[Senate Hearing 117-592]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-592

                           NOMINATION HEARING

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 27, 2022

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
51-186 PDF                  WASHINGTON : 2023                    
          
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                     COMMITTEE ON VETERANS' AFFAIRS

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

                              ----------                              

                             April 27, 2022

                                SENATORS

                                                                   Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     2
Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    12
Blackburn, Hon. Marsha, U.S. Senator from Tennessee..............    13
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    15
Murray, Hon. Patty, U.S. Senator from Washington.................    17
Brown, Hon. Sherrod, U.S. Senator from Ohio......................    19
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    22

                               WITNESSES

Shereef M. Elnahal, MD, Nominee to be Under Secretary for Health, 
  Veterans Health Administration, Department of Veterans Affairs.     4

Raymond M. Jefferson, Nominee to be Under Secretary for Benefits, 
  Veterans Benefits Administration, Department of Veterans 
  Affairs........................................................     6

                                APPENDIX
                          Nomination Material

Shereef M. Elnahal, Nominee

  Prepared statement.............................................    35

  Response to Pre-hearing Questions for the Record submitted by:
    Hon. Jerry Moran.............................................    38
    Hon. Jon Tester..............................................    50

  Response to Questions for the Record submitted by:
    Hon. Sherrod Brown...........................................    57
    Hon. Bill Cassidy............................................    59
    Hon. Jerry Moran.............................................    60
    Hon. Patty Murray............................................    63

  Questionnaire for Presidential Nominees........................    64

Raymond M. Jefferson, Nominee

  Prepared statement.............................................   111

  Response to Pre-hearing Questions for the Record submitted by:
    Hon. Jerry Moran.............................................   118
    Hon. Jon Tester..............................................   126

  Questionnaire for Presidential Nominees........................   131

 
                           NOMINATION HEARING

                              ----------                              


                       WEDNESDAY, APRIL 27, 2022

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:15 p.m., in 
Room SR-418, Russell Senate Office Building, Hon. Jon Tester, 
Chairman of the Committee, presiding.
    Present: Senators Tester, Murray, Brown, Blumenthal, 
Hirono, Sinema, Hassan, Moran, Cassidy, Sullivan, and 
Blackburn.

              OPENING STATEMENT OF CHAIRMAN TESTER

    Chairman Tester. Well, Senator Moran said he is on his way, 
and so in that vein I call this hearing of the Senate Committee 
on Veterans' Affairs to order.
    The purpose of this hearing will be to hear from the 
President's nominees to serve as Under Secretary for Health, 
Dr. Shereef Elnahal, and Under Secretary for Benefits, Raymond 
Jefferson.
    Dr. Elnahal, let us start with you. Our job is to decide 
whether you are up to the task of meeting our nation's 
veterans' health care needs, and you need to be. It has been 
six years since the VA has had a confirmed Under Secretary for 
Health. During that time, the VA has faced one of the toughest 
challenges in decades, that being the COVID-19 pandemic. Since 
the start of the pandemic, more than half a million VA-enrolled 
veterans have contracted COVID, and more than 21,000 veterans 
have died, including 8,500 veterans receiving care from the VA.
    All of this has taken a toll on front-line employees. We 
need to be taking care of them now more than ever. As Under 
Secretary for Health, how you care for your staff will mean 
everything, and hiring and recruiting will be half the battle.
    It is also important you are making sure veterans are given 
appropriate information on how long it will take for them to be 
seen and the quality of care they receive at the VA and in the 
community.
    If confirmed, I will also need you to take a critical look 
at the caregiver program. This includes changing the Trump 
administration's restrictive regulations, halting the discharge 
of legacy participants, and reevaluating the program's 
eligibility requirements to ensure they meet the full intent of 
Congress.
    As if all these issues were not enough, the VA is still 
struggling to get its electronic health record modernization 
program moving in the right direction, and a strong VHA role is 
needed to make sure that this program works.
    Finally, as you know, the VA recently released its 
recommendations for changes to facilities and health care 
services across the country, and this includes every State, 
including mine. I need to know whether you are the type of 
leader who will do that, what is right for our veterans, and 
not seek to apply a cookie-cutter health care model that 
negatively impacts veterans under the process, particularly 
those veterans that live in rural areas.
    Mr. Jefferson, we need to know whether you are the right 
person to lead VBA. I am hoping your answers to members' 
inquiries will help this Committee make that determination.
    VBA faces several challenges as we emerge from the 
pandemic, from a backlog of more than 200,000 disability 
compensation claims to debates over how to provide benefits for 
toxic-exposed veterans. Whether it is through a carefully 
crafted automation system or reform of a troubled medical 
disability examination program, VBA needs a leader that 
protects veterans at every step of the process.
    I do want to thank you both for your willingness to serve. 
I look forward to our discussion today.
    With that, I will turn it over to Senator Moran.

               OPENING STATEMENT OF SENATOR MORAN

    Senator Moran. Mr. Chairman, I need to be able to trust you 
that when I am late getting here that you will start.
    Chairman Tester. The problem is, Senator, I am not as 
verbose as you, so I had to time it right.
    Senator Moran. Mr. Chairman, thank you. Thank you for 
holding this hearing, and I look forward to hearing from our 
witnesses today.
    You both have been nominated to lead really important 
aspects of care for our Nation's veterans, two of the most 
important jobs within the Department of Veterans Affairs. You 
have significant responsibilities, and nothing about your 
nominations in my view can be taken lightly. I could outline 
all the dollars spent, the benefits provided, the amount of the 
budget, but among many of the appointed positions within our 
Federal Government, these two are among the most important, and 
they affect the lives of men and women who served our Nation, 
who we are responsible for caring for.
    And the seriousness of your positions weigh heavily upon me 
and, I assume, my colleagues here on this Committee. Thank you 
for your willingness to serve. Achieving the goals that we set 
out for the Department of Veterans Affairs requires relentless 
leadership. It requires experience.
    Dr. Elnahal, I am interested in hearing more about your 
experience and how you would lead the VHA to tackle the many 
challenges that the Chairman just outlined.
    The Benefits Administration is equally critical to the 
well-being of veterans and dependents. Disability payments 
provide financial security to veterans who are unable to work 
due to service-connected injuries. Readjustment benefits, like 
the GI Bill the VA Home Loan Guaranty provided transformational 
opportunities for veterans to achieve success in their careers 
and in their communities after they have served. When we tell 
veterans that they can use these benefits, we often make some 
of the--they often make some of the biggest decisions in their 
lives. They make choices that affect them and their family 
members.
    And, we need to make certain that we are doing it in the 
right way. Our Under Secretary of Benefits must have expertise 
and a proven track record to lead a large Federal workforce if 
you are to be successful in making that delivery the kind of 
experience that our veterans should encounter.
    Mr. Jefferson, I have reviewed the information you provided 
this Committee about your experience, and I have looked at the 
management concerns raised during your time as Assistant 
Secretary of the Department of Labor's Veterans' Employment and 
Training Service. I am concerned by the Labor Department's 
decision to restrict procurement authority for vets and with 
your ability to accurately characterize key aspects of your 
2011 Inspector General investigation, as well as how you chose 
to characterize those results in your lawsuit related to the 
2011 resignation.
    Given those circumstances, I admittedly have concerns about 
your nomination. I realize that is why we have hearings, that 
is why we have the opportunity to have conversations, and I 
look forward to hearing what you both have to say today.
    And I thank you, Mr. Chairman, and I thank our two 
witnesses, our two nominees, for their willingness to serve.
    Chairman Tester. Thank you, Senator Moran.
    I am now going to introduce the two nominees, and then I 
will administer the oath individually.
    Dr. Shereef Elnahal is a physician who has served as 
President and Chief Executive Officer of the University 
Hospital in Newark, New Jersey, since 2019. Prior to this role, 
Dr. Elnahal served as New Jersey's 21st Health Commissioner. He 
also served as Assistant Deputy Under Secretary of Health for 
Quality, Safety, and Value at VA from 2016 through 2018. He is 
a graduate of Johns Hopkins University, Harvard Business 
School, and Harvard Medical School.
    Next up, Ray Jefferson. Mr. Jefferson is the President of 
the Jefferson Group, a global leadership development 
consultancy, as well as Chair and co-founder of the Service 
Academies Global Summit. He served as a White House fellow and 
worked as a special assistant to the Secretary of Commerce. In 
2009, Ray Jefferson was the Assistant Secretary for Veterans' 
Employment and Training at the Department of Labor. He is a 
graduate from the U.S. Military Academy at West Point in 1988 
and served as an Army officer with the Infantry, Rangers, and 
Special Forces.
    Dr. Elnahal, will you please stand as I administer the 
oath? Raise your right hand, please. Do you, Dr. Elnahal, 
solemnly swear or affirm that the testimony you are about to 
give before the U.S. Senate Committee on Veterans' Affairs will 
be the truth, the whole truth, and nothing but the truth, so 
help you God?
    Dr. Elnahal. I do, Senator.
    Chairman Tester. Let the record reflect that he answered in 
the affirmative.
    Next, Ray Jefferson, please stand and raise your right 
hand. Do you, Ray Jefferson, solemnly swear or affirm that the 
testimony you are about to give before the U.S. Senate 
Committee on Veterans' Affairs will be the truth, the whole 
truth, and nothing but the truth, so help you God?
    Mr. Jefferson. Yes, Senator.
    Chairman Tester. Let the record reflect that Ray Jefferson 
answered in the affirmative.
    You each will have seven minutes for your opening 
statement. Try to make it as quick to that because there will 
be a lot of questions.
    We will start with you, Dr. Elnahal, for your opening 
statement.

