[Senate Hearing 117-669]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-669

                     THE STATE OF VA SERVICES IN HAWAII

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

                              FIELD HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                               __________

                            OCTOBER 5, 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
52-235 PDF                       WASHINGTON: 2023         
        
        
        
                 SENATE COMMITTEE ON VETERANS' AFFAIRS

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

                              ----------                              

                            October 5, 2022

                                SENATOR

                                                                   Page
Hirono, Hon. Mazie, U.S. Senator from Hawaii.....................     1

                               WITNESSES
                                Panel I

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

                                Panel II

Diane Haar, Hawaii Disability Legal Services, LLLC...............    17

SMSgt Roxanne Bruhn, USAF (Ret.), Veteran........................    19

Col. Ronald P. Han, Jr., USAF (Ret.), Director, State of Hawaii 
  Office of Veterans' Services...................................    22

David J. McIntyre, Jr., President and CEO, TriWest Healthcare 
  Alliance.......................................................    26

                                APPENDIX
                          Prepared Statements

The Honorable Denis R. McDonough, Secretary of Veterans Affairs..    37

Diane Haar, Hawaii Disability Legal Services, LLLC...............    46

SMSgt Roxanne Bruhn, USAF (Ret.), Veteran........................    48

Col. Ronald P. Han, Jr., USAF (Ret.), Director, State of Hawaii 
  Office of Veterans' Services...................................    51

David J. McIntyre, Jr., President and CEO, TriWest Healthcare 
  Alliance.......................................................    58

 
                   THE STATE OF VA SERVICES IN HAWAII

                              ----------                              


                       WEDNESDAY, OCTOBER 5, 2022

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                       Honolulu, HI
    The Committee met, pursuant to notice, at 9:03 a.m., in 
Oahu Veterans Center, 1298 Kukila Street, Honolulu, Hawaii, 
Hon. Mazie Hirono, presiding.

    [Whereupon, the proceedings were called to order after 
which the following occurred:]

            OPENING STATEMENT OF HON. MAZIE HIRONO,

           ACTING CHAIRMAN, U.S. SENATOR FROM HAWAII

    Senator Hirono. Good morning, everybody.
    This field hearing of the Senate Veterans' Affairs 
Committee will now come to order. It would be good if I turn on 
the mic.
    Good morning, everybody. I just gaveled in the hearing. 
It's lovely to see all of you. And, really, I welcome all of 
you but what is really particularly special today is that we 
have the Secretary of the Veterans' Administration; and I would 
say that I don't remember the last time that we had a secretary 
come to Hawaii to listen to our concerns and we're all very 
appreciative that you are here.
    So I am going to begin with my remarks.
    Again, I want to welcome everybody. I want to thank all of 
the witnesses starting with, of course, the Secretary. And I 
also want to thank the Oahu Veterans Center for hosting this 
hearing. The last time we did this was a number of years ago, 
so I'm really glad that we are back here to listen to the 
concerns. And I'll ask all of our veterans who are here, some 
of whom I got to meet, including some of the veterans who were 
exercising in one of the rooms back there and it's--it's one of 
the things that happens here, Mr. Secretary. And they also do 
video exercising, especially during the pandemic. So there are 
a lot of services that are provided.
    I want to let you know that I have had the opportunity to 
work with Mr. Secretary even before he became the Secretary 
when he was working for President Obama, and I can tell you 
that Sec. McDonough is a hands-on, can-do person. And I knew 
this when he was the Chief of Staff for President Obama and 
going forward as Secretary of the VA that I have worked with 
him on issues that really matter to us here.
    And, in fact, earlier this year we passed the Honor Our 
PACT Act. This is historic legislation to expand VA health care 
access to more than 3.5 million veterans who were exposed to 
toxic substances while in the service; and there are about 
100,000 veterans, Mr. Secretary, in Hawaii; 30,000 or so of 
them live off of Oahu and the neighboring islands and you will 
hear some of the particular issues relating to our neighbor 
island vets; and about 12,000 of our veterans are women. So 
the--I want to mention the PACT Act includes former Congressman 
Mark Takai's Atomic Veterans Healthcare Parity Act which made 
veterans who participated in the Enewetak Atoll cleanup and 
were consequently exposed to Agent Orange eligible for VA 
healthcare services.
    I want to acknowledge former Congressman Mark Takai because 
he was such an advocate for veterans and we lost him way too 
soon, but his provision is included in the PACT Act.
    And last year the Johnny Isakson and David P. Roe Veterans 
Healthcare and Benefits Improvements Act was signed into law. 
This law contains the most comprehensive update to VA services 
for women veterans ever. Women veterans are the fastest growing 
group of veterans.
    And later today I look forward to taking you, Mr. 
Secretary, to tour the Windward CBOC in Kaneohe which opened in 
December 2021. I'm also proud for the VA's commitment to expand 
services in Hawaii with the Daniel K. Akaka VA Clinic in 
Kapolei. This clinic will provide important care for veterans 
not only on Oahu but across Hawaii and the entire Pacific 
region. It is totally appropriate that this particular CBOC is 
named for Senator Akaka because as we all know he was such a 
champion for veterans, and this CBOC was first conceived by 
Senator Akaka nearly 20 years ago.
    And I appreciate your partnership, Mr. Secretary, in 
getting it over the finish line. In fact, I called Mr. 
Secretary and I said we are having some issues with the CBOC 
and what can you do to help us; and he just immediately did it. 
So when I say he's a can-do, hands-on person that is really 
very, very true.
    And then most recently while abortion remains legal in 
Hawaii nearly half of all women veterans live in states where 
abortion is not and it's outlawed, and we have about 600,000 
female veterans, maybe 300,000 of them according to testimony 
you provided to the veterans committee a couple of weeks ago in 
DC. About 300,000 of them are of childbearing age. And I 
commend the Secretary very much and the VA for putting forward 
a proposed rule that would enable the VA to provide abortion 
services in the instances of rape, incest, and for the health 
and life of the mother. I personally would like them to go 
further but I'm just really glad that not only did they respond 
to a letter that I led some of my senate colleagues in asking 
the VA to come forward with this proposed rule, that I'm very 
grateful with the very swift response.
    Okay. I just skip around because you know what? I want you 
guys to know that I have had occasion to work with our 
Secretary so I just want to pretty much end by saying that 
while we made great progress in terms of our veterans who have 
been exposed to toxic conditions, while we are paying attention 
to the growing number of female veterans, while we listen to 
the--the veterans who are experiencing homelessness, we just 
got by the way $1.5 million in Hawaii to address the--the issue 
of veteran suicide, there is a lot that we can all do together.
    So I know that the Secretary is going to address a number 
of those concerns and I do want to mention as we talk about the 
suicides that the evidence shows that AP to AAPI, Asian 
American Pacific Islander, group of veterans has a higher 
incidence of suicide. And I brought this up in one of our 
hearings and asked that the Secretary and the VA Administration 
to pay attention, to be focused on this particular cohort group 
of veterans and this $1.5 million that's coming to the State of 
Hawaii will help us do that.
    So for everything that we are all doing together and for 
the Secretary's leadership, I welcome all of you.
    With that, I would like to introduce the Secretary. I have 
a separate introduction just for you.
    Secretary McDonough. Oh, my.
    Senator Hirono. Yes.
    Secretary McDonough. You're very generous.
    Senator Hirono. He has a very long resume, but Mr. 
Secretary was sworn----
    Secretary McDonough. Could we include that in the record?
    Senator Hirono. Well, we should tell people what a great 
person you are. So just a little bit.
    He was sworn in as the 11th Secretary of the VA in February 
2021, and because I sit on the VA Committee I was really glad 
to be among those who voted for him out of our committee and 
then also on the floor.
    As I mentioned, he previously served in the Obama 
administration as the 26th White House Chief of Staff. During 
his confirmation hearings, Secretary McDonough testified to 
this committee that he would work, quote, ``work tirelessly to 
build and restore VA's trust as a premier agency for insuring 
the well-being of America's veterans,'' end quote. Over the 
past two years that is exactly what he has done. I have 
appreciated his partnership in our work on behalf of our 
veterans across Hawaii and throughout our country, and I look 
forward to our continuing collaboration.
    Mr. Secretary, please proceed.

