[Senate Hearing 117-625]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-625

                 REVIEW OF THE FISCAL YEAR 2023 BUDGET
                AND 2024 ADVANCE APPROPRIATIONS REQUESTS
                 FOR THE DEPARTMENT OF VETERANS AFFAIRS

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                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                               __________

                             JUNE 14, 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                    
51-534 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

                              ----------                              

                             June 14, 2022

                                SENATORS

                                                                   Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     1
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     8
Boozman, Hon. John, U.S. Senator from Arkansas...................    10
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    11
Blackburn, Hon. Marsha, U.S. Senator from Tennessee..............    13
Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire......    16
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    18
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    20

                               WITNESSES
                               
                                Panel I

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

                                Panel II

Patrick Murray, Director, National Legislative Service, Veterans 
  of Foreign Wars................................................    23

Roscoe Butler, Associate Legislative Director, Government 
  Relations, Paralyzed Veterans of America.......................    25

Shane Liermann, Deputy National Legislative Director, Disabled 
  American Veterans..............................................    25

                                APPENDIX
                          Prepared Statements

Opening statement of The Honorable Denis McDonough, Secretary of 
  Veterans Affairs...............................................    33

The Honorable Denis McDonough, Secretary of Veterans Affairs.....    39

Joint statement of Patrick Murray, Director, National Legislative 
  Service, Veterans of Foreign Wars; Roscoe Butler, Associate 
  Legislative Director, Government Relations, Paralyzed Veterans 
  of America; and Shane Liermann, Deputy National Legislative 
  Director, Disabled American Veterans...........................    57

                              Pre-Hearing
                        Questions for the Record

Department of Veterans Affairs response to pre-hearing questions 
  by:
  Hon. Jerry Moran...............................................    67

                        Questions for the Record

Department of Veterans Affairs response to questions submitted 
  by:
  Hon. Jerry Moran...............................................    85
  Hon. Patty Murray..............................................    95
  Hon. Kyrsten Sinema............................................    99
  Hon. Sherrod Brown.............................................   108
  Hon. Bill Cassidy..............................................   111
  Hon. Mazie Hirono..............................................   115
  Hon. Tommy Tuberville..........................................   123
  Hon. Marsha Blackburn..........................................   128

The Independent Budget response to questions submitted by:
  Hon. Richard Blumenthal........................................   132
  Hon. Bill Cassidy..............................................   134
  Hon. Mazie Hirono..............................................   135
  Hon. Kyrsten Sinema............................................   135

 
                 REVIEW OF THE FISCAL YEAR 2023 BUDGET
                    AND 2024 ADVANCE APPROPRIATIONS
                            REQUESTS FOR THE
                     DEPARTMENT OF VETERANS AFFAIRS

                              ----------                              


                         TUESDAY, JUNE 14, 2022

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:06 p.m., in 
Room SR-418, Russell Senate Office Building, Hon. Jon Tester, 
Chairman of the Committee, presiding.
    Present: Senators Tester, Brown, Blumenthal, Sinema, 
Hassan, Moran, Boozman, Tillis, Sullivan, Blackburn, and 
Tuberville.

              OPENING STATEMENT OF CHAIRMAN TESTER

    Chairman Tester. I call this hearing to order.
    It is great to have the Secretary of the VA in front of us 
again today. Considering what we are dealing with on the floor, 
I am sure there are going to be a lot of good questions. But 
the reason for this hearing is to take a look at the budget for 
fiscal year 2023 that you put forth.
    As I said earlier, we are very, very close, as you all 
know, to having this PACT Act become a reality. It is a big 
deal because we are taking care of all areas of toxic-exposed 
veterans after decades of inaction by our Government. This bill 
has had broad bipartisan support with the vast majority of 
Senators voting to move it forward, and I think everybody on 
this Committee could agree there is no need to waste a lot more 
time to get the benefits where they are due.
    There is a negotiation on amendments going as we speak, and 
the Ranking Member and I could not do this, but we did agree 
upon a couple amendments when this bill went out, both 
Republican amendments. Unfortunately, we are not the ones doing 
the negotiation; the leadership is. And so they are continuing 
to hopefully move forward on that.
    So we have got a lot to visit about today, and I am sorry 
about my dysfunction. I apologize for that. But with that, I 
will turn it over to you.

               OPENING STATEMENT OF SENATOR MORAN

    Senator Moran. You gave me such an opening, Mr. Chairman, 
but since we are on the record . . .
    Chairman Tester. I know, I know.
    Senator Moran. Mr. Chairman, thank you. I would leave my 
remarks about this hearing for the time when it comes for me to 
ask questions, because I do want to address the topic that 
Senator Tester raised in regard to Sergeant First Class Heath 
Robinson honoring our PACT Act. We are currently considering 
this Act. Tonight at midnight, 30 hours will expire, and we 
should have another set of votes. We are able to have this 
hearing because we are not being intruded on by any votes for 
amendments. And passing toxic exposure legislation has been a 
significant priority for Senator Tester and for me in this 
Congress. In the last Congress, in my view, we were able to 
deliver a number of landmark pieces of legislation, most 
importantly mental health legislation for veterans. In this 
Congress, we are committed to passing long-lasting solutions 
for reforms for veterans exposed to burn pits.
    About a month ago, we announced a bipartisan agreement and 
introduced the legislation that the Senate is considering. Part 
of that agreement, as the Chairman indicated, was that he and I 
agreed that there would be two amendments considered on the 
Senate floor; during our negotiations, we reached that 
agreement. Those two amendments would be Republican amendments. 
There would be no Democrat amendments. And the reason that I am 
here talking about this topic is that even the two amendments 
that Senator Tester and I agreed on certainly have not been 
brought for consideration on the Senate floor.
    I indicated to Senator Tester when we negotiated the 
agreement about amendments that I could not bind my colleagues, 
and other members, including members of this Committee, have 
offered amendments, and my view is that a bipartisan bill on 
toxic exposure should have a bipartisan opportunity for the 
minority to make some suggested changes.
    Here are a few of the reasonable amendments. Every 
amendment that has been offered by Republicans appears to me to 
be reasonable. It is not outside the realm of this legislation. 
They are all germane. I have an amendment to codify existing 
law on the accurate method of counting a veteran's wait time at 
the VA and that the access standards which determine when a 
veteran may choose care in the community should be codified.
    Senator Blackburn also has an important amendment giving 
greater choice to veterans. The intent of these amendments is 
to assure that veterans, if there are operational problems 
created at the VA hospitals and clinics as a consequence of the 
toxic exposure bill, then community care is more readily 
available as a safety valve.
    I also offered an amendment to strike the creation of a 
fund which would classify over $116 billion in discretionary 
costs associated with the bill as entitlement spending. I 
believe this untested and unique way of classifying spending 
lessens congressional oversight at a time of massive debt and 
deficits, and it sets a bad precedent.
    That said, I have since filed amendments to merely get the 
policy of this fund to what I think was the intent of my 
colleagues who supported its creation.
    Senator Lee has an amendment requiring the Secretary to use 
science when evaluating presumptions established under the 
bill. Senator Ernst has an amendment requiring the Secretary to 
certify that the resources and authorities provided through 
this bill will not be a negative consequence for veterans in 
the system. And there are at least three amendments proposing 
offsets to the cost of the bill with spending reductions 
elsewhere.
    My colleagues deserve a fair consideration of reasonable 
and thoughtful amendments to improve this bill for our 
veterans. Regardless whether any of these amendments are 
adopted, I am frustrated there has been no movement on even 
considering them.
    In comparison, the House had 6 votes and adopted 27 
amendments when it considered the PACT Act. This is one of the 
most significant legislative packages ever to come out of this 
Committee, and I am proud of the work that the Chairman and I 
and our members of this Committee have done to reach an 
agreement. Given the magnitude and size of this legislation, 
there needs to be a bipartisan process on the Senate floor. 
This bipartisan process should include the input from my 
colleagues, especially when it is included in our agreement.
    I want to advance the Robinson Act without unnecessary 
delay, and reaching agreement on amendments is the fastest way 
to do that. I am hopeful that in the days ahead before final 
passage of this bill we can let our colleagues be heard through 
the amendment process, pass or fail.
    Thank you, Mr. Chairman.
    Chairman Tester. Thank you, Ranking Member.
    I would just say that negotiations are going on. We just 
came out of a caucus, you guys just came out of a caucus, and 
we continue to push folks--I do, anyway--to negotiate in good 
faith and come up with a set of amendments that hopefully both 
sides can agree upon. That has not happened yet, which is 
fairly typical in bills that go down. You are right, this is a 
big bill, and I think there is some opportunity to do some 
stuff.
    Just one thing on the OCO account, though, the OCO-esque 
account. It is not a new idea. It is patterned exactly after 
the OCO account that was used to fund the conflict that we are 
treating the veterans for when they come back home. So that is 
it. But I appreciate the working relationship we have, and that 
is going to continue.
    Secretary McDonough, you are on the first panel. We are 
going to hear from the VA on why they believe this budget is 
appropriate and how it will enable them to support the veterans 
in fiscal year 2023 and beyond.
    On the second panel, we are going to hear from VSOs, 
veterans service organizations, who wrote this year's 
Independent Budget. Each year the Independent Budget offers an 
informed perspective on what the VA needs to live up to the 
promises our Nation has made to our veterans. Right now their 
voices are more essential than ever as we work to get the toxic 
exposure legislation across the finish line.
    Now I want to introduce Secretary McDonough, but, first, 
and more importantly, I want to introduce his daughter, Addie, 
and his niece, Grace, who are in the audience. It is good to 
have you here, ladies, and it should be an interesting meeting. 
You get to watch your uncle and father get totally slammed to 
the ground.
    [Laughter.]
    Chairman Tester. Secretary McDonough, the floor is yours.

