    [Senate Hearing 117-671]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 117-671

                                 HEARING ON THE
                         DEPARTMENT OF VETERANS AFFAIRS
                    IMPLEMENTATION OF THE SFC HEATH ROBINSON
                             HONORING OUR PACT ACT

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                               NOVEMBER 16, 2022

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

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

                                        __________

                                U.S. GOVERNMENT PUBLISHING OFFICE
    52-301 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

                                  ----------

                               November 16, 2022

                                    SENATORS

                                                                       Page
    Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
    Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     2
    Tuberville, Hon. Tommy, U.S. Senator from Alabama................     9
    Brown, Hon. Sherrod, U.S. Senator from Ohio......................    11
    Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    13
    Blackburn, Hon. Marsha, U.S. Senator from Tennessee..............    15
    Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire......    17
    Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    21
    Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    22

                                   WITNESSES

    The Honorable Shereef M. Elnahal, Under Secretary for Health,
      Department of Veterans Affairs.................................     3

    Joshua Jacobs, Senior Advisor for Policy Performing the Delegable
      Duties of the Under Secretary for Benefits; accompanied by the
      Honorable Guy T. Kiyokawa, Assistant Secretary for Enterprise
      Integration; John W. Boerstler, Chief Veterans Experience
      Officer; Patricia R. Hastings, DO, MPH, FACEP, RN, Chief
      Consultant, Health Outcomes Military Exposures, Veterans Health
      Administration; Robert T. Reynolds, Deputy Under Secretary for
      Automated Benefits Delivery, Veterans Benefits Administration;
      and Tracey Therit, Chief Human Capital Officer.................     5

                                    APPENDIX
                               Prepared Statement

    Joint statement of the Honorable Shereef M. Elnahal, Under
      Secretary for Health, Department of Veterans Affairs; and
      Joshua Jacobs, Senior Advisor for Policy Performing the
      Delegable Duties of the Under Secretary for Benefits...........    33

                           Submissions for the Record

    National Executive Committee of the American Legion; Resolution
      No. 15: Oversight of Camp Lejeune Justice Act..................    59
    Department of Justice Technical Assistance on Section 706 of H.R.
      3967...........................................................    64
    Inhofe Amendment to PACT Act.....................................    67

                           Statements for the Record

    Kristina Keenan, Assistant Director, National Legislative
      Service, Veterans of Foreign Wars of the United States (VFW)...    79
    Lawrence W. Montreuil, Legislative Director, The American Legion.    84
    Rosie Torres and Army Captain Le Roy Torres, Founders of Burn
      Pits 360.......................................................    88

                                 HEARING ON THE
                         DEPARTMENT OF VETERANS AFFAIRS
                             IMPLEMENTATION OF THE
                               SFC HEATH ROBINSON
                             HONORING OUR PACT ACT

                                  ----------

                          WEDNESDAY, NOVEMBER 16, 2022

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 3 p.m., in Room
    SD-G50, Dirksen Senate Office Building, Hon. Jon Tester,
    Chairman of the Committee, presiding.
        Present: Senators Tester, Brown, Blumenthal, Hirono,
    Sinema, Hassan, Moran, Cassidy, Sullivan, Blackburn, and
    Tuberville.

                  OPENING STATEMENT OF CHAIRMAN TESTER

        Chairman Tester. I call this meeting to order. My Bulova
    says it is 3:00, straight up, so I appreciate you all being
    here.
        I want to thank Mr. Elnahal and Mr. Jacobs for being here
    to discuss implementation of a very important bill that we
    talked about a few months ago, pretty extensively. It is called
    the PACT Act. Our PACT Act is historic in that it provides
    health care and benefits to generations of veterans that have
    been long forgotten.
        Expanding health care and benefits to so many, however,
    does come with its challenge. For example, under the PACT Act,
    thousands of Vietnam-era veterans are now presumptively covered
    for hypertension, something that, by the way, the bill said was
    going to be implemented in 2027, but the Biden administration
    in the VA said we are going to do it now because it is the
    right thing to do. Thank you for that.
        That means, though, that the VA has to process thousands of
    new disability compensation claims. Of course, it would have
    been easier to cut benefits, to abandon Vietnam vets with
    hypertension, or to ignore burn pit veterans with cancer, but
    that is not what this Committee did. That is not what the
    United States Senate did. That is not what Congress did. That
    is not what the Biden administration did.
        What we did was what previous Congresses had not, and that
    is we passed a bipartisan bill to pay for the true cost of war.
    We also gave the VA new authorities and funding to make sure it
    could take care of not just the toxic-exposed veterans but also
    older veterans already in the system.
        Look, we all know there are going to be hiccups. Veterans
    who previously filed claims will now hear of many more of their
    brothers and sisters joining them in line. But the VA must
    ensure that each of them gets the right decision as quickly as
    possible. Other veterans who rely on VA for quality health care
    will see new faces in hospital waiting rooms. VA must ensure
    that they get the quality care that they deserve.
        So while we soon will hear more about certain challenges,
    my promise to the veterans listening today is that the VA and
    Congress will work together to overcome these challenges,
    because it took far too long to pass the PACT Act, but passage
    was the easy part. Implementation, making sure veterans
    actually get what is promised to them, that is the true test.
        With that I will turn it over to my Ranking Member, who I
    congratulate on his reelection, Senator Jerry Moran.