                            PANEL I

                              ----------                              


         STATEMENT OF THE HONORABLE DENIS R. MCDONOUGH,

                 SECRETARY OF VETERANS AFFAIRS

    Secretary McDonough. Senator, thank you so much for the 
invitation to come to this wonderful State and for the 
opportunity to testify about the critical issues so important 
to Hawaii in general, but also the great tradition of service 
that is manifest by Hawaiians.
    I want to also thank you for your steadfast support of 
veterans, for their families, caregivers, and survivors all 
across the country, of course, and especially here in Hawaii.
    Before I get to the topic of today's hearing and 
understanding that Hurricanes Fiona and Ian are literally on 
the other side of the country, I did want to quickly touch on 
them. Our hearts go out to everyone who is impacted by these 
terrible storms and we're doing everything we can to help. 
Before the storms, we worked closely with our Federal and local 
partners to keep veterans safe, including evacuating 152 
veteran patients in Bay Pines, Florida, and transporting them 
to other VA facilities.
    And since the storms we've taken several additional steps: 
One, reaching out directly to veteran patients and VA employees 
to make sure they are safe; Two, we've offered a pause in VA 
debt payments to every veteran impacted by these storms; Three, 
in Puerto Rico all healthcare operations are normal with one 
exception, the Ponce Outpatient Clinic which is partially 
operational because they are transitioning to a new facility; 
Fourth, in Florida all medical centers are fully operational;
    And five, all of our cemeteries in Puerto Rico, Florida, 
and South Carolina are open for visitation and burial services. 
Now, of course, there's still a lot of work to be done as we 
recover from and rebuild after these storms, something 
obviously Hawaii is familiar with. And I assure you that we at 
VA will not rest until vets, their families, and VA employees 
get the support that they need.
    Now back to today's topic. There are an estimated, as you 
just heard from Senator Hirono, 113,000 veterans in Hawaii. And 
our shared mission at VA in Congress and as a nation is to 
serve each of them, every one of them as well as they have 
served our country. We serve vets like the late Senator Inouye 
whose heroism and service in World War II earned him the Medal 
of Honor, and whose service in the Senate resonates loudly to 
this day.
    We serve vets like the late Senator Akaka, also a World War 
II veteran and the first US Senator of native Hawaiian 
ancestry. And we serve vets like native Rodney Navarro, 
Hawaiian native Rodney Navarro whose story I'd like to quickly 
share with you.
    Rodney's a veteran who had a rough time after leaving the 
Navy, struggling with homelessness, justice involvement, and 
mental health issues. Back in 2018, he found himself 
incarcerated at the Maui Community Correctional Center facing a 
dire and direct ultimatum: either remain in jail or receive 
treatment for PTSD and substance abuse. Rodney chose treatment, 
a decision that gave him a much needed second chance in life.
    He excelled in the treatment program, got sober, and then 
began receiving help from VA's Supportive Services for 
Veteran's Families program or SSVF, a program that gave him the 
support he needed to climb out of homelessness and a program 
that Senator Hirono has fought tirelessly to get us additional 
funding for. As a result, Rodney was able to get back on his 
feet and rebuild his life and start to contribute to the 
strength of his community once again in the same way he had 
contributed to the strength of this great country through his 
service in the Navy.
    That right there is an example of how we can together 
deliver for Hawaii veterans. And that's exactly what you do so 
very well in Congress, Senator Hirono, with your strong 
leadership and tireless advocacy. And that's what we at VA 
strive to do every day for Hawaiian veterans and for all 
veterans to serve them as well as they have served us.
    Now, I want to talk quickly about what we're doing to 
fulfill that mission. That means providing veterans with timely 
access to world class healthcare, something that you've been 
very diligent in pushing us to do, deferred benefits in the 
lasting resting places that is their first health care.
    When it comes to providing care to veterans and their 
families, study after study show that veterans in our care at 
VA do better in terms of health outcomes than veterans that 
receive care in the private sector. Veterans' trust scores for 
outpatient care have averaged over 90 percent during the past 
year. We have permanently housed more than 26,000 formerly 
homeless veterans just this year putting us on track to meet 
our goal of housing 38,000 homeless veterans, permanently 
housing 38,000 homeless veterans before the year ends.
    And I'm proud to say that since President Biden took 
office, VA has delivered more care to more veterans than any 
time in our Nation's history. Notably, in 2021 we had a record 
33 million completed community care appointments. Now, we're 
not--we're not where we need to be on timely scheduling of 
those referrals but we're making steady progress and reducing 
wait times.
    And as you've consistently raised with me, Senator, I know 
that this is particularly important for our vets here in Hawaii 
and broadly in the Pacific.
    During Deputy Secretary Remy's Indo-Pacific site visit back 
in August, he met extensively with local staff at VA facilities 
to hear their concerns and assessments about how VA was 
serving--is serving vets in Hawaii and across the Pacific. The 
feedback he received was varied but one of them stood out above 
the rest, and that is that healthcare of all types is in short 
supply throughout the Pacific Islands in Hawaii.
    Senator Hirono. Yes.
    Secretary McDonough. So let me address that for a second 
and I know we'll talk about this at greater length. We are 
looking at ways to extend the use of telemedicine and other 
virtual tools to reach vets here in Hawaii and throughout the 
Pacific. We're working with our Federal partners including at 
the Department of Health and Human Services whose Health 
Resource and Services Administration, HRSA, funds community 
healthcare centers in rural and remote areas.
    We made hiring and retention our top, one of our top 
priorities to make sure that we're both attracting and keeping 
great medical professionals to serve Hawaiian vets. And we're 
continuing to increase our capacity here in Hawaii, including 
as the Senator just said, building the Senator Akaka Outpatient 
Clinic to serve the more than 87,000 veterans on Oahu. So we're 
going to keep working on this and make sure that we're 
delivering world class healthcare to all Hawaii vets, and if I 
don't I know who I'll hear from first.
    Next, we're laser-focused on delivering the benefits that 
veterans have earned and deserved. Right now we're processing 
veterans' claims faster than ever before. In fact, VA processed 
1.7 million veteran claims this past fiscal year shattering the 
previous record which was the year before by 12 percent. And 
we're already--we already have many more claims coming in as a 
result of the PACT Act that Senator Hirono just talked about, 
which Senator Hirono got through the Senate and President Biden 
signed into law in August.
    Thank you, Senator, for the work you did to pass this 
historic law because it's going to help VA deliver care and 
benefits to millions of toxic-exposed veterans and their 
survivors, including so many here in Hawaii.
    So to anyone listening today, I ask that you share these 
three messages with veterans and survivors you know:
    First, we want veterans and survivors to apply for their 
toxic exposure related care and benefits right now. We do not 
want you to wait.
    Second, we will begin processing PACT Act benefits for 
veterans and survivors at the earliest date possible, which is 
January 1st.
    And third, any veteran or survivor can learn more about the 
PACT Act by visiting va.gov/pact. That's va.gov/pact or calling 
1-800-MyVA411, 1-800-MyVA411 because we want every veteran, 
every single one to get the toxic exposure care they need and 
the benefits that they have earned.
    And last but in no way least, we're focused on honoring 
veterans with the lasting resting places they deserve. 
Nationwide we're now providing 94 percent of vets with access 
to burial sites within 75 miles of their homes. We've expanded 
our Veteran Legacy Memorial program which keeps veterans' 
stories alive long after they're gone to approximately 4.5 
million veterans. And I'm proud to say that here in Hawaii 100 
percent of veterans have access to burial benefits because 
every Hawaii veteran has earned a lasting resting place in this 
beautiful State befitting their selfless service.
    So, Senator Hirono, those are just a few of the ways that 
we're working together to serve Hawaii's 113,000 veterans and 
all vets together. I look forward to continuing this work with 
you and your committee to do this important work and to keep 
serving veterans like Rodney Navarro, as well as they have 
served us. So thank you for listening and for your ongoing 
support and for inviting me here. I mentioned to you as I 
arrived that an invitation from Senator Hirono is--to put the 
invitation in air quotes, but it is nevertheless very generous. 
I'm here for two reasons: One, the great tradition of service 
in Hawaii and, two, because of this great advocate on behalf of 
Hawaii and Hawaii veterans, Senator Hirono.
    So thank you so much for having me.
    Senator Hirono. Thank you very much, Mr. Secretary. I'm 
really glad that you talked about the PACT Act and how 
important it is for the veterans who have been exposed to toxic 
substances in Vietnam, for example, and the Middle East. They 
come forward and apply for this coverage because one of the 
issues, Mr. Secretary, in working with veterans is the outreach 
that needs to happen.
    Secretary McDonough. Yes.
    Senator Hirono. And the information that needs to get out 
to the veterans because not every veteran comes to access.
    Secretary McDonough. Right.
    Senator Hirono. They do not all access the system and so 
there are thousands of veterans who should be informed that 
this coverage is now available; and if you know any veterans or 
are there things that you can do through your social media, et 
cetera, to get the word out that they need to apply to get this 
coverage that they should do so. It's one of the challenges as 
I've talked with veterans all across the State just the 
information that needs to be imparted.
    So there is a lot that we can do. I remember when ending 
homelessness among veterans was the number one priority for one 
of our earlier VA secretaries, and it was very--it was very 
challenging and we did not meet that because obviously we're 
still dealing with veteran homelessness.
    Do you want to talk a little bit about what is it that 
you're doing that is decreasing the number of veteran 
homelessness and putting them into permanent housing?
    What are the kind of ways that are working to reduce the 
number permanently?
    Secretary McDonough. Yes. Thank you very much, Senator; and 
I apologize. I just got a note that I was hard to hear so 
apologies for not holding the mic closer.
    It is true that Senator Shinseki, another proud son of 
Hawaii, did make ending veteran homelessness our goal as an 
agency. He succeeded in halving the number of homeless 
veterans, so without setting that big audacious goal he 
wouldn't have gotten there.
    So we intend to continue this aggressive posture with your 
help. The bottom line what we have shown in many communities 
across the country because this is an issue that obviously 
Hawaii is grappling with significantly, but so are communities 
across the country.
    Senator Hirono. Yes.
    Secretary McDonough. And that's just--that's homelessness 
generally, not just--not only veteran homelessness.
    Senator Hirono. And especially, Mr. Secretary, in a place 
like Hawaii where the cost of housing is very, very high and it 
makes the challenge of housing homeless population, veterans or 
otherwise, or in fact----
    Secretary McDonough. Exactly.
    Senator Hirono [continuing]. Families really, really 
challenging. So I hope that there are things that we can do 
particularly from Hawaii that's going to meet the needs of our 
homeless. But, please, go on.
    Secretary McDonough. Yes. So--and we can really--we can 
definitely get into the specific programs that I think with 
your help we've been able to really crank up over the course of 
the last couple of years.
    But there's basically two major things that we are doing at 
VA. We are succeeding in bringing in--so we set a goal earlier 
this year to house 38,000, permanently house 38,000 homeless 
veterans this year. We assess that there are about 45,000 
homeless veterans in the country. We are on track to meet that 
goal.
    What we do particularly well at VA is that we aggressively 
identify who the homeless veterans are. In communities across 
the country we have a by-name list of the homeless veterans. We 
are able to identify what the challenges are facing those 
veterans. Oftentimes, you are correct, it is as in Hawaii a 
high cost of housing states or cities where it's a particularly 
difficult challenge. But it's also that veterans have 
particular challenges whether that's substance use disorder, 
untreated mental health challenges and justice involvement, or 
financial challenges. That's why this year--so the first thing 