                            PANEL I

                              ----------                              


           STATEMENT OF THE HONORABLE DENIS MCDONOUGH

    Secretary McDonough. Mr. Chairman, thank you, Ranking 
Member Moran, thank you very much. Thanks in particular for 
expressing the welcome to my family, about whom I am very, very 
proud.
    With your consent, Mr. Chairman, and with the Ranking 
Member's consent, I will just submit my opening comments for 
the record, and we can get straight into questions.
    Chairman Tester. So ordered.
    Secretary McDonough. Great.

    [The opening statement of Secretary McDonough appears on 
page 33 of the Appendix.]

    Chairman Tester. So the fiscal year 2023 request includes 
resources needed to process newly announced presumptions to 
include asthma, sinusitis, rhinitis. Is that correct?
    Secretary McDonough. That is correct.
    Chairman Tester. Does it include the rare cancer 
presumptions?
    Secretary McDonough. It does.
    Chairman Tester. Okay. How many claims from asthma, 
sinusitis, and rhinitis does VA anticipate for fiscal year 
2023?
    Secretary McDonough. For FY 2023, for those three, we 
anticipate 100,144 claims and about 70,000--69,886--appeals. So 
that is a workload of around just over 170,000 cases.
    On the rare respiratory cancers, we think that these--since 
we call them ``rare,'' we believe the claims will be rare. So 
we think that those will be accounted for in our overall 
request.
    Chairman Tester. Okay. If we are able to pass the Sergeant 
First Class Heath Robinson PACT Act, which has less than a 
quarter of the claims in fiscal year 2023 that you anticipate 
for the three that I just mentioned--asthma, sinusitis, and 
rhinitis--what kind of resource support would you need?
    Secretary McDonough. Well, we are running that through our 
process right now, Mr. Chairman, so I do not have a specific 
number for you. But we have been looking at a series of 
enhancements under existing authorities and existing dollars to 
get ready for this. So from automation to hires--we are in the 
process of hiring over 2,000 additional claims personnel to 
potential contracting and claims process improvements. We think 
that we will be in a good position to handle that in the first 
year.
    Chairman Tester. As far as workforce goes, this budget 
requests $42.2 billion for medical service staffing to provide 
for 282,789 FTE, an increase of just over 14,000 over last 
fiscal year. However, we have heard from the VA about the 
difficulty of recruiting and retaining health care providers in 
this labor market where anybody can get two jobs if they are 
looking for one.
    Is the requested funding level adequate given that the 
latest data--although it was challenged at the last hearing we 
had, but given the latest data shows 56,000 vacancies at VHA?
    Secretary McDonough. Yes, our request includes all the 
necessary funding for the needs that we see in the system for 
FY 2023. So we think that the funding for the health care 
personnel is up to date and is sufficient.
    We think, though, as we have discussed in this room, and 
you and Senator Moran have been generous enough to provide in 
the context of your agreement, that we need additional 
authorities to enhance pay in certain instances, to enhance 
retention capability in certain instances. So it is true that 
is a very tight, very dynamic labor market, especially for 
health care personnel. But we think that both in the 
President's request and in the authorities that you have given 
us that we will be in a position to handle it, notwithstanding 
the fact that that aggregation of vacancies over time 
continues, but we do this year by year to make sure that we 
have the people that we need.
    Chairman Tester. Okay. The fiscal year 2023 revised request 
includes an additional $4.3 billion in community care funding. 
My understanding is this funding level is driven in part by a 
lack of administrative staff and support necessary to execute 
in-house dollars. Correct me if I am wrong on that.
    Secretary McDonough. That is a variable in the equation. 
Probably the more impactful variable in that equation is use, 
both because--mostly because of pent-up demand in the system 
and greater eligibility because of the way we handled the 
pandemic. And so, yes, our ability to manage more quickly and 
get people into care more quickly is obviously impacted by the 
tightness of the labor market. That is why the President's 
request does ask for additional HR personnel and why we 
continue to ask you for the authorities that you have included 
in the PACT Act.
    Chairman Tester. Okay. The caregivers program funding 
budget asks for $1.9 billion, which is a $433 million increase 
over the last fiscal year. However, the VA recently halted 
discharges from the program and expansion to veterans of all 
areas and is scheduled to begin in October 2022.
    Secretary McDonough. Yes.
    Chairman Tester. So is the requested level of funding 
adequate to provide for the influx of applicants and 
participants that, quite frankly, are expected and I hope 
occurs in the caregiver program?
    Secretary McDonough. Yes, we believe it is adequate, and we 
are hoping for the same thing that you are hoping for.
    Chairman Tester. Okay. I am going to turn it over to 
Senator Moran for his questions. I am going to also turn--
because I do not know what Jerry's schedule is, I will turn the 
gavel over to Brown, and I am going to go see a doctor.
    Secretary McDonough. Okay. Godspeed.
    Senator Moran. Well, Mr. Secretary, since I now do not have 
to worry about the gavel being held by Senator Tester, I am 
going to take a moment to tell you that, in difficult town hall 
meetings in my time as attempting to be an elected official, I 
always invited my 90-plus-year-old mother to come to the town 
hall meeting with me. And it calmed the nature of the questions 
and attacks that were made against me. I could never convince 
our two daughters to ever sit behind me, so you are fortunate 
to have a niece and a daughter here. I am now calmed down and 
will act very respectful toward you this afternoon.
    Secretary McDonough. Mission accomplished.
    Senator Moran. Well done. I outlined, as you know, that we 
are considering the Heath Robinson PACT Act in the Senate. 
Senator Ernst has an amendment that I outlined to you in my 
opening statement. The administration issued statements of 
support for both the House-passed PACT Act and the Robinson Act 
currently on the Senate floor.
    Can you certify, which is what Senator Ernst is looking 
for, is this indication that you can execute this bill that 
includes supportive resources and funding that you ask for and 
sets up funding for the future, can you implement this 
legislation without negative operational impacts on existing 
disability claims processing and health care delivery for 
veterans?
    Secretary McDonough. I can, Senator. I can certify that. I 
understand--you and I have talked about this for some time. I 
believe this is a very important piece of legislation. I think 
it will be very difficult to implement. But oftentimes the most 
important things are difficult, and I think that we are ready 
for it. We have been preparing for this. You are giving us 
additional authorities and additional funding. And taking care 
of one generation of veterans, for example, those who were 
exposed to burn pits after 1991 need not come at the expense of 
veterans who sacrificed so heroically for us in World War II or 
Korea or Vietnam or otherwise. And so I think that we can do 
this and we can do this well and will in all cases do it 
transparently with you so that you understand precisely what we 
are doing.
    Senator Moran. The medical care budget request for fiscal 
year 2023 and the advanced appropriation request for 2024 
requested $70.5 and $74 billion, respectively, for VA's medical 
services account.
    Secretary McDonough. Right.
    Senator Moran. During the pandemic the VA requested and 
received supplementary funding to help combat COVID-19 as well 
as adjusted its base request for fiscal year 2022 to account 
for long-term COVID funding. In written responses to prehearing 
questions ahead of the 2022 budget hearing, VA officials wrote 
that while the 2023 advanced appropriation request of $70.3 
billion would help address a wave of veteran utilization due to 
deferred care, it expected the growth in workload levels to 
stabilize to pre-pandemic levels, thus requiring fewer 
resources in fiscal year 2024. However, the fiscal year 2024 
advance appropriation request shows an increase in 
appropriations well above the pandemic levels.
    And so my question is: Please explain what conditions have 
changed over the past year that support an increase in fiscal 
year 2024 instead of a decrease to pre-pandemic funding levels 
as previously projected?
    Secretary McDonough. Yes, I think it is a fair question, 
and I think it is a good question. I think the principal issue 
is the Omicron variant, meaning that we would have anticipated 
that the return to care would have peaked by now, surely, but 
even several months ago. But because of the virulence of the 
Omnicron variant, we did not see the peak return to care that 
we anticipated.
    Moreover, we continue to believe and continue to see more 
complex conditions related to complications from veterans 
infected by the various variants of COVID-19. So the difference 
between last year and this is the introduction of the Omicron 
variant and the impact that had on ongoing operations. You will 
recall that our staff unable to work, which today is about 
3,000, got as high as 16,500 in January and February, which 
impacted access to care. It is an introduction of the Omnicron 
variant and ongoing recognition of the intensity of long COVID 
and the complications that come with it, especially with an 
older, more complex set of health conditions for older veterans 
that has complicated the outlook for fiscal year 2024.
    Senator Moran. Let me ask another question this round. I 
introduced a bill called the ``GHAPS Act.'' You and I have had 
this conversation about access standards under community care. 
You have indicated, the VA has indicated to us that it is 
premature, you are reviewing. We expected a report on June 6th. 
A few days before that, we were noticed that that report would 
not be available on time.
    Can you explain to the Committee--let me say it this way: 
As a result of the review, at this point in time you ought to 
be able to tell us what is the content----
    Secretary McDonough. Yes.
    Senator Moran [continuing]. Even though the report has not 
yet been delivered to Congress.
    Secretary McDonough. Fair.
    Senator Moran. Do you have any plans to change the access 
standards or change the way that wait times are calculated in 
community care eligibility?
    Secretary McDonough. Yes. Yeah, so good, and look, I have 
tried to say into the record and in discussions with individual 
Senators, both privately and here publicly, as well as House 
members, that I consider the June report very, very important. 
In fact, I consider it so important, I asked for an extra month 
to work on it. We have, in fact, completed much of the work on 
it. What we know is that demand for health care over the course 
of the pendency of these three years of the Mission Act has 
increased. It has increased more intensively for care in the 
community than for care in the direct system, such that right 
now I could tell you, if you were to roughly measure by 
relative value units, the units by which we measure how much 
care we give to veterans, about a third of the care that we 
give right now is care in the community. That is a high number, 
and that is the highest number yet of the three years of the 
Mission Act. So that gives you a rough order of magnitude of 
what we are seeing.
    Care overall, as you have seen in the budget itself, is 
growing. Care in the community as a portion of that is growing. 
I said to you guys last year in this round of hearings on the 
budget that I was worried about the rate. Last year, it was 
about 26, 27 percent. Now it is about 33 percent. So that is 
the finding.
    And, again, I did not want to surprise you when we sent it 
up here in writing. It is good idea to make sure that you saw 
it in writing. I thought I had flagged for you that it was 
going to take until July.
    One of the things that would help is if we could get our 
Under Secretary, because I would like him in the chair, 
because--and this gets to the last question. My hunch is that 
we should change the access standards. We would do that 
pursuant to public comment and regulation making, and we would 
do that in full consultation with you, such that you would be 
in a position to comment about it; you would be in a position 
to share your reaction to it, as would the general public.
    Senator Moran. I, too, Mr. Secretary, am anxious for the 
deputy, the Under Secretary, to be in his job because he 
testified he supports the current access standard guidelines.
    Secretary McDonough. Okay. Well, look, for that reason, I 
am not going to hoist him with my views. You know, I think he 
happens to be a health care professional, so we should probably 
have his views on this.