                   OPENING STATEMENT OF SENATOR MORAN

        Senator Moran. Mr. Chairman, thank you for that. Thank you
    for your opening statement, thank you for the success that we
    have had in regard to the PACT Act, and I appreciate all of our
    witnesses being here today.
        At the beginning of today's hearing I want to first
    indicate that I recognize this is National Military Families
    Month, and I recognize our military families in Kansas and
    across the Nation. While one person may wear the uniform, we
    know that military service is family service, and I thank all
    of the family members of our servicemembers for their
    sacrifices.
        Sergeant First Class Heath Robinson Honoring Our PACT Act
    is the largest expansion of veterans health care and benefits
    in the VA's history. This is landmark legislation. It delivers
    long-overdue care and benefits to all generations of toxic-
    exposed veterans. As the process to implement the PACT Act
    continues I will work with my colleagues to make certain that
    the VA is following the law and connecting the right veterans
    with the right care at the right time.
        The health effects of toxic exposure can take many years to
    manifest, so it is critical that veterans and the VA are
    proactive about screening and caring for these effects.
        I am encouraged to see that toxic-exposed veterans are
    rapidly submitting claims to the VA for disability benefits for
    toxic wounds incurred during military service. More than
    136,000 claims have already been submitted.
        While this is a significant step, I am concerned about the
    operational impact. It is what slowed us down a bit in getting
    this legislation into law, and the operational impact on the
    VBA, and we will continue to monitor how VA handles its surge
    in claims.
        I want to again urge the Department to utilize all the
    tools at its disposal and work with outside experts to
    implement innovative and efficient ways to administer exams,
    process claims, and provide resources, benefits, and care to
    veterans and survivors. Operational impacts to the Department
    were a significant concern of mine, and will continue to be a
    significant concern during implementation.
        These new provisions, including enhanced recruitment and
    retention measures, more efficient hiring mechanisms, and
    streamlined ability to execute new medical facility leases
    should help the VA mitigate the impacts to benefit the
    processing and care delivery for existing veteran patients
    while serving this new veteran population under the PACT Act.
    Veterans must not be left waiting in longer lines for benefits
    or care.
        I am particularly interested in discussing provisions aimed
    at staffing VA medical facilities, particularly those in rural
    areas, to care for the influx of toxic-exposed veterans, as
    well as hiring and training those who will handle and process
    the disability benefit claims. These positions are critical to
    making certain veterans receive the care and benefits they need
    in a timely manner.
        I look forward to today's discussion. Mr. Chairman, I have
    been asked what our next piece of legislation is that this
    Committee may consider, what is the next goal of the Committee,
    and we certainly, in my view, had success in regard to the
    MISSION Act, we had success in regard to the John Q. Hannon
    Suicide Prevention Act, and now the PACT Act. And my answer to
    those who ask is I think our number one priority in this
    Committee, by Committee members and by the VA, ought to be the
    appropriate, sufficient, implementation of the legislation we
    have passed. This hearing is one I requested and I appreciate
    you holding it today, and I am anxious to work with the VA to
    make sure our veterans, whatever their disability arises from,
    are cared for. Thank you.
        Chairman Tester. Thank you, Senator Moran.
        Before we get into the introduction of the first and only
    panel I would say that I absolutely agree with you. I think
    oversight and implementation of all the acts that you passed,
    and others, are going to be critically important. And that is
    not to say we are not going to do legislation, because we are.
    But I do think our primary focus should be on oversight.
        Today this hearing has one panel with key leaders crucial
    to the VA's success as we talk about the PACT Act. First we
    have Dr. Shereef Elnahal, who is Under Secretary for Health. It
    is good to have you in front of the Committee, Doctor.
        Next we have Josh Jacobs, who I would be remiss if I did
    not tell you that he is turning 29 again today. He is a Senior
    Advisor for Policy Performing the Delegable Duties of the Under
    Secretary for Benefits, which is short to say that he has got
    an important job.
        Also accompanying the two of them we have Guy Kiyokawa,
    Assistant Secretary for Enterprise Integration; we have John
    Boerstler, who is the Chief Veterans Experience Officer; we
    have Dr. Pat Hastings, Chief Consultant, Health Outcomes
    Military Exposure; we have Rob Reynolds, Deputy Under Secretary
    for Automated Benefits Delivery; and Tracey Therit, Chief Human
    Capital Officer.
        We are going to start with your statement, Dr. Elnahal.
    Then we will move to Mr. Jacobs and his opening statement. You
    have the floor.