we're doing is making sure that we know the veterans, we know 
their particular challenges and getting them wraparound 
services, that is to say the full suite of services whether 
that's health care, substance--mental health care, substance 
abuse disorder, or increasingly financial support and legal 
support to get them out of justice involvement such that they 
can address the issue that made them homeless in the first 
place. That's the first and major thing we're doing and we're 
doing it well, although we're not to zero yet.
    The second thing we're doing--and this goes directly to 
your question about high cost cities and states--is we are 
focusing aggressively on prevention of homelessness in the 
first instance. We're in a position to do this because of 
programs that we have like housing loan guarantee through our 
mortgage programs and through our financial services center. I 
happened to be traveling this week with one of our leaders from 
our financial services center where we have an ability to have 
clarity about particular looming financial challenges facing 
veterans, and when we get evidence of those early we can work 
with them to address those challenges before those challenges 
become crisis and then they're on the street.
    So wraparound services recognizing the unique needs of 
homeless veterans in the first instance.
    Second, preventing veterans from becoming homeless. That's 
why going back to that excellent work that Senator Shinseki--or 
sorry, Secretary Shinseki did, General Shinseki did--we believe 
that we can show we've either permanently housed or prevented 
from being homeless a million veterans in the United States.
    Senator Hirono. What I'm hearing you saying in particular, 
Mr. Secretary, is that the key is to know who the homeless 
veteran is and it's not one-size-fits-all. It is really to 
tailor the programs and the support to the particular needs of 
that veteran. I think, you know, while that takes a lot longer 
it can be to the kind of permanent results that you are 
seeking.
    One of the issues that the veterans always raise, 
especially the veterans who live on the neighbor islands, is 
accessibility to healthcare and I brought this up when I think 
we were having a chat a couple of weeks ago about the 
reimbursement of travel because often the--the providers, the 
healthcare providers, are not available on the neighbor 
islands. They have to come to Oahu. And so I think there needs 
to be more clarity as to when the travel expenses can be 
reimbursed from--by the VA.
    Can you tell us a little bit more about how is it that a 
veteran can find out if a healthcare travel need can be 
reimbursed or not?
    Secretary McDonough. Yes. Thank you very much. And in fact, 
you did raise this with me as you often do raise issues of 
access for Hawaiian--Hawaii's veterans.
    Senator Hirono. He can't get away from me.
    Secretary McDonough. Yes. I think they're picking that up.
    Senator Hirono. Thank you.
    Secretary McDonough. So much so that even when you travel 
to the other side of the country I still come, so--so the 
beneficiary travel. There is a threshold issue which is if you 
are 30 percent service-connected and I know our veterans in the 
audience and both watching understand what that means, but if 
you are 30 percent connected--30 percent service-connected, you 
will qualify for beneficiary travel full stop. If you are 
having trouble getting reimbursed for the beneficiary travel 
and you're at 30 percent, make sure that you contact the 
Senator, you contact me directly or you contact the Beneficiary 
Travel Office at the clinic, or you talk to the veteran--the 
patient advocate. I'm not saying that we're perfect. We aren't, 
but we are getting very good at speedy, speedier reimbursement. 
So that's the first thing.
    If you're 30 percent service-connected, you qualify. If you 
qualify, work, and you're still running up against challenges, 
make sure that you reach out to us either through your senator 
or through my office directly or through our teammates here who 
are all sitting right here in the front row here in in-state.
    The website on reimbursement rates and the reimbursement 
program can be found at [email protected]. 
Vatravelpayreimbursement. That's the second thing.
    We should--all that information should--it is there for 
you. If you have feedback on how we can make it more readily 
available to you, please let us know.
    Third, and I know this will be the subject of the second 
panel, and this is a subject you and I have been going back and 
forth on, is we'd love to have it be such that veterans needn't 
travel here for as much travel--for as much care as they do 
need to now. So that goes to our efforts to increase 
telemedicine access, our effort to increase availability of 
localized community care networks and we're working very 
closely with our third party administrator, TriWest, to insure 
that there are robust networks across the islands in the State. 
That's work that's by no means done, but we'll stay on top of 
it and this is a constant, you know, a constant priority for us 
because there's no more important thing for us to do than 
insure timely access to the world class care we have.
    Senator Hirono. Understanding--thank you, Mr. Secretary. 
Understanding that there is a provider scarcity on the neighbor 
islands, so now that it has been clarified and the veterans 
probably know that that if you're 30 percent rated disabled 
that you are able to get reimbursement.
    But does that reimbursement also apply to elective care on 
Oahu, for example, as long as you're 30 percent disabled or is 
there another----
    Secretary McDonough. The beneficiary travel applies to 
travel for care whether that care is provided in the direct 
care system, you know, so like the Weaver Clinic for example, 
or whether it's provided through the community here in Oahu. So 
whether it's elective, you know----
    So, again, provided it's referral made by your primary 
care, you know, physician, wherever you get that care that is 
reimbursable care. You just have to get over that 30 percent 
service connection and then you're in.
    And I'm happy to note I see the admiral in the front row 
here, Admiral Robinson, who's our director here of the Hawaii 
Healthcare System, nodding in agreement so I say that without 
fear of rebuttal later.
    Senator Hirono. I would be curious to know what percentage 
of the veterans of the 112,000 or 117,000 veterans in Hawaii 
meet that initial threshold, so if the Secretary doesn't know 
for the next panel would you let me know so that when I get 
these inquiries that we can be very clear as to who would 
qualify for beneficiary travel reimbursement?
    Secretary McDonough. We'll make sure we get that into the 
record if not answered today for sure.
    Senator Hirono. One of the ongoing issues--and you touched 
upon this, Mr. Secretary--is the need to recruit and retain our 
provider network and including, by the way, the people who are 
in the VA Hospital system and it's been quite the challenge.
    Are you making inroads in recruiting and retaining the 
providers of the network of nurses and physicians and 
specialists within the VA system itself? How are we doing on 
that score?
    Secretary McDonough. Yes, so we have a weekly staff meeting 
to prepare the week ahead and I list our priorities every week, 
and every week and the top three priorities of the department 
are hiring, hiring, and hiring. So this is a major challenge 
for us.
    Let me give you an example. We believe that we need to hire 
45,000 nurses in the next three years. Those are nurses of all 
specialties and all, you know, ranks: registered nurses, nurse 
practitioners, LPNs, assistant nurses, 45,000. July was the 
first month of this calendar year that we hired more nurses 
than we lost through retirements or through leaving to go to 
other--other healthcare systems.
    Senator Hirono. How did that happen? Did you provide more 
benefits, higher salaries?
    Secretary McDonough. Yes. So there's two things. One is 
what we're doing and the second thing is what is happening in 
the community.
    What we are doing is we are using the authority that you 
gave us in what is called the RAISE Act. Senator Hirono, 
Senator Tester, Senator Moran got together and got through the 
House and Senate which gives us additional authority to 
increase pay for nurses specifically. So we're using those 
authorities. Those relate expressly to pay.
    The second thing we're doing is we're using the authorities 
now available to us from the PACT Act which is the new law that 
covers, as we said, toxic exposure. There's a whole part of 
that law that gives us additional authorities to retain and to 
hire medical professionals. Let me give you an example of what 
it allows us to do.
    There's something that's particularly helpful for us here 
in Hawaii called the Three R's: Recruitment, retention, and 
relocation bonuses. For a long time we used to have to go to 
the Office of Personnel Management, OPM, which is a separate 
agency in the government. So you have to first work your way 
through the morass of bureaucracy at the VA then go, like, 
several blocks away and work yourself through a different 
morass of bureaucracy just to get the ability to use this Three 
R's capability. And as we've just said, relocation costs if 
you're coming to Hawaii are high. Retention costs are high. So 
we--you've given us in the PACT Act the ability, for example 
now, of our own accord to just go ahead and use those bonuses.
    The second thing is oftentimes what would happen is a nurse 
would be recruited by saying, hey, we'll give you a signing 
bonus. We received in some places where those bonuses were as 
high, I just heard earlier this week, as $70,000. My mother was 
an emergency room nurse. I told you about my family out front, 
Senator. My mom worked midnights, came home in the morning, 
sent us all to school, got a little bit of sleep then went back 
to work the next night. She had 11 kids doing that. I wish my 
mom had the leverage in the market that nurses have right now. 
So I don't begrudge the nurses that one bit. I think it is 
terrific that nurses are being paid what they should be paid. 
But we were capped in many cases or limited in what we could 
do, including we could say, yes, we'll give you a bonus as 
well, but we've got to wait until the end of the year to pay 
you your bonus. So you stay the year, we'll pay your bonus; but 
if you go across the street you'll get your bonus the day you 
start, so you've given us now the authority to pay that bonus 
out front.
    So those are the things that we're doing using these 
authorities to more quick--to better remunerate nurses. What's 
happening in the community and then one thing we have to fix--
what's happening in the community right now is many nurses I'm 
hearing increasing stories of and it'll be interesting to hear 
if that's the case here in Hawaii, which we'll talk about I'm 
sure in the hearing today, but also in our visit this 
afternoon--is nurses are seeing the beneficial things that 
happen in the--including the better nurse-to-patient ratio, 
better retirement benefits, better work/life balance, and 
they're now having shifted to the attraction during the 
pandemic of other settings are now shifting back to us. So 
we'll see if that continues.
    The third thing is something we have to do a better job of. 
We have to get better at onboarding our personnel. We go find 
someone, we hire her. That person when we hire her is 
conditionally hired based on what is called ``onboarding'', 
which is a series of background checks, paper filling out 
exercises even in some cases writing an essay about why you 
want to be a nurse. I wish that were a joke but it's not. That 
sometimes can take three to four months after you're hired and 
during which time you are not paid. We can't continue to be 
competitive if we continue to conduct our business that way.
    So we do some things well, some things are changing in the 
community, one thing we have to do better on and this is 
squarely on me, we have to hire faster, onboard more quickly, 
so that we get vets providing care--sorry. Nurses providing 
care of vets.
    Senator Hirono. Thank you for that explanation. It tells a 
story of how you have to identify where the roadblocks are and 
then remove those roadblocks. Often, it's really specific such 
as requiring an essay.
    When I got on the VA Committee and one of the things that 
happened was, of course, the whole crisis of the tremendous 
wait times and the fact that it was really difficult to hire 
personnel for the VA because there were so many steps that they 
had to go through; and so we actually had to amend the law to 
authorize VA to more quickly hire people, but it goes to show, 
Mr. Secretary, there is still work to be done.
    And by the way, there is a nursing shortage throughout the 
country. We in Hawaii know that Governor Ige recently issued an 
executive order to enable nurses to come to Hawaii without the 
need for them to be licensed in Hawaii. So there is a huge 
nursing shortage.
    And the other issue that we should note is one thing about 
the pandemic, we knew that a lot of people on the front lines 
were immigrants and a lot of the nurses--a huge percentage of 
nurses in our country are immigrants. We need to fix our 
immigration system. We need to enable more professionals and 
others, especially in some of these needs categories to come to 
our country. Very much impacted by the way during the Trump 
administration, they--the immigration numbers fell dramatically 
so we need comprehensive immigration reform. We need to 
