Most 
recently, I thought the conversation I had with Senator Moran 
was very, very useful to me and to us. So the first thing we 
need is a continued open channel.
    Second, I raised two things earlier. I think we need to 
really go to work on Title II of this thing, and I think that 
some of that is incumbent on us to make sure that we get to you 
how we are running our pilot and how it works.
    Three is I think that there is relatively simple fixes on 
things like this really frustrating, vexing even, issue of 
major medical leases for new facilities. We have 31 of those 
now pending. We would like to get those done so we can move 
into bigger facilities.
    And then there is this question of the ``eaches'' in the 
conditions, and I think we should--I am not in a position now 
to kind of go into those, but I think we have had really good 
conversations heretofore. We should keep working those.
    Senator Murray. Okay. Very good.
    Secretary McDonough. And then lastly, sorry, we will need 
resources. The CBO says basically $325 billion over 10. That is 
about 60 percent mandatory, 40 percent discretionary. Not a lot 
of people around here understand the difference between those. 
I mean, you all do, but on our end of the table. But if there 
is anybody who knows that very well, it is you. So we need both 
mandatory authority, and we need discretionary capability to 
make sure that we get this done in a timely way.
    Senator Murray. Okay. Thank you. We are continuing to push 
VA to improve the user experience for veterans while receiving 
care and accessing their benefits. If Congress is able to pass 
some comprehensive legislation to address toxic exposures, VA 
is going to have to have systems in place that are easy for 
veterans to navigate. How can we make processing service-
connected disability claims less difficult for veterans who 
experienced toxic exposures?
    Secretary McDonough. That is an excellent question, and I 
think there is two things in particular I want to highlight 
that we are doing. I think we are taking a series of prudent 
steps that I think will get us in a better position to manage 
something as big as this.
    One is the claims process modernization which includes 
things like digitizing records, which we are doing thanks to 
the AARP. We are able to use overtime to digitize a lot of 
records, a million in the last year or so alone. We have to--so 
that is one, claims modernization, and there is a whole bunch 
of work behind that.
    The second is we have to get the veteran at the middle of 
this process, and so our Veterans Experience Office is 
developing a series of efforts to try to ensure that everything 
we build is built around the veteran experience.
    Senator Murray. We are thinking about all this ahead of 
time. That is my point.
    Secretary McDonough. That is my point, yes.
    Senator Murray. Because the last thing we want to do is 
pass something and then have everybody frustrated because they 
cannot access it, it is not understood, as you well know.
    Secretary McDonough. That is next to the last thing we want 
to do. That is for sure.
    Senator Murray. Correct.
    Secretary McDonough. I think the last thing we want to do 
is--well, anyway, I agree with you.
    Senator Murray. I also want to ask you about health equity. 
Women veterans are serving in increasing numbers, and I was 
happy to see the President's budget actually requests--
highlights women's health as a priority. But we need to make 
sure that women veterans' needs are the focus as we move 
forward on this. How is VA tracking the impact of toxic 
exposures on women's health, including their reproductive 
health and fertility?
    Secretary McDonough. Thank you very much. So first of all, 
I am glad you pointed out the President's budget. It has a big 
investment, $9.8 billion in women's health, including $767 
million. Those are basically, roughly 12 and 10 percent 
increases over similar numbers from last year.
    We have to get up this power curve. One way we get up this 
power curve is providing more services and providing 
professionally so that women veterans want to come to us for 
their care.
    Senator Murray. Right.
    Secretary McDonough. As it relates to research, we are 
increasing our focus on impact on women's health, including 
gender-specific health impacts of toxic exposure. That includes 
on reproductive health, and it includes, for example, on impact 
on breast cancer and----
    Senator Murray. Are you tracking that now?
    Secretary McDonough. We are tracking that, yes. And thanks 
to investments from you, Senator Boozman, and others, we are 
increasing access to mammography in VA facilities. And by the 
way, this is one of the big places that our vets get 
authorization and referrals for care in the community.
    Senator Murray. Thank you very much, Mr. Chairman.
    Chairman Tester. Senator Tuberville.

                    SENATOR TOMMY TUBERVILLE

    Senator Tuberville. Thank you, Mr. Chairman. Thank you for 
your work on this. I know since I have been here you have been 
knee-deep in it, so thank you for all your hard work.
    And thanks to the people here that have put their life on 
the line for all of us here and thanks to you for being here 
today.
    I have talked to the Secretary of Defense about this burn 
pit problem. And sometimes we need to use a little bit of 
common sense. Instead of putting people in harm's way, there 
could have been a lot of this that could have been avoided 
instead of just doing things the easy way. So hopefully in the 
future, we can use a little bit of common sense, but sometimes 
that does not go very far in government.
    Secretary McDonough, thanks for being here. You know, the 
House passed the PACT Act. It requires the VA to establish a 
working group consisting of representation from DOD, HHS, EPA, 
among others. The purpose of such a working group is to 
identify opportunities for collaborative research regarding 
health consequences of toxic exposure experienced during active 
military service. What gap do you envision such a working 
group, as described in the PACT Act, addressing that is not 
already happening through the ongoing research partnerships 
between the VA and other agencies?
    Secretary McDonough. That is a fair question. Sir, I have 
not had a discussion with the House members on that part of 
that title in particular, but my hunch is that I think they 
think--I think they are trying to help us codify some of the 
work that we are doing. They may have also broader designs, but 
I am not in a position to talk to them about that.
    I do think that this interagency table is a really valuable 
one for us because, you know, for example, there has been 
discussion that somehow we just invest a very small amount of 
our research in this. We are growing that. We are growing it 
still, and we will be coming back to you all to talk about some 
of the ideas we have in this space, including for information 
on--for technology on research. But we can leverage the rest of 
the Federal Government by having everybody around that table 
and making sure that we are sharing information there.
    Senator Tuberville. So you think it is going to help?
    Secretary McDonough. I do.
    Senator Tuberville. Yes. You know, one piece of a potential 
toxic exposure legislation is how to address the current 
disability claims backlog in addition to the number of claims 
that would be added under the new legislation. Given the 
current backlog is upward of 244,000 and legislation such as 
the PACT Act could add another 1.5 million claims on top of 
that, what consideration is given to how the claims may be 
prioritized in the process? Have we thought about that?
    Secretary McDonough. Yes. As a general matter, we have, you 
know, a system whereby a claim is addressed as it comes in, 
which is to say it is addressed in the order it arrives.
    There are certain ways to expedite a particular claim. For 
example, homeless veterans' claims are expedited. In 
extraordinary health circumstances, a claim is prioritized. But 
we do not envision metering or anything.
    We envision working this through the system, which is why 
we are trying to spend as much time as we are now in taking the 
prudent steps to prepare that I have talked about and why we 
are going to need some help with getting additional resources 
on the other side of this. And it is why it is so important 
that we get our Under Secretaries of Health and Benefits in the 
chairs, and I know you guys will be having hearings with them 
later this month.
    Senator Tuberville. If a post-9/11 veteran has a claim 
pending today but wants to apply for additional benefits after 
additional presumptives have been made----
    Secretary McDonough. Yes.
    Senator Tuberville [continuing]. How would the VA handle 
this?
    Secretary McDonough. I think it would kind of depend on 
where the particular claim stands, the existing claim stands, 
but we would probably adjudicate the first one, then go 
adjudicate the subsequent additions on them. We are constantly 
adjudicating claims on top of existing claims for veterans.
    We do not have to just--it is not a one-time--you know, 
today is the time for Coach Tuberville to come in to get all of 
his claims adjudicated. You can come in today. We will manage 
one, that one, through the process. As additional claims come 
up, you file for those, and we will work through those with 
you.
    Senator Tuberville. Thank you.
    Thank you, Mr. Chair.
    Chairman Tester. Senator Blumenthal.