             STATEMENT OF THE HONORABLE SHEREEF M. ELNAHAL

        Dr. Elnahal. Thank you Mr. Chairman, Ranking Member Moran,
    and members of the committee. Thank you for the opportunity to
    appear before you today to discuss VA's implementation of the
    PACT Act. I am joined by my VA colleagues with whom I am
    honored to testify in front of you today, and you already
    introduced them graciously.
        The PACT Act marks the most significant expansion of
    veteran care and benefits in decades, empowering VA to do more
    for veterans exposed to toxins during their service. This law
    is extraordinary, as it not only allows many more veterans to
    benefit from VA, it affords us to the tools we need to execute
    it. I am proud of the incredible work VA has already done, and
    we are eager and ready to implement the full extent of this
    law.
        In VA we have one guiding question: Are veterans at the
    center of everything we do? We are not orienting ourselves
    around what would be best for VA but rather what would be best
    for veterans.
        Today I want to share VA's three-pronged approach to PACT
    Act implementation. First, we must reach every veteran who may
    qualify for these new benefits and care to ensure they are
    aware of this opportunity. Second, we must build our capacity
    to better serve current veterans and those who we will welcome
    to our system for the first time. And third, we must build the
    path into the future to include groundbreaking new research on
    toxic exposures.
        On outreach to veterans who could benefit from the PACT
    Act, we are working every day to ensure that there is no wrong
    door for veterans to access VA care. Our Veterans Experience
    Office has mapped the veteran engagement journey across all of
    our possible touchpoints with veterans. Whether a veteran or
    survivor comes to VA through a medical center, a benefits
    office, our website, or any other way, we are ensuring that
    veterans receive information about these new benefits in each
    interaction.
        As soon as the Senate sent the bill to President Biden's
    desk we launched va.gov/PACT, a one-stop-shop website for
    understanding the PACT Act and applying for benefits. We also
    enhanced 1-800-MyVA411, an easy-to-remember telephonic front
    door for veterans and their supporters, which includes access
    to 24/7 live agents.
        We are reaching out to veterans directly through their
    communities and through local VA medical centers. During the
    week of December 10th, we will host events at over 80 sites
    across the country. These events will include targeted
    outreach, including claims clinics, health care enrollment, and
    toxic exposure screenings. We are also reaching out to over
    300,000 participants in our Burn Pit Registry through email,
    regular mail, and social media.
        And VA implemented a nationwide effort to screen veterans
    who already get care from VA, to help determine potential toxic
    exposures during their service. In just over one week, this
    clinical screening has already reached over 166,000 veterans,
    with over 37 percent reporting exposures. And as of November
    8th, this is now a routine part of VA health care in every
    medical center, and it will allow us to refer veterans directly
    to VBA as they may qualify for enhanced benefits or an increase
    in their priority group.
        On building VA's capacity to deliver on PACT Act benefits
    and care we simply must hire enough employees to execute this
    law. I want to thank this Committee and the PACT Act for the
    PACT Act's broad range of flexibilities for hiring and
    retaining staff. To date, VA has implemented four sections of
    Title IX, resulting in several new tools to help with
    recruitment and retention.
        We are on track to complete policy changes around all
    hiring provisions by the end of this calendar year. Hiring
    faster and more competitively by consistently implementing
    these new authorities everywhere is my top priority.
        We are also making a historic investment in hiring
    additional health care enrollment specialists. As of October
    25th, more than 3,600 of these specialists have been trained to
    determine PACT Act eligibility.
        We also need to build on VA's brick-and-mortar footprint
    into the future, and the PACT Act allows us to do just that.
    The law immediately authorized 31 new leases, which will expand
    access through new sites of care. We are also thankful for the
    more efficient leasing process and appreciate our ongoing
    partnerships with GSA, OMB, and this Committee to get these
    leases done expeditiously.
        I am also particularly heartened by the new ways that we
    can work with our academic affiliates and DoD to meet the
    health care needs of veterans. Co-location with our partners
    just makes sense for the veterans we serve in our system.
        And on what comes next for veterans, families, caregivers,
    and survivors, VA has a strong tradition of research that has
    improved veteran lives. We will lead efforts to create an
    interagency Toxic Exposure Research Working Group to develop a
    5-year strategic research plan. This research is critical to
    investigating whether toxic exposures may lead to other
    conditions that are not yet considered presumptive.
        As Secretary McDonough often says, our mission at VA is to
    serve veterans as well as they have served our country. This
    law empowers us to do exactly that, and we could not have a
    team that is more invested and prepared to do so. We will stop
    at nothing to get this implementation right, and we will not
    rest until every eligible veteran and survivor gets the care
    and benefits they have earned.
        Mr. Chairman, this concludes my testimony. Thank you for
    your time today, and I look forward to answering any questions
    you may have.