understand that there are--that most of the nurses frankly come 
from the Philippines. They are trained where there are massive 
wait times for them to come to our country. So there are things 
that, you know, that we need to address the huge nursing needs.
    And there's also huge needs for doctors, by the way, so 
then the question that I have is that we--I'm sure that the VA 
system is already working very closely with the John A. Burns 
School of Medicine because one of the ways that we can retain 
medical personnel is to provide them with the opportunity for 
residency in the state system. I'm told that people who do the 
residencies in another state they tend to stay in those places, 
so I hope that we're providing whatever residency opportunities 
that the VA can provide to the John A. Burns people and I--
you're nodding?
    Secretary McDonough. Yes, can I say something about this?
    Senator Hirono. Yes, please.
    Secretary McDonough. In fact, we do, we do. We have 16 
residents from the John A. Burns School. I would like to see us 
grow our residency program for the--for doctors, but we also 
have a big nurse residency program in the country, but it's 
only right now about 1500 nurses. And the same thing, there's 
1500 slots. The same thing is true with nurses as is with 
doctors, which is nurses who conduct their residencies with us 
are more inclined to stay with us. They're sticky.
    Senator Hirono. Yes.
    Secretary McDonough. So we want to see an increase of that. 
We'd like to see an increase of that by about--and I think 
we'll see this in the president's budget request for next year 
by about 5X so we'd like to grow that from 1500 slots a year to 
7500 slots a year because I think the demand is there.
    The second thing that we can do and I say this to the 
aspiring med students and doctors and nurses who are watching 
is we have very aggressive loan repayment, student loan 
repayment programs. These have just gotten even more generous 
thanks to your work in the PACT Act, but we can often see 
through loan repayment and loan forgiveness through your 
service at VA that we're able to help our providers, docs and 
nurses, and their student loan debt in 10 to 15 years as they 
served with us.
    Senator Hirono. I'm glad you covered the student loan 
issue. Mr. Secretary is going to be doing a roundtable with 
some of the students in the University of Hawaii system. You 
mentioned earlier there are about 17,000 veterans in our system 
and so the--can you speak about how the Biden administration's 
recent actions on Federal student loan forgiveness will support 
student veterans in Hawaii and elsewhere? Maybe you can just 
provide a little bit more to that?
    Secretary McDonough. Yes. So we obviously work very closely 
with the Department of Education on our student programming, 
veteran student programming. Much of what I'm going to talk 
about now speaks expressly to the Department of Education 
announcement last month where President Biden has insured that 
working and middle class Americans can get a little bit more 
breathing room in up to $20,000 in debt relief in Pell Grant 
recipients and up to $10,000 to other borrowers.
    While I don't have specific Hawaii data on who will 
benefit, just to put this in perspective, student veterans are 
a part of Hawaii's estimated 111,500 borrowers who are eligible 
for this relief. And about half of those are Pell Grant 
eligible----
    Senator Hirono. Yes.
    Secretary McDonough [continuing]. Meaning half of those, 
about 65,700, would be eligible for the up to $20,000.
    The Student Debt Relief Plan will help borrowers and 
families continue to recover from the pandemic and prepare to 
resume student loan repayments in January 2023. Nearly 90 
percent of relief dollars will go to those earning less than 
$75,000 a year and no relief will go to any individual or 
household in the top five percent of income. So, again, the 
focus is very intently on working families.
    And then it's targeted relief for borrowers with the 
highest economic need. The administration's actions will also 
help narrow the racial wealth gap. Nearly 71 percent of black 
undergraduate borrowers are Pell Grant recipients, 65 percent 
of Latino undergrad borrowers are Pell Grant recipients, and I 
just said half of the borrowers in Hawaii are Pell Grant 
recipients. So it should be and will be weighted toward those 
student veteran borrowers who are, you know, obviously as many 
of us were when we were younger, working to bring down yet not 
making a lot of money and trying to get by.
    Senator Hirono. I know that the student loan forgiveness 
program is very targeted. It's not as though we're just handing 
out money to everybody out there.
    Secretary McDonough. Right.
    Senator Hirono. It's very targeted and when we reduce the 
student loan burden then that inures to the benefit of the 
family, the community, and everyone so it's very targeted. And 
on Pell Grants I have been a champion of Pell Grants and 
knowing full well that they--a huge number of veterans go to 
school on Pell Grants.
    Now one of the things that happens, though, is every 
student who gets onto the Pell Grants need to complete what's 
known as the Free Application for Federal Student Aid called 
FAFSA, and currently generally we know that student veterans 
complete FAFSA at lower rates than other students. Why this is 
the case, I do not know.
    Is there anything that the VA has done to improve the FAFSA 
completion rate for student veterans? Is this an issue that has 
come to your attention?
    Secretary McDonough. I'll be very candid with you, Senator, 
which is that I am familiar with your history on FAFSA, 
including having enacted the FAFSA Simplification Act I think 
which will help, but I will confess to you that before I was 
preparing for this hearing I was not aware of the challenges 
facing veterans. So this is one of the things that I will take 
from my preparation for this hearing--from this hearing itself 
and see if there are things that we can do in the inner agency, 
i.e., with the Department of Education, with our partners, our 
VSOs. I see some of our VSOs represented here today, but also 
factor this into our transition planning for active duty 
military.
    I sat down with a group of Air Force personnel yesterday in 
Dallas and Las Vegas. We talked about the whole question of 
access to healthcare as they transition into veteran status, 
but we'll see if there's a way we can include FAFSA and access 
to student loan and in addition to the GI Bill opportunities we 
have into our transition planning.
    Senator Hirono. We know that veterans in Hawaii but 
elsewhere, everyone, they have childcare costs, they have 
housing costs so I think that this is another area where 
whatever we're providing for veterans' housing, for example, in 
a State like Hawaii, is there recognition that housing costs 
are very high and therefore adjustments are made to providing 
housing support for veterans in a place like Hawaii?
    Secretary McDonough. Yes, so we are in a place like--well, 
in every state we are statutorily tied to the basic allowance 
for housing that is established by DOD. You will have seen an 
announcement from Secretary Austin about two weeks ago in 
recognition of the fact that many of our lines of investment in 
our military personnel need updating, that he has increased 
many of those lines of support so that will directly translate 
to our ability to provide additional housing support through 
some of our programming. But as it stands right now we're 
directly tied to DOD, so this is something that the secretary 
and I have been talking about which is how are we making sure 
that in these--in difficult times, you know, our families have 
access in these high cost states, high cost cities--have access 
to the maximum amount of assistance we can get them.
    We just heard--I just heard from Patty on my team. We 
visited Punchbowl yesterday. She visited Punchbowl yesterday. I 
too often hear about personnel who work for VA, including at 
the National Cemetery Administration. These are people working, 
many of them veterans, overwhelmingly veterans, working full 
time. They are still on Food Stamps. I find that unacceptable, 
so we're looking at a variety of special pay rates, special 
year end bonuses to make sure that they have, A, recognition of 
their excellent work, B, they don't have to find themselves 
struggling to make rent, struggling to pay for food.
    Senator Hirono. I think that a lot of these indicators have 
been set and we need to revisit these kinds of set amounts for 
housing, et cetera, to reflect the realities, current 
realities.
    I mentioned that there is a higher incidence of veteran 
suicide which is a huge concern across the board, but in 
particular the higher incidence of suicides among Asian 
American, Native Hawaiian and Pacific Islander veteran groups. 
And I had raised this with you and I had asked that the VA 
specifically address this cohort of veterans.
    Are there things that you can update us on what the VA is 
doing to address this particular group of veterans?
    Secretary McDonough. Yes, so let me get to the specific 
group of veterans in a second. I just want to call everybody's 
attention to four things:
    One, suicide prevention continues to be our number one 
clinical priority; Two, we released two Mondays ago the annual 
report on suicide prevention, which provides the data for the 
year, the most recent year that we have comprehensive data. We 
get data through the CBC. It usually has a two-year lag, so we 
just published the 2020 data. We saw more than 6,000 veterans 
die by suicide in the year 2020, which is heartbreaking and 
unacceptable, and in fact until there are zero we won't stop 
pushing on this. At the same time there were about 220 fewer 
suicides, deaths by suicide, in 2020 than there had been in 
2019, and in 2019 there had been fewer than there had been in 
2018. So we've now seen the biggest reduction in suicide among 
veterans, death by suicide among veterans since about 2005, 
which gives me some hope that----
    And this is the third point, the things that we're doing 
including investing in comprehensive care, thanks to your 
support for our Office of Mental Health and Suicide Prevention, 
dramatically ramping up access to the Veteran Crisis Line by 
using--by urging veterans to dial 9-8-8, a simple three-
letter--three-number telephone exchange. Just by dialing 9-8-8 
and then pressing 1 veterans or family members in crisis can 
reach care immediately and we can get veterans in crisis into 
care that day.
    So we are making progress including by using also as you 
just said, I think some of the grants that you've--Hawaii's 
been awarded under the Sgt. Fox program where we invest in 
local veteran associations which know veterans best.
    Senator Hirono. Yes.
    Secretary McDonough. That's the third thing.
    Expressly then on AAPI vets, native Hawaiian vets, we are 
working on culturally competent care.
    Senator Hirono. Yes, yes.
    Secretary McDonough. And we're making sure that that 
training is available not only to our providers here in Hawaii, 
but also available to national resources like the Veteran 
Crisis Line, so you have us focused on this. We are making sure 
that we are attacking this through every avenue we can, 
including by making sure that we have access--or trained 
professionals are trained in culturally competent care.
    The last thing I'll say is this: Those veterans watching, 
those family members watching, please visit us at va.gov/reach, 
va.gov/reach, where you'll find a full listing of information 
best, you know, professional laid--professionally laid out, 
professionally tested information to insure that even if you're 
not in crisis today if you find yourself in crisis what you 
will want to have prepared yourself for to include the use of 
gun locks, gun safes, getting some distance between veterans 
and firearms in a time of crisis. So please visit us at va.gov/
reach.
    Senator Hirono. Thank you. The fact that 6,000 veterans as 
you mentioned passed away through suicide in 2020 is--it is 
heartbreaking and I think the kind of very specific identifiers 
that you're talking about for our veterans to prevent suicide 
is the kind of thing you're doing for our homeless veterans, so 
I think that is what's needed.
    I know that we are getting to the end of the one-hour 
period. There are other issues relating to support for veteran-
owned small businesses and we have the Small Business 
Administrator present only a few weeks ago, and she is also 
focused on those needs and anyone here who's interested in 
veteran-owned small businesses and would like to get some 
information on that, we have information there. And then the 
entire area of mental health services for veterans and 
telehealth, that is all areas that I know you're already 
pursuing.
    So, Mr. Secretary, thank you very much for your attention 
and time and your commitment to all of the veterans. I remember 
when I talked with him and he called when he had been nominated 
for this position, and I had not particularly associated Sec. 
McDonough with veterans' issues, but he told me otherwise and 
what he really made clear, though, was that he was very, very 
focused and committed in improving the lives of our veterans 
and I take him at his word and he has been doing just that.
    So thank you very much.
    We are going to take a little bit of a break as we set up 
for the second panel. Thank you.
    Secretary McDonough. Thank you so much.
    Senator Hirono. As we say in Hawaii, mahalo.
    Secretary McDonough. Thank you very much. Mahalo.