                STATEMENT OF SHEREEF M. ELNAHAL

    Dr. Elnahal. Good afternoon, Chairman Tester, Ranking 
Member Moran, and distinguished members of the Senate Veterans' 
Affairs Committee. It is an honor to appear before you as the 
President's nominee for Under Secretary for Health.
    I would first like to thank you for the productive meetings 
I have had with many of you. I appreciated learning more about 
what you see as the most critical issues facing veterans across 
the Nation. Advancing the quality and safety of health care for 
veterans is a tremendous responsibility, and I am privileged to 
be called upon to do so, if confirmed.
    I would like to take a moment to introduce my family 
members who are here and without whom I would not be here 
before you. First, my wife, Marwa, who is my companion, life 
partner, and best friend. My three children could not join us 
today because they probably would have disrupted the 
proceedings--they are age six, four, and two--but they are the 
light of my life. I am also joined by my mother, to whom I am 
eternally grateful for the values and work ethic she instilled 
in me, as well as my brother, Kareem, sister, Sarah, uncle, 
Hisham, aunt, Suzie, and my mother-in-law, Soheir, all of whom 
support me immensely and whom I love very much.
    As all of you know, the health challenges that veterans 
face could not be more pressing. The nation is grappling with a 
pandemic, and the VA and this Committee are working through 
hard challenges on access to care, VA infrastructure, and the 
largest electronic health record implementation in history.
    I am excited for the opportunity to take on these 
challenges, if confirmed. In short, I would not be sitting 
before this Committee right now if not for veterans and if not 
for VA. As a medical student, I served veterans at the West 
Roxbury VA, which was among my first clinical rotations. I 
remember meeting a veteran there who had traveled more than an 
hour with crushing chest pain before arriving in that emergency 
room. He knew, and I knew, that he was likely having a heart 
attack, but after he was stable I asked him why he had chosen 
to come to that hospital over several others that were closer 
to him. He told me he did not see himself being treated 
anywhere else and that VA was his hospital with his doctors and 
his nurses. That moment I will never forget because it 
encouraged me to always work for organizations that have that 
effect on people.
    Since then, many experiences taught me how our military 
members lead with grit and resilience, but I was able to see 
this service firsthand at the outset of the COVID-19 pandemic. 
In April 2020, as COVID was spreading rapidly in Newark, my 
hospital was overrun with patients and staffing shortages. At 
that time, we knew little about this virus, and it hit our 
community hard.
    A saving grace for us were the women and men in uniform, 
U.S. Army Reserve clinicians, who came and helped our staff 
through the worst of that crisis. I also worked alongside 
National Guard members to build a field hospital for surge 
capacity in northern New Jersey. And again, this past winter as 
Omicron was surging, active duty Army clinicians came to us 
again with the support of the Biden administration. Each time, 
my staff and I were reminded of what these heroes in uniform do 
for us every day. They protect us, they keep us safe, and that 
fact was not abstract for me or my staff. If confirmed, this 
opportunity would be my own way of paying that service forward 
to veterans across the Nation.
    I have held different vantage points relevant to this 
opportunity throughout my life as a patient, a physician, and 
as a health care administrator. I was diagnosed with type 1 
diabetes when I was 12 years old, and although I was blessed 
with many supports, I have had my fair share of hard times as a 
patient. I know what it means when President Biden says that 
health care is a basic human right. For me, that belief is 
personal.
    Later in life, when I started as a medical resident, I 
immediately noticed that despite the best intentions and 
exceptional skills of my fellow health care professionals, the 
systems of care around us were letting patients fall through 
the cracks. That is why I have dedicated my career to improving 
those systems of care.
    This mission led me back to VA, and VA made the health care 
leader I am today. VA prepared me to serve as New Jersey's 
Health Commissioner, a responsibility for protecting the health 
and well-being of nine million people in my State at a scale 
similar to the number of veterans I would serve if confirmed. 
As part of that role, I ran the State psychiatric hospital 
system, where we were able to reduce violent assaults, curb 
overcrowding, hire hundreds of new clinicians, and invest 
millions in capital to improve the environment of care, 
standardize trauma-informed care across the hospital system as 
well.
    I then moved to lead University Hospital in Newark, New 
Jersey, a level one trauma center and the main source of health 
care for a vulnerable community. In addition to leading the 
hospital through the pandemic, before I arrived, the hospital 
was under the oversight of a State monitor for failures in care 
quality, patient safety, financial performance, and poor 
community trust. Together with my workforce, I turned that 
hospital around by investing in a culture of respect and 
accountability. The result was an improvement in the hospital's 
Leapfrog Hospital Safety Grade and a financial turnaround that 
resulted in more than a $50 million improvement in operating 
margin in less than two years.
    I know what it is like to lead hospitals in both government 
and nonprofit sectors, to shoulder all the pressure of 
executing a sacred health care mission on behalf of vulnerable 
people. I know the challenge and task of leading large and 
diverse workforces, and I know that the most essential 
ingredient to successful leadership is a true belief in, and 
respect for, the front-line heroes who shoulder that mission at 
the point of care. And, I know the Secretary shares this 
vision, front and center.
    Veterans deserve an Under Secretary for Health who can 
execute on the mutual priorities of this Committee and the 
Administration, but veterans also deserve a VHA leader who has 
more faith in the health system and its people than anyone else 
on the planet. I believe VA is a national treasure and that 
this is true because of its people. I believe VHA can be the 
best health care system in the nation. And I am more than 
honored to be sitting here now as a candidate for this role, 
and I am encouraged that with all of you on this Committee as 
colleagues and partners we would improve veterans' lives 
together.
    Thank you for considering my nomination, and I would be 
happy to answer your questions.

    [The prepared statement of Dr. Elnahal appears on page 35 
of the Appendix.]

    Chairman Tester. Thank you, Dr. Elnahal.
    The floor is yours, Mr. Jefferson.

               STATEMENT OF RAYMOND M. JEFFERSON

    Mr. Jefferson. Chairman Tester, Ranking Member Moran, 
distinguished members of the Committee on Veterans' Affairs, 
thank you for your service to our Nation, your commitment to 
our nation's veterans, and your consideration of my nomination. 
I come before you today to ask for the privilege of serving our 
Nation's veterans a second time and to seek your advice and 
consent to do so as the Under Secretary for Benefits.
    This week, I had the opportunity to meet with several of 
you or your staffs. I have listened carefully as you shared 
your priorities and concerns and benefited from your ideas, 
advice, and insights about how the team at VBA can enhance our 
service in accomplishing the mission of providing benefits to 
servicemembers, veterans, and their families, caregivers, and 
survivors.
    I am honored and humbled to be nominated by President Biden 
and also deeply grateful for the confidence he and Secretary 
McDonough have in me to help them achieve their vision for VA.
    I am joined today by many friends and by my mother, Mrs. 
Nadia Jefferson of Guilderland, New York. My mother is Egyptian 
American and a proud immigrant. My father was African American 
and has since passed away. Both of them were lifelong public 
servants.
    Distinguished members of this Committee, I am passionate 
about serving veterans with the team at VBA because it was a 
VBA program that transformed my life. I have had engagement 
with VA for over 22 years and am a recipient of other VA 
benefits such as disability compensation and medical care. I 
graduated from West Point in 1988 with a major in leadership, 
commissioned in the Infantry, and then held leadership 
positions in the Presidential Honor Guard, the 75th Ranger 
Regiment, and 1st Special Forces Group.
    On Friday, October 18, 1995, while attempting to protect my 
teammates from a defective hand grenade that was detonating 
prematurely during a classified Special Forces training 
mission, I lost all five fingers on my left, nondominant hand. 
That moment changed my life forever. My personal journey as a 
disabled veteran and an amputee has given me a firsthand 
understanding and appreciation for the needs that our veterans 
have and the challenges that many experience as they seek 
services from VA.
    After my accident, I thought my life was over and that 
there was nothing to live for. I was afraid that things would 
never, never be the same again. That experience taught me 
humility, empathy, and the importance of being able to ask for 
help. I know personally what it is like to have your life 
changed in an instant and to struggle to put it back together. 
I know personally what it is like to lose your sense of 
direction and a sense of purpose, meaning, and significance 
that comes from being in the military. I know personally how 
difficult it can be for a veteran to ask for help. And, I know 
that my journey is one that many other veterans have 
experienced. I can relate to veterans and servicemembers who 
are going through unplanned or difficult life transitions 
because I have gone through them myself.
    By participating in VBA's Vocational Rehabilitation and 
Employment program, I was able to receive the support and 
financial assistance needed to build a future for myself and to 
achieve my dreams. I know firsthand the power, potential, and 
capability that VBA's programs and services have to transform 
the lives of veterans and transitioning servicemembers and to 
help us realize our goals and realize our dreams.
    In 2009, I had the privilege of being confirmed by this 
distinguished Committee to serve as the U.S. Assistant 
Secretary for Veterans' Employment and Training at the 
Department of Labor. My life's purpose is to help people and 
organizations to dream big, overcome their challenges, and 
achieve their potential. This is exactly what VBA's programs 
and services do for our Nation's veterans.
    I want to honor and recognize the 25,000 team members who 
work at VBA, who rose to the occasion during COVID and who 
provide services and benefits to millions of veterans, their 
families, caregivers, survivors, and transitioning 
servicemembers on a yearly basis. I value and respect what 
VBA's leadership team and team members do each and every day to 
serve our Nation's veterans.
    I also want to honor and recognize the many national 
veterans service organizations and military service 
organizations. Their work is noble, and they provide a 
necessary and invaluable combination of services to the men and 
women who have served our Nation. Their counsel has been 
invaluable to me over the years, and I am grateful for the 
friendships that we have formed. If confirmed, I would continue 
to engage with them proactively and regularly to seek their 
advice on addressing challenges, making improvements, and 
enhancing veterans' overall experience at VBA.
    Secretary McDonough has previously shared his priorities 
with this Committee. I believe in and share his priorities. We 
know that there are already important opportunities for 
improvement and important priorities that will require 
attention. The first of these is addressing the claims backlog, 
preparing for pending legislation such as the PACT Act, 
enhancing veteran satisfaction, and improving the overall 
efficiency, proficiency, and accuracy of claims processing so 
that it is fast, fair, and accurate. A second priority would be 
further enhancing the effectiveness and outcomes from VBA's 
programs in the areas of transition, education, employment, and 
economic empowerment. A third priority would be leading and 
managing VBA in the manner that unleashes the full potential of 
its team members and that synchronizes people, processes, 
programs, and technology with performance measurement and 
performance accountability.
    The team members at VBA, many of whom are veterans, are our 
greatest asset. They deserve the best training, the right 
tools, and an inspiring work environment that reflects the 
noble purpose of the work they do.
    In closing, I am grateful to this Committee for its long 
history of unwavering bipartisan commitment to veterans, and I 
look forward to your questions.