                   SENATOR RICHARD BLUMENTHAL

    Senator Blumenthal. Thank you, Mr. Chairman. Thank you to 
you and the Ranking Member for your work on the PACT Act, which 
has been a long time in coming. It is the result of a lot of 
years' work on a bipartisan basis, and I think it will 
accomplish a great deal.
    And thank you, Secretary McDonough, for your full-throated 
endorsement of it and to the President of the United States, 
who has brought leadership I think that has opened a new era in 
Presidential support for the VA.
    Very significantly, we are recognizing National Vietnam 
Veterans Day which is a very important reminder of the battle. 
And it was a real fight to get recognition for Agent Orange. 
The VA had to be dragged, kicking and screaming, into the 
scientific real world, in fact, even to the point of defying a 
court order. Incredibly, the VA defied a court order to resist, 
it said, the cost of the presumption for Agent Orange.
    So, two points. Number one, to go back to Senator Sanders's 
remark, when we go into a war, these kinds of health care 
coverage are part of the cost of that war. They are not 
something we think about afterward. We have to change America's 
state of mind. If you commit to a war, if you commit to sending 
any American into combat, beyond the presumption, it ought to 
be a matter of simple fact that we cover illnesses that that 
veteran has afterward.
    You know, in the legal world--and I have been in litigation 
as a trial lawyer for quite a while--presumption is a way of 
ducking a question. It is literally a way of avoiding a 
question. Often, there is a rebuttable presumption.
    What we need in health care for veterans is an unrebuttable 
presumption. In other words, you have the illness; it is going 
to be covered. And so I hope that we can change the mindset 
here.
    And I really want to pay tribute to the team that you have, 
thousands of them, many of them in Connecticut, doing a great 
job, dedicated, hardworking, compassionate, caring, and your 
leadership as well.
    But I think this system of presumptions is part of the 
problem because it locks us into a decision-making mode that is 
costly and cumbersome--you have used the word ``cumbersome''--
and time consuming. And that is the last point that I would 
just emphasize here.
    You know, a lot of these folks who are here with us today, 
for them, this is personal. I have two sons who have served. 
Fortunately, they are both fine. One was in Afghanistan in 
Helmand Province as a Marine Corps infantry officer; the other 
was a Navy SEAL.
    A lot of people are going to wake up tomorrow morning and 
have to go through a full day wondering and worrying, and their 
families. So time is not on our side here nor was it on the 
side of the Agent Orange Vietnam veterans because they were 
dying, and many of them are now dying.
    So I want to just suggest that the PACT Act is a great 
start. It is very important. It will change people's lives. But 
we also ought to think about a new model.
    And I want to ask you specifically about the Palomares and 
the K2 veterans. K2. You have said on page 11 of your 
testimony, that there--I am quoting. ``There have been concerns 
over several potential exposures related to service at K2, and 
VA will continue to seek information on K2 exposure 
opportunities.'' I would like to see that process accelerated. 
I would like to see it telescoped. And, the same with 
Palomares.
    The people--the folks in Palomares cleaned up after a plane 
crash with radioactive material without any protective gear. 
The people at K2 were at an all-Soviet base that was 
contaminated with oil and all kinds of other stuff--I could use 
other words--that the Soviets did not--you know, as is 
illustrated by now Ukraine, they do not give a hoot about the 
health of their people. And they did not care about the health 
of the people they stationed there, but we should because we 
took it over and our people were there for about four years, 
2001 to 2005.
    So I can--I am out of time. So I think I need the 
Chairman's indulgence to ask you for a commitment, but if you 
could commit to getting back to me with an answer.
    Secretary McDonough. I will. I commit to that.
    Senator Blumenthal. Thank you.
    Chairman Tester. Senator Blackburn.