    [The prepared statement of Secretary McDonough appears on 
page 37 of the Appendix.]

    [Whereupon, a short recess was had.]

    Senator Hirono. Everyone, I am going to call this hearing 
back into session. We're going to go onto panel two and I would 
like to welcome everyone on the second panel. Before we begin, 
I want to remind each of you on the second panel I know some of 
you wrote pretty extensive testimony and I would appreciate it 
if you could--I know you have a shorter version but, of course, 
your full testimony will be included in the record of this 
hearing.
    I'd like to first introduce Diane Haar of Hawaii Disability 
Legal Services. You can wave here, that's okay. There's Diane.
    Then next we have retired Air Force Senior Master Sergeant 
Roxanne Bruhn? Roxanne, welcome.
    We are also happy to welcome Ronald Han, Director of the 
State of Hawaii's Office of Veterans' Services and a retired 
Air Force colonel.
    You've got to wave to them. Okay, there you go. They need 
to know who you are. I know they already do.
    And our final witness of this panel is Mr. David McIntyre, 
Jr., co-founder, president and CEO of TriWest Healthcare 
Alliance.
    And thank each of you for being with us today. And for 
those of you who have served our country, ``Mahalo nui loa'' 
for that.
    And now we will start with Ms. Haar.

                            PANEL II

                              ----------                              


                    STATEMENT OF DIANE HAAR,

             HAWAII DISABILITY LEGAL SERVICES, LLLC

    Ms. Haar. Thank you, Senator.
    Senator Hirono. Can you help her with the mic?
    Ms. Haar. Thank you, Senator. And thank you for coming home 
and being with us today and bringing this important event to us 
today.
    My name is Diane Haar. I'm a licensed attorney. I practice 
in the State of Hawaii, the Pacific territories, and the 
Philippines. My practice is devoted to representing veterans 
and others with disabilities. I am a VA disability attorney and 
I represent veterans for other types of disability programs, as 
well. I'm happy to report I actually just got someone benefits 
this morning.
    Senator Hirono. Great.
    Ms. Haar. In the course of my practice, one of the things 
that I end up doing is talking to an awful lot of medical 
providers, so we're getting the veterans' medical records and 
they open up to me a lot about the problems they're having with 
billing. And I'd like to thank VA for things that are going 
better; and one of the things that's going better is a few 
years ago we had a lot of veteran medical providers, a lot of 
doctors, mental health providers just drop out and refuse to 
take any more VA patients because they weren't getting paid for 
nine months or a year. It was taking a really long time and 
some of these folks didn't know if they'd ever get paid.
    This has gotten a lot better. Now it takes at most about 60 
days. I don't know if that's every medical provider. I'll say 
over the last couple of weeks I spoke to providers here and on 
our neighbor islands. While they seek me out because they knew 
I was coming here, I wanted to see how things were going out 
there. So I went out and sought them out. And what I actually 
found out is we're still in danger of losing medical providers. 
This is supremely important.
    As you guys know, we have a VA Medical Clinic here in 
Honolulu. We have community-based outpatient clinics on Oahu, 
on our neighbor islands and our territories. We don't have a VA 
medical center. The clinics are relying on others sometimes for 
specialty care. For our neighboring islands, they're relying on 
providers that can give veterans care closer to home. And this 
is really important because honestly some of our veterans are 
pretty poor. You know, they'll be reimbursed by VA but they 
can't afford it in the first place and these referrals make a 
huge difference.
    The problem we're seeing is those who've been treating 
veterans for a while now, those who have been treating veterans 
for two years or more are getting these overpayment notices, 
and what they're getting is notices from VA saying you owe 
$5000, $8000, some other large amount. And as you know, most of 
our medical providers here are pretty small, you know, one-doc 
shops who are doing their own billing.
    VA is sending them these letters telling them if they don't 
pay the money back immediately, the VA will take out of what 
they owe them or what they're supposed to owe them in the 
future from any future veterans they take. And this is a major 
disincentive to keep taking veterans.
    Worse, the providers have let me know it takes an 
inordinate amount of time to try to sort this out. A lot of the 
phone calls they make, it's incredibly hard for them to reach 
someone who can actually discuss the overpayment with them, let 
alone someone who can ferret out what the problem is and help 
them sort it out. And they let me know if they stay on top of 
it, most of these will be resolved in their favor. However, 
like I said, these are one-doc shops, you know, or just a 
couple of docs shops and they're doing their own billing. All 
the time they spend on this is money that they're not paid for. 
It's money that they can't--it's time they can't spend treating 
patients. It's money that they don't have, so it really makes 
them question whether they're going to take more VA patients. 
And I'll say it goes beyond that. I had doctors really reach 
out to me and let me know that they really are really seriously 
considering not taking veterans anymore. They've got one foot 
out the door already because they don't know how to handle 
this.
    And they're telling me it's a double whammy because these 
are fees that were already cut down when they initially 
submitted their request and now they're being asked to pay more 
back and they just can't afford it.
    And I know it's been brought to me by the providers, by 
vets, my husband had to leave but he served for 25 years and is 
now in the VA system, and he is in significant pain. I really 
admire him. He's in significant pain and pain management and he 
goes to these providers regularly, and both of these outside 
providers are telling him the same thing, ``I don't know if I 
can continue to do this. I don't know if I can continue taking 
the time to fight these overpayments.''
    So I wanted to bring this to you today to let you know, we 
are a small State. I work with a lot of homeless, I work with a 
lot of veterans and I know--I have every confidence in you 
because I know you know how important these providers are and 
how important this medical care is. We can't afford to lose 
these folks and we are all so grateful for you allowing me to 
give this testimony today and----
    Senator Hirono. Thank you.
    Ms. Haar [continuing]. For everything you do for us and for 
everything that I know you'll do to help us because it's super 
important that we keep these providers in the loop. I know 
telehealth is on the horizon as well but, you know, as I was on 
big island last week and there are areas that cell phones don't 
reach.
    Senator Hirono. Oh, yes.
    Ms. Haar. And providers--those of us out there, even I do 
it, do home visits. We go see people where they're at. That's 
how we are on Hawaii. So having these providers able to get 
reimbursed, able to pay for their own housing, able to stay off 
Food Stamps, it's huge. So thank you for allowing me to speak.

    [The prepared statement of Ms. Haar appears on page 46 of 
the Appendix.]

    Senator Hirono. Thank you.
    And, Mr. McIntyre, I hope that you will address some of 
these concerns raised by Ms. Haar in terms of reimbursement and 
the issues facing the provider community and that's a group 
that you work with, right? Okay.
    So the next person will be Ms. Bruhn.