    [The prepared statement of Mr. Jefferson appears on page 
111 of the Appendix.]

    Chairman Tester. Thank you, Mr. Jefferson.
    I will go first. The questions will be five minutes, and we 
will do as many rounds as we need to do.
    Dr. Elnahal, Congress has given the VA an ample budget and 
hiring authority to bring on qualified staff. It is frustrating 
that the VA continues to struggle to fill positions, 
particularly in rural States. Just so you know, there are 
56,000 VHA vacancies, including more than 2,000 physicians, 
15,000 nurses as of last December.
    You have been a hospital administrator before. What are you 
going to do to help bring on more qualified personnel?
    Dr. Elnahal. Well, Chairman, thank you for the question. I 
agree that the sacred health care mission of the VA, but also 
any health care system, simply cannot be fulfilled without 
having people to do it, talented health care professionals who 
put the mission above all else.
    And I think in the VA there is a particularly compelling 
mission that can be circulated more widely in professional 
society forums and literally every forum where these talented 
heroes are looking for jobs. VA should be present at every 
single one of those forums, in every single corner of the 
country, and one thing I would do if I were confirmed is to 
investigate how much we are advertising VA as an opportunity 
for these professionals across the country.
    The second thing I would do is make sure that every 
possible flexibility in making sure that the folks we bring on 
are compensated fairly is up to par and as competitive as 
possible with the private sector. And I am grateful to this 
Committee for passing the RAISE Act that increases the number 
of tools in the Secretary's tool belt to be able to do so, and 
I would certainly benefit from that authority.
    But, thirdly, I really do think that the health care 
organizations that will be competitive into the future will not 
just be able to hire and onboard and recruit folks but actually 
retain that, and that requires creating a supportive work 
environment, making sure that you are prioritizing well-being 
of your employees, and making sure that everything that health 
care workers deserve is provided to them to complete the 
mission, including staffing. You can be in a position, from my 
experience, where you simply do not have enough staffing and 
you actually overspend your staffing budget because you have to 
spend more on overtime, agency staff, et cetera, which actually 
puts you in the bad part of operations on both sides, 
financially and in quality and patience safety.
    So this is a major priority for me, and if confirmed, I 
will focus intently on it.
    Chairman Tester. Okay. Mr. Jefferson, VBA is a cumbersome 
administration to manage, with many arguably nonrelated 
programs: compensation and pension, Home Loan Guaranty, burial 
benefits, education, life insurance, and Veteran Readiness and 
Employment. VBA has about 25,000 employees. How many employees 
did you manage at VETS?
    Mr. Jefferson. Yes, Senator. At VETS, we had about 250 team 
members and about 1,500 State employees who we provided support 
and collaborated with.
    Chairman Tester. Okay. And so how are you going to handle 
for managing an organization that you previously handled, which 
was significant but certainly not as huge as what you are 
getting into, to manage the 25,000 employees from VA and the 
many different business lines that they have to offer up?
    Mr. Jefferson. Senator, thank you for that question. My 
entire professional background has been preparation for this 
role. I actually graduated from West Point in 1988 with a major 
in leadership.
    I have worked in all three sectors, and if confirmed, this 
would be my fourth time serving as an appointee. I had the 
privilege as the State of Hawaii's Deputy Director for the 
Department of Business, Economic Development, and Tourism, and 
brought transformational change and best practices there. We 
had previously covered my role as Assistant Secretary for 
Veterans' Employment and Training. I have also served as a 
White House fellow and special assistant to the U.S. Secretary 
of Commerce.
    I have been able to demonstrate impact, change, 
accountability, and results in every leadership role that I 
have had. And presently, I work with CEOs and C-suite leaders 
all around the world of the largest organizations, from the 
full arc to strategy implementation to execution to results, in 
helping them to achieve outcomes with large numbers of people 
and large budgets.
    In closing, even in large organizations, the leadership and 
management is done by relatively small teams, and one of my 
strengths is the ability to bring the team together, develop 
and amplify it, orient it in the direction it needs to go, and 
achieve results with that team.
    Chairman Tester. Thank you.
    Senator Moran.
    Senator Moran [presiding]. Chairman, thank you again.
    Dr. Elnahal, let me spend a little time on issues related 
to the MISSION Act. The MISSION Act required the VA to create 
access standards to determine eligibility for the veteran 
community care program, and the VA finalized those access 
standards in 2019 and set an eligibility threshold at a 20- or 
28-day wait time or 30- or 60-minute drive time depending upon 
the service required. I think those standards are reasonable 
and believe they provide veterans with a concrete measure they 
can rely on in terms of accessing that care.
    Do you support those current access standards of 20- or 28-
day wait times and 30- or 60-minute drive times? And, an 
explanation of your yes-or-no answer.
    Dr. Elnahal. Senator, I support the guidelines from the 
standpoint of how they reflect the veteran's experience. I 
think whatever method we use to measure access needs to be 
tangibly connected to what the veteran actually sees. So the 
drive time that a veteran experiences is obviously an example 
of that, and the number of days from the date of request for 
appointments is the actual time that the veteran sees before 
they get their appointment. So that certainly satisfies the 
criteria I think is necessary to define access standards, and 
so I think they are very reasonable.
    Senator Moran. You may have just answered this question 
because my second commentary on this topic, which I would 
categorize as a question, but really it is my views and seeing 
if you share them, wait time calculation. The access standard 
regulations, I think, are very clear. I do not need to say, ``I 
think.'' That is a politician talking. They are very clear that 
timeliness is measured from the date of request.
    Yet, recent reports indicate that in many instances the VA 
uses inconsistent methodology to calculate and publish wait 
times. These inconsistencies not only obscure how long veterans 
have to wait, but they can add delay, which is, in my view, 
unacceptable.
    If confirmed, would you commit to calculating and 
publishing wait times based upon the date of request to ensure 
veterans have access to timely care and accurate data on wait 
times?
    Dr. Elnahal. I would commit to that, Senator, and I think, 
you know, we all know how complex measuring and reporting 
access is. There are multiple ways of doing so, but whatever 
the final set of metrics that we use ends up being has to fit 
the criteria that I mentioned, in my view, which is reflective 
of the veteran's experience. And when it comes to the number of 
days waiting for an appointment, request date is more 
reflective of the veteran's experience.
    Senator Moran. I appreciate the theme in both of your 
answers about the veteran's experience, and that has been in my 
view as I have read what you have responded in numerous 
circumstances. You are putting the veteran's perspective up 
front, and that is valuable.
    The third in regard to the MISSION Act is best medical 
interest. There are six ways that you can access community 
care. You have to meet one of six criteria is a better way of 
saying that, including one of those is what is in the veteran's 
best interest. The best interest provision explicitly states 
that the decision to refer the veteran to community care is 
between the veteran and the provider, between the veteran and 
his or her provider, physician, or other provider.
    We hear too often--and there will be a theme in my 
conversation here as we wrap up, that we continue to hear that 
facility administrators at the local level are overruling the 
decisions made by the veteran and his or her provider and 
denying that best medical interest referral.
    In your pre-hearing responses, you specifically note that 
the ultimate determination for these types of referrals should 
be made by the veteran with their provider of record. If 
confirmed, how will you make certain that the letter of the 
law, and that law is followed, and that those referrals occur 
based upon those decisions by those two individuals?
    Dr. Elnahal. Senator, I will just say that I firmly believe 
that the determining party on best medical interest should be 
the provider caring for that veteran. They know the veteran 
best. They know what the next best step in care is for that 
veteran, and that should be a determination based on clinical 
need. And certainly, managerial and administrative imperatives 
or agendas should not get in the way of that sacred 
relationship and should not get in the way of that 
determination.
    And in order to do that, first is--the first task I would 
have, if confirmed, is to make that clear to the organization 
and make also clear that that conversation, that sacred 
relationship, between the provider and the veteran is enhanced 
when both the veteran and the provider have the full slate of 
options in front of them, both internal to VA, inclusive of in-
person and telehealth, but also in the community, with 
associated access metrics for each of those options. That is 
what I would strive to do as Under Secretary for Health, if 
confirmed.
    Senator Moran. Doctor, thank you. Let me tie those three 
questions together. In some many instances, when I or my 
colleagues--let me just speak for myself in case this is not 
their experience. When the Department assures me that this is 
the policy and this is what is to occur across the country, 
time and time again, the reports from home is that they do not 
know that policy, they have not been told that. And so it is 
easy for me to get assurance from somebody in your position 
that this is what we are going to do or this is what the policy 
is.
    And I just would highlight for you, in your position, if 
confirmed, you also have a significant responsibility and need 
to make certain that what you determine the policy is, is what 
is known as the policy in hospitals and clinics across the 
country.
    Dr. Elnahal. Senator, I agree that that is a very important 
factor to focus on. You can make all the policies you want as 
an administrator. If they are not known and understood to the 
field, in particular, medical center directors, VISN directors, 
and the entire teams of employees caring for veterans, then the 
policy is not meaningful. And so I would commit to having as 
many internal controls as possible but, more importantly, 
conveying the purpose of the policies in a transparent way to 
the VA workforce, to make sure that the policies are known, 
they are understood, and the purpose for them is appreciated.
    Senator Moran. It apparently is easier to convince me that 
the policies--to assure me that the policies are being carried 
out and this is the policy, much more difficult to actually 
have them implemented in that way.
    Dr. Elnahal. I agree, Senator.
    Senator Moran. Thank you.
    Senator Hirono.