                    SENATOR MARSHA BLACKBURN

    Senator Blackburn. Thank you, Mr. Chairman.
    And, Mr. Secretary, as always, thank you for your time and 
for being here with us. I think you know that I have got some 
concerns, and the backlog is one of those. I understand we are 
at 240,000 on the backlog. That is correct?
    Secretary McDonough. That is correct, down from about a 
peak of 260-some odd thousand in October, yes.
    Senator Blackburn. And employees are showing back up to 
work in person?
    Secretary McDonough. Yes. I mean, you know, we have--as a 
general matter, we have now for many years had max telework 
arrangements with our workforce. And I think productivity has 
been remarkable, including earlier this year under max telework 
where our claims processors claimed--adjudicated more than 
7,500 claims per day for 20 days in a row for the first time in 
the history of VA. So I think the team is working really hard.
    Senator Blackburn. And about how many claims per person are 
they able to do in a day?
    Secretary McDonough. Oh, that is a good question. I do not 
have that metric.
    Senator Blackburn. Could you get that for me?
    Secretary McDonough. Absolutely.
    Senator Blackburn. See, my concern is if you look at the 
PACT Act I am afraid it is going to be a false promise, and I 
know you know that is my concern because your estimate is that 
we would go to 1.53 million on the backlog on claims. And I do 
not want veterans to think we did something but then we are not 
able to implement it.
    And I know you have got 1,700 that you are going to onboard 
in order to become claims adjudicators, correct?
    Secretary McDonough. That is right. We have onboarded about 
1,750, 1,742 exactly, as of this morning. They are in training. 
We have a couple more on top of that. And then if we get the 
PACT Act, we are going to need additional people on top of 
that. And obviously, we have a bunch of people who are working 
overtime right now, too.
    Senator Blackburn. Right.
    Secretary McDonough. And doing it--I just--look, I want to 
brag on this team. I think they are working really hard----
    Senator Blackburn. Okay. Well----
    Secretary McDonough [continuing]. And doing it pretty well.
    Senator Blackburn. I appreciate that. But see, even if you 
onboard the 1,700----
    Secretary McDonough. Yes.
    Senator Blackburn [continuing]. Then it takes two years to 
really get them up to speed.
    Secretary McDonough. Well, I think probably about nine 
months, but . . .
    Senator Blackburn. Nine months?
    Secretary McDonough. Yes.
    Senator Blackburn. All right.
    Secretary McDonough. But the broad point you are making is 
a fair one, absolutely.
    Senator Blackburn. And this is of tremendous concern to me. 
So if we were to do the PACT Act and if you have to get these 
people onboarded, and then you are going to need additional 
individuals onboarding, then my concern is how long it is going 
to take for them to even be able to get any benefit at all from 
this program. Already today, we have got cases that have been 
out there for months without being----
    Secretary McDonough. Yes, in Tennessee.
    Senator Blackburn. In Tennessee.
    Secretary McDonough. Yes.
    Senator Blackburn. Without getting answers. And our VSOs 
complain about the slow pace of the VA in getting back to them 
with answers.
    Secretary McDonough. Yes.
    Senator Blackburn. So I am very concerned about how long it 
is going to take for the VA to respond if they say: ``Well, we 
do not have the proper infrastructure. We do not have the 
proper training. We do not have the appropriate number of 
personnel.''
    Secretary McDonough. Right.
    Senator Blackburn. Then you are going to have veterans and 
their spouses who are going to be more frustrated than ever, 
and I am quite concerned about this.
    And the Chairman knows, and Senator Moran knows, I have 
said many times I think that the only way we would be able to 
do this and to meet the standard of care is allowing community 
care right off the bat so that that promise made is a promise 
fulfilled because at this point you do not have the capacity to 
meet the need. Correct?
    Secretary McDonough. Yes. So thanks very much for the 
question. I mean, you know, we have been talking about the 
capacity and what we would need to meet it over the course of 
this. I have not looked at the final version of the PACT Act to 
understand when implementation dates are and all that kind of 
stuff. This is all stuff that this is your business, not mine, 
but these are all things that surely would factor into our 
ability to be prepared.
    But we are taking a series of very important steps to get 
ready. There will be more that we need to do. There is no 
question about it.
    And look, let us be very clear that enrolled veterans have 
legal rights under the MISSION Act once they are enrolled 
irrespective of when they became enrolled and for, you know, 
the basis on how they became enrolled.
    And those are the timelines and the distance metrics that 
you all have laid out. We will have that conversation over the 
course--as we have been talking, over the course of this spring 
and summer as we report to you under the MISSION Act on how 
community care is going, including how a veteran who gets care 
in the community--how we are getting record of that visit 
back----
    Senator Blackburn. Right.
    Secretary McDonough [continuing]. So we can help manage 
that vet's health and wellness. So I think there is a lot to 
chew on here.
    I have not met a person yet who thinks that a vet who comes 
to--is enrolled with us, by virtue of an expansion made 
available through the PACT Act, should not have access to 
community care. I think that would be the law of the land, of 
course.
    Senator Blackburn. Well, of course, I am out of time. We 
want to make certain that a promise made is a promise kept.
    Secretary McDonough. Fair enough.
    Senator Blackburn. So we are looking very closely at this. 
Thank you.
    Thanks, Mr. Chairman.
    Chairman Tester. Senator Hirono.

                      SENATOR MAZIE HIRONO

    Senator Hirono. Thank you, Mr. Chairman. I would like to go 
on record--first of all, thank you for having this hearing 
because it is a long time coming to address the impact of toxic 
exposure on our veterans. And I have heard some of my 
colleagues say that this is just going to be way too expensive. 
I think it is way too expensive because we in Congress have not 
addressed this matter for years on end.
    So thank you, Mr. Secretary, for being here. And I thank 
all of the veterans and the individuals who represent veterans 
organizations for your advocacy in this matter.
    And in fact, I agree that the VA's capacity to implement 
the PACT Act, assuming that we pass it--and thank you for your 
support, Mr. Secretary--needs to be addressed, the capacity to 
implement. But at the same time, I thought that the effect of 
the PACT Act is to enable more veterans to access VA care, 
which is one of the major goals that you have, Mr. Secretary. 
So at large, that is what the PACT Act's effect should be.
    Secretary McDonough. Yes.
    Senator Hirono. And we are going to have to figure out--you 
know, give you the resources to implement it.
    I think one of the most difficult aspects of what we 
require of veterans to make the service connection evident is 
they bear the burden of proof, and whoever has the burden of 
proof has a really high burden. For example, unless there is a 
presumption that a medical condition is service-related, the 
individual servicemember--or maybe you can get a group of 
servicemembers. Nonetheless, let us say that the individual has 
to prove that his or her medical condition was service-related.
    So what does this mean? What kind of evidence is an 
individual servicemember supposed to provide to meet his or her 
burden of proof that the condition was service-related?
    Secretary McDonough. Well, so obviously this is kind of the 
lifeblood of the Veterans Benefits Administration, and so, you 
know, we have a whole list of available, you know, proof points 
and evidentiary points that vets can work. We obviously work 
very closely. And you know, it would be a useful question to 
ask to the next panel, the VSOs, who are great partners to us 
in making sure that their members are in a position to come 
forward with well-built, well-developed, strongly supported 
claims.
    And so there is a variety of ways to do that, Senator.
    Senator Hirono. Yes.
    Secretary McDonough. But again, the presumptives do play a 
very important role----
    Senator Hirono. Yes.
    Secretary McDonough [continuing]. In expediting that. It 
does not dot every ``I'' and cross every ``T,'' but it does 
establish an important condition for the vet.
    Senator Hirono. I agree. But without the presumption, the 
burden of proof on the veteran is pretty high, requiring 
things, information such as all the years that the person may 
have been exposed to a toxic condition. A lot of this is 
information that even the DOD does not apparently keep. In 
fact, one of the questions I had asked in an earlier SASC 
hearing was what aspects of military health concerns with the 
work environment do they even track. For example, do they track 
what exposure to a 10-acre burn pit meant? I would not even 
know that.
    It seems that the DOD--so their response to my question was 
that they really do not do the kind of health surveillance, 
evidence tracking that they should be doing so that the 
servicemember, the veteran, has some basis on which to make his 
or her claim that this is service-related. So that is something 
that I hope that you can prevail upon the DOD. They should pay 
attention to the conditions in which our servicemembers are in, 
not to mention that they are not even given any protective gear 
when they are in these conditions.
    And you probably are not the person that I should be 
hitting over the head with. It should be Secretary Austin 
perhaps. But really, you know, I hope that you are working----
    Secretary McDonough. We are.
    Senator Hirono [continuing]. Closely with DOD----
    Secretary McDonough. We are.
    Senator Hirono [continuing]. To have DOD follow and track 
this kind of evidence so that we can get veterans into VA care.
    So I do thank you for all of the advocacy----
    Secretary McDonough. Thank you.
    Senator Hirono [continuing]. And the work that you are 
already doing in so many areas. As far as I am concerned, you 
are to be commended.
    Thank you, Mr. Chairman.
    Chairman Tester. Senator Hassan.