    [The prepared statement of Secretary McDonough appears on 
page 39 of the Appendix.]

                     SENATOR SHERROD BROWN

    Senator Brown [presiding]. Thank you, Senator Moran. 
Welcome, Mr. Secretary. Nice to see you and your family again.
    Secretary McDonough. Nice to see you.
    Senator Brown. First of all, thank you for the special 
attention, including your visit to Chillicothe and the 
attention you have paid to that very important and historical 
hospital center, so thank you.
    Secretary McDonough. You bet.
    Senator Brown. The Senate is close to keeping our 
commitment. I particularly credit Senator Moran and Senator 
Tester, everybody on this Committee but particularly the two 
leaders, the Heath Robinson Honoring Our Veterans Act, Honoring 
Our PACT Act. I appreciate the support and the work you and 
your staff did. I would like to ask you about the steps you are 
taking, taking off on Chairman Tester's comments and assertion, 
to make sure VA medical facilities are prepared for more 
veteran patients. We are aware of the recommendations you sent 
forth earlier this year to modify or close VA facilities. Those 
recommendations were based on old pre-COVID-19 data and 
certainly did not take into consideration the reach of COVID 
and did not take into consideration the PACT Act, obviously. So 
as you saw when you visited Chillicothe, these facilities mean 
so much to veterans.
    So talk about the steps you are taking to ensure that the 
VA workforce and physical facilities will be ready for expanded 
enrollment because of the Heath Robinson Act. And how would the 
enrollment change your planning for VHA's future requirements?
    Secretary McDonough. Yes, I think that is a very helpful 
question. First and foremost, as we discussed the last time I 
was here for the hearing on the PACT Act, I asked for some 
relief from the, I would suggest, anachronistic way that CBO 
scores how we get new leases. As you know, we are the only 
Federal Government agency that is required with each new lease 
to get a new independent legislated authorization. So you have 
now included that, the Chairman and Ranking Member Moran have 
included that for 31 new leases. So those are for clinics and 
facilities across the country that will be then available as we 
ramp up the number of veterans over the course of the life of 
the PACT Act. So that is the first thing.
    The second thing, on health care workforce, you included 
the RAISE Act in the context of the omnibus this year wherein 
we also got a very generous appropriation for this year, 
especially for the health care account, the medical care 
account. So we are now in a position to compete more 
aggressively with nurses. We have some 10,000 nurses next month 
who will be in a position to see--that is about one-eighth or 
one-ninth of our workforce of nurses--will see their salary 
increase as a result of that action.
    Third, included in the PACT Act are a series of workforce 
authorizations that will allow us to be more competitive in 
hiring and then, therefore, retaining specialists and experts 
in VA clinical positions. So that is the answer to the first 
part of your question.
    The answer to the rest of the question is we are watching 
to see what you all choose to do with the nominees for the AIR 
Commission. In all cases, under the Mission Act we are required 
to go back and look each four years at what the needs are in 
each of those markets across the country. We are prepared to 
continue to do that in coordination with and consultation with 
local stakeholders, local communities, informed by new data, 
informed by new statute, including the PACT Act.
    So an example of that: VISN 10, in which Chillicothe 
resides, the leadership in VISN 10 is talking with the medical 
center director in Chillicothe about one of the issues that we 
talked about on our visit, which is residential treatment 
programming for Chillicothe. We will be looking at steps like 
that irrespective of what you all decide to do with the 
commission, the commissioners. But we will be looking at that 
in the context of the second four years or the second 
Quadrennial Review. We will continue to look at that informed 
by new data and share the outcome of that consideration with 
you.
    Senator Brown. I know it is not an easy juggling act with 
COVID, with the AIR Commission still hanging out there, and 
with the new responsibilities that you are happily taking with 
the Heath Robinson Act, so thank you.
    The last point I want to make. My time is about up. You 
have answered questions about this in the Committee. We have 
had individual conversations at the VA and elsewhere about it, 
with the electronic health record modernization rollout. Thank 
you for the steps you have taken to hold Cerner accountable for 
the recent outages and degradations. I have had conversation 
with them, as many have. It is a large endeavor. We need to 
know the system is reliable. Some members of this Committee I 
would say are more unhappy than I am with the Cerner rollout in 
Columbus.
    Secretary McDonough. I have noticed.
    Senator Brown. I know you know that. Columbus has gone 
pretty well. Just reassure me that you understand these 
problems and that you will work in Washington State and Ohio, 
and I believe the next State is Idaho. Is that right?
    Secretary McDonough. Oregon.
    Senator Brown. Oregon.
    Secretary McDonough. It went live in Oregon this weekend.
    Senator Brown. I get those Western States mixed up. I am 
sorry.
    Secretary McDonough. Yes, well, I do not. But I hear you. 
You have my commitment on that. Let me just say on Columbus, I 
think you are right. I mean, I agree with your 
characterization, which is it has been relatively smoother. 
That said, to my considerable frustration, this issue of the 
pharmacy component of the Cerner product is still not what it 
should be in the 21st century. It turns out that 
pharmaceuticals are a big part of how we provide care, and the 
fact that that operates the way it does in certain areas, a 
massive frustration. And I know that is true in each of the 
facilities so far.
    So we will stay on top of it. I have been staying in touch 
with members both in these public settings and with updates, 
especially those in Ohio, like your State, obviously, 
Washington State, and now Oregon, and we will stay on top of 
this.
    Senator Brown. Thank you, and I will have a question for 
the record about veterans' homelessness.
    Senator Brown. Senator Boozman from Arkansas.