                      SENATOR MAZIE HIRONO

    Senator Hirono. Thank you. I ask the following two initial 
questions of all nominees before any of the committees on which 
I sit, so I will ask you these questions, and we can start with 
Dr. Elnahal answering and then Mr. Jefferson.
    Since you became a legal adult, have you ever made unwanted 
requests for sexual favors or committed any verbal or physical 
harassment or assault of a sexual nature?
    Dr. Elnahal. No, Senator.
    Mr. Jefferson. No, Senator.
    Senator Hirono. Have you ever faced discipline or entered 
into a settlement related to this kind of conduct?
    Dr. Elnahal. No, Senator.
    Mr. Jefferson. No, Senator.
    Senator Hirono. Dr. Elnahal, you led a fairly large 
hospital during a global health event, and now you are going to 
be responsible for the largest health care system in our 
country. So what lessons from your time at University Hospital 
during the COVID-19 pandemic would you bring to this role with 
VA?
    Dr. Elnahal. I think the most important lesson, Senator, is 
that as a leader I quickly had to not only understand, but act 
upon, the principle that my purpose for being there during the 
crisis was to support the front-line who were seeing our 
patients during the worst of the crisis. That was my entire 
agenda throughout the pandemic. It led me to the right 
decisions, including hazard pay for my workforce when I did not 
know when I would be able to--if I would be able to afford it 
and we were not sure whether the provider relief funds were 
going to come from Congress. Thank you for that and your 
service in the Senate. And--but it was the right decision 
because folks were going through economic hardship at the same 
time that they were risking their lives seeing patients every 
day.
    And so that is just one example of the principle that I 
would use in any crisis, whether it is the pandemic or a 
different hardship that our employees face.
    Senator Hirono. That is good because in all the time that I 
have sat on this Committee the VA has been, in my view, in 
perpetual crisis, whether you know, it is the backlog of cases 
or the various, how shall I say, bad things that have been 
happening to the 56,000 or so vacancies. So it has been in a 
perpetual crisis.
    One area of ongoing concern, though, is suicides among 
veterans, and there are indications that API veterans have a 
higher suicide rate than others. And I note that you co-founded 
the VHA Innovation Ecosystem to foster the spread of innovation 
and best practices that will improve the veteran care, so that 
includes really the concern over veteran suicide. So did the 
creation of this entity show you some innovative approaches to 
preventing veteran suicide?
    Dr. Elnahal. It did, Senator. It was a really huge honor 
for me to be able to do that work in VA years ago. Just one 
example--and this was an example targeted to rural veterans in 
particular. We noticed a best practice from a medical center 
where they actually had group visits with chaplains for folks 
reentering and transitioning from service to create a support 
group for veterans, simple idea, simple to execute, but was 
something that we thought could benefit thousands more veterans 
across the Nation if we made it known to the organization, and 
we implemented it. And that was one of the main best practices 
that we actually started with, a list of 15, that was 
specifically targeted to suicide prevention.
    You mention the API experience in terms of suicide risk 
among veterans. That is something I would focus on intently. We 
want to make sure that equity is threaded through everything we 
do as an organization, as the Secretary has emphasized, and 
that would be my pledge to you as well.
    Senator Hirono. So are you saying that one of the best 
practices is to have a place where veterans can go to get 
therapy or counseling? That seems very basic, but how many 
veterans take advantage of that kind of program?
    Dr. Elnahal. Well, I would have to get caught up on that if 
I were confirmed and be able to give you an accurate number. 
But what is great about that example as a best practice is that 
it is not costly, it is not complex to implement, requires no 
specific equipment or technology, but it is something that 
could save a life. It is an example of a community-based 
intervention that----
    Senator Hirono. Yes.
    Dr. Elnahal [continuing]. Provided a support group to 
veterans who needed it.
    Senator Hirono. I hope that you will really pay attention 
to, and have a commitment toward, addressing veteran suicide 
with whatever procedures you can follow.
    And we have a lot of vacancies in Hawaii. We have, I think, 
vacancies within the doctors, and one of the ways that I think 
that can be addressed is for the VA to provide opportunities 
for residency within VA. And I do not know if there is 
something very specific that wherever there are hospitals and 
there are VA clinics that there are residency opportunities 
because I think that there is a tendency for doctors who do 
residency in a particular area to stay in that area. So I hope 
that that is something that you also look into so that we can 
replenish the hospital staff within VA and they are also--it is 
a challenge to fill those positions, too.
    Thank you very much, Mr. Chairman.
    Chairman Tester [presiding]. Senator Blackburn.