               STATEMENT OF SMSGT ROXANNE BRUHN,

                      USAF (RET.), VETERAN

    Ms. Bruhn. Aloha, everyone. My name is Roxanne Bruhn. I am 
a 32-year veteran of the Hawaii National Guard and retired from 
the United States Air Force. I wanted to testify because this 
is my experience with the VA, and I'm only speaking for myself 
but then this may have happened to other female veterans 
primarily.
    I was part of the VA journey after my retirement in 2015. 
One of my first experiences with the VA was that I, you know, 
I'm a 13-year veteran so I'm used to taking orders; you tell me 
you want this, this, and this done and I will do it because I 
am a good airman, I follow instructions. So I took all of my 
legal documents and submitted it to the reception area because 
that's what I was told to do, bring all my records and take it 
to them. I did that.
    Somehow my records got lost.
    Senator Hirono. Oh.
    Ms. Bruhn. To this day they don't know where my records are 
at, so I got a--I got a letter stating that I didn't follow and 
I needed to submit my documents for my PCP to continue to 
reevaluate me. So I went back to the VA and resubmitted my 
documents and I waited there and I was insistent, and I said I 
was not going to leave until these documents are placed in my 
records because it was lost the first time. I got a lot of 
resistance and, you know, people were very unhappy with me 
because I was insistent that I wasn't going to leave until my 
documents were placed in my records. But, you know, one time 
you're burned you're not going to allow that to happen again 
because, you know, this was the start of my journey.
    The next time I went to see the VA, I'm a good airman 
again; my appointment was at 8:30 so I arrived at 8 because if 
you're on time you're late.
    Senator Hirono. Yes.
    Ms. Bruhn. So I'm early. I'm sitting in the waiting area in 
the women's clinic and I check in and I'm waiting. Then these 
two staff members come in. You know, I'm thinking they're going 
to start their work. They come out and they tell me, ``Excuse 
me, ma'am, but you have to leave.''
    And I'm like, ``Why?'' ``Oh, because we're going to a staff 
meeting and you have to vacate the waiting area, you have to 
wait outside in the hallway.''
    And I couldn't understand why would I have to do that when 
the doors are all locked? I'm not going to try to break into 
the area. But I went outside and I waited because they had a 
staff meeting and then they came at a quarter to 9 and my 
appointment was at 8:30, but it's okay as long as I get seen. 
But no other clinic in the VA makes their people leave their 
waiting area if they're going to have a meeting, so why was the 
women's clinic different? Why would they make the women who 
were waiting leave the area so that they could lock it up?
    Already I was starting to have this anxiety because it 
seemed as though every time I would go to the VA for my 
appointment nothing went right. I always--I started to be 
apprehensive and waiting for that other shoe to drop because 
something doesn't go right.
    I was seen by my PCP on several occasions and each time she 
would review my medical record--my medications and say, ``Oh, 
are you still taking this?'' And she would check it off. 
Somehow my prescriptions would be dropped from the system.
    I don't know what she was doing or what she had to do but 
every time I saw her I lost all my prescriptions, so I couldn't 
go for my refills which made it hard for me when it came time 
for my refills that I didn't have any, even though I already 
had like three more--three more prescriptions left. And this 
happened not one time, this happened like three or four times 
and then I would have to--they don't pick up the phone. I 
called and I'd leave a message; I don't get a call back. I 
call, I leave a message, they don't call back. So I ended up 
emailing in a secure message and then two days later I would 
get a email responding to me saying, ``Oh, we'll let your PCP 
know.''
    So already this is now going on two weeks without my 
refill. I'm running low, which is my fault; I should not have 
waited that long but I don't know if everybody is like really 
on top of your medications. You figure you have medications 
that you could just call in and they'd get it mailed to you.
    So it just compounded a situation, a feeling of not being 
treated well. The one thing that threw me over the edge was 
when I went on a--I had an appointment on a Saturday morning 
and I was there early, and I waited for like an hour-and-a-half 
and I kept asking, ``What's going on?'' And no one would tell 
me that my PCP didn't come to work yet. So my appointment was 
at 8:30, but she didn't arrive until after 9 and I--and how I 
knew that is because I saw her running into the clinic and 
there was no apology. But, you know, if you were late, you have 
to reschedule because, you know, you're backing up into someone 
else's appointment. But it's okay for the patient to wait one 
hour. You know, that was unacceptable.
    My PCP referred me to a therapist because I was assaulted 
when I was in the military when I was on active duty and it 
caused--it caused problems that I wasn't aware of. I repressed 
this assault because if you were to tell someone what happened, 
you are female and you're labeled, and then your career can 
take a huge hit if--if this--if this gets out. And so I had 
this repressed anger that I didn't realize that was causing me 
the problems at work where I was--I was always angry. It went 
home where I was having difficulties with my marriage because 
of this repressed anger and, luckily, my PCP, she saw this, she 
referred me to a therapist and I was so happy to see my 
therapist, but they would only allow me a few visits. You were 
only allowed, like, three or four visits and then you--then you 
had to see a regular therapist, but there was no female 
therapist available. So what do I do?
    She then referred me out to the community of care service 
for my therapist and that's who I am continuing to see to this 
day is that therapist.
    But why wasn't there any female therapists? There was only 
males and why was there no female that could help a female 
veteran who suffered an assault while on active duty? You know, 
I didn't feel comfortable talking to another male about what 
happened to me and I felt much--I felt freer to speak to a 
female than to a male, but it was through that--those issues 
that I asked then to be referred out to community of care, 
which is now who helps me, who I see on a regular basis for my 
care is the community of care which I was just being told by my 
doctor that they may stop because they're not getting paid on 
time and that it's not worth their while and that's going to 
really hurt me to have to go back and then have the same type 
of issues follow me, you know, at the VA.
    I really--I'm very, very thankful for the community of care 
ability because that has helped me to overcome the--the mental 
issues that I didn't know I have. You know, you don't know what 
you don't, and I didn't know; but luckily someone saw and 
pointed me in that direction and I'm thankful for the VA for--
my PCP for seeing that I had this anger thing going on, and I 
guess it's--I guess it's because of my anxiety. Every time I 
had to go to the VA my anxiety level comes up because nothing 
goes right. That anger issue came up so it--it--in the final 
result, it worked out. But I can't--but I would be remiss in 
not seeing that the VA has come a long way and I'm very 
thankful for Dr. Robinson and what he's done, what he's doing 
for the VA.
    My husband and I had excellent care when we--during the 
pandemic, we got our COVID shots through the VA when they 
opened up--they opened it up to your--to your caregiver, to 
your spouse, which was very good because if I get COVID--if he 
gets COVID and he gives it to me, what's the sense? So it was 
very helpful that VA allowed the spouse to get the shot as well 
as the veteran, and so I'm very grateful for that. But I really 
feel in my heart that the women's health clinic at the VA needs 
to have a better--a better handle. They need to understand that 
women veterans are not special in the sense where we need 
special care and we need to be coddled, but we have different--
different things that needs to be addressed.
    We need--we need more females. We need them, the 
mammograms, those types of things, I--I cannot stress enough 
that I feel that the women veterans are under-served and that 
more should be done for our women veterans here in Hawaii.
    Thank you very much for allowing me this time, Ma'am.

    [The prepared statement of Ms. Bruhn appears on page 48 of 
the Appendix.]

    Senator Hirono. Thank you, Ms. Bruhn.
    Mr. Han?
    Yes, there are people out there who acknowledge it and 
agree with you. Me, too.
    Go ahead, Mr. Han.

             STATEMENT OF COL. RONALD P. HAN, JR.,

                     USAF (RET.), DIRECTOR,

          STATE OF HAWAII OFFICE OF VETERANS' SERVICES

    Mr. Han. Thank you so much, Senator Hirono. I'm very, very 
thankful to you for all your hard work. You know, our 
congressional delegation with what you do on the Senate at the 
Veterans' Affairs Committee and our Senator Schatz in the 
Krowseman [phonetic] case comes fairly working together and do 
amazing things for our veterans. So thank you so much for your 
legislation efforts.
    And I also want to thank the Secretary for his commitment 
and his dedication. Your presence here today, Sir, speaks 
volumes of how you put your veterans first. I hear that all 
across the entire spectrum from my other state veterans 
directors out there, so thank you, Sir.
    I've been here, this is my second time. Back in 2014, 
Senator Hirono, thank you so much offering me the opportunity 
to testify. I was here with Mr. Dave McIntyre. We sat almost in 
the same positions we are in today and, frankly speaking, the 
VA was as you pointed out--was under duress. It was a 
completely different--that's eight years ago.
    Things have changed quite a bit. We have seen the 
differences. You know, it was all about the institution; how 
did we fit the veteran to the institution? Now it's about the 
veteran's experience, it's about what do you do for veterans? 
It's about how the veterans feel about things, so we have seen 
the changes and so I just wanted to cover very quickly--I know 
I put a lot in my written testimony, but just very briefly, 
State Office of Veterans' Disability Claims. We handle and work 
very closely with the counties and eight State veteran 
cemeteries. We have like ADCOM control, operational controls 
with the counties.
    I also wanted to point out that incredible time. Roxanne 
already put out a lot of things about the pandemic, but we went 
into a telecom mold like many others and so we started 
processing 25 to 30 percent more disability claims than we ever 
had before. We never shut our doors. The State shut down. We 
had a high infection rate across the Nation, but we never shut 
down. What was important about that is we were able to put 
those claims into the VA, and the VA went and they went on 
overtime. A lot of them worked on Saturdays with their staff.
    I also agree with Roxanne about the shots in arms. It 
wasn't just here in Oahu. That's one of the biggest things that 
our veterans talk about, you know. And Senator Hirono already 
brought it out. Let's not just talk about Oahu, let's talk 
about the State as a whole, you know. Everything gets sucked up 
about Oahu, but the neighbor islands deserve just as much 
emphasis and focus as any place else. And they went out there 
and they put shots in arms, vaccines, flu shots, amazing kind 
of things.
    And I love Roxanne's commentary about that because it took 
care of the family members as well. We overlooked that. This 
was a tough time for everyone the last two years and the VA 
really stepped it up.
    I go back to my testimony. I kind of concentrated on three 
different areas. One was on excess, one was on timeliness, and 
the other one was on quality. And so I have seen excess for the 
VA improve in many different directions. Sitting next to Mr. 
McIntyre with TriWest, understanding how we go to civilian 
providers in community, and you already touched upon it 
already. There is a lot of shortfalls with our healthcare 
providers overall. But once the veteran and, Roxanne, you 
mentioned it or Roxanne mentioned it already, once the veteran 
receives an appointment in the healthcare system, they get very 
good support even with the sponsored members that are out 
there. The key is to get in--getting into that queue. Never 
easy to do, but the quality is there.
    Also, I would also make mention that there's been a lot of 
hiring. We've seen that with Dr. Robinson's staff, with John 
Lombardo's staff, also with more services, with Jim Horton's 
staff. So that's a good thing. Telemedicine, telehealth, it 
absolutely was a game changer for us during the pandemic. That 
cannot be over-emphasized and I really believe that, you know, 
we still have some veterans that we're trying to get up to 
speed on things, but we are patient and we want to try to help 
them as best that we can. Some have Wi-Fi capability issues; 
others are in really rural set of areas. They just can't get 
connected, but we will never give up and you pointed that out, 
Secretary. There's not enough we can do for our veterans.
    Also, I want to make mention of the fact that the startup 
of the Daniel K. Akaka CBOC is another important--thank you so 
much, Senator, and thank you so much, Secretary. You do not 
realize how much that's going to help with the programs that we 
have throughout the State, not only throughout the Pacific as 
well.
    And guess what? You're setting up the same kind of programs 
with Dr. Robinson and Craig Oswald's in the room over on Maui 
and over on Kawai. It's a unique concept. It's a one-stop shop. 
And we're proud that the CBOC is going to be there, the vet 
center is going to be there along with the State Office of 
Veterans' Services. A lot of support there. So they don't have 
to go to three or four different locations, have to navigate 
their way through things. It will all be provided to them if 
you want to read them.
    I also want to make mention of another important first 
step. Again, thank you so much, Senator, and your hard work, 
Senator, along with Secretary McDonough. The Daniel K. Akaka 
State Veterans Home. A 120-bed skilled nursing facility long 
term care, 60 percent completed over in Kapolei.
    We had a longstanding shortfall and we're so very proud to 
see this come to fruition. We're looking at our first intakes, 
it should be completed May of '24. So the first intakes 
probably latter part of that year and into calendar year '25. 
It's a much-needed facility. We're one of three States--the 
Yukio Okutsu is our very first State veterans home that has 
adult daycare built into it, and we're going to do the same 
thing for here on Oahu.
    Again, that's opened up to the entire State not just Oahu.
    I also want to make mention of the fact that the programs 
that I've seen where access has really been important, Purple 
Heart and Civil Veterans Equal Access Act of 2018. Sometimes we 
miss--miss that, you know, where our veterans now even with a 
zero disability rating can gain access to the commissaries. It 
may seem something small to people, that's a huge benefit for 
our veterans. It's too bad we don't have enough commissaries on 
the neighbor islands, but we can work on that for the future 
maybe.
    Also, VA Caregivers Support Program. We just started up one 
in October. That's another one that's going to help our family 
members of survivors being able to take care of their veterans. 
Again, a lot of excess issues.
    You already mentioned about the veteran homeless program. 
We have a very robust program here in Hawaii. Like, you 
mentioned, Mr. Secretary, we have a number, it's about 228. 
Most of those are sheltered. There are some unsheltered and 
they have them in the data system, including Partners of Care 
interagency consult. They work very, very jointly across the 
State and I really believe that, yes, one veteran is too many; 
and the only reason why the veteran might be on the street is 
because they don't want to accept the help. We work harder and 
harder and harder every year to get them to accept that help.
    You mentioned about wraparound services. The people here 
are very, very committed and those numbers were a lot different 
back in 2014. So you're absolutely right; we have come a long 
way, Senator.
    Also, some of the other important programs--you mentioned 
about suicide prevention. So we have undertaken, Senator Hirono 
and Secretary McDonough, the Governor's Suicide Challenge. It's 
about time. You know, we have other escape partnerships; 
there's about 35 of them. So what that basically does, it runs 
DOD, State, Federal, county, and private partners together to 
start working on preventive measures programs, Senator, that 
need to be done and that just started in May of 2022.
    So we're taking best practices across the States and 
incorporating them here in Hawaii. So you're going to see a lot 
more information of programs about that. And we can't--we just 
have to keep focusing, you know, because that's everybody's 
responsibility. That's just not just the service providers or 
the folks that work in mental health. That's everybody's 
responsibility.
    I also wanted to make mention of the fact that, you know, 
we also have participation in women's programs. There is a 
State subcommittee on that full time who work very closely with 
your coordinators in the VA. They're embedded in there. They're 
doing a real good job and the minority of LGBQT and war 
veterans are also available services that we also participate 
with. But also the VEO Office, the Veterans' Experience Office.
    Asian-American and native Hawaiian and Pacific Islander, 
Pacific Region project now. Senator Hirono mentioned about 
that, but there is now a deep dive that is going to that for 
this specific group. So there is a review and asking of the 
community partners out there, what do we really need for this 
special demographic? So we can go ahead and challenge ourselves 
to put those kind of programs into the VA. So we see that 
happening out there, Vivian Hudson [phonetic] and the team that 
are there, they're doing some amazing work. That has never 
happened before since I've been here and that's very, very--
that's a welcoming sight to see that happen.
    Also, the benefits home loan guarantee. I know nobody wants 
to make mention of that, but you know, interest rates were very 
good in the pandemic and most of our veterans took advantage of 
it. It created a lot of extra work for a lot of things. You 
know, mainly in the home loan guarantee business that issued 
the claims, but that is absolutely a good thing for folks 
refinancing their home. Now, the rates are well over seven 
percent, triple almost; but I would tell you that the team 
really worked hard to be able to take care of veterans for 
that.
    And in Hawaii, you know, the median cost of a home, Senator 
Hirono touched on it, right? It's over a million dollars. You 
know, it's over a million dollars. So we really have to really 
kind of bear down on what the veterans have to do to survive 
out here, you know, and which is going to bring up a couple of 
other things.
    I also want to make mention of the fact that Blue Water 
Navy, the Camp Lejeune, and the Historic PACT Act--and thank 
you, Senator Hirono, and the Secretary for your support of 
that. Modernization of claims appeals, there's just some 
amazing things happening with access. You know, we're not 
declaring victory for all those things, but the thing about it 
is we started. We did some things that have completely 
revolutionized what we did, what we should've done back in 2014 
and we see it happening.
    I'll also tell you what time it is now.
    Senator Hirono, you beat me to the punch. So we do have 
some issues with VA travel and it's involving reimbursements. 
So when it comes to per diem, when it comes to out-of-pocket 
expenses, and a simple example. The big island, you've got a 
veteran out there that needs to go to Kona to Hilo to the 
service providers there. It's a two-and-a-half, sometimes 
three-hour drive. They've got to find a hotel. That hotel is 
already above the median, you know, the--the threshold for 
reimbursement and then next thing you know it, they're taking 
money out of their pocket. And in some cases some veterans are 
making the decision before they leave for treatment and saying, 
you know, I can't afford it; I'm going to forego treatment. So 
somehow, some way we've got to find a way to localize, you 
know, that part of it.
    I don't know if we need to have, you know, special 
specialists that are familiar with the region. I understand the 
special nuances of the veterans' experience that are going out 
there and then, of course----
    Senator Hirono. Mr. Han, I know you're wrapping up, aren't 
you?
    Mr. Han. I'm going to wrap up. And so, you know, lastly the 
Burial Equity Act. I'll just leave it with this. Thank you so 
much, Senator, for the opportunity. So Burial Equity Act is--
and I know you've had a special session with Governor Ige back 
in July at the Governors' Western Conference, so it opens up 
for reserves and our guardsmen, but it doesn't come with 
resources. And the burden now is on the State and it's very 
difficult to see individuals not get the adequate eligibility 
because there's not a money funding resource pot put together. 
But that's all I have.
    I just want to say thank you, Senator. Sorry for going 
overtime and thank you for pulling the hook on me and----
    Senator Hirono. Thank you.
    Mr. Han [continuing]. And thank you, Secretary McDonough.