                  SENATOR MARGARET WOOD HASSAN

    Senator Hassan. Thank you, Mr. Chairman, and thank you and 
Ranking Member Moran for this hearing.
    To all the Vietnam veterans here today and watching, 
welcome home, and thank you to Secretary McDonough for 
testifying today.
    I want to start by noting that I support the Honoring Our 
PACT Act, and I look forward to working with Chairman Tester 
and Ranking Member Moran to strengthen this legislation so that 
veterans exposed to toxic substances can get the health care 
and benefits that they need and they have earned. We have to 
work quickly to get this done for veterans in my State and all 
around the country. I am going to ask a couple of questions 
about that effort. I have three questions, but I wanted to 
start with a slightly more general topic.
    I am concerned that the VA's recent recommendations to the 
Asset and Infrastructure Review Commission could reduce access 
to care for veterans in New Hampshire, including veterans 
exposed to toxic substances. New Hampshire is one of the only 
States in the country that lacks a full-service VA medical 
facility. I sent you a letter this month with the other 
Senators from New Hampshire and Vermont, asking the VA to 
forego any actions that would limit veterans' ability to get 
care at VA facilities in our States.
    When we spoke a few months ago in this Committee, you 
supported VA facility upgrades in New Hampshire, including 
expanding ambulatory, surgical facilities in our State, but the 
VA's recommendations to the AIR Commission risk moving in the 
opposite direction. Can you please speak to the importance of 
preserving access to VA care and VA facilities and what you 
will do to ensure that AIR Commission will recognize that and 
avoid making changes to reduce VA care in States?
    Secretary McDonough. Yes. As a general matter, I think I 
would say three things. One, this is the start of this process, 
not the end of it.
    Senator Hassan. Yes.
    Secretary McDonough. So I think as you and I have 
discussed, the role of the Commission here will be very 
important.
    Senator Hassan. Yes.
    Secretary McDonough. And then the President has an 
independent decision to make about the Commission and what it 
thinks about our work, one.
    Two, as a general matter, across the country and in New 
Hampshire specifically, we tried to ensure that our 
recommendations increased access rather than decreased it, but 
I think this is something we ought to keep debating, and surely 
you ought to make sure the Commission takes a hard look at.
    Senator Hassan. Well, I----
    Secretary McDonough. Three----
    Senator Hassan. Oh, go ahead.
    Secretary McDonough [continuing]. As it relates to our 
conversation in this Committee, as I was looking at the New 
Hampshire recommendations, I was expressly thinking of the 
conversation I had with you at that moment because I did make a 
commitment to you. And I think if you look closely at our plan 
about Manchester, for example, I think there is a full range of 
options available to VA going forward that not only honor the 
kinds of access questions that you raise----
    Senator Hassan. Yes.
    Secretary McDonough [continuing]. Including expansion of 
surgical and ambulatory care in that facility----
    Senator Hassan. Right.
    Secretary McDonough [continuing]. But also an opportunity 
for us to increase partnership with other providers in the 
State.
    Senator Hassan. Right.
    Secretary McDonough. And so we are a very important part of 
the health infrastructure in your State, and I am proud of 
that. And I anticipate these AIR Commission recommendations 
will increase that role, but I think we should continue to 
hammer this out because it is really important.
    Senator Hassan. Yes. And it is really important. Obviously, 
I am committed to it to make sure that our veterans----
    Secretary McDonough. Absolutely.
    Senator Hassan [continuing]. In New Hampshire can get the 
care they deserve, they have earned, in our State. So I look 
forward to continuing to work with you on that.
    Now let me see if I can get to the other two questions. 
Melanie Spears is a Granite State veteran. She deployed to 
Afghanistan in 2012. After more than a year of VA visits due to 
pain in her abdomen, she was diagnosed just last month with 
cancer. Veterans exposed to toxic substances need health care, 
but they also need VA personnel to identify their conditions 
early on.
    The Honoring Our PACT Act includes a provision that 
requires the VA to provide training to VA health care personnel 
so they can identify, treat, and assess veterans exposed to 
toxic substances. In November, the VA also noted that it would 
expand training for VA and non-VA providers to help better 
treat veterans with toxic exposures. Can you please speak to 
how more training would help VA health care personnel better 
treat veterans exposed to toxic substances?
    Secretary McDonough. Yes. I mean, I have a belief that 
because we are as familiar as we are with--not perfectly so, 
but I think we are much more culturally competent on the kinds 
of exposures and challenges, conditions that veterans are 
subject to. So I actually think that we do a pretty good job of 
that training now. We could always do better, but in all cases 
we have a much greater wherewithal of capability to understand 
what our vets have been through. So additional training of the 
type that we announced in November will make us that much more 
capable, and I think at the end of the day, I hope, we can 
convince veterans that that is a reason that they should come 
to us for their care when they have that option.
    Senator Hassan. And I appreciate that. I will note that I 
think that there are some holes in the training guidelines that 
are being suggested, and I would like to follow up with you on 
that.
    Secretary McDonough. Please do.
    Senator Hassan. And the last thing--Mr. Chair, I realize I 
am out of time. We have talked before about the importance of 
primary care physicians having questionnaires that they use to 
help screen veterans for toxic exposure. I am pleased that 
provisions that address that that we had put into our 
legislation are included in the PACT Act, but I would like to 
find out if you are starting to develop that questionnaire 
because I do not think you have to wait for the PACT Act to 
pass----
    Secretary McDonough. Yes.
    Senator Hassan [continuing]. And I would like to work with 
all of you on that.
    Secretary McDonough. Yes, let us do it, and let us talk 
about it. The Burn Pit Registry is also a place where the 
questionnaire itself is so burdensome as to ultimately be not 
very helpful.
    Senator Hassan. Okay.
    Secretary McDonough. And so this is another place where a 
questionnaire of the type that you are advocating can be useful 
as well as the commitment I made in my testimony today that 
those vets who participate in our Burn Pit Registry, who want a 
full clinical examination, should get it. And so that is an 
execution challenge. That is one that we think is really 
important for the obvious reason that you lay out.
    Senator Hassan. Thank you and thank you, Mr. Chair, for 
your indulgence.
    Chairman Tester. Senator Manchin.