                    SENATOR MARSHA BLACKBURN

    Senator Blackburn. Thank you, Mr. Chairman, and thank you 
to each of you for being here and giving us your time today.
    Dr. Elnahal, I want to come to you. The GAO report that was 
issued on the VA, it was a review from October 2013 to 2017, 
and you were the Assistant Deputy Under Secretary at that time 
and were responsible for programs that identify quality of care 
concerns and ensure health care providers are reporting to 
appropriate agencies when concerns arise.
    And a recent report from the VA OIG--and you are shaking 
your head. I guess you are familiar with this. It demonstrated 
that there is a continued lack of oversight on this issue and 
over 40 percent of the studied cases, the reviewed cases, were 
mishandled. This is an issue, and we hear about this so 
regularly in our offices, the delays, the backlog, what is 
perceived as unfairness in the VA. People--and it is one of the 
reasons so many veterans are saying, just let me go to 
community care.
    So if you were confirmed, then how are you going to ensure 
that proper and timely oversight and that VA employees are 
actually learning some hard lessons and then are applying what 
they learn because this issue has drug on for over a decade?
    Dr. Elnahal. Well, Senator, the first thing I will say is 
that it is a very fair question because the quality of the 
oversight and the diligence of that oversight on clinical 
practice has everything to do with whether veterans get the 
right care, so it is an extremely important issue.
    I am familiar with the GAO report----
    Senator Blackburn. Okay.
    Dr. Elnahal [continuing]. Of course, that you are talking 
about. It had to do with timely reporting to State licensing 
boards for VA clinicians.
    Senator Blackburn. There are two reports.
    Dr. Elnahal. Yes.
    Senator Blackburn. Right. And I am assuming you are 
familiar with each of the two.
    Dr. Elnahal. I am, Senator.
    Senator Blackburn. Okay. Thank you.
    Dr. Elnahal. So in response to that, I worked with senior 
leadership at VHA to revamp policies in the Agency to do a few 
things. The first, expanding the number and types of providers 
that we report to the National Practitioner Databank so it is 
not just physicians and dentists. Important for anyone who see 
a veteran to have the same standard of care quality.
    Senator Blackburn. So a universal form, basically.
    Dr. Elnahal. A policy by which every licensed practitioner. 
If there were issues with credentialing----
    Senator Blackburn. Okay.
    Dr. Elnahal [continuing]. And if there were issues with 
performance, they would also be reported.
    Also, made sure that the process by which this happens was 
more timely, so setting timeliness standards for medical staff 
committees and medical center directors to ultimately determine 
and make these decisions so that you are not sitting on a case 
that lasts for months without a determination.
    Senator Blackburn. Let me ask you, should there be a shot 
clock placed on the timeliness issue that requires a decision 
within a given period of time?
    Dr. Elnahal. That has everything to do with the third thing 
that we did.
    Senator Blackburn. Okay.
    Dr. Elnahal. Which was to actually have an audit tracking 
tool----
    Senator Blackburn. Okay.
    Dr. Elnahal [continuing]. To track the time needed and time 
taken to report these folks----
    Senator Blackburn. Okay.
    Dr. Elnahal [continuing]. To license boards, if needed.
    Senator Blackburn. All right.
    Dr. Elnahal. I was in a policy setting role at that time. 
If confirmed, I would be in a very operational role----
    Senator Blackburn. Okay.
    Dr. Elnahal [continuing]. Where I would be actually 
responsible for implementation. You have my pledge to look into 
this issue if I am confirmed.
    Senator Blackburn. Okay. That is great. Let me move on, but 
thank you for that.
    Mr. Raymond, thank you for your service to our Nation. VBA 
provides benefits, disability compensation benefits to nearly 
six million veterans and their survivors and handles the 
pension benefits for 357,000 veterans and their survivors. So 
if you are confirmed, you are going to be responsible for 
ensuring that the benefits are distributed fairly to veterans 
and their survivors.
    And in your position at DOL VETS, you pushed to get a 
friend of yours a government contract, which ended up with your 
friend being paid $3,000 via a government purchasing card 
without the benefit of competition. And this is not a fair 
standard of practice, and it calls to question if you are 
qualified to be at the helm of an administration tasked with 
providing benefits in an impartial and consistent manner. So 
how can we be assured that you will advocate for fair benefits 
for all veterans when you have previously demonstrated 
favoritism in your role at DOL VETS?
    Mr. Jefferson. Senator, thank you for that question. And in 
my role at DOL VETS, I emphasized always, from day one to the 
end, to go--for us to follow all guidelines, all regulations, 
all procedures. And the allegation which you are speaking of is 
one that I have been cleared of by a Federal court of law. We 
have done our contracting appropriately. We have engaged with 
all appropriate parties at the Department of Labor.
    Senator Blackburn. All right. I went back and reviewed some 
things, and neither DOL's nor OIG's 2019 letters to you assert 
that the allegations against you were baseless and without 
merit. So it does cause some concerns because this is something 
that is vitally important.
    And just as we talk about the backlog----
    Mr. Jefferson. Yes.
    Senator Blackburn [continuing]. And just as we talk about 
timeliness, fairness is going to be an imperative. So I hope 
that you understand our concerns with this.
    I know I am over time, Mr. Chairman, and I will yield back, 
but I have got a couple of other questions I will submit for 
the record.
    Chairman Tester. We will have another round if you want, or 
you can submit them for the record.
    Senator Blackburn. Okay. Thank you.
    Chairman Tester. Thank you, Senator Blackburn.
    Senator Blumenthal.

                   SENATOR RICHARD BLUMENTHAL

    Senator Blumenthal. Thank you, Mr. Chairman.
    Mr. Jefferson?
    Mr. Jefferson. Yes.
    Senator Blumenthal. Let me, first of all, thank you for 
your service. Thank you for what you have done for veterans at 
the Department of Labor and through the Service Academies 
Global Summit.
    One of the conundrums, the real dilemmas, facing this 
nation is the shortage of people with skills to fill jobs that 
are open now. Based on your experience at the Department of 
Labor, do you have any insights as to what you can do--and I 
know this is a somewhat tangential aspect of what would be your 
job if you are confirmed on benefits, but are there steps that 
the VA can take to encourage more veterans to get back into the 
workforce, give them the skills they need to fill those jobs, 
because I think this one of the major challenges and 
opportunities of our time?
    Mr. Jefferson. Yes. Senator, thank you for that question. 
And this function, this role, of VBA is very personal to me 
because I went through the Vocational Rehabilitation and 
Employment Program and experienced firsthand the power of these 
programs. And so I heard that you used the word ``tangential,'' 
and if confirmed, this would be a primary focus in addition to 
claims backlog: veterans' transition, educational services, 
economic empowerment, and employment.
    In serving as Assistant Secretary for Veterans' Employment 
and Training, we partnered with the U.S. Chamber of Commerce 
and Employer Support of the Guard and Reserve and co-launched 
Hiring Our Heroes Job Fairs that have resulted in over 617,000 
veterans and military spouses finding jobs to date thus far. We 
also revamped the Transition Assistance Program, and maybe I 
can speak more about that later today.
    Sir, VBA has resources, talented team members, and a 
mandate to work with the transitioning service members and to 
help them to identify what their goals are and then create an 
individual transition plan for each individual so that they 
achieve meaningful careers, meaningful employment, and which 
are not just economically empowering but that also provides a 
great degree of satisfaction. So this would be a core focus, if 
confirmed, sir.
    Senator Blumenthal. I am glad for that very important 
answer, that it would be a core purpose----
    Mr. Jefferson. Yes sir.
    Senator Blumenthal [continuing]. And not a tangential one, 
because I think that would be tremendously significant to the 
veterans who are served by the VA.
    Dr. Elnahal, you and I talked privately about the issue of 
the VA health care facility in West Haven. It is among the 
health care facilities that desperately needs to be rebuilt. It 
is in the process now of receiving a new surgical tower that 
will also be supplemented by a new parking garage, both of them 
long overdue. We have been working to achieve them for some 
time. And I commend Secretary McDonough for his leadership and 
the VA for moving forward, but there is more that needs to be 
done because it is an aged facility. 1955 is when it was built. 
And there will be new surgical suites, but in-patient care, 
other kinds of facilities need revamping and rebuilding.
    I would like to hear from you the kind of commitment that I 
think you expressed privately to me about the need to rebuild 
and revamp that facility in West Haven and perhaps other 
facilities around the country where similar capital investment 
needs to be made.
    Dr. Elnahal. Senator, I have a particular appreciation for 
these issues. I run a safety net hospital now. And because of 
disinvestment over time, the hospital is actually newer than 
the one in West Haven, but I could not go a month without some 
type of infrastructure failing. A pipe bursting that required 
us to remove operating rooms from service, clinical areas from 
service, that impacts care.
    And it would impact care to veterans to make our clinicians 
and employees, if I am confirmed, work in plants, hospitals, 
buildings that are not commensurate and up to standard with the 
talent of those employees.
    I initiated a process for our hospital to be replaced and 
worked, and continue to work, to get funding to do that in 
Newark. I would commit the same not only for West Haven, which 
is a process that you already started, as you mentioned, but 
for any hospital in the VA in which the infrastructure is 
failing and where we do not have the funds authorized for that. 
I would be very transparent, alongside the Secretary, with this 
Committee and to Congress on what the infrastructure needs are 
and the capital investments needed.
    Senator Blumenthal. My time is expired, but both of your 
responsibilities, if confirmed, would be immensely important, 
and I look forward to working with you. Thank you both for your 
service.
    Thank you.
    Chairman Tester. Senator Murray.

                      SENATOR PATTY MURRAY

    Senator Murray. Thank you very much, Mr. Chairman.
    The VA's strength, as the largest integrated health care 
system in the country, gives it really the ability to lead best 
practices in health care and conduct research and reach 
veterans in all areas, including in our rural areas through 
mobile medical outreach, telehealth, and other innovations. 
Veterans really look to the VA to get the high quality, 
culturally competent care that they have earned.
    So I just wanted to say this today, Mr. Chairman. In recent 
weeks, my office has heard from concerned veterans and 
employees that VA is considering a reduction in inpatient 
services at Mann-Grandstaff VA Medical Center in Spokane, and 
veterans and staff at that facility have really spent the last 
few years navigating this new health care record system that 
has been plagued by issues, to put it lightly. So to reduce 
inpatient services at a time when local communities, especially 
surrounding rural communities, need more care, not less, would 
be a real mistake. And instead of placing more stress on a 
facility that has already taken on so much, the VA needs to 
give employees the resources and the flexibility they need to 
just do their job and get our veterans the high quality service 
that they have earned.
    And, Mr. Chairman, I just wanted to make that very clear at 
the top of this Committee.
    But, Dr. Elnahal, I wanted to ask you, having spent some 
time away from the VA, what lessons would you bring back to the 
Department when it comes to access to care and reaching all of 
our veterans?
    Dr. Elnahal. Absolutely, Senator, and I think the 
overarching principle here is to map the journey of the patient 
in trying to access our system. We did that for our ambulatory 
care center. We discovered major problems at University 
Hospital with the call center to be able to get an appointment 
and also referrals from the emergency room into longitudinal 
care in our ambulatory center, and we have made strides in 
trying to improve that.
    So it really starts at the point of care. It starts at the 
point of understanding the veteran's experience in trying to 
get access to care. And I know the VA has incredible efforts in 
human center design and mapping the journey of veterans. In my 
view, that has to be front and center with whatever we take out 
of Washington to implement and support the field in improving 
access.
    So I have personal experience with that. There were access 
issues in the psychiatric hospital system that I ran in New 
Jersey that we improved as well. I would try to bring those 
lessons back, and frankly, continue, I think, the forward 
thinking work that VHA is already doing on access.
    Senator Murray. Okay. I look forward to working with you on 
that.
    Since 2010, more than 65,000 veterans have died by suicide, 
which is more than the total number of deaths from combat 
during the Vietnam War and the operations in Iraq and 
Afghanistan combined. I know suicide prevention is a high 
priority for the Administration. It is for everyone on this 
Committee as well. So with approximately 200,000 servicemembers 
transitioning now to civilian life every year, how will you 
work, Dr. Elnahal, to ensure veterans are receiving continuous 
and timely mental health care during that transition from DOD 
to the VA health care facilities?
    Dr. Elnahal. Senator, I will say that I share your view 
that veteran suicide is a national tragedy and that we must do 
everything we can to bring that number as close to zero as 
possible, and I would commit to doing so if confirmed into the 
role.
    I think the John Scott Hannon Act, which this body passed 
and this Committee, of course, passed, is a great framework for 
how to address this issue. Title I of that Act talks about 
everything that the VA can do in the transitioning period, 
where we know the risk for suicide is much higher in that six-
month period after service and moving back into civilian life.
    Veterans need to be supported in every step of that 
process. Making the enrollment process in VA is a piece of 
that, but that is why that Act and the VA's implementation of 
that, with its strategic plan, focuses so much on community 
based prevention in addition to connecting veterans with 
longitudinal mental health care. We know the data also shows 
that veterans who are experiencing care and are within the VA 
system for care have a lower suicide rate than veterans who are 
not in the system even if they had the same combat experience 
and service experience. So it is not just community based 
prevention and intervention. It is also ensuring that access to 
mental health services in VA is as best that it can be.
    Senator Murray. And I am specifically concerned about that 
transition from DOD to VA, where we lose people, and we have to 
keep track of that and do a better job.
    Dr. Elnahal. I agree, Senator.
    Senator Murray. Okay. Thank you.
    Thank you, Mr. Chairman.
    Chairman Tester. Senator Brown.