        [The joint statement of Dr. Elnahal and Mr. Jacobs appears
    on page 33 of the Appendix.]

        Chairman Tester. Thank you, Doctor.
        Next we will have Mr. Jacobs' testimony.

    STATEMENT OF JOSHUA JACOBS ACCOMPANIED BY THE HONORABLE GUY T.
     KIYOKAWA; JOHN W. BOERSTLER; PATRICIA R. HASTINGS; ROBERT T.
                      REYNOLDS; AND TRACEY THERIT

        Mr. Jacobs. Good afternoon, Chairman Tester, Ranking Member
    Moran, and members of the Committee. Thank you for inviting us
    to discuss VA's implementation of the PACT Act.
        As you know, VA has struggled for decades to address the
    health effects of harmful environmental exposures that occurred
    during military service. Historically, the process for VA to
    establish a new disability as a presumptive condition has taken
    too long and been too complex, taking precious time that ill
    veterans simply do not have. Now the passage of the PACT Act
    allows us to begin to right these historic injustices and
    deliver benefits to millions of potentially eligible veterans,
    some of whom have been waiting for decades.
        The PACT Act is not only adding over 20 new presumptive
    conditions related to toxic exposures and new locations for
    exposure to Agent Orange and radiation, but it's also
    strengthening how we hire and train new personnel, deploy new
    technology, and establish new presumptive conditions in the
    future.
        Given the serious nature of toxic exposures, we made all
    conditions outlined in this new law presumptive the day the
    bill was signed, rather than phasing them in over years, as the
    law anticipated. For veterans who file for a PACT Act-related
    claim before August 10, 2023, the one-year anniversary of the
    bill's signing, their claim and benefit will be retroactive to
    the date of the bill's signing.
        I want to take the next few minutes to explain the three-
    pronged approach that VBA is undertaking to deliver on the
    historic promise of the PACT Act. First, we are focused on
    hiring efforts up and down the organization. VBA has been
    preparing for the PACT Act implementation since last year,
    hiring approximately 2,000 additional employees. In the next
    few months, thanks to the Toxic Exposure Fund, we anticipate
    adding almost 1,900 more employees to our rolls. And in
    addition to hiring the right people, we are also focused on
    training them. All claims processors, whether new or current
    employees, will have the training necessary to process claims
    under the PACT Act. This training is crucial to ensure that all
    new PACT Act claims are processed correctly and quickly.
        Second, we are looking at all of our policies and processes
    to enable more efficient benefits delivery. To expedite VA's
    ability to begin processing PACT Act claims by January 1st, VA
    is drafting subregulatory guidance which will be followed by
    formal regulations to implement the PACT Act. We anticipate the
    subregulatory guidance will be published in the Federal
    Register in December. VA is also actively engaged with all
    contract medical examination vendors to ensure they are
    prepared to undertake the increased volume of PACT Act-related
    examinations, and we have contracted with a fourth exam vendor
    to expand capacity.
        Third, VA is using automation as a decision support tool to
    expedite claims by determining eligibility, auto-ordering exams
    when necessary, and gathering all relevant data and
    information, which is indexed into an intuitive format that
    gives our claims processors the ability to make quality claims
    decisions quickly. While VA's issued-based claims quality is
    currently more than 96 percent, we want to continue that focus
    by ensuring this technology drives consistent, standardized,
    accurate, and timely decisions for veterans. These tools have
    already reduced decision timeliness from several months to
    several days for the small number of claims that have leveraged
    this technology at one of our four pilot sites.
        But the best implementation plan in the world does not
    matter if veterans' families and survivors do not know about
    the law or how to submit a claim. As Dr. Elnahal mentioned in
    his statement, we are making every effort to meet veterans
    where they are, through print and social media, radio and
    television, directing engagement with veterans' groups large
    and small, traditional and nontraditional, and many other ways
    as well. This also includes targeted outreach to traditionally
    underserved veteran populations--women veterans, Native
    American veterans, African American, and Hispanic veterans.
        The PACT Act helps meet generations of unmet demand from
    veterans and survivors, and we are already seeing this demand.
    The day after the bill was signed into law, veterans set an
    all-time record for benefits claims filed online. And since
    then, as of this past Saturday, veterans have filed nearly
    146,000 PACT Act-specific claims. While we are receiving more
    claims than ever before, VA is also delivering more benefits
    more quickly and more accurately to more veterans than ever
    before, and we are processing claims at the fastest rate in VA
    history.
        I was here a decade ago, as a senior advisor with the VA,
    when the backlog was at its peak, and for members who followed
    the claims backlog for that long you may be asking, are we
    about to watch the same story unfold here today?
        I am happy to say that today we are in a better position to
    tackle this increased workload. When I was last with VA, there
    was a significant investment made to move from a paper-based
    system, where floors were literally buckling under the weight
    of all the paper we stored, to a paperless claims process, and
    now that investment, as well as many others, are paying
    dividends.
        In fiscal year 2022, we processed 1.7 million veteran
    claims, shattering the previous year's record by 12 percent,
    and we have gotten the claims backlog down to the lowest in
    years, below 150,000 claims as of this month, and we have more
    work to do.
        As we continue to encourage more veterans and survivors to
    apply for this PACT Act benefits we do expect an increase to
    the inventory and the backlog in the short term. But the
    efficiencies I just described and the three-part implementation
    plan we are executing have established a solid foundation as we
    work to deliver on this historic law.
        I know I speak for all employees when I say we are truly
    excited about the opportunity to provide the support and
    benefits to millions more of our Nation's veterans. It is both
    a challenge and a promise we look forward to meeting.
        This concludes my statement. Mr. Chairman, we would be
    happy to answer any questions you or other members of the
    Committee may have.