                      SENATOR JOHN BOOZMAN

    Senator Boozman. Thank you, Mr. Chairman. And, again, thank 
you for being here, Mr. Secretary.
    Secretary McDonough. Thank you.
    Senator Boozman. It is always good to see you. I appreciate 
the communication and the outreach. You do a great job in that 
regard. We appreciate your work on behalf of veterans and your 
ongoing efforts with the implementation of Staff Sergeant 
Parker Gordon Fox Suicide Prevention Grants and the women's 
health initiatives passed in the Deb Sampson Act over the past 
year.
    Secretary McDonough. Yes.
    Senator Boozman. Preventing veteran suicide, supporting the 
VA and their changes to better provide care to female veterans 
and ensuring veterans have access to the care and benefit 
certainly is a priority of mine, and I know it is a priority of 
yours and a priority of the Committee. I commit to continue 
working with you through this budget process to ensure those 
priorities are resourced and supported.
    Secretary McDonough. Thank you.
    Senator Boozman. It is good to see your daughter and niece 
here. I have got three daughters and three grand-daughters.
    Secretary McDonough. You are six times blessed, my friend.
    [Laughter.]
    Secretary McDonough. Six times blessed.
    Senator Boozman. The VA's fiscal year 2023 budget request 
of $301.4 billion is a 13.3-percent increase from last year's 
record budget. As you point out in your testimony, this is a 
114-percent increase in the VA budget since fiscal year 2013. 
Regarding medical care, the VA requested $122.7 billion, almost 
a 22-percent increase from last year, noting that the VHA did 
not see a 22-percent increase in veteran enrollment.
    What are the primary factors contributing to the 
significant increase in health care costs? And do you believe 
this trend will continue?
    Secretary McDonough. Yes, thank you very much. Let me just 
go back to the--I just want to say the President signed into 
law two additional Acts last week that will increase our 
ability to provide timely access to mammography across the VA 
system. That is because of you and your leadership on this. 
Nobody has been more aggressive and more supportive of our 
women veterans than you have been, and so I am really, really 
grateful for your work on that.
    Senator Boozman. Thank you.
    Secretary McDonough. We believe that the issue that is 
driving cost overall is obviously health care cost inflation, 
which has been an issue for us for generations, one.
    Two, complexity. Fifty percent of our veterans are 60 or 
older, we know that, so that number is only going to increase 
over time, that is to say, their age. And as veterans age, as 
anybody ages, the intensity of the cost and the reliance on the 
system increases.
    I will say that the pandemic definitely had an impact on 
cost and on spending on the health care, the medical care 
account, and the last thing is, you know, I have been studying 
a lot of charts pursuant to the questioning that I was just 
going back and forth with the Ranking Member on related to the 
Mission Act. CBO did anticipate increased costs associated with 
the Mission Act, and we see that. And so that would be the 
fifth thing I would say in terms of the impact on cost.
    So, overall, health care inflation, reliance, intensity, I 
put those together as complexity, the COVID pandemic, and then 
the Mission Act. I think those are the things--I think those 
continue to be complicating factors. I like to believe that we 
are getting smarter at this and are going to be in a better 
position to manage those costs, though, and so I hope we can 
get those under better control. A 100-percent increase over, 
you know, these basically 9, 10 years is a lot.
    Senator Boozman. I appreciate the VA's continued commitment 
to improving the care and the access for veterans in 
geographically rural areas. In my home State of Arkansas 
providing access to high-quality health care in rural areas of 
the State is a significant challenge for the VA medical system. 
The fiscal year 2023 budget request includes $307 million for 
the Rural Health Initiative, which is level with 2022 funding. 
Is the VA assuming any risk in providing care to veterans who 
live in rural parts of the country by not increasing funding?
    Secretary McDonough. We do not think so. Due to your 
generosity, we grew that account by about 20 percent last year, 
so we feel like we are in a good position because of the 
investments we have been able to make over the last year. And 
so I think what you see there in terms of our planning for 2023 
is a recognition that we can get better and more strategic 
about how we are making these investments, and we are not 
assuming additional risk. I think we are just trying to get 
more competent in our economic management of the budget.
    Senator Boozman. Thank you, Mr. Secretary.
    Secretary McDonough. Thank you, Senator.
    Senator Moran [presiding]. Senator Blumenthal.

                   SENATOR RICHARD BLUMENTHAL

    Senator Blumenthal. Thank you, Senator Moran. Thanks for 
being here, Mr. Secretary.
    Secretary McDonough. Thank you, Senator.
    Senator Blumenthal. You and I have talked frequently about 
the VA facility in West Haven. I think we are in agreement that 
it needs rebuilding beyond just cosmetic renovation. There is 
construction going on concerning a new surgical suite and new 
parking, but the main facility itself is more than 50-years-
old. In fact, it really requires that investment provide some 
world-class care from doctors and nurses and other staff that 
are really the gold star of medical care and quality, but they 
are working with a facility that is aged and aging. So I hope 
that your continued commitment to that cause will be there.
    But that facility is only one of many that require similar 
reconstruction, and your discussion of the VA facilities in 
your testimony indicates that the median age of the VA's 
physical portfolio is 58 years as compared to private hospitals 
at 11 years. I think that is just extraordinary. And 69 percent 
of VA hospitals are over the age of 50. There is no way that 
the Veterans Administration can continue quality care with 
facilities of that age at a time when technology requires that 
the entire structure of a facility be designed and built to 
accommodate the most modern means of delivering care, of 
monitoring patient health, of summoning help when it is needed.
    I am not a doc, but I have been through VA facilities, some 
of the oldest and some of the newest, and other hospitals, and 
even to this semi-informed layperson, this strategy is 
untenable. In fact, it is not a strategy. And I know I am 
telling you something you and the VA already know, but I am 
disappointed, as are the VSOs, to see that the investment this 
year is only $2.2 billion or $3 billion. I am not sure which 
number is correct: $3 billion in your testimony, $2.2 billion 
by my calculation. But you have determined that $24.1 billion 
is required to address major construction infrastructure 
requirements over the next 10 years.
    So what are we doing?
    Secretary McDonough. Yes, fair enough. I think the 
difference--thank you very much for the question. I think the 
difference between the two numbers that you are pointing to 
reflects our use of the transformation fund.
    Senator Blumenthal. Right.
    Secretary McDonough. This is a fund that allows us to re-
plow overages back into VA IT and VA infrastructure so----
    Senator Blumenthal. That is the $968 million in estimated 
unobligated balances.
    Secretary McDonough. Exactly. So I think that is the--when 
you talk about the difference between 2.2 and 3, that is the 
difference. Point one.
    Point two, the investment that the President has submitted 
in this budget is the highest ever investment in VA 
infrastructure. Do I wish it were more? I do, because the needs 
are extraordinary. But we are in a position that we can only 
execute--we are asking for as much as we can execute well. You 
know, we have a history of underperforming, shall we say. One 
need only recall the situation in Denver.
    Senator Blumenthal. And I visited there, so I am personally 
familiar with it.
    Secretary McDonough. So we are showing by our work and I 
think showing quite well--our most innovative new project is in 
El Paso where we are demonstrating, again, a quicker, more 
effective, more cost-effective way of deploying new 
infrastructure investment. So there is only so much we can 
credibly execute. There is only so much we can do on the 
ground, so think of West Haven. It is a pretty big campus, but 
not huge. You could not go in there and continue doing what we 
do every day and do all of the overhaul that we need to do. So 
there is a give-and-take between provision of care every day 
and upgrading of the facilities.
    So what you see in that budget is, A, the largest-ever 
request; B, what we believe we can execute cost-effectively for 
the taxpayer; and, C, what we think we can execute while not 
having it come at the expense of care of veterans. And so until 
we can look at this holistically, as we propose, for example, 
in the AIR Commission, we are not going to be in a position to 
continue to do this piecemeal.
    Senator Blumenthal. My time has expired, so I have other 
questions. I may try to come back for a second round. But let 
me just say, you know, America is America. It builds trillions 
of dollars of office buildings and residential complexes. In my 
part of the State, it is more than possible to execute better 
and more. I am putting it in very simplistic terms.
    Secretary McDonough. Yes.
    Senator Blumenthal. But if we do anything in terms of 
building, it ought to be for our veterans, and we get the best 
minds, the best contractors, best subcontractors to do it for 
the VA. And I take your point about having to deliver care--in 
other words, fly the plane at the same time you are trying to 
build it. But I will take you through the West Haven campus, 
another personal invitation to you, and show you where you can 
start building a new facility and keep the old one still 
running.
    Secretary McDonough. Okay.
    Senator Blumenthal. I guarantee you, I will do it.
    Secretary McDonough. I will look forward to that.
    Senator Blumenthal. I will join arm in arm with you.
    Secretary McDonough. Okay.
    Senator Blumenthal. And I have been to Colorado, so I know 
how things can go south with lack of proper supervision, and I 
will just say your administration has been very different from 
the ones that we have seen before. I have been on this 
Committee for 12 years now, and I am proud of the work that you 
are doing, and I think that gives us an opportunity that we 
should seize with this new era.
    Thank you.
    Secretary McDonough. Fair enough. Thank you very much.
    Senator Moran. Senator Blackburn.