                     SENATOR SHERROD BROWN

    Senator Brown. Thank you, Mr. Chairman.
    Good to see you both here.
    Dr. Elnahal, good to see you again and thanks for your 
willingness to serve at the VA again. When you were last before 
this Committee, six or seven years ago, something like that, we 
discussed the Department's Diffusion of Excellence initiative. 
Scott Bryant and the Chillicothe VAMC testified regarding the 
e-screening practice they were working on there. Chillicothe is 
a hospital that serves Appalachia, a huge area of southern Ohio 
where there are a lot of veterans.
    In March, Secretary McDonough, as you know, issued 
recommendations to the AIR Commission. One of those 
recommendations was to close Chillicothe, an integral piece of 
Ohio's VA health care system. The facility serves 20,000 
veterans, with 1,400 employees, many of whom I have met.
    As you know, this privatization of the VA kind of came out 
of the Tea Party Movement a decade-plus ago, and we are reaping 
whatever the opposite of benefits are from this discussion and 
what has happened with the AIR Commission.
    So my staff and I, as a result, have spent the last month 
traveling through Appalachia. I have been to Chillicothe twice. 
One meeting was with veterans; one meeting was with employees, 
many of whom were also veterans. My staff has gone all over to 
Legion Posts, community centers, VFW halls. People are 
concerned or worse. They worry about losing their VA doctor, 
having to go out of the community for care, driving for several 
hours.
    Chillicothe also has some of the best mental health 
services of any VA in this VISN. Rural communities like 
Chillicothe do not have as many providers as big cities do, and 
even those providers do not have the breadth of veteran-centric 
knowledge that VA physicians and other providers have, as you 
know.
    My question is this--sorry for the long intro. How will you 
ensure the VA has quality options in the community if services 
shift over time to make sure veterans do not lose continuity of 
care?
    Dr. Elnahal. Thanks for the question, Senator. I think it 
is really important to focus on the adequacy of the network 
that actually services community--services veterans in the 
community. There is an opportunity to really double down and 
look at what standards we have and how many providers and where 
they are located with the scheduled recompete of the network, 
which is coming up in the next 18 months, as I have learned.
    And access to care for veterans in Ohio and veterans across 
the country is a major consideration and making sure that 
community care options are available, especially where VHA does 
not have internal services in specific service lines. That is a 
criteria in the MISSION Act for access to community care, and 
it is one that I would look very closely at in consultation 
with the Secretary and the White House and others to ensure 
that that network is more than adequate, especially with regard 
to mental health, knowing how much of a priority that is and, 
frankly, the top clinical priority, mental health and suicide 
prevention.
    Senator Brown. Thank you. Two other real brief questions. I 
may go a bit over, Mr. Chairman. I will do my best.
    I support moving on the PACT Act. We have talked about many 
provisions that originated in this Committee. How do you ensure 
VHA has the resources, the physical space, the medical 
professionals, the administrative staff to care for veterans 
exposed to burn pits and other environmental toxins?
    Dr. Elnahal. Senator, I am really pleased to see the 
multiple actions that the Secretary has taken in the last 
several months to afford more presumptive eligibility for 
different conditions, most recently, multiple rare cancers for 
burn pits and airborne hazards. I think that is a reflection of 
the Secretary's and the President's desire, as the President 
has stated himself, to extend as much as possible in terms of 
benefits to veterans with these exposures. And VHA, of course, 
has an office that continuously analyzes the data and 
determines what the associations are and makes those 
recommendations.
    I am very pleased also to know that the budget that this 
Committee and this body passed is a lot more resources to be 
able to prepare the system for whatever comes next, whether 
that is more veterans as a result of presumptive eligibility or 
if there is legislation working with this body to ensure that 
the resources are there. That would be my responsibility as the 
manager of VHA, to make sure the system is ready on the other 
end to take in these veterans and care for them.
    Senator Brown. Thank you. I have been on this Committee, as 
the Chairman has, got on the Committee the same day, and 
watched the slow-moving response still to Agent Orange over all 
those years. We kept adding but not quickly enough, and then 
the last administration showed so little interest in burn pits. 
And I am really encouraged by the President and by your 
comments and by Secretary McDonough wanting to move quickly on 
making sure that people that are injured from these burn pits 
get the kind of treatment.
    Last question. I wanted to follow up briefly on Senator 
Murray's comments about suicide. How do we remove the stigma 
and the barriers related to mental and behavioral health?
    Dr. Elnahal. It starts with a declaration, Senator, that 
mental health care is health care. It is not something 
separate. It is part of the overall health of somebody to make 
sure their mental health and well-being is as best that it can 
be. And that stigma needs to be--that needs to be eliminated, 
and you also need to wrap it around with the right 
infrastructure and the right capacity to be able to meet those 
needs. But wherever we can, in every forum we can, we have to 
keep saying that it is okay not to be okay and that veterans in 
particular, their mental health issues, especially as a result 
of their service, are our responsibility in VA for the 
enrollees to address.
    And so I would commit as much as I can to you to make sure 
that this is a priority and that every forum we have and every 
chance we have we communicate that mental health is health care 
and VHA invests in that mission holistically.
    Senator Brown. Thanks, Dr. Elnahal.
    Thank you, Senator Tester.
    Chairman Tester. Thank you, Senator Brown.
    I am going to stay with you, Dr. Elnahal, for a minute 
here. Senator Murray talked a little bit about electronic 
health records. The price tag for this effort--and it is not an 
effort that is going particularly well--is about $16 billion 
over 10 years based on IG reviews and congressional oversight 
work. It is expected to be more expensive and take longer than 
that. The system still has issues in Washington State, where it 
was launched, but the VA is pressing forward in other parts of 
the country. There are concerns by Congress. There is concern 
by staff. There is concern by stakeholders.
    If you are confirmed, what role do you see yourself 
playing, and what are your top priorities so this system 
actually ends up delivering, which I think it is critically 
important we get it to a point of delivery, for our veterans, 
for our medical professionals, and for the taxpayers?
    Dr. Elnahal. I think I would play several roles, Senator, 
if I am confirmed, in that initiative. The first is being an 
important representative of the experience of our clinicians in 
the field within VHA and their interactions with the system. I 
have to be one of many voices to express any concerns they have 
and also raise issues that can be mitigated as soon as possible 
to the Deputy Secretary and others so that they can mitigated.
    So first is an advocate for the clinicians and the staff 
within VHA, but second is a champion. Unless the leader of VHA 
says that this is a strategic imperative and that there is a 
full speed ahead effort to make this right, it is going to be 
hard to implement it successfully, and so I would commit to 
being a close partner with the Secretary, the Deputy Secretary, 
Dr. Adirim, and her whole infrastructure and working with VHA 
as a close partner, to ensure that this initiative is 
implemented in a way that not only protects patient safety but 
enhances it over time, with a workforce that is using the 
system to the full capacity that it can.
    Chairman Tester. So just a real quick follow-up, we have 
had a number of hearings on the electronic health record and 
what is right and what is wrong with them. In one of the 
hearings, it was pointed out that, in general, physicians and 
nurses do not much like this. They do not like changing the way 
things are being done, and I get it. Change is hard.
    What are you going to do on that front? What can you do on 
that front from a leadership standpoint, from an education 
standpoint, from a communications standpoint to deal with this 
because if they are not bought in it is not ever going to work?
    Dr. Elnahal. Well, the first thing I would say, Senator, to 
VHA staff and clinicians is that I have been through electronic 
health record implementations before. As a resident, we had to 
cut our clinic panels by half. We had to have folks, right at 
the point of care, troubleshooting, making sure that whatever 
we wanted to do was executed well, and that in the process, 
within the workflow of clinicians, people were learning how to 
use the system. And that process lasted for weeks, so you know, 
reducing this, the clinic volume during our residency by half 
for weeks, when I was resident, which of course impacts access 
in a temporary way. But ultimately, it was implemented 
successfully because the experience of the clinicians was first 
and foremost what was emphasized and what management responded 
to during the course of that implementation.
    I pledge to you, Senator, that I would consider the folks 
using the system at the point of care to be the most important 
stakeholder in informing how we proceed going forward.
    Chairman Tester. Okay. Look, by the way, if we had all the 
money we have spent on technology in my days in the State 
legislature and here, we would probably pay down the national 
debt significantly. It is an incredible amount of money, so it 
is a big issue.
    Mr. Jefferson, before I get to Senator Sullivan, in recent 
years, Congress has enacted critical legislation to strengthen 
VA's oversight of schools receiving veterans' earned benefits 
such as the Post-9/11 GI Bill and the VRRAP program. However, 
despite Congress's and VA's effort to curtail predatory schools 
that target veterans, we continue to see student veterans fall 
prey to these institutions.
    Now Congress closed the 90/10 loophole, and that is a good 
thing. We did that in the American Rescue Plan. What else can 
be done to protect student veterans?
    Mr. Jefferson. Senator, thank you for that question. Bad 
actors need to immediately be identified and removed from the 
system and removed from having any engagement with veterans and 
with VA. If I have the privilege of being confirmed, one of my 
first priorities will be to look at what is the current state 
of outcomes, what is the current state oversight, and what have 
we identified thus far in terms of what bad actors may still be 
engaging with veterans.
    I would also want to spend time getting feedback from the 
veterans service organizations, the military service 
organizations, those specifically who are looking at this issue 
and who have identified bad actors who are in the system.
    I would also want to work with other Federal Government 
agencies as appropriate to leverage their strengths and 
leverage their authorities so that we can ensure that veterans 
are set up for success and any predatory entities, businesses 
that are taking advantage of our veterans are, one, identified, 
two, there is public awareness made, and three, that they are 
held responsible and accountable for their behavior to the 
greatest extent allowed by law. It is completely unacceptable.
    Chairman Tester. Agree. Thank you.
    Senator Sullivan, if you are ready.