        [The joint statement of Mr. Jacobs and Dr. Elnahal appears
    on page 33 of the Appendix.]

        Chairman Tester. Well, thank you for that statement, Mr.
    Jacobs, and there will be questions, and I will start with
    mine.
        Look, the passage of the PACT Act allows a whole bunch more
    veterans to get health care and benefits that they have earned.
    This does mean, however, that VHA and VBA have to be prepared
    to accept new patients and new claimants into their systems.
        Dr. Elnahal, how is the VA preparing to provide timely
    health care to newly enrolled veterans while still taking care
    of the folks who are already enrolled?
        Dr. Elnahal. It is a very relevant question, Mr. Chairman.
    It is something we are thinking about every day on the health
    care system side.
        I will ask Tracey in a minute, Ms. Therit, to go through
    some of the hiring authorities that the PACT Act affords us and
    how that will increase our rolls. But that is first and most
    important way that we need to build capacity. We simply need
    enough clinicians and the folks who support them in our health
    care system to be able to tackle the increased demand that we
    expect to see, because that is what veterans deserve.
        We are also trying to, on top of that, make sure that we
    increase our productivity across the system. Our Office of
    Integrated Veteran Care is engaging in multiple efforts to do
    just that, one of which is actually standardizing our clinical
    grids based on specialty, to have standard times, on average,
    that it takes to see veterans, depending on the type of care
    they are getting, and then hold our clinicians and leadership
    accountable for resourcing those clinics to be able to meet at
    least an 80 percent productivity standard in those clinics.
        We are also going to make sure that our network adequacy is
    where it needs to be with our Community Care Network, knowing
    that we will need to rely on that, to a degree, to meet this
    demand.
        Ms. Therit?
        Ms. Therit. Senator, thank you for that question, and we
    greatly appreciate all of the authorities in Title IX. There
    are 20 subsections in Title IX. Up to this point we have
    implemented policy and guidance in 50 percent of those
    sections, with 70 percent targeted by the end of the year.
        We are implementing the Title IX authorities to support VHA
    and VBA with their hiring of the workforce that is needed to
    serve veterans in six waves. The first wave was to remove the
    restrictions on housekeeping aides. I am pleased to say that in
    90 days we have increased our onboard rate by 3.2 percent,
    hiring over 700 housekeeping aides under this new authority in
    the last 90 days, and strengthening our onboard capacity to
    provide clean and safe medical facilities.
        We also, in our second wave, are reaching out to college
    graduates and postsecondary students and increasing the student
    loan authority limits to bring in that next generation of
    talent to our VA workforce and our facilities.
        In the third wave, which is equally important to
    recruitment, is retention. What are we doing to recognize the
    amazing workforce that we have and keep them at the VA? So we
    have removed some of the restrictions on awards and bonuses as
    well as increasing our limits on special contribution awards.
        And then the last wave that we just completed
    implementation is improving our systems. You are very familiar
    with the challenges that we have in hiring related to our
    systems, and we have made some enhancements which give greater
    visibility where things are in the hiring process so that we
    can move them along quickly.
        Our fifth wave is the competitive pay. Competitive pay is a
    challenge, to make sure that we get the right VHA and VBA
    personnel as well as OIT personnel and personnel throughout the
    Department on board. So we have a lot of critical pay
    authorities, special salary rate authorities, incentives, and
    waivers of pay limit to make sure that we have no barriers and
    limitations to getting who we need on board to serve veterans,
    and we greatly appreciate that help.
        Chairman Tester. Yes. So keep your mic on. So I am just
    going to take one of them--college grads, increasing student
    loan limits--which is really important and I think can be a
    very effective tool. How are you letting college grads know
    that the VA is here and they are willing to help with their
    college education if they go to work for you?
        Ms. Therit. We are partnering with Student Veterans of
    America to make sure that that word is getting out through
    those channels. We are also working with colleges and
    universities in the local areas. I know VHA and VBA have
    established a lot of partnerships with institutions of higher
    education in their communities.
        VBA is using the college grads authority. Office of
    Research and Development is using the postsecondary students
    authority. So that is a lot of the communications that we are
    doing and we welcome others to add to the things that we are
    doing at both the local level and the national level.
        Chairman Tester. I appreciate that. It is a tough job
    market out there. I mean, good for the employee; not so good
    for the employer. So anything you can do to be aggressive is
    much appreciated.
        I do not have enough time for you to answer my next
    question so I am going to go to Senator Tuberville.