                    SENATOR MARSHA BLACKBURN

    Senator Blackburn. Thank you. And we appreciate your time 
as always.
    Secretary McDonough. Thank you, Senator.
    Senator Blackburn. I want to pick up right where I talked 
with you the last time you were before us.
    Secretary McDonough. Yes.
    Senator Blackburn. And, of course, with the PACT Act, 
looking at the workload, and you all do not have the personnel 
to meet that added workload. You know you would need more 
people. You know there will be a ramp-up time that is necessary 
to meet that impact. And when you look at the hiring process, I 
had down in my notes that it is taking you all 95 days to hire 
and on-board someone. So I looked at some of the models that 
are used by hospitals and other organizations, and doing an 
algorithmic pre-vetting, they are lowering that hiring process 
to 16 days to get someone through that process. That is 
attractive to a lot of doctors and nurse talent, things of that 
nature.
    So where are you all with this hiring process and when it 
comes to staffing and moving people within the organization 
from one position to another where you are needing to fill 
those positions? Talk with me a little bit about that.
    Secretary McDonough. Yes, I think it is an excellent 
question. I appreciate your asking it. I think, you know, what 
precisely we will need in the Veterans Health Administration 
and in the Veterans Benefits Administration to execute the PACT 
Act, we are going through that with a fine-toothed comb now, 
and we will come back with you and we will work with you on 
that.
    There is no doubt, however, in either case that our hiring 
and on-boarding is too slow. I have been updating you on the 
process at VBA, the Benefits Administration, for the last seven 
months about how quickly we can hire and on-board 2,094 people. 
We are still at between 1,850 and 1,900 of those people. I 
think that is too slow, because there is a hiring and then 
there is a training tail on the end of that.
    So what are we doing? So now let us talk about VHA. We are 
immersed in more rapid hiring and on-boarding. We have just 
gotten agreement from OPM to continue for another year the 
direct hire authority, which of the many variables in the 
equation of bringing people on is perhaps the most impactful, 
accounts for probably a third of the savings we are able to get 
in terms of time to hiring. But the hiring and on-boarding 
process is still so sclerotic that we are finding things that 
can change. So let me give you an example----
    Senator Blackburn. Okay. You have--let me interrupt you 
just a second.
    Secretary McDonough. Sure.
    Senator Blackburn. When you look at the budget, do you have 
the money positioned properly to rectify this situation?
    Secretary McDonough. We do.
    Senator Blackburn. Okay. And when you look at claims that 
are there, I think VBA's claim backlog right now is just north 
of 188,000.
    Secretary McDonough. Correct.
    Senator Blackburn. So what is the process for speeding up 
that? Because my VSOs talk to me all the time about the length 
of time that it takes to even get a response that the claim is 
in the queue.
    Secretary McDonough. Yes, so I want to just give you an 
example, and I will come back to that question. On VHA, if you 
are on-boarding as a nurse, you still in VA, I am told, have to 
write an essay about being a nurse at VA. I think that is 
antiquated and we should get rid of that. So that is the 
degree, that is the level at which we are operating and getting 
to the bottom of this on-boarding.
    Senator Blackburn. Okay.
    Secretary McDonough. On claims, we are, as you say, just 
under 190,000. We were at 265,000 a couple months ago. We are 
bringing that down because of overtime, because of hiring, and 
because of----
    Senator Blackburn. And returning people to work?
    Secretary McDonough. Yes, well, our people, to their great 
good credit, I have to say, productivity in VBA in the context 
of the pandemic increased.
    Senator Blackburn. Okay.
    Secretary McDonough. It actually did not decrease; it 
increased. And so as we think about questions about do people 
come back into the office or do they work virtually, we are 
taking that into consideration. We are just about done with all 
of our negotiating on that, so we will come up with kind of a 
full report.
    Senator Blackburn. Okay. I have got one other thing.
    Secretary McDonough. Sure.
    Senator Blackburn. I understand that the White House is 
considering appointing Brenda Sue Fulton as the VA Assistant 
Secretary----
    Secretary McDonough. Yes.
    Senator Blackburn [continuing]. For Public and 
Intergovernmental Affairs. They are doing this because they 
could not get her into a Senate-confirmed position. And for 
your awareness, in the past Ms. Fulton has tweeted, and I am 
quoting the tweet: ``Let us be real. When one of our two 
national political parties is unable to call out racism, our 
system is broken. It is not a political statement to say the 
GOP is racist. It is a moral statement and one backed up by an 
increasing mountain of evidence.''
    And she was quoted in the Windy City Times with this quote: 
``The U.S. has a powerful right-wing, anti-gay, anti-abortion 
lobby that purports to represent Christians. These radicals--I 
cannot bring myself to call them Christians since their 
language and actions hold no resemblance to the Jesus I know 
from the Bible.''
    Now, she is not qualified to serve our Nation's veterans 
and to serve as a member of your staff, and I hope that you 
will resist the push to put her in as the Assistant Secretary.
    Thank you. I yield back.
    Secretary McDonough. Senator, I just want to--I do not know 
Sue Fulton well, but what I know of her--I was not aware of 
those quotes, but I have no reason to rebut them if you found 
them. I am not trying to question their veracity. Sue Fulton is 
a United States Army officer who served with--you know, 
honorably, a West Point graduate, and a committed public 
servant. And so, you know, I would not write similar things, 
but I can commend to you that the Sue Fulton that I have come 
to know has served the country well, and I think she would be a 
credit to the VA team.
    Again, I am just learning these things that you have just 
read.
    Senator Blackburn. [Off microphone--inaudible.]
    Secretary McDonough. Okay. Thank you.
    Senator Moran. Senator Blackburn, thank you.
    Senator Hassan?

                  SENATOR MARGARET WOOD HASSAN

    Senator Hassan. Thank you, Senator Moran. I want to thank 
you and the Chairman for having this opportunity with the 
Secretary.
    Secretary McDonough, it is really good to see you.
    Secretary McDonough. Thank you.
    Senator Hassan. Thank you again for coming to the New 
Hampshire Memorial Day ceremony at the veterans' cemetery. Your 
participation really was appreciated by Granite Staters, by our 
veterans, and the veterans service organizations who got to 
meet with you afterwards.
    Secretary McDonough. I was thrilled to be there.
    Senator Hassan. It was a great visit, so thank you.
    As you know and as I am sure you were reminded of during 
your visit, New Hampshire is one of three States, along with 
Alaska and Hawaii, that does not have a full service VA 
hospital.
    Secretary McDonough. Yes.
    Senator Hassan. Something I have long sought to change. My 
colleagues and I have consistently pushed the VA to 
appropriately prioritize infrastructure and maintenance 
projects in its annual budget to ensure that all veterans have 
access to the care that they need. However, it is important 
that the VA recognize the undue burden placed on veterans who 
live in States without a full-service VA hospital like New 
Hampshire.
    Mr. Secretary, you have previously testified that the VA 
considers the fact that some States lack a full-service 
hospital when you are planning the budget.
    Secretary McDonough. Right.
    Senator Hassan. Can you provide more information about 
that? How did the VA actually consider the lack of a full-
service hospital when developing the allocations for this 
year's budget proposal?
    Secretary McDonough. Yes, it is a fair question, and what I 
would like to do is take that one, Senator, and come back to 
you in writing on it or come see you and talk you through on 
it, because I think I have enough of an answer to be not 
particularly informative.
    Senator Hassan. Okay.
    Secretary McDonough. So if I might take that one and come 
talk to you.
    Senator Hassan. That would be good to follow up on because 
I think that is the kind of tangible examples we are trying to 
find and follow up on.
    Secretary McDonough. Yes.
    Senator Hassan. Let me ask you another question. You and I 
previously discussed the importance of the VA's Solid Start 
program----
    Secretary McDonough. Yes.
    Senator Hassan [continuing]. Which is an initiative begun 
under the prior administration to contact newly separated 
veterans to help them access the resources and programs that 
they need and they have earned. My bipartisan bill with 
Senators Cramer and Cassidy, the Solid Start Act, would 
strengthen and make permanent this essential VA program, and I 
hope we can get the bill signed into law in the coming months.
    The VA's second annual report on the Solid Start program 
came out just a few weeks ago. The report shows that those who 
have successful Solid Start interactions are more likely to 
take advantage of the benefits and services that they have 
earned due to their military service. However, that same report 
showed that the VA was only able to reach 41 percent of the 
youngest veterans, age 18 to 22, compared to more than 80 
percent of veterans in the higher age brackets. Younger 
veterans can benefit from many of the VA's programs, including 
for education and health care, but they may not be aware of 
these programs or be thinking about the long-term importance of 
these services.
    So as the VA continues to refine this program and hopefully 
when it becomes permanent under our legislation, how will you 
work to ensure that the VA is more successful in reaching 
younger veterans so that they can better understand and access 
the VA services that they have earned?
    Secretary McDonough. I think that is a good question. I 
agree with you that Solid Start, as you said, which was started 
a couple years ago under the previous administration, is a good 
innovation. We are taking three concrete steps and then we are 
taking a fourth thing which I will lift up.
    First, we are using more targeted emails with younger vets.
    Second, we are trying to use text messaging as a reminder 
for younger vets.
    And third is we are trying to use two-way text messaging to 
schedule our outreaches to vets so they are not just cold 
calls, that, in fact, they arrive at a time of the vet's 
preferred--that the vet prefers.
    So those are the three steps we are using technology--
albeit the first step is email, but more targeted email--that 
is going to be more conducive to younger vets.
    Senator Hassan. Yes.
    Secretary McDonough. The fourth and perhaps more important 
thing, as with so much else we are doing, we have started a 
human-centered design project with the Veterans Experience 
Office to build the Solid Start around younger vets rather than 
just build a program and hope that younger vets come to the 
program. So we will be more than happy to come up and talk to 
you and your fellow cosponsors about that if that would be 
useful to you. But as with so much else that we have done over 
the course of the last, you know, 8 or 10 years, we are trying 
to build programs in a way that respond to veterans' lives 
rather than just building a program and then making them change 
their life to come to us. That is the whole idea behind this 
VEO project.
    Senator Hassan. Well, thank you for that. And because I am 
almost out of time, I am not going to go into my last question 
in full. I know Senator Tester talked to you about the 
caregivers program.
    Secretary McDonough. Yes.
    Senator Hassan. Obviously, a great concern to a lot of my 
constituents who have relied on caregivers, and why don't I 
submit to you for the record just the steps involved in your 
team's reassessment of the eligibility criteria for the 
caregivers program and where we are right now and kind of 
follow through with that. I am hearing a great deal of concern. 
I also know how important and successful the program has been.
    Secretary McDonough. Yes, I am hearing the same concern 
where I have talked, I think, to almost every member of the 
Committee on this question because you are all hearing that 
concern. We have put a stop to reassessments. Nobody will be 
moved out of the program. And as importantly, we are talking to 
VSOs, many of them here today, and directly with caregivers and 
veterans about how to improve the program.
    Senator Hassan. Okay.
    Secretary McDonough. The bottom line is it has not lived up 
to expectations in many ways, so we are going to work that.
    Senator Hassan. Okay.
    Secretary McDonough. And you have my commitment to do that.
    Senator Hassan. All right. I appreciate that very much. 
Thank you, Mr. Chair.
    Senator Moran. Senator Tillis.