    [The prepared statement of Mr. Han appears on page 51 of 
the Appendix.]

    Senator Hirono. I know you have a lot to say.
    Our last speaker is Mr. McIntyre, please.

              STATEMENT OF DAVID J. MCINTYRE, JR.,

                       PRESIDENT AND CEO,

                  TRIWEST HEALTHCARE ALLIANCE

    Mr. McIntyre. Thank you, Senator Hirono. Thank you for your 
effective leadership on the issues that are important to 
Hawaii's veterans and for the invitation to join you and 
Secretary McDonough and my fellow panelists for the hearing 
today.
    My name is Dave McIntyre, President and CEO of TriWest 
Healthcare Alliance.
    In the '80s I was the lead health staffer for the Senate 
Indian Affairs Committee, so I know a bit about Hawaii, Alaska, 
the Pacific Territories; and I was actually the author of the 
Indian Health Care Improvement Act that stood for 25 years 
until it was reauthorized.
    I'm joined today by Karl Kiyokawa who leads our team here 
local in the islands that's focused on providing support needed 
by VA veterans and providers to make the programs that we 
support a success. All of us associated with TriWest, including 
Hawaii's own HMSA, have been privileged to support VA and now 
DOD for more than 25 years as they work to meet the healthcare 
needs of those sacrificed so much for our freedoms our Nation's 
military personnel, their families, and veterans.
    In 2013, we were honored to be selected to serve in support 
of VA in 28 states including in Hawaii and the Pacific 
Territories as they sought to efficiently and consistently find 
a way to provide access to care in the community through a 
consolidated network of credentialed specialty care providers. 
We stood that up in 90 days.
    We then subsequently were called on to do the same in 
primary care and urgent care. Today our network of some 5600 
providers across the State of Hawaii are engaged in the work to 
support VA. Not perfect, but a start. They've delivered more 
than 55,000 care encounters for veterans, women's health, 
mental health, cancer care, dental visits, heart transplant, 
primary care, urgent care and PT, and everything in between. 
They nor we have sought to replace VA. We simply are there to 
augment VA and to support them as they need the elasticity to 
provide services in the spaces where they're unable to do that 
directly.
    Among our most important responsibilities is the process 
and paying of claims. As the son of an Army doc and the son of 
a nurse, Secretary McDonough, my mom was a nurse, too, I have 
the goal of being the fastest and most accurate payer to 
healthcare providers for their services as a thank you for the 
service that they provide to veterans. Because of this, we 
changed out our claims process in the last year and are re-
engineering this function. I'm proud to say that in Hawaii for 
the entire 2020 period, we've been paying 99 percent of clean 
claims--not claims, but clean claims within five days. The 
requirement is 30. And that's about the place that we'd like to 
be because we understand at the end of the day that the rates 
that we get to pay with are constrained against demand, and so 
we've gotten to this industry leading performance and that's 
not been easy, but we know that there's some old claims that 
need to be cleaned up to make sure that everyone is in the 
right place.
    And we regret the difficulty that this has posed for those 
whose claims are in the last mile of cleanup. Listening to Ms. 
Haar's testimony and I'm looking forward to the list as I'm 
sure our VA colleagues are of those that are in the provider 
subset that received these demands for overpayment. It's 
unclear to me without that detail as to whether those are ours 
or they're the VA's or whether they're ours together. But I'm 
confident that we and VA will get to work in cleaning those up.
    To speed up our progress, we recently took some steps to 
automate parts of the work and we've increased the size of the 
staff working these challenged claims for the State of Hawaii 
and the broader Pacific, and we will not declare victory until 
those are done.
    We expect that based on conversations over the weekend and 
last night to be concluded by the end of this month, not next 
month, not next year, the end of this month. Our work in the 
critical areas brought us to light the fact that we got some 
efforts that need additional focus.
    First, the staffs that do billing for the providers in some 
cases need some rudimentary training to make sure that those 
claims that are submitted are done properly, and we're going to 
commit to doing that training together with the VA involved. We 
plan to be in the Pacific in Guam in the next three weeks to 
address the same issues with the providers down there.
    Number two, we found that a number of providers in the 
islands are not submitting their claims electronically, so we 
want to make sure that they understand how that's done and 
they're enrolled to do that and most importantly that they're 
enrolled to get paid electronically, because when you have that 
work the payment can be in less than five days because it works 
on an automated basis.
    And lastly in the dental area as we work to replace VA's 
direct contracts with those in the network, we are in the 
process along with VA of making sure that the claims issues 
that those providers had historically are cleaned up.
    Last, and I think this is a place where you and the 
Secretary can potentially help all of us, is that we are 
required today under a law to tell providers that they only 
have six months to file a claim. That is unique to the VA. In 
Medicare, Medicaid, TriCare in the private sector they have up 
to a year. I believe that this is an artifact of budget of 
predictability and budget execution, and I think we're at a 
point where we're stable enough now on both sides to make the 
change to allow provider billing operations to have a 
consistent time frame against which they work.
    In our network across the 21, 28 states, we have every 
academic facility that's a partner of the VA, and it was really 
important to us that they be part of the network. We're owned 
by two academics that are in that cohort. They cannot file a 
claim within six months to save their life, and so when they 
end up showing up eight months later, we have to deny it and 
then that starts a whole process on all sides--their side, the 
VA, and our side--of trying to clean that up. And there's a lot 
of inefficiency and ineffectiveness in this space, so I look 
forward to the possibility of working with you and Secretary 
McDonough to try and address whether that ought to be changed.
    Mahalo for the invitation to appear today. I'm honored to 
serve the VA, my colleagues are honored to serve the VA and 
veterans, and I look forward to any questions you may have.