                        SENATOR TOMMY TUBERVILLE

        Senator Tuberville. Thank you, Mr. Chairman. Thank you,
    panelists, for agreeing to be here today and taking time out.
    What a serious problem we have here. We have been working on
    it, what, a couple of years now. Even when I got here the
    Chairman was working on it at that time, before then.
        Let me start by saying I voted against the final passage of
    this legislation. I have got 500,000 vets in the State of
    Alabama, and do not think I did not hear from them. I knew it
    would be a big vote, and that is why I approached it with an
    open mind. While this legislation was being considered, my
    staff and I met with numerous VSOs and heard from hundreds of
    veterans in Alabama. After many candid conversations I made an
    informed decision to vote no, and my position remained
    consistent on every PACT-related vote.
        Sadly, my colleagues on the left here politicized this
    process and we rushed it. To me we rushed to pass this
    legislation.
        You know, I believe the bill's imprecise, unrealistic
    language only sets the VA up to fail. That being said, I hope
    you all prove me wrong, because our veterans need help. They
    need a lot of help. As a member of this Committee I want to be
    as helpful as possible to all of you.
        So Mr. Jacobs, earlier this month the VA announced that it
    would expedite claims for veterans with cancers to ensure they
    are getting timely access to the care and benefits they
    deserve. The VA also announced that it would prioritize the
    processing of the claims for veterans with terminal illnesses
    and those experiencing homelessness.
        Question. With more than 136,000 PACT Act-related claims
    already filed, and existing backlogs of 100,000 or so, how can
    you be sure that veterans with cancers are not getting
    overlooked?
        Mr. Jacobs. Thank you very much for that question. You
    know, we have an existing prioritization ability that we
    implement right now where if we know that a veteran is
    homeless, is experiencing financial hardship, is over 85, and
    several other categories, we are able to prioritize that claim
    for expedited consideration. We have 25,000 employees across
    the country, 60 percent of whom are veteran. Simply put, they
    get the job done.
        We are expediting cancer claims for the PACT Act because of
    the severity of the conditions often associated with many of
    these cancers and the length of time it has taken for us to be
    able to deliver these benefits and connect them to the health
    care that they need.
        So we have a well-proven process to be able to expedite
    those claims. We were able to execute that, and I would just
    ask you, to the extent that you hear from your constituent who
    have cancer or have one of these other elements that may
    require us to prioritize it, you let us know. We can expedite
    when we know that a particular claim meets one of these
    conditions, but if you happen to have that information you let
    us know and we will make sure we get the job done.
        Senator Tuberville. So we are prioritizing, right?
        Mr. Jacobs. Yes, sir.
        Senator Tuberville. Okay. PTSD, you know, we are having
    huge problems with that. We are having people dying every day,
    and we need to do a better job with that. But that is another
    point.
        What about homelessness? Talk about that point. Where do
    you rank them? How do you go about categorizing that group?
        Mr. Jacobs. If we have an indication that a veteran is
    experiencing homelessness we will be able to prioritize that
    claim for consideration. Oftentimes we do that in partnership
    with our VHA colleagues. We recognize there is no wrong door in
    VA. And so we provide wraparound services. We want to make sure
    that we are prioritizing claims decisions so that we can get
    the veteran and his or her family the benefits that they need
    to help them with their life. We also want to make sure, to the
    extent that they are dealing with other issues, that they have
    the health care support and the other wraparound services that
    they need to help address the issues in their life and get back
    on their feet.
        Senator Tuberville. Thank you. Dr. Hastings, as you know,
    Section 801 of the PACT Act requires the VA to study the health
    of veterans who served at Fort McClellan between 1935 and 1999.
    However, during a recent briefing, VHA identified Section 801
    as a challenge to implementation because, and I quote,
    ``sufficient data on Fort McClellan's veterans during this time
    period may not exist.''
        Can you please elaborate on this issue and describe, you
    know, your conversations with the DoD up until this point?
        Dr. Hastings. Absolutely, sir. Deployment Health Working
    Group we exchange data with DoD at all times, you know, back
    and forth. It is a challenge to go back to 1935. As you know,
    some of the mortality records did not start until the 1970s. We
    are leaving no stone unturned to find the data that we need. We
    are also working with the Agency for Toxic Substance Disease
    Registry, who has a petition to look at Fort McClellan. So we
    are working with them also.
        I was sent to Fort McClellan three times for my nuclear,
    biologic, and chemical training. I was there for a week at a
    time. Fort McClellan had a very small cadre of permanent party,
    and people coming through there for basic training or for other
    training. It was very transient. So those records will be a
    challenge, but I can assure we are looking everywhere and we
    will get every record possible, going back as far as possible.
        Senator Tuberville. Thank you very much. Mr. Chairman, I am
    out of time, and I would like to submit my remaining questions.