                      SENATOR JOE MANCHIN

    Senator Manchin. Chairman Tester and Ranking Member Moran, 
I want to thank you for the kind consideration. I want to thank 
you for holding this hearing and for all the work that you all 
have done to find a consensus on this issue, and it is 
extremely important.
    I have always said that the military and our veterans is 
what holds our country together. It rallies all of us, 
Democrats and Republicans, and that is the best thing that I 
can tell you that we do here is when you all come and tell us 
the concerns you have and how we can be of help. It is our duty 
to take care of all the brave men and women who have selflessly 
fought to defend the Nation.
    Many of our veterans in West Virginia and across America 
who are exposed to open air burn pits are now facing health 
complications without health care coverage and benefits, and 
millions have been exposed to toxic materials, and that number 
is only rising. Our Committee is unique in taking care of the 
veterans, and it is not a partisan issue. It is simply our 
responsibility. So I know that we can find a solution and we 
will get this done.
    I also appreciate, Secretary, you being here and to share 
with us your thoughts, recommendations for Honoring Our PACT 
Act and how we can get our veterans the care they need as soon 
as possible.
    A couple things I wanted to ask you, sir. I am very pleased 
to see the collaboration including in Honoring Our PACT Act 
between the VA and the Department of Defense in the provisions 
of the bill on interagency research into toxic exposure, 
especially the important further understanding of the 
correlation between exposure and adverse health effects. So 
does the bill as it currently stands adequately divide the 
responsibility between the VA and DOD?
    Secretary McDonough. You know what? I think that is a good 
question. I want to say to you ``yes,'' but I also want to take 
the question to make sure that I get--come back----
    Senator Manchin. If you can because we can make some 
adjustments to the bill----
    Secretary McDonough. Yes.
    Senator Manchin [continuing]. To make it work the way it 
should work.
    Secretary McDonough. Yes.
    Senator Manchin. I know all of our intention is to do that, 
but sometimes when you write a bill you have no clarity and 
there is an overlapping and you get nothing accomplished. So we 
want to make sure that that is clear.
    Also, can the VA and the DOD collaborate further and get 
ahead of the curve to ensure that our veterans are not exposed 
to toxins in the course of their service going forward? Have we 
been able to separate and understanding the danger we are 
putting them in by changing how we operate in the field? And 
that would come back from you all----
    Secretary McDonough. Yes.
    Senator Manchin [continuing]. Giving your information to 
the DOD.
    Secretary McDonough. Yes. Look, you have heard me say in 
this room before, and you have heard me say this to you 
privately, that I think Secretary Austin is uniquely focused, 
and generously so, on how to care for our vets. This is an 
issue that we have had conversations about. I do not want to 
make any kind of operational commitments or even raise 
operational----
    Senator Manchin. Yes.
    Secretary McDonough [continuing]. Things that I do not have 
a say in, but I know that DOD is very focused on this.
    Senator Manchin. In all the agencies, we have challenges. 
We all mean well----
    Secretary McDonough. Yes.
    Senator Manchin [continuing]. But things go wrong at times, 
and you know that. When you took over, there was a--you had a 
tremendous backlog to work in getting us up to speed.
    And I think all of you heard the story about the VA in West 
Virginia and the deaths we had. It is just totally mindboggling 
today. I cannot even--the horror that the families are going 
through. But I can tell you we put through great legislation to 
correct a lot of the things, and the whole thing is holding 
accountability.
    Secretary McDonough. Yes.
    Senator Manchin. So in addition to accountability, we need 
to make sure implementation that measures that no veterans are 
being left behind. So my question would be: Do you feel that 
Honoring Our PACT Act currently has enough standards for 
accountability and implementation, and if not, where could we 
fix any gaps? And if you have not gone in--if your staff could 
give us----
    Secretary McDonough. Yes.
    Senator Manchin [continuing]. The adjustments that might be 
needed, we need to identify that now.
    Secretary McDonough. Yes.
    Senator Manchin. Because I do not want any of you all to 
leave here thinking that we have got a perfect piece of 
legislation and we fixed everything that was wrong and we find 
out the language is not there to do it.
    Secretary McDonough. It is a fair question, a good 
question. And I do not have anything specific with me today on 
accountability, but I will take that.
    Senator Manchin. Well, there is different iterations of the 
bill.
    Secretary McDonough. Of course.
    Senator Manchin. You know, we had one on our side; they had 
one on their side, and this and that.
    Secretary McDonough. Yes.
    Senator Manchin. And we tried to start blending that.
    Secretary McDonough. Yes.
    Senator Manchin. And you got DOD responsibility, and you 
got VA responsibility, and if they are not correlated--I know 
you had that ability in your previous job. You had to make a 
lot of things happen, and I know you can make this happen, but 
if you need us to help write that language or make the 
adjustments that makes your job easier and better.
    Secretary McDonough. Yes. My hunch is that we have a lot of 
useful accountability tools, including one that you all gave us 
in 2018 that would apply obviously to this going forward, but I 
think it is a good question. I have taken note on it, and we 
will make sure to get back.
    Senator Manchin. I can assure you, as far as the bipartisan 
effort that we are all making right here, whatever you 
recommend that we could help to make this really happen because 
it is a big undertaking and I know we want to get it right.
    Thank you, Mr. Chairman. I appreciate your patience.
    Senator Manchin. Thanks, Senator.
    Chairman Tester. Thank you. Secretary McDonough, I believe 
it is about 98 minutes in. Thank you very much. I guess we are 
going to have to do these more often because that way people 
will not have a whole bunch of questions to ask you. So it is 
good.
    Secretary McDonough. I will come; Mr. Chairman, I will come 
anytime you request my presence.
    Chairman Tester. I appreciate your testimony and your 
frankness, and you are now released.
    Secretary McDonough. Good.
    Chairman Tester. And now we are going to hear from three 
VSOs whose members are impacted by the consequences of toxic 
exposure every day. I want to first introduce somebody who has 
been at this Committee a lot, Shane Liermann, the Deputy 
National Legislative Director of the Disabled American 
Veterans. We also have Christopher Slawinski, who is the 
National Executive Director of the Fleet Reserve Association. 
And lastly, we have Kristina Keenan, Associate Director of the 
National Legislative Service for the Veterans of Foreign Wars, 
the VFW.
    In many respects, this panel is the most important panel we 
are going to hear from today because these three groups 
represent part of the men and women who have served for the 
last 20 years that we are talking about with toxic exposure. So 
I want to thank you all for being here, and I am going to turn 
it over to you for your opening statement, Shane.