    [The prepared statement of Mr. McIntyre appears on page 58 
of the Appendix.]

    Senator Hirono. Thank you very much.
    Mr. McIntyre, you mentioned that with regard to these 
letters that are being sent to providers demanding repayment of 
overpayments, you were not sure whether they're going to your 
providers or whether they're going--where they're going.
    So is this something that, Mr. Han, are you aware that this 
is happening and that there are providers who are supposed to 
send thousands of dollars back to, I take it, VA?
    Mr. Han. Yes, so we really don't get involved in the health 
care portion, Senator. So we would just defer to the Veterans 
Health Care activity and Secretary McDonough mentioned about 
patients' advocates. It could be in regard to the service 
providers and their--and their payment back, but we wouldn't 
get involved in that with the State.
    Senator Hirono. Okay. I'm just mystified, Mr. Secretary, as 
to why this is happening and there's no explanation and 
resulting in already a lack of private providers, I guess, or 
people who participate privately in the system leaving the 
system. So I hope we can find out what's going on and resolve 
it in some way.
    Mr. McIntyre, you mentioned that part of your concern is 
that the providers are not submitting their request for 
reimbursement electronically.
    Is this because they're solo providers and a lot of them 
are not set up to do that? That they need help? They--they--
they are not doing things electronically? They're still writing 
things out.
    Is that an issue for your provider community?
    Mr. McIntyre. In some cases, yes, and those providers 
should be able to submit the claims on paper; but for those 
that can do it electronically, it's the most effective way to 
make this work. And so we're going to reach out to the 
providers that are not signed up electronically over the next 
couple of weeks in the islands and take them through the 
process of how they do that in order to try and help them with 
efficiency and accuracy. The one thing that happens when you 
file electronically is it allows you from the system's 
perspective to make sure that all the information is entered 
correctly where you can't go to the next step and you can't 
ultimately push ``Send''. That, ma'am, is the reason really at 
the end of the day why that electronic submission is important.
    Senator Hirono. You mentioned that you have 5600 providers. 
How many of these providers are solo practitioners? Do you 
know?
    Mr. McIntyre. I'd say probably in the islands it's about 30 
to 40 percent.
    Senator Hirono. So, Ms. Haar, those are the people that 
you're hearing from? You mentioned that a lot of our provider 
community are solo, so they probably need help with submitting 
electronically. I mean, there's probably a number of these 
aspects and there's something else that they need help with.
    Ms. Haar. Most of the people that I spoke to were solos, 
but I would say Roxanne referenced Straub as well. I didn't 
talk to the big facilities.
    Senator Hirono. Let's talk about the need for I would say 
the need of women veterans to have gender appropriate services, 
including some--as Roxanne Bruhn mentioned. So for you, Mr. 
Han, would you acknowledge that we need to do better in terms 
of providing appropriate, gender appropriate services----
    Mr. Han. Absolutely.
    Senator Hirono [continuing]. For our female veterans? And 
for her to have been treated that way, you know, no veteran 
should feel as though she was not treated well.
    Mr. Han. Absolutely.
    Senator Hirono. So what are you doing? What is your 
advocacy with regard to providing care and the--what we need to 
do for female veterans?
    Mr. Han. So, once again, Senator, we don't have a health 
care portion of it, but we do have a State subcommittee that 
focuses on women veterans, so they've had several summits, in 
person summits, over the last five years. They had a virtual 
summit just recently, and most of it was to talk about those 
kind of issues. It did involve the VA here locally. It did 
involve other service providers, so there's a lot of 
information that is again passed up.
    So the big issue is how do we feed that into the local 
piece of it and then up into the national piece?
    I know Secretary McDonough has special minority groups and 
committees. Part of it has women's committees set up. I belong 
to the National Association of State Directors for Veterans' 
Affairs; they have a very robust women's committee that's--and 
we have one right out of Arizona that partakes in that, so as 
information is provided we send that information to our 
national counterparts, and they in turn look at legislation, it 
may be entered into congressional or we work directly with the 
VA on those subcommittees.
    So that's the process that we do.
    Senator Hirono. The concern regarding the appropriate 
treatment of women veterans has come up quite frequently in the 
Veterans Committee and so we need to be very intentional about 
the kind of attitudes that can be exhibited when a woman 
veteran shows up, that, you know, talk about being traumatized. 
They're there for a service and if the veteran is treated in a 
way that is really disrespectful or dismissive, that is 
something that the attitudinal kind of changes that are hard to 
deal with, but we have to be intentional.
    Of the 5600 providers how many of them, Mr. McIntyre, are 
women?
    Mr. McIntyre. I don't know that answer specifically. I will 
get that for you, but we have a couple of hundred OB/GYNs, we 
have people there in the other specialties that women would 
rely on, and I believe that to be consistent with the ratio of 
the providers that are in the islands that are females serving 
females because 5600 is a big network for these islands. So 
we'll get you that data on specifically the gender of the 
providers themselves.
    Senator Hirono. I just would be interested to know if it 
makes sense to recruit as part of the network of providers to 
go out and specifically recruit female providers.
    I don't know if that makes sense, Mr. Secretary. Is that 
something that you've been----
    Secretary McDonough. Yes, for two years in a row we've 
asked for the highest level of investment in what we call 
gender specific care. Gender specific care allows us to invest 
in specialists and invest in technology specifically for the 
kinds of things that we heard discussed in the testimony 
earlier. So we were just talking here that we're obviously 
going to get to the bottom of this specific situation that you 
confronted.
    But I think Admiral Robinson and I were just talking that, 
you know, I think you'll see that the technology and the 
providers are different than what we heard about earlier. 
That's not to say it was right before and it's not to say it's 
perfect now. It's to say that we're improving and that's a 
direct result of the investments that we've asked of from 
Congress and that Congress has given us over the course of the 
last two years.
    Senator Hirono. As I mentioned, the intentionality 
regarding the gender appropriate services to female veterans, I 
think that's really important especially so you're now 
proceeding with providing abortion services, which is something 
that albeit in the instance of rape, incest, or for the health 
and safety of the mother, but these are services that you have 
not heretofore provided, and so there's going to be a whole 
range of those kinds of providers, Mr. McIntyre, that will need 
to be brought into the system, I'd say.
    Do you have a comment?
    Mr. McIntyre. I think those providers for the most part are 
in the network now and available to the VA staff that does the 
same and they have the ability when setting the appointment to 
talk with the provider about gender specific desires on the 
part of the veteran, and as a company our policy is to follow 
the Secretary's policy. And so you should expect zero gaps in 
that space.
    Senator Hirono. And especially as you are also in states 
which do not allow abortions, so especially in those states. 
That would not be Hawaii but we still get a lot of inquiries 
because of the chaos and the fear generated by the overturning 
of Roe is across the country.
    Ms. Bruhn, I am curious to know but apparently according to 
Mr. Han I think there is some sort of a task group or a group 
here in Hawaii that focuses on care for female veterans.
    Are you involved with that?
    Ms. Bruhn. Yes, I am.
    Senator Hirono. Good.
    Ms. Bruhn. Yes, I am, Senator, yes.
    Senator Hirono. And I hope you're seeing some changes in 
how women are treated here as a result of the recommendations.
    Ms. Bruhn. I go to community of care now, Ma'am, so I have 
not been there physically to see any changes. I'd like to think 
that there have been. I'm hoping that there is because if I 
lose my community of care I'm going to have to go back to the 
VA. So I'm hoping that there's been changes.
    Senator Hirono. I'm sorry. Can you describe for me, I 
believe you said you go to the community of care? You----
    Ms. Bruhn. Yes.
    Senator Hirono [continuing]. Go outside of the VA services?
    Ms. Bruhn. Yes, yes, yes. I am now being seen by my PCP at 
Straub Clinic. I'm treated by my cardiologist and my internist 
all at Straub because my PCP referred me through the system. It 
was a very painful--very painful; I'm not saying it was easy by 
any sort but, but I finally got all that I needed and it's in 
place so I'm hoping that I'm able to keep it.
    Senator Hirono. I take it that you're getting better 
treatment through the community of care process than what you 
described as your experience with VA?
    Ms. Bruhn. Yes, you're correct, and----
    Senator Hirono. And when--when was it that you had this 
kind of treatment in the VA system?
    Ms. Bruhn. I left the VA system in 2020.
    Senator Hirono. So that wasn't very long ago. Let us hope 
that there are improvements in how female veterans are treated.
    So this goes to as I said attitudinal changes, which takes 
some time, but we have to be intentional.
    I think that I am at the end of this panel's time. Is that 
right?
    Ms. Bruhn. I do have one thing I would like to say, 
Senator.
    Senator Hirono. Yes?
    Ms. Bruhn. Is that I'd like the VA to try to look at the 
thought process because when you talk to any veteran, even for 
myself, whenever I think ``VA'', I always think, ``They're 
going to tell me no.'' They're going----
    Senator Hirono. Wow.
    Ms. Bruhn. They're going to put as much roadblocks in front 
of me that I have to overcome in order for me to get treatment, 
in order for me to be seen. I really hope that there is a 
method or that there is a way that the process change of the 
environment of the culture will change. When veterans said or 
when you're told a veteran to go to file a claim or to go to 
medical, that--the veteran will not automatically say, no, I 
don't want to do that, because they're going to give me a hard 
time because that seems to be the prevalent thought when you 
talk to any veteran who--who has to journey through the VA 
system is that they're going to give me a hard time and the 
answer is going to be no and I have to fight, and so I'm hoping 
that that will change.
    Senator Hirono. Thank you. Obviously, there are a lot of 
veterans out there who agree with you and with that 
observation; and so--but we need to be a lot more intentional 
about how people are going to treat veterans, the female 
veterans, and across the board.
    You know, it's like how do we get to yes, right? That 
should be the framework. I have to say that to my staff, too. 
How do we get to yes without breaking any laws or anything like 
that? That's not what I'm talking about.
    I do want to thank the second panel and I know that there 
are a number of our organizations who are with us today and I 
want you to know that my staff is here to be of assistance if 
any of you who represent organizations or individuals, if you 
need services my staff is here to help you and we're in the 
back there. I think there's a--yes, they're waiting. So we'll 
do that.
    Mahalo nui loa for your attention and your commitment 
because we are all in this together, and the focus on providing 
the services that the veterans deserve and need. Aloha.
    This hearing is adjourned.
    [Whereupon, the hearing was adjourned at 11:10 a.m.]

                            A P P E N D I X

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