                      SENATOR THOM TILLIS

    Senator Tillis. Thank you, Mr. Chairman. And thank you, 
Secretary, for being here.
    Secretary McDonough. Thanks, Senator.
    Senator Tillis. I especially appreciate you bringing your 
daughter, who is a proud Davidson Wildcat, going to school only 
about 10 minutes from where I live.
    I also want to thank Chairman Tester, Ranking Member Moran, 
and all the Committee's professional staff members for their 
tireless work to get to the point where you are on the PACT 
Act. I started working on toxic substances issues when I first 
came to the Senate with the Ensminger Act and a number of other 
things that I feel like we were woefully behind.
    I support the vast majority of what is in the PACT Act. In 
fact, some of the work that my team did and other members on 
the TEAM Act are embedded in there, and, of course, the Camp 
LeJeune toxics language is in the bill, too. But I am still 
concerned with the operational impact. It is more of a scale. 
Secretary McDonough, you and I have met many times--I want to 
continue to thank you for your accessibility--and talked a 
little bit about my background in terms of operational 
implementations. And I know in response to Ranking Member 
Moran, you said that you certified that the PACT Act could be 
implemented.
    Secretary McDonough. Yes.
    Senator Tillis. And it could be implemented within 
acceptable margins for performance, I assume. I do not think 
you said that, but I assume that.
    Secretary McDonough. You say it better than I did.
    Senator Tillis. I am trying to get my head around, if I 
were working with a company--and I have worked with companies 
in the past--and they said we are about to have a 10- or 15-
fold increase in demand--in this case, claims backlog--over a 
brief period of time, what gives you a level of confidence to 
say that you can certify it and have it achieve acceptable 
levels of performance? I am worried about the estimates. It is 
an estimated 220,000 claims backlog today. I have heard 
estimates on the benefits side and the health care side, I 
think about 75 percent of the population may not be receiving 
medical care today; the other 75 percent are either through the 
VA or other options. But just the sheer magnitude with all the 
work that you are doing, with the implementation of the 
electronic medical record, the transformation that you are 
going through, how can the VA absorb this level of change with 
the high degree of success in the time frames outlined in the 
PACT Act?
    Secretary McDonough. Yeah, I think it is a fair question, 
and so we have been thinking about this and talking to a great 
number of people across the board on this, and I have been 
using some of the language that I learned from you, including 
there is somebody sitting very near me who is going to be the 
one throat to choke on overseeing this.
    So let us take a step back. Let us just talk about claims 
for a minute. Last year, we got a hundred--1.65 million claims, 
roughly, right? This year, we think we will get 1.75 million 
claims.
    Senator Tillis. And would you consider that a run rate--we 
are talking about--so that is current run rate, current 
benefits.
    Secretary McDonough. Current run rate, the number this year 
includes the rare respiratory cancers, the three presumptives 
that we got in there, Blue Water Navy, but to be honest, we are 
probably a good 10 to 12 months ahead of the timeline that we 
have given you on Blue Water Navy, for example, and then the 
three additional presumptives that you all put in the Defense 
Authorization Act at the end of 2020. So we began servicing 
those claims in early 2021.
    So, yes, that is run rate, but that is a run rate that came 
up--that is three, six, 15 additional claims. Now, those are of 
different levels of rarity, and some are Vietnam level claims 
and some are post-9/11 claims. But that will give you a sense--
so 175 is current run rate, but that was not the run rate a 
year ago, as we just said, and it sure was not the run rate two 
years ago.
    So what have we done in the meantime? We have hired 
basically 2,000 people, and of those, we have, I think, 94 
percent of the claims professionals in chairs right now, 
meaning they are getting trained. Now, as you know, the problem 
with training is both somebody who just gets hired is not fully 
productive, but somebody else who is fully productive is 
training that guy. So he is off the line and the new guy is not 
yet on it. So we are going to get those 2,000 up to speed. So, 
that is step one.
    Step two is what can we take out of this process that is 
superfluous, right? So we are looking at this significantly. 
Right? I do not know how much is there. There is not as much 
there as there was 10 years ago, but I refuse to believe that 
there is zero.
    The third thing, we have been digitizing records, well, for 
the last 10 years, but intensively for the last two years. We 
are now in a position using AI to automate claims. By the end 
of this year, we will have the 12 most frequent claims 
automatable, right? How much reduction is that going to get us? 
I am not in a position yet to know, but I will know in the 
next, you know, month to six weeks.
    Lastly, since these claims are, you know, we basically 
think a million and a half, so you go from a million and a half 
claims over the next two years, so you go from a million seven 
five this year to, you know, an incremental--you know, almost a 
100-percent increase. That is going to be--it looked pretty 
lumpy. So do we need to entirely hire up for that, or can we 
both hire up and contract out?
    So those are the four steps. Those are the four steps that 
I think you would sit down with any CEO and say these are the 
things that can move this. I will be in a position, as I say, 
in the next couple of months to come sit with you guys and say 
this is where I think the savings are, this is where I think we 
can get, because, you know, each claim is going to probably 
have multi-pieces to it. These are the things that we can move 
more quickly; these are going to be the things that are going 
to take longer. And I think with that kind of precision, when 
you have 420,000 people, the guys working the claims are not 
the guys working the EHRM, right? And so the challenge for us 
is to be transparent about it, to be clear about what people 
should expect of it, establish goals, and then hold ourselves 
to those and hold ourselves accountable to you. And that is 
what we will do.
    Senator Tillis. Thank you. I am also going to submit some 
questions for the record.
    Senator Tillis. Thank you for being here today.
    Secretary McDonough. Yes, thank you.
    Senator Moran. Senator Sullivan, finally.