                            PANEL II

                              ----------                              


                  STATEMENT OF SHANE LIERMANN

    Mr. Liermann. Thank you. Chairman Tester, Ranking Member 
Moran, and members of the Committee, on behalf of DAV's more 
than one million members who have wartime service related 
wounds, injuries, diseases, and illnesses, we thank you for the 
opportunity to discuss toxic exposures and the impact of 
Honoring Our PACT Act which DAV strongly supports. I defer to 
our written testimony where we discuss the bill and all of our 
recommendations to strengthen it.
    Mr. Chairman, we thank you, the Ranking Member, and this 
Committee for all of your efforts and hard work on the COST of 
War Act and many other pieces of toxic exposure legislation.
    Today is National Vietnam War Veterans Day, and we are 
still discussing legislation that will impact veterans exposed 
to Agent Orange 50 years later. We recognize the service and 
sacrifice of Vietnam veterans, their families, and survivors.
    Mr. Chairman, we are at the precipice of a monumental 
event, solving the puzzle of comprehensive toxic exposure 
legislation for past, current, and future generations of 
veterans exposed to environmental hazards. As a Nation, we have 
responded too slowly to provide health care and benefits for 
toxic-exposed veterans. It took over 60 years to recognize 
diseases due to contaminated water at Camp Lejeune, 50 years 
for mustard gas exposure, 40 years for radiation exposure, and 
we are still adding diseases of location for Agent Orange-
exposed veterans 50 years later.
    There are thousands of veterans exposed to toxins and burn 
pits who we are already too late for, such as Ms. Ashley 
McNorrill. She was deployed to Iraq, where she was exposed to 
burn pits which she noted was only a few feet from her chow 
hall. After service, Ashley and her husband tried to start a 
family but were unable to conceive due to what they were told 
was endometriosis, which required a hysterectomy. After they 
adopted two small twin boys, she decided to have the 
hysterectomy, and during the surgery it was discovered she had 
stage four appendiceal cancer, a rare form of the disease 
occurring only in one or two cases out of a million.
    After years of VA claims and appeals without success, she 
sought out the assistance of a DAV benefits advocate in South 
Carolina, and then Ashley was awarded total and permanent VA 
disability benefits. However, shortly thereafter, she succumbed 
to her burn pit-related cancer and left her husband and two 
young sons behind. The Honoring Our PACT Act would ensure that 
Ashley and veterans like her would have access to health care 
and benefits sooner rather than later.
    We recognize comprehensive toxic exposure legislation would 
increase VBA's workload, and we must be focused on solutions to 
mitigate these increases. We suggest VBA develop a plan now 
that considers the following mitigation strategies, to include 
establish a unique end product code for all new presumptives 
added by new toxic exposure legislation and implement a triage 
unit to address presumptives directly as they come into the VA. 
Also, they can use authority similar to pre-stabilization 
ratings, administrative decisions, or memorandum ratings as 
well.
    These suggestions can be implemented under VBA's current 
authority. However, we recommend that they are codified. This 
will give VBA those same authorities for future presumptives or 
similar instances of increased workloads.
    In addition, the PACT Act authorizes $150 million for VBA 
to begin a major overhaul of IT infrastructure, including 
claims automation. These funds can be used to automate and 
implement the suggestions we have noted. We urge VA to develop 
a plan now that includes leveraging these existing authorities.
    DAV supports waiving PAYGO for comprehensive toxic exposure 
legislation as it cannot truly happen otherwise. Toxic exposure 
legislation must be considered a cost of war and not hindered 
by PAYGO.
    Mr. Chairman, we must take full advantage of the 
opportunity to enact thoughtful and meaningful toxic exposure 
legislation, but veterans and their families cannot afford to 
continue to wait for decades like past generations who were 
exposed to mustard gas, radiation, contaminated water, and 
Agent Orange. As noted historian C. Northcote Parkinson said, 
``Delay is the deadliest form of denial.'' We must act now.
    Mr. Chairman, this concludes my testimony, and I am pleased 
to answer any questions you or the Committee may have.

    [The prepared statement of Mr. Liermann appears on page 78 
of the Appendix.]

    Chairman Tester. Shane Liermann, I want to thank you for 
the testimony for the Disabled American Veterans. Thank you 
very much.
    Next, we have Christopher Slawinski who is with the Fleet 
Reserve Association. Chris, you are up.

               STATEMENT OF CHRISTOPHER SLAWINSKI

    Mr. Slawinski. Thank you. Chairman Tester, Ranking Member 
Moran, and members of the Committee, my name is Chris 
Slawinski; I am the National Executive Director of the Fleet 
Reserve Association. I served 20 years in the U.S. Navy, four 
years on active duty and 16 years in the Navy Reserve. I am 
here today to discuss veterans' toxic exposure, representing 
the concerns of the oldest sea service association.
    For over 97 years, the FRA has served the enlisted men and 
women of the active, reserve, and retired communities plus 
veterans of the Navy, Marine Corps, and Coast Guard. The 
Association is congressionally chartered, recognized by the 
Department of Veterans Affairs, and entrusted to serve all 
veterans who seek help.
    As one of the leading supporters of the Agent Orange Blue 
Water Navy bill, which was enacted in 2019, FRA is grateful for 
its passage and the expansion of the presumptions that were 
sponsored by you, Chairman Tester, in 2020. The Agent Orange 
legislation helps vets that served during the Vietnam War. Now 
Congress needs to protect those veterans who more recently 
served and are currently serving.
    Military service for our Nation can require servicemembers 
go to places that may expose them to toxins that cause 
illnesses and diseases that may not be diagnosed for years or 
even decades after their service. That is why FRA is an active 
member of the Toxic Exposures in the American Military or TEAM 
coalition. The coalition wants to ensure that veterans who had 
exposures to burn pits and other environmental toxins gain 
access to VA health care benefits. We look forward to working 
with this Committee, the House committee, and bill sponsors to 
passage of a comprehensive bill on toxic exposure this year.
    We understand the cost aspect of this legislation is a 
significant consideration. That said, the need for reform is of 
paramount concern to the veterans community. Too many toxic 
exposure claims have been denied due to a high standard of 
proof currently required.
    In response to the President's State of the Union Address, 
the VA has proposed adding certain rare respiratory cancers to 
the list of presumed service connection disabilities in 
relation to military environmental exposure to particulate 
matter. The VA determined, through a review of scientific and 
medical evidence, there is a biologic plausibility between 
airborne hazards, specifically particulate matter, and 
carcinogenesis of the respiratory tract. The unique 
circumstances of these rare cancers warrant a presumption of 
service connection. Based on these findings, VA Secretary 
proposed a rule that will add presumptive service connection 
for several rare respiratory cancers for certain veterans. FRA 
believes this is a step in the right direction.
    Prostate cancer is the number one cancer diagnosed by the 
Veterans Health Administration. Recent studies have reported 
over 500,000 veterans are living with prostate cancer and are 
receiving treatment within the VHA. There are over 16,000 of 
those with metastatic disease, and there are over 15,000 new 
diagnoses annually. The need to standardize treatment across 
VHA with the introduction of a comprehensive, systemwide 
prostate cancer clinical pathway should be implemented.
    Studies have shown that prostate cancer develops more 
frequently in men exposed to Agent Orange, and the VA has 
established it is a presumptive condition, thus qualifying 
exposed veterans to full disability benefits. New data supports 
the link between prostate cancer and exposure to jet fuel, 
cadmium, and aircraft component cleaning solvents.
    As I mentioned earlier, I served on active duty for the 
United States Navy for four years. I worked as an aviation 
electronics technician. My primary duties were associated with 
being a final checker and troubleshooter on the flight deck of 
the USS Coral Sea. Daily, I was exposed to jet fuel, exhaust, 
and other toxins while performing my duties for my squadron. 
This past September, I was diagnosed with stage four prostate 
cancer which has metastasized to my bones. I do not have a 
family history of this cancer.
    I have been very fortunate to receive my treatment in the 
defense health care system. I can honestly say that the medical 
staff at Walter Reed is among the best in the world. While I am 
fortunate to receive this care through DHA, others are not as 
fortunate. That is why I am here to advocate for them today.
    In closing, allow me to express the sincere appreciation of 
the Association's membership to all the members of the Senate 
Veterans' Affairs Committee and your outstanding staffs for our 
Nation's veterans. I await your questions.