                      SENATOR DAN SULLIVAN

    Senator Sullivan. Yes, Mr. Chairman. Thanks a lot. Thanks 
for waiting. Sorry.
    Gentlemen, sorry. Congratulations on your nominations.
    Mr. Jefferson, I just want to dig into this--first, I 
appreciate your military service.
    Mr. Jefferson. Thank you, Senator.
    Senator Sullivan. I think that is an important component 
for the VA. You have an impressive background.
    I want to dig into a little bit more on the Inspector 
General report, OIG report, that you told multiple government 
officials that the OIG blessed your plan to pay an associate 
via a government purchasing card. I think that is not correct. 
Can you just help clear all this up----
    Mr. Jefferson. Yes, Senator.
    Senator Sullivan [continuing]. Because it is something that 
has come up in your background and record? It seems confusing 
to me as I have read it. So what is the real deal here?
    Mr. Jefferson. Senator, we know from research that we need 
three things to build trust. The first is credibility, the 
second is reliability, and the third is authenticity.
    I am a veteran. I have served our Nation for 15 years in 
uniform, and I take my integrity very seriously. I and my 
senior team have always directed the individuals in the 
organization who do contracting and procurement to follow all 
appropriate rules and regulations and guidelines. And I take my 
integrity so seriously that I spent my entire life savings, 
sir, over the course of eight years to clear my name.
    Senator Sullivan. Mm-hmm.
    Mr. Jefferson. Now I can understand that the IG, in my 
opinion, at the time was doing the best they can with the 
information they had. I believe they did not know that two of 
the individuals they were relying on primarily had been found 
to have lied in other investigations.
    I believe that the IG plays a very important role and that 
whistleblowers should be protected. I also feel, sir, that all 
parties involved should be protected and that there should be 
due process as a result.
    I have been cleared of these allegations by a Federal court 
of law. I take my name, my family's name very seriously, and I 
did that, sir, for two primary reasons: one, because my 
integrity as a veteran and, second, because I hoped to one day 
have the privilege of serving our nation again.
    Senator Sullivan. So your--so the Federal--and again, I am 
just reading this, so I am just trying to understand where the 
truth is. So you think the OIG's report--you would just 
disagree with it then? Is that . . .
    Mr. Jefferson. Sir, I disagree. When this first happened, I 
expected to have a due process opportunity within just a few 
days of being informed of the report. Unfortunately, that was 
not the case. And so the reason it took eight years, the reason 
it was at the expense of my entire life savings, down to the 
minimum required deposits needed to keep a savings and a 
checking account open, is because, as I was told, the Federal 
court wanted to look at every single aspect of the situation to 
see if there was one single thing that they had found we had 
done wrong, and it took eight years to receive a clearing of 
all of those allegations.
    Senator Sullivan. Okay. All right. I appreciate that.
    Dr. Elnahal, let me ask you, you know, we have not had an 
Under Secretary in this really important job since, I think, 
Dr. Shulkin. Geez, Louise. That is not good. So we need someone 
confirmed here.
    You know, in my experience on this Committee, the Secretary 
or the Under Secretary is a hugely important job. The following 
background really helps in terms of their ability to do the job 
well: military service, professional background in medicine or 
health care management, and the ability to manage a large, well 
intended but sometimes extremely bureaucratic organization.
    Give me a little bit of what your background presents. You 
do not have all those three criteria, but I am not saying that 
is disqualifying. What in your background can make sure you are 
able to do this job, which is a really important job that we 
need someone in the position?
    Dr. Elnahal. Thank you, Senator, for the question, and I 
agree the experience of whoever ends up in this position is 
extremely important because the mission is extremely important.
    I believe I am qualified for the following reasons. The 
first is that I know what it is like to run a full-service, 
acute care hospital, which is where everything converges from 
Washington, DC in the VA health system: medical center 
directors, network directors, and the folks that they are 
responsible for in delivering that mission. I can speak to that 
experience, and I know what is like, and hopefully, that will 
give me the perspective needed to be able to run such a large 
organization and execute on the imperatives of this Committee 
and the Administration. So that is the first point.
    The second point is that I have not only been in those 
positions, both in the State psychiatric hospital system in New 
Jersey but also a full civilian hospital, acute care, level one 
trauma center, but I have made improvements in all 
opportunities that I have had to those systems in meeting that 
mission. As I mentioned in my opening statement, we reduced 
violent assaults in the State psychiatric hospital system, we 
hired hundreds of clinicians in a very understaffed situation, 
we had overcrowding in hospitals that we reduced over time, and 
we made the care experience better for the folks working there 
and, most importantly, for the patients.
    At University Hospital, under the oversight of a State 
monitor for poor financial performance, poor quality, and 
basically poor community trust and regulatory compliance, we 
made improvements in all three of those to a point where now 
the performance of that hospital is on par with the best of New 
Jersey, in my view.
    And I would take that record and do my best to apply it in 
this position.
    I am not a veteran, but I commit to constantly, constantly, 
getting the perspective and the opinion of veterans, both who 
work around me in VA--by the way, about a third of the 
workforce are veterans----
    Senator Sullivan. Yes.
    Dr. Elnahal [continuing]. But also from veterans service 
organizations and State veterans organizations as well, to get 
that full perspective.
    Senator Sullivan. Great. Mr. Chairman, do I have minute to 
ask just a few more questions?
    Chairman Tester. Go ahead.
    Senator Sullivan. Let me ask on mental health, for both of 
you, so I just spent--well, let me get a commitment from both 
of you here. So I represent a State with more veterans per 
capita than any State in the country, and we are proud of that 
in Alaska. So can I get your commitment, if you are confirmed, 
both of you, soon in your tenure to come up to Alaska with me 
and meet the amazing veterans in my State?
    Dr. Elnahal. Yes, Senator, absolutely.
    Mr. Jefferson. Senator, it would be an honor to do so. And 
I have actually been to Alaska during my previous time of 
service, meeting with veterans there, meeting with Native 
Americans there, and we had very productive dialogues that led 
to better-based service and better outcomes. It would be an 
honor to return to Alaska, sir, one more time.
    Senator Sullivan. Good. I look forward to having you guys 
up there.
    Mental health. So we have real high suicide rates in 
Alaska, unfortunately. I just spent last week--now this is not 
veterans; this is active duty. You may have seen the national 
articles. We have this incredible spike in the U.S. Army 
Service in Alaska, suicide rates that are just through the 
roof, active duty suicide rates. I spent two days doing town 
halls with Democrat Congresswoman Jackie Speier of San 
Francisco, who chairs the Armed Services Subcommittee on 
Personnel.
    Can I get your sense, Dr. Elnahal, on what you think?
    This has been a big priority of ours here, how to address 
this issue of veteran suicide, which is the numbers are through 
the roof as well. If you have ideas--that is a bipartisan issue 
on this Committee that we want to get on. Do you have any 
thoughts on that?
    Dr. Elnahal. I do, Senator, and I share VHA's already 
stated priority of mental health and suicide prevention as the 
top clinical priority. I would carry that forward as well.
    I know that the Agency is armed with a great framework for 
how to address this issue with the John Scott Hannon Act, to 
include important work on community-based prevention, working 
with community stakeholders to provide a support network for 
veterans at risk for suicide.
    A very important thing is getting veterans enrolled for 
care and actually delivering that care with adequate access, 
whether that is through telehealth, in person care, for most 
people, both, but also doing everything we can to identify with 
data, with programs like REACH VET that actually identify folks 
in advance who may be at higher risk based on very rigorous 
research that allows the system to do that.
    You would have my commitment to employ all of those tools 
in addressing this public health crisis.
    Senator Sullivan. Great. Thank you.
    Mr. Chairman, I have one more, but I can submit----
    Chairman Tester. You know what? Senator Moran will wait. Go 
ahead.
    Senator Sullivan. What is that?
    Chairman Tester. Go ahead. Senator Moran will wait.
    Senator Sullivan. Well, it is actually a bill that Senator 
Moran, I am sorry, that the Chairman and I co-sponsored, and it 
is just looking at the issue. It is not saying you need to do 
it, but a lot of my veterans say, hey, we can--there can be 
some help with regard to some of the needs they need on 
cannabis research. The VA is very reluctant to do anything, 