                         SENATOR SHERROD BROWN

        Senator Brown [presiding]. Without objection. Senator
    Tester has asked me to chair for the time being, so thank you,
    Senator from Alabama.
        I will ask my questions and then turn to Senator Hirono. I
    think Senator Moran will likely be back by then.
        First of all, thank you all for serving. Your work at the
    VA is maybe more important than it has ever been. I have done
    about 15 roundtables about the PACT Act, in urban areas and
    rural areas and suburban areas all over the State, and there is
    a lot of excitement but there is a lot of ignorance about what
    it does. So your work and your outreach is especially
    important.
        I would like to address first the electronic health record
    modernization efforts. I thank Dr. Elnahal for his visit to
    Columbus in September. While I did not see you there I was
    recently at the facility with Deputy Secretary Remy and heard
    firsthand from frontline employees some of the same things you
    heard about the challenges with the Oracle Cerner program. You
    know all that. I do not need to dwell on it. I am concerned
    that the facility's recent sale data could reflect a drop in
    patient care and satisfaction to the EHR program, causing
    veterans to seek care outside of the VA, something we would
    prefer not, but if it a necessity to them it is.
        We need to address patient care and satisfaction issues.
    Many veterans may not be aware that the new system has caused
    issues for medical providers and support staff. You know all
    that.
        I just would like you publicly, Dr. Elnahal, to commit to
    continuing to work with VISN 10 officials in Columbus to ensure
    the facility has the support and the resources it needs to
    safely implement the new system.
        Dr. Elnahal. Absolutely, Senator, and it was my visit to
    Columbus which triggered conversations here with VA leadership
    writ large around the need to have this assess-and-address
    period that we are undertaking with the electronic health
    record, to make the system better for the sites already using
    it. And I can tell you, the leadership and the team, down to
    the front line, in Columbus are extraordinary. They want to get
    this right. It is incumbent upon us to hold Oracle Cerner and
    ourselves accountable for doing so, and I do pledge that,
    Senator.
        Senator Brown. They do want to, but there is a healthy
    skepticism among sort of all levels of employees. I probably
    met with 15 in one meeting, 5 in another, and walked through
    the facility and heard it pretty consistently. But you know
    that. I just wanted to say it publicly.
        Mr. Jacobs, as I mentioned, I have held a number of
    roundtables, meeting with Vietnam veterans who talk about their
    Agent Orange experience, and frankly, we have learned from
    that, of course, the way that we did the PACT Act, as you know,
    the PACT Act is named after someone from Columbus. His mother-
    in-law has been talking to me about this for several years, and
    Senators Tester, Moran, and I have worked on this, obviously,
    together.
        I appreciate the steps the VA has taken to inform veterans
    of these benefits. We need to get creative about how we do this
    outreach. The VA has to somehow expand its capacity to continue
    to do what you do, plus expanding the Agent Orange outreach and
    all the new PACT Act veterans.
        So I have three or four questions of you, Mr. Jacobs, if
    you would. I will just do all the three questions together and
    you can answer them together. How is expanding outreach to
    veterans who might not have access to the internet or younger
    veterans who have not interacted with the VA, if you could talk
    for a moment about that? Are you working with DoD so
    servicemembers about to leave know of these benefits? I have
    found in the past that is not always the case. And is VA
    planning in-person events at medical centers, or in the
    Department, open to sending mobile teams to rural areas to
    expand outreach? We know there are several VA hospitals in
    Ohio. There are 31 or 32 CBOCs, and there are veterans that are
    not even near the CBOCs. So talk to those three if you would,
    Mr. Jacobs.
        Mr. Jacobs. Great. Thank you very much, Senator Brown. As I
    mentioned in my opening statement, outreach is a critical
    priority for us. This law is historic but it does not mean a
    thing if veterans and their families and survivors do not know
    about it and they do not know how to apply.
        There is an active outreach plan that we are executing on
    multiple fronts. I am going to ask my colleague, John
    Boerstler, who runs the Veteran Experience Office, to talk a
    little bit more about that, using human-centered design to
    reach veterans and their families where they are. And we are
    taking some of the human-centered design insights that we have
    learned through their work to target our outreach.
        I will also say we have a unique tool that is in isolated
    execution. So in our New Orleans regional office we have a
    database system that is able to identify, parish by parish in
    Louisiana, where we have veterans, and the percentage of
    veterans that are utilizing their benefits, so we can isolate
    our outreach to help identify and fill in the gaps. And often
    those are in rural, underserved locations.
        And so we are going to be working to expand that to other
    States in partnership with the States and other partners. But
    let me turn to John.
        Senator Brown. And Mr. Boerstler, if you would--thank you--
    while answering that just talk to us about when someone comes
    into the Dayton VA, say, or comes into a CBOC in Zanesville for
    something else, what you do about informing them of potential
    PACT Act exposure and treatment.
        Mr. Boerstler. Yes. Thanks very much, Senator. And as Dr.
    Elnahal mentioned earlier, we are getting the word out in terms
    of training more of our frontline staff and clinicians about
    asking specific questions related to PACT Act and to toxic
    exposures across the board. So there is literally no wrong
    door. If you come in for a screening then you will be directed
    to hopefully file a claim and then enroll in VA health care.
        In terms of outreach in rural areas specifically, we have a
    wonderful program called the Veteran Experience Action Centers,
    which we have done in Montana, we have done in South Dakota, we
    have done in Alabama as well, and these are really great
    partnerships with the State Departments of Veterans Affairs, as
    Mr. Jacobs alluded to, where they are incredibly effective at
    rural veteran outreach. So using not only those three-day
    enrollment sprints--where we are focusing on helping them file
    claims, enroll in VA health care, filing their pre-need
    applications for memorial services--we are also measuring that
    experience along the way and then tapping into outreach
    mechanisms that, as you mentioned, if they do not have access
    to broadband or internet we are hitting the radio stations, we
    are using our community veteran engagement boards, we are
    asking all of force multipliers at the county and the parish
    level to help us get the word out.
        And as Dr. Elnahal alluded to in his opening remarks, we
    are launching at 80 sites, so VA medical centers and regional
    offices partnering across the country that first week of
    December to do this week of awareness, where we are going to
    have claims clinics mixed in with enrollment sprints. It should
    be incredibly impactful.
        And then finally, sir, I will mention toward transitioning
    servicemembers and their families. We have just updated the VA
    Welcome Kit, which is kind of your single front door for
    information that veterans can get, and the first page that you
    have in there is our one-pager on the PACT Act, and if they
    qualify, based on their deployments and their symptoms. So we
    are really excited to push that further upstream to those that
    have not transitioned out of the military yet as well as
    sending it to those recently separated veterans and their
    families.
        Senator Brown. Thank you. Senator Hirono, who I believe has
    not voted yet either. So thank you.