                      SENATOR DAN SULLIVAN

    Senator Sullivan. Thank you, Mr. Chairman. And, Mr. 
Secretary, good to see you.
    Secretary McDonough. Nice to see you.
    Senator Sullivan. By the way, to Senator Blackburn's 
statement on Ms. Fulton, you might want to look at the tweets, 
derogatory tweets she made about women Marines. I am not sure 
you want someone serving veterans who has put out some, you 
know, not so pleasant stuff about women serving in the Marine 
Corps, but that is a whole other topic.
    I think Senator----
    Secretary McDonough. As a general matter, I am not for 
picking on Marines one way or the other.
    Senator Sullivan. Well, you better watch out if you are 
picking on Marines, but Senator Tillis--but I do not want to 
make light of that.
    Secretary McDonough. No, I do not----
    Senator Sullivan. I do not think she is qualified at all, a 
Senate confirmation for being really problematic, and----
    Secretary McDonough. I know I am talking to a Marine, so 
that is why----
    Senator Sullivan [continuing]. You need to take a hard 
look. Seriously, you need to take a hard look. I agree with 
Senator Blackburn 100 percent.
    Senator Tillis' line of questioning I think was really 
important. A number of us have been working on toxic exposure 
with you in a bipartisan way.
    Secretary McDonough. Yes.
    Senator Sullivan. I know Senator Moran has been working on 
this really hard. I sure hope the Majority Leader and Senator 
Tester can keep their commitment to us to make this a 
bipartisan bill. But I will be a little bit more blunt because 
I do not have, you know, the consulting background and 
expertise that Senator Tillis has. Here is my concern: We all 
want to help these veterans. I have been focused on this issue, 
like him, for years. But I am worried that the eligibility and 
the ramp-up--my understanding is 2.5 million veterans will have 
eligibility---will be so dramatic that the system itself risks 
collapsing or delaying so much that veterans currently in the 
system--say a Marine who got his legs blown off in Afghanistan, 
right?--that all of a sudden the ability to care for that 
person gets delayed.
    Secretary McDonough. Yes.
    Senator Sullivan. So there are some huge issues here.
    Secretary McDonough. I agree.
    Senator Sullivan. Can you commit to us to say, no, I have 
looked at the PACT Act, the 23 presumptives--by the way, how 
many of those are based on science that the VA supported, the 
23 presumptives in the bill?
    Secretary McDonough. I have to refresh my memory on which 
were in the House, which were in the Senate. As you know, like 
you, since I got in this job, I have been moving presumptives 
as quickly as we can.
    Senator Sullivan. I know you have.
    Secretary McDonough. We have done now 12, and so some of 
those are included, at least some that were in the House and 
some in the Senate. And so----
    Senator Sullivan. Maybe you can get back to me on that. But 
can you assure this Committee that what we are all trying to 
make sure does not happen will not happen.
    Secretary McDonough. Yes.
    Senator Sullivan. And 2.5 million people being eligible, 
the numbers--and what can we do to prepare for that.
    Secretary McDonough. Yes, look, I--yes, you have my 
commitment on that, right? That is point one.
    But I have been thinking a lot about this, as you might 
suspect, as you have, too, and I guess I am also sitting here 
and asking myself the question: If these veterans are suffering 
from conditions that were incurred because of their service, 
because it happened at a different time than another veteran, 
and because it is going to be hard on VA and us and our people 
is not a good enough reason, in my view, to wait to get this 
person taken care of. And I am not saying that is what you are 
arguing, but I do think that----
    Senator Sullivan. I am not arguing----
    Secretary McDonough. Yes, I know you are not arguing that. 
But my point is if we are in a position now to get millions 
more claims--right?--is it 2 million new veterans, 3 million 
new veterans, 4 million new veterans? We are going to get 
detail on that. And is it one claim per or is it three? 
Generally, we see one veteran makes a new claim every three 
years. So the numbers matter, as Senator Tillis is asking; the 
sequencing matters. We are digging into all of that.
    Senator Sullivan. I am just worried about the due diligence 
on this in a whole host of areas that the macro impact--I have 
seen the VA make decisions that have collapsed the system in my 
State.
    Secretary McDonough. Yes, you and I have talked about that.
    Senator Sullivan. And that hurts everybody.
    Secretary McDonough. Yes.
    Senator Sullivan. Everybody, and I worry about that right 
now.
    Secretary McDonough. If I can assure you that I worry 
enough about this for both of us, I would do that. But, you 
know----
    Senator Sullivan. Let me turn to my State because we have 
still got to get you up to Alaska. We have had----
    Secretary McDonough. I tried.
    Senator Sullivan. Well, we are not done yet. The Senate was 
in session when you were going to be there, which I did not 
want you to go without me.
    Secretary McDonough. I am teasing. I just do not want 
anybody to think I was waiting for summer or something. I want 
to go in the winter.
    Senator Sullivan. I know you did, and I appreciate that. 
Mr. Chairman, if I may just finish my question?
    We have had an expansion of our VA facilities across a 
number of communities, which we really appreciate. I was 
actually visiting one on the Kenai Peninsula very recently. But 
there has been this issue of the VA budget as it relates to 
Alaska. Senator Hassan mentioned that we are one of three 
States that do not have a full-service VA.
    Secretary McDonough. Right.
    Senator Sullivan. And the smallest within its regional 
network, the VA health care system. So here is my concern: Is 
there a way to get more flexibility in terms of spending to 
hire more people in the VA systems, in the VA facilities that 
we are now building? And related again to the PACT Act, would 
expanded enrollment in the VHA, which we are likely to see, 
impact States like Alaska with a smaller workforce but still a 
very large veteran population per capita? Again, I am worried 
about kind of a confluence of events that could really 
negatively impact----
    Secretary McDonough. Yes.
    Senator Sullivan. I was just home last weekend. We have a 
CBOC in Wasilla that we have lost a doctor. We have had some 
problems now there with wait times. Once again, we are kind of 
falling behind from a spot where we have made a lot of 
improvements, and I am wondering if there is more focus on 
States like mine without full-service VA facilities but big 
populations in the PACT Act coming.
    Secretary McDonough. Yes, so we are looking aggressively at 
time to hire, on-boarding, what we can get out of there, what 
of the improvements that we have made in terms of time to hire 
during the pandemic we can maintain. Importantly, OPM is 
helping us there. And even more importantly, you all in the 
context of the pandemic are giving us additional workforce 
authorities to ensure that we can both--I do not know what 
happened with the doc, but the first thing we need to do is 
retain the docs that we have. And you are giving us new 
authorities to do that. Pay is a big one. And then you are 
giving us enhanced recruiting authorities as well.
    And so, yes, we are thinking very diligently about this and 
planning very diligently about making sure that we have the 
people in the spots and that we have the buildings for the 
increased demand that we anticipate seeing. So each of these 
things are envisioned in the Ranking Member's agreement with 
the Chairman. We feel good about that. There will be execution 
challenges, to be sure, but we are aggressively planning and 
preparing for that.
    Senator Sullivan. Okay. Thank you.
    Thank you, Mr. Chairman.
    Senator Moran. Senator Sullivan, thank you.
    Mr. Secretary, thank you for being with us.
    Secretary McDonough. Thank you.
    Senator Moran. I appreciate your conversation. You can 
imagine that at least one of your answers to my questions means 
I have a lot of follow up to do.
    Secretary McDonough. Yes, you do, and I look forward to it. 
Thank you very much.
    Senator Moran. I will now call the second panel, three 
veterans service organizations who wrote this year's 
Independent Budget. We have said many times that Congress needs 
to take its cues from the veterans, and I am looking forward to 
hearing your thoughts on this year's budget proposal.
    First, I would introduce Roscoe Butler, the Associate 
Legislative Director for the Paralyzed Veterans of America.
    We also have Shane Liermann, the Deputy National 
Legislative Director of Disabled American Veterans.
    And, lastly, we have Patrick Murray, Director of National 
Legislative Service for the Veterans of Foreign Wars.
    They will each provide a part of one joint statement on 
behalf of the Independent Budget. Gentlemen, the floor is all 
yours, although I have got some housekeeping to do. I need to 
go vote in the HELP Committee, and I am trying to figure out if 
there is anybody here who is going to not only hear your 
testimony but conduct the hearing. The answer apparently is 
yes, and I will work my way back here. And, Senator Sullivan, 
given the chance that you might have to ask unlimited 
questions, you may decide that you want to chair this hearing.
    [Pause.]
    Senator Tillis [presiding]. Thank you all for being here. 
Sorry, I have been in and out, because this is also NDAA markup 
week, and I serve on three subcommittees. I have another 
subcommittee that I will have to be going to shortly. But we do 
want to hear your testimony.
    Do you have prepared opening statements?
    Mr. Murray. We do.
    Senator Tillis. We want to move, starting with Mr. Butler--
oh, I am sorry. Mr. Murray.

                            PANEL II

                              ----------                              


                  STATEMENT OF PATRICK MURRAY

    Mr. Murray. Thank you very much, Senator Tillis.
    The Independent Budget, or IB, is a collaboration of DAV, 
PVA, and the VFW that for more than 30 years has provided 
independent, nonpartisan feedback and recommendations on the 
administration's budget.
    We would like to thank this Committee and especially the 
staff. We are on the eve of passing one of the largest veterans 
benefits expansions in generations. We are pleased to see that 
VA will direct funds from the Recurring Expenses 
Transformational Fund toward its construction accounts, but 
while this is a good step, we believe it only shows the lack of 
a sufficient amount in the original budget request. VA's 
construction budget should be at a minimum 3 percent of its 
overall operating budget just to keep up with the growing 
backlog. But in order to reduce the backlog, in addition to a 
higher budget request, more employees and contractors would be 
needed to oversee the resulting workload.
    Neither VA's Office of Construction and Facilities 
Management, or CFM, nor the individual VA facilities have the 
manpower to plan and oversee VA's infrastructure at the levels 
needed to significantly reduce the construction backlog.
    Traditionally, when the IB testifies before Congress about 
staffing, as we will here in a minute, we discuss the tens of 
thousands of shortages of medical providers. That is an 
incredibly important topic considering the reports about VA's 
staffing often cite the words ``severe shortages'' in critical 
medical fields. However, I would like to use this opportunity 
to discuss the hundreds and thousands of unfilled facility 
management positions. These often overlooked staffing shortages 
could provide immediate remedy for some of VA's infrastructure 
problems.
    CFM has approximately 32 percent vacancies at VA's central 
office and throughout the VA system of facilities. An entity 
that has an even higher vacancy is the seismic program, which 
currently has an 86-percent vacancy rate since being 
established in 2019.
    These positions are critical for VA to eventually eliminate 
the infrastructure backlog, and every effort needs to be made 
to fill these jobs. In a May 2020 report to Congress, VA 
described the challenges of hiring and retaining CFM personnel. 
There needs to be changes to the hiring authorities to make 
these positions more competitive not only with the private 
sector but with other Government agencies.
    Partnerships in VA are incredibly important. Congress must 
eliminate the sunset date on the CHIP-IN program and expand 
enhanced-use lease programs. The CHIP-IN is not an everyday 
solution to VA infrastructure issues, but whenever an 
opportunity arises to accept donated facilities, VA must be 
able to accept any facility at any value if it is in VA's best 
interest.
    The VA Medical Center in Aurora, Colorado, was finally 
completed in 2018 after being delayed over a decade and costing 
millions of dollars over the original cost estimate. Part of 
this reason was the project was finally brought back on track 
with the inclusion of the U.S. Army Corps of Engineers. The 
Independent Budget believes VA should partner with the Army 
Corps whenever possible to help reduce the construction 
backlog.
    Senator Tillis, thank you for the opportunity to discuss 
these topics. I would now like for Mr. Butler to discuss some 
of our thoughts on health care.

    [The joint statement of Messrs. Murray, Butler, and 
Liermann appear on page 57 of the Appendix.]