    [The prepared statement of Mr. Slawinski appears on page 88 
of the Appendix.]

    Chairman Tester. Thank you, Chris. Thanks.
    Kristina Keenan, VFW.

                  STATEMENT OF KRISTINA KEENAN

    Ms. Keenan. Senators Tester and Moran and members of this 
Committee, on behalf of the VFW, the Veterans of Foreign Wars 
of the United States, and its auxiliary, thank you for the 
opportunity to speak on this important issue.
    At a Senate Armed Services Committee hearing on toxic 
exposure two weeks ago, the Department of Defense was asked, 
how many servicemembers that deployed to Iraq and Afghanistan 
would have been exposed to airborne hazards and burn pits? The 
response, all of them.
    The Honoring Our PACT Act is the comprehensive solution for 
toxic exposures. It will provide veterans with health care and 
benefits and creates a presumptive framework to address any 
toxic exposure, past, present, and future. This is the priority 
of over 40 veterans service organizations, all of which support 
passing the PACT Act.
    The PACT Act may be a House bill, but this was born in the 
Senate. The TEAM Act was first introduced by Senators Tillis 
and Hassan; the Veterans Burn Pits Exposure Recognition Act 
introduced by Senators Sullivan and Manchin, the SERVICE Act 
introduced by Senator Boozman, and the Health Care for Burn Pit 
Veterans Act introduced by Chairman Tester and Ranking Member 
Moran, these bills shaped Titles I, III, and VI of the PACT 
Act.
    The VFW is grateful for the Senate foundations of this 
comprehensive legislation. We have worked closely with your 
offices to get this right. We ask that the Senators who 
introduced or co-sponsored these bills pledge their support for 
passage of the PACT Act.
    Regarding the cost, some Members of Congress, they say that 
they need to be responsible, fiscally responsible with taxpayer 
money and that veterans are taxpayers, too. Congress spent 
trillions in taxpayer dollars on the Global War on Terror. 
Being responsible is accurate. Servicemembers were sent into 
harm's way, and some came home and developed serious illnesses. 
We are responsible for these men and women. Providing them 
health care and benefits is responsible.
    We are talking about veterans. Veterans. What is more 
responsible than taking care of the people who risk their very 
lives defending this country? This is a cost of war. This is 
responsible, and it is personal for all Americans.
    Veterans here in this room, in these buildings, were 
exposed to hazards and toxins in service, and I am not just 
talking about us veterans here on this panel or sitting behind 
me. Senator Sullivan was exposed to open air burn pits as were 
Senators Duckworth, Cotton, Ernst, Graham. Senators Kelly and 
Peters served in areas with oil fires and chemical hazards. 
Senator Carper served in Vietnam, exposed to Agent Orange. 
Senator Blumenthal's sons, as he mentioned, were exposed to 
open air burn pits. And Senators Moran, Tester, Boozman, you 
all have staff that served in Iraq and Afghanistan. They worked 
and slept next to open air burn pits during their time in 
service.
    Everyone knows a friend, a family member, a colleague, a 
coworker, someone who was exposed to toxins in service to our 
country. We need to take care of this problem once and for all.
    How many Vietnam veterans had to die before we got the 
legislation right? How is it that today, on National Vietnam 
War Veterans Day, of all days, that we are still trying to fix 
toxic exposure at VA?
    The members of this Committee, you have the opportunity to 
be leaders in this historic moment. All eyes of the veteran 
community are on you right now. You can help pass this bill and 
not divert to a smaller version that leaves veterans still 
waiting. Every day, every week, every month that delays the 
PACT Act, more veterans get sick and die. Be the champions of 
this solution and be on the right side of history.
    We, the veterans sitting before you, sitting next to you, 
sitting behind you, and all around this country fought for you. 
Now we need you to fight for us.
    Thank you for the opportunity to provide my remarks. I look 
forward to answering any questions you may have.

    [The prepared statement of Ms. Keenan appears on page 96 of 
the Appendix.]