even starting to research the benefits that can come from the 
medical use of cannabis.
    We have a bill that just says, hey, VA, just start to take 
a look. I do not even think they need legislation to do it. 
They want the top cover of a Republican and Democrat to do it, 
so we are trying to do that.
    Do you have a view on that? I know you did some work on 
that in New Jersey, if I am not mistaken.
    Dr. Elnahal. I did, Senator. I was--when I was Health 
Commissioner, I ran the medical marijuana program in New 
Jersey. We expanded access to the program across the State and 
made it easier for veterans to enroll as well.
    As you know, Senator, this issue is very complex from the 
national standpoint and the Federal Government standpoint 
because it remains a Schedule 1 drug, and so you would have my 
commitment to have these discussions with leadership across the 
Administration but also with this Committee and try to come to, 
you know, a right set of next steps.
    Senator Sullivan. Did you see any benefits or takeaways 
from the work you did in New Jersey on this topic for veterans, 
or it is too early to tell?
    Dr. Elnahal. There are no studies that look at veterans, 
that I am aware of, in New Jersey and where they have benefited 
from the program. I did serve as an advocate for the program 
across the board for all patients who are eligible for specific 
conditions. It is a condition-based system. But the 
intersection with Federal law was not something I had to 
contend with at the time.
    Senator Sullivan. Okay.
    Dr. Elnahal. And so that would be the layer of issues that 
I would have to address if confirmed for the role.
    Senator Sullivan. Good. Thank you.
    Thank you, Mr. Chairman. Thank you, Senator Moran.
    Chairman Tester. I am glad you brought the issue up, 
Senator Sullivan, because I get the Schedule 1 and I get it, 
but there are so many States that have legalized this. There 
are so many claims that talk about how great marijuana is for 
treating things. And if it is great and it does supplant 
pharmaceuticals, I am all in. But if it ain't and we do not 
have the research to back it up, I think we are making a huge 
mistake. And so we should be doing this research, and if it 
takes an act of Congress we will do it, but I hope you are 
aggressive in pushing the VA to do the research within the law. 
Okay?
    Senator Sullivan. And then if you need the law, we will get 
our law passed.
    Chairman Tester. That is right on, yes.
    Senator Sullivan. Yes.
    Chairman Tester. Senator Moran, we are anxiously waiting 
for your questions.
    Senator Moran. I am sorry that has been the case most of 
the day and most of the afternoon in which you have been 
waiting for me.
    Mr. Jefferson, one question for you and one question for 
the doctor.
    Mr. Jefferson, in two instances, including the official 
committee questionnaire, you state that government defendants 
in your civil lawsuit related to your 2011 resignation from 
DOL, from the Department of Labor VETS, agreed that the 2011 
OIG report was, quote, ``baseless and without merit.'' Both the 
Department of Labor and the OIG confirmed to my staff that that 
is an incorrect characterization of the settlement agreement. 
Further, the OIG's 2019 revisions to the 2011 report only 
changes the OIG's conclusion to unsubstantiated. I think there 
is a difference between baseless and without merit and 
unsubstantiated.
    And I think earlier this afternoon, in regard to a question 
from Senator Blackburn, you indicated you were cleared.
    And I just wanted to have you describe for me how you see 
the differences between those words. I am of the view that 
words matter. Explain to me how you saw, or what you think, is 
the circumstance of your--the changes in this report.
    Mr. Jefferson. Senator, I believe words matter. I believe 
experience matters. And I believe integrity matters and that 
our veterans deserve leaders of the absolute highest character 
and ethical backbone to provide services to them.
    Senator Moran. Thank you.
    Mr. Jefferson. Sir?
    Senator Moran. I was not sure if you were done.
    Mr. Jefferson. No.
    Senator Moran. Okay.
    Mr. Jefferson. Yes. Sir, I truly support the role of 
whistleblowers and the role of the IG, and I know that the IG 
in this situation was doing the best that they could with the 
information that they had.
    The facts are that I was never given a due process 
opportunity at the time to go ahead and address those 
allegations, and I spent eight long years providing answers to 
every question I was asked, and I was told it took so long 
because the investigators wanted to see if there was anything 
they could find that I or the senior team had done wrong. And 
that--as a veteran, sir, I did that at the expense of my entire 
life savings because I value my family's good name and I wanted 
to have the privilege of serving our Nation again.
    I believe the IGs play an important role. I believe that 
all parties, regardless of your role in an organization, 
deserved to have their rights protected and that due process is 
essential and important.
    I can understand that the IG today may want to say that the 
allegations were not baseless, but after an eight-year 
investigation a Federal court of law had found that not one of 
those allegations was substantiated. And if I had had the 
opportunity to have due process in 2011, maybe it would not 
have required my entire life savings to clear my name and to 
clear family's good name.
    I would be honored to serve our Nation again. These two 
tabs, this Ranger scroll and this Special Forces scroll, are 
indication of the fact that I would do whatever it takes to 
serve our Nation's veterans and to get results the right way, 
sir.
    Senator Moran. Mr. Jefferson, thank you for your service to 
our country.
    Dr. Elnahal, Congress passed the Veterans Health Care Act 
in 1992 and unequivocally prohibited the VA from providing 
abortions. However, after writing to Secretary McDonough last 
year to remind him of this prohibition, he responded that the 
VA's prohibition is, quote, ``a policy decision rather than a 
statutory one.'' This is a departure from the VA's previous 
position, which is, I quote, ``cannot, by law, provide abortion 
services.'' It was publically stated on the VA's website.
    I raise this today because the VA's argument is that 
despite congressional authorization and prohibitions on what it 
can and cannot do it has general treatment authority to 
override those decisions by Congress.
    I have never been in the United States Senate in which it 
worked as I believe it should. I miss the days that I at least 
read in history when Republicans and Democrats were united in 
their belief that the Article I, the Executive Branch of--I am 
sorry. Article I, the Legislative Branch has the authority to 
determine the law and the Executive Branch enforces it, 
executes it. And I wish there were days in which we were lined 
up, in which perhaps even regardless of the position you take 
on the law, whether it is right or wrong, that Congress was 
firm with the Executive Branch in saying it is our 
responsibility legally, constitutionally, to make these 
decisions.
    And I just want to reiterate today--I mean, unfortunately, 
I think what has happened over time is that Republicans end up 
supporting Republican administrations' decisions and Democrats 
end up supporting Democratic decisions. And really, our 
freedoms and liberties that Mr. Jefferson fought for are 
determined by an Executive Branch that only executes laws, and 
our liberties are intruded upon when it is something different 
from that.
    So I would reiterate today that we do not hold hearings, we 
do not vote and pass legislation just so those laws will 
ultimately end up as mere suggestions to the VA on how it ought 
to operate.
    And I hope and I expect--this is a conversation I have had 
with Secretary McDonough--I just highlight for you, please, in 
every endeavor that you make, try to execute the laws as 
Congress passed, and when we have done it wrong, which is not 
infrequent I am sure, come tell us that the law needs to be 
changed. It is the requirement of the Constitution, something 
that the people that you serve at the VA and the people that we 
try to take care of in this Committee fought and many died for, 
those words that define how our freedoms and liberties are 
determined.
    So I just--maybe you would commit that if you are confirmed 
you would follow the law and congressional intent as you do so.
    Dr. Elnahal. I would, Senator. That is my understanding of 
the oath of office I would take, and I would take that 
responsibility very seriously.
    Senator Moran. Thank you.
    Chairman Tester. Thank you, Senator Moran.
    I want to thank the nominees for being here today. As many 
members have said, we want to thank you for your willingness to 
serve.
    I want to thank you and the committee members for the 
thoughtful dialogue that has occurred here today.
    I would ask that any post-hearing questions be sent to the 
clerk no later than tomorrow at 5 p.m. That is for the members, 
any post-hearing questions be sent to the clerk no later than 5 
p.m. tomorrow, and I would ask that the nominees respond as 
quickly as possible.
    With that, this hearing is adjourned.
    [Whereupon, at 4:44 p.m., the Committee was adjourned.]

                            A P P E N D I X


                        Nomination Material for

                           SHEREEF M. ELNAHAL

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                        Nomination Material for

                          RAYMOND M. JEFFERSON

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