                   STATEMENT OF ROSCOE BUTLER

    Mr. Butler. Thank you.
    Overall, the IBVSOs believe the Administration's VA budget 
request for fiscal year 2023 is a very strong proposal that 
would provide comprehensive and justified increases across most 
of the discretionary appropriation accounts. The 
Administration's total medical care funding request of 
approximately $122 billion is relatively close to the IB 
estimate.
    Although the IB's and Administration's recommendations for 
fiscal year 2023 are much closer than they have been in recent 
years, we continue to differ on the appropriations for VA 
health care. Our recommendation reflects multiple components, 
including the current service estimate, the increase in patient 
workload, and additional medical care program costs. It 
reflects increases based on uncontrollable inflation and a 
projected Federal pay raise for all VA employees in fiscal year 
2023. The IBVSOs estimated a 4 percent increase in VA health 
care utilization due to deferred demand, increase sickness, and 
morbidity for COVID. Our estimate of growth in patient workload 
is based on a projected increase of approximately 81,000 new 
unique patients.
    The IBVSOs differ with the Administration in terms of 
funding for suicide prevention. The Administration says its 
plan to reduce spending in this area by $101 million, which is 
largely driven by the completion of the requirements of the 
2019 Executive Order establishing PREVENTS. We believe the move 
to reduce funding in this area is premature and could undermine 
the recent progress achieved in combating this complex problem. 
Our recommendation includes sufficient funding to hire 
approximately 450 new FTEs to support the new 988 National 
Suicide Prevention Lifeline and increases in staffing and 
resources so the vets in the program can expand their fleet of 
aging Mobile Vet Center Vans.
    Lastly, VA has underprioritized the long-term services and 
support programs for years. This cannot continue, as the number 
of veterans in the oldest age cohorts are increasing 
significantly. VA's Geriatric and Extended Care Strategic FY 
2020 to FY 2024 Plan projects expenditures for long-term care 
will double by 2037. To keep up with the demand for long-term 
services and supports, the IBVSOs are recommending an increase 
of $375 million for VHA's Institutional Care and Home and 
Community Based Programs.
    Thank you, Senator Tillis, and I will be available to 
answer any questions you may have.

                  STATEMENT OF SHANE LIERMANN

    Mr. Liermann. Senator Tillis, on behalf of the Independent 
Budget VSOs, we are pleased with the Administration's budget 
request for the general operating expenses, specifically the 
Veterans Benefits Administration (VBA) and Board of Veterans' 
Appeals (BVA).
    Earlier this year, the IBVSOs recommend additional FTE and 
$100 million for overtime, primarily to help VBA make progress 
on reducing the backlog of disability claims. Additionally, we 
requested these resources to prepare VBA for an influx of 
claims related to VA adding new presumption diseases, now 12, 
and in anticipation of Congress passing toxic exposure 
legislation, the PACT Act, hopefully very soon.
    VA's budget request would provide funding to add 795 new 
FTE, which will aid in processing claims for new respiratory 
conditions associated with toxic exposures and it will provide 
for claims modernization and automation, as well.
    This funding will also be instrumental in helping to drive 
down the current backlog of pending claims.
    For the Board of Veterans' Appeals, the IBVSOs recommend an 
additional 15 Veterans Law Judges, or VLJs, and an additional 
100 FTE to assist in reducing the backlog of hearings that are 
currently pending within the Board.
    VA's budget request for the Board of $285 million is a 25 
percent increase over fiscal year 2022. This would provide the 
Board with 256 new FTE, including 12 additional Veterans Law 
Judges, 151 decision writing attorneys, and 93 appellate 
support and administrative staff. We believe these funding 
levels will assist in addressing the legacy and AMA appeals 
while also putting the Board in a position to prepare for the 
potential influx of appeals due to the court decision of 
Beaudette v. McDonough.
    While there are a few minor differences, VA's budget 
request for VBA and the Board of Veterans' Appeals is very much 
in alignment with the Independent Budget's recommendations.
    Senator Tillis, overall the proposed budget for the general 
operating expenses is a 13 percent increase over fiscal year 
2022 and the IBVSOs are pleased with this strong budget 
proposal from VA.
    This concludes our testimony and we would be pleased to 
answer any questions you, Senator Tillis, may have.
    Senator Tillis. Well, thank you all.
    I want to start by thanking you for your past service and 
your continued service to our country and to veterans.
    As you were going through your testimony, Mr. Murray, I was 
trying to tally things. I did not get the numbers, but you were 
talking about additional positions that you feel like the 
budget request fell short on. What was that number again?
    Mr. Murray. For which position? We talked about
    Senator Tillis. Roughly, what order of magnitude for all of 
them?
    Mr. Murray. I believe it was 30 or 32 percent for CFM 
positions across VA. The Secretary mentioned, they can only do 
so much workload. They only have so many people. We want them 
to increase--not only fill the positions they have, increase 
that amount so we can give them more workload to knock down the 
budget.
    Senator Tillis. Mr. Butler, on suicide prevention, I think 
you mentioned about 450 FTEs. Incidentally, I am sympathetic 
with your position. I do not think we need to take a step back. 
But I think it was 450 FTEs?
    Mr. Butler. Yes, sir.
    Senator Tillis. The reason I ask that question again, there 
are so many things I am learning in the U.S. Senate. But one 
thing I did relatively well when I had a day job was 
organizational transformation. And I have heard, in your 
testimony, hundreds of positions that need to be filled to 
fulfill current promises.
    The budget request has another 795 FTEs to process claims 
for the current run rate, not the future run rate for the PACT 
Act.
    Mr. Murray, I heard you loud and clear. I think the PACT 
Act has tremendous policy in it. But I am very worried--I 
actually was on a train between Dirksen and the Capitol and I 
ran into some folks who were from VFW visiting members on the 
Hill. I think you were on that train.
    Mr. Murray. You ran into me.
    Senator Tillis. Yes. And I remember saying that my concern 
has more to do with us getting this right. And I believe you 
said it may be a long line, but at least it is one that they 
will be able to stand in.
    I think at the end of the day though, we have to get this 
right. I hope that through agreement we can consider amendments 
that we can convince you all would be positive and make it more 
likely that we can actually implement the policy, which we all 
agree with.
    But I do have to continue. I am looking at one amendment, 
for example, I am cosponsoring is Senator Blackburn's amendment 
on community care as a safety valve. Are you familiar with that 
amendment?
    Mr. Murray. A little, yes.
    Senator Tillis. It would be interesting, I will not stake 
you out here, but it would be interesting as we are talking 
about some possible amendments, and if we keep the agreement 
that there will be two Republican amendments, I think it would 
be very helpful for you all, for your respective organizations, 
to take a position on it. Because I do think it is a safety 
valve in community care for the roughly 25 percent of veterans 
that we think are not receiving some care for the illness that 
when the PACT Act is passed will be a presumptive condition 
where they are entitled to care.
    So it would be helpful to look at that. I think Senator 
Lee's amendment on science-driven presumptions are also ones 
that I would hope that you all would look at.
    In terms of your opening statements, the resourcing for 
current commitments and programs, I tend to agree with. I think 
PREVENTS is one that I am particularly concerned with. But I am 
concerned with the implementation of this program.
    After we got off the train, I got to thinking, I hope we 
are having a good discussion two years from now. When the zone 
gets flooded and the hundreds or thousands of people that may 
be necessary, either within the VA or within the community, to 
actually fulfill a promise we are going to make. And what we 
have to do along the way is not break promises that we have 
already made.
    This is a new promise. It is an important one. But all of 
our former promises are every bit as important.
    Mr. Murray. So Senator, I agree with you. However, I would 
say that I believe we are in this position because we are 
already breaking our promise to the men and women who served 
our country. Honoring the PACT Act is fulfilling that promise.
    To your point about workload and capacity, I understand 
that this could result in 1.5 million claims, as has been said 
before. But it is not all at once. It is a phased-in approach. 
And the work done by the House and by the folks in the Senate 
here to mitigate that, is meant to make sure that we are not 
going to flood the system.
    Part of the PACT Act has those workforce provisions so that 
we cannot only take care of the people that we will be adding 
to the system, but the current personnel, as well. So we do 
believe this is incredibly important.
    To your amendment about community care. Community care is 
VA care. Community care is a needed supplement to VA care. 
However, I believe the language of that amendment is maybe a 
little bit too prescriptive in that it would allow every 
veteran who is exposed to toxic--it would push every veteran 
who is exposed to toxic substance into community care. So while 
I understand the intent, to make sure that veterans get the 
care they need, I believe it would then push every single 
person to the community.
    As we have seen what happened with COVID-19, the community 
was the one that was facing the breaking point. VA was actually 
the health system in America that stood up, took those punches, 
and not only withstood and provided care to veterans, actually 
helped out in the communities in which they are in.
    Senator Tillis. I think that is a fair point. I guess we 
will talk with Senator Blackburn's staff. I do not think it is 
a complete--I mean, if you just assume, for the sake of 
simplification, that the 25 percent are not receiving care, 
this is not a mandate to send them all into community care. 
There has to be some balancing. And that difference, you know, 
my State has very different capacity from many other States in 
the Nation. So I think that that is a fair point.
    Mr. Murray. And again, well intentioned but we believe the 
language maybe needs to be looked at a little closer. That is 
all.
    Senator Tillis. I think, you know things are moving fairly 
quickly. So I think that the other proposals, the amendment 
could get in there and that we could vote on in the coming days 
or the next week or so, I think it would be helpful for you all 
to weigh in so that we have your opinion.
    Mr. Murray. Gladly.
    Senator Tillis. Again, it is not about--and I think you are 
right. I mean, if they have a service-connected illness, we 
have an obligation to support our veterans. I support that. I 
have since I have been here. I just want to make sure we get 
this right and I do not want to see you all on a panel 18 or 24 
months from now saying we got it wrong. So it takes a lot of 
eyes on it. We are all partners together and we have to own 
jointly, not only Members of Congress but the VSOs, to make it 
work.
    Well, thank you all for your testimony. If I did not have 
two other markups that I had to go to, I would probably pepper 
you for another 20 or 30 minutes.
    Thank you again for your service and I look forward to our 
continued engagement.
    We are going to keep the record open for five days.
    The Committee is adjourned.
    [Whereupon, at 4:36 p.m., the Committee was adjourned.]

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