    Chairman Tester. Thank you for your testimony, Kristina. I 
am going to stick with you for my first question. The PACT Act 
runs about $325 billion over 10 according to the CBO. The COST 
of War Act runs currently at about $413 billion over 10. Could 
you once again tell me what I should tell the people that say 
we simply cannot afford this kind of expenditure?
    Ms. Keenan. This is a cost of war. As I mentioned in my 
testimony, Congress approved trillions of dollars over the last 
20 years in conflicts. We have passed large pieces of 
legislation for veterans in the past, MISSION Act, Choice Act, 
and we waived PAYGO.
    For something this large, there are not enough offsets to 
pay for all of it. We really have to consider how we are going 
to pay for this. It is so big. We need to just find a way. This 
is a cost of war.
    Chairman Tester. Okay. This is for you, Shane, but anybody 
can jump in on this. There were some questions about the fact 
if we pass the PACT Act or the COST of War Act that services 
for veterans who are currently enrolled in the VA, who get 
services from the VA, would not get as timely a service as they 
would otherwise. What is your response to that?
    Mr. Liermann. Probably about 12 years ago, maybe 13, there 
were over 1 million claims backlogged and pending within the VA 
system. And were any actions taken? Not right away. It took 
years of veterans to get actions done.
    So are we familiar with this territory? Absolutely, we are. 
But I also do know that any veteran is not going to tell their 
fellow veterans, sorry, you do not get benefits today because I 
am in line and you have to wait.
    Veterans are in this together. We understand that there is 
going to be increased workloads within VA. Well, VA has the 
authorities to correct that, and along with this Committee, we 
can find ways to make that streamlined, more efficient, so no 
veteran has to wait. And, we do not have to consider giving new 
benefits because other veterans may have to wait longer. That 
should never be a conscionable thought within our veterans 
community.
    Chairman Tester. So the President has basically endorsed us 
to take care of toxic exposure, and I applaud that and thank 
Secretary McDonough for his support of this bill.
    So this is for you, Chris. Why not just let the Executive 
Branch do it? Why should Congress stick their fingers in this?
    Mr. Slawinski. The bottom line is that we have waited for 
administrations to basically act in the past. The Blue Water 
Navy bill--I joined the Fleet Reserve Association as part of 
their staff in 2004, and I fought side by side with Vietnam 
veterans for a number of years to get that bill passed. We went 
to the VA and talked to the Secretaries and said, ``you have 
the administrative authority to make a change.'' And they 
looked at us and said, ``show us the science.'' We showed them 
the science. They continued to delay. So it took an act of 
Congress to get it done.
    We do not want to--waiting is going to kill people. We 
cannot wait for any administration to make a decision on 
whether it is the right thing or wrong thing to do. We know 
that Congress has got the authority to basically make sure that 
they can push the Administration and push the VA into the right 
direction to get things accomplished.
    Chairman Tester. So this goes to anyone who wants to answer 
it. What would you say to the people who say that if we pass 
the PACT Act or the COST of War Act, and we have a procedure by 
which the VA can determine toxic exposure and make sure that 
the benefits and health care are there for those folks who have 
been exposed, that this would be a false promise to those folks 
because the VA simply does not have the capacity?
    Ms. Keenan. I am going to jump in and answer that. I think 
that is a good question, and I know people are concerned, but 
there are provisions within the bill to provide VA additional 
resources. The VFW and DAV, PVA together compose the 
independent budget VSOs, and we make budget recommendations for 
VA every year. So we know going forward VA is going to need 
some IT upgrades. They are going to need to train more 
personnel. The Secretary identified some of their needs. So I 
think Congress needs to be fully aware that VA is going to need 
more, but that should not slow the process.
    Veterans would rather be in the queue than knocking at the 
door, not able to get in. They need to be able to get into the 
process even if it takes a little bit longer, but knowing that 
they have access is going to reassure veterans who need to get 
in.
    Chairman Tester. Senator Moran.
    Senator Moran. Chairman, thank you and thank you to our 
three witnesses representing many, if not all, the veterans 
organizations and many, if not all, the veterans.
    Christopher, first of all, best wishes, best regards, hope, 
prayers for you and your well-being. Thank you all for your 
service.
    Kristina, let me--this is a narrow topic within this Act, 
but your testimony seemed to indicate that not all of the VSOs 
have been included in the development of the pilot program and 
its decision-making process. And you mentioned how the VFW 
would like to work with the VA and make recommendations in that 
process. I have heard that complaint elsewhere as well. Any 
thoughts you would like for me to know, or us to know, about 
that? And secondly, are there any amendments to include in the 
PACT Act that would ensure that process--that includes a 
trigger from an outside entity?
    Ms. Keenan. Well, the bill does include some VSO 
involvement within the process. So we do appreciate that that 
was included. However, in the developments of VA's current 
pilot program, it is really critical to have veterans service 
organizations to provide input. And I say service organizations 
because the VFW, for example, has over 2,000 VA-accredited 
service officers. So we have got people on the ground working 
and assisting veterans with their claims that really know and 
understand the adjudication process, the realities of how long 
it take, some of the miscommunications that we have with them.
    So to have the VFW at the table before something is fully 
fleshed out but to really offer our expertise is not only on 
this issue but all issues something that we really want to have 
and just to ensure that everything is--nothing is overlooked 
and that we are really involved in the entire process.
    Senator Moran. Thank you. Mr. Liermann, Shane, the Agent 
Orange Act of '91 required the Secretaries to determine whether 
a presumption was warranted within 60 days of a NASEM report 
and, if so, prescribe regulations within 60 days of making that 
determination. I am told that you were involved in that 
legislation, and it has been the law of the land since 1991. My 
impression is the PACT Act mandate nearly doubles that time 
amount that the Secretary has to make those determinations. Can 
you talk about that difference and if that makes sense or that 
is an area that needs attention?
    Mr. Liermann. Absolutely. Thank you. Actually, those 
protections and those triggers for the timeframes in the 1991 
Agent Orange Act actually expired in 2015 and have not been 
reauthorized. So right now, there are not any and, hence, why 
hypertension, bladder cancer, and other conditions were never 
added even though they were recommended.
    We think putting a timeframe--whether 60 days, 90, or 120, 
we want to make sure, one, we give the Secretary ample time to 
review and make decisions. And two, we want it to be--we want 
them to be held to that standard, right, because if you take a 
look back over the years on the number of presumptive diseases 
it was not always within that 60-day window. It was close. But 
we want to give them the opportunity to make those decisions, 
and we need those authorities and safeguards back.
    Senator Moran. So the actual number of days is less 
significant than the data and there being a requirement and 
also the reminder that they ought to mean something once they 
are put into law.
    Mr. Liermann. Exactly, Senator. It is the trigger. Whether 
it is 60, 90, or 120, that trigger is the most important part.
    Senator Moran. I have never had a Secretary of the 
Department of Veterans Affairs, this or previous, that ever 
asked for a little bit of delay in a congressionally mandated 
timeframe. So we will hold--we will try to hold the VA 
accountable to those standards.
    Mr. Chairman, thank you.
    Chairman Tester. I want to thank the panel very, very much. 
A couple things. You guys were here. You heard the Secretary 
field a bunch of questions. You guys know the lay of the land 
better than anybody because you represent the veterans that are 
out there, and I just want to thank you for taking time out of 
your schedule to be here today.
    There is work to be done here, and I am glad you all three 
and others, 37 others just like you, are on the ground giving 
us input because I think it is really, really, really 
important.
    For the folks who normally do not come to a Senate 
Veterans' Affairs Committee, I want to say thank you for coming 
today. Normally, we do not have this many people show up, and 
we like to have you show up. So thank you all for being here. I 
think it does express to this Committee how very, very 
concerning the issue of toxic exposure is and why we need to do 
something about it. And so thank you for all being here, too, 
and the same thing for everybody that is watching at home.
    I think everybody wants us to do right by our veterans. We 
just need to make sure that we find the sweet spots so we are 
able to do that because, quite frankly, all we have to do is 
look at Agent Orange and see that those folks, many of them, 
died before there was any benefits. The reason they had the 
ailments that they had, I believe, was directly due to a very, 
very intense herbicide called Agent Orange that was made to 
kill plants but also killed people.
    So with that said, I really look forward to working with 
everybody here today, the Secretary, Ranking Member Moran, to 
get a comprehensive piece of legislation to the President's 
desk as soon as possible.
    As far as recordkeeping here, we are going to keep the 
record open for two weeks for any additional comments and if 
there is any additional questions that need to be asked.
    With that, thank you all for being here, and this hearing 
is adjourned.
    [Whereupon, at 5:37 p.m., the Committee was adjourned.]






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