                          SENATOR MAZIE HIRONO

        Senator Hirono. Thank you, Mr. Chairman. Let me go, first
    of all, to the situation at Red Hill, which was our own
    basically toxic exposure events. And I think, Secretary
    Elnahal, you are familiar with what happened there.
        As we talk about loss of data, et cetera, and the need to
    coordinate between DoD and VA, these are thousands and
    thousands of people who were exposed to jet fuel leaks at Red
    Hill. And it occurs to us that there should be a way for some
    kind of tracking and tracing of the health issues attendant to
    this exposure while they are currently in active service as
    well as presumably they are going to become veterans.
        So is this something that you all are already doing
    something with the DoD to make sure that all these people who
    experienced this exposure are not lost? I think Ms. Therit, you
    also talked about the need to coordinate records, health
    records, with DoD.
        Can you just talk a little bit about how you expect to keep
    track of all these people, 94,000 people, at least, who were
    exposed to the Red Hill situation?
        Dr. Elnahal. Yes, Senator. First of all, I enjoyed visiting
    Hawaii for the NASDVA convention and had a chance to spend time
    with Dr. Anderson and his team at the Pacific Islands Health
    Care System.
        I am aware of this, certainly, and Dr. Hastings can help us
    summarize the exciting work that the Interagency Research
    Working Group is going to do, specifically on investigating jet
    fuel exposures and conditions that may result from that. Dr.
    Hastings?
        Dr. Hastings. Absolutely, sir. Senator, Red Hill is one of
    the cohorts that we are concerned with. We are concerned with
    many and we do follow them. There is a registry of those people
    that were exposed that DoD has. We meet monthly with the
    Deployment Health Working Group, and though it says
    ``deployment health'' we also cover garrison exposures. Those
    exposures at Red Hill would fit into that.
        And this is a cohort that we will follow into the future,
    and this will be decades of following up. But that is what my
    office does routinely. We follow cohorts. We look at the health
    outcomes. We look at how to care for those veterans and their
    families. You know, this is not exactly a Camp Lejeune
    scenario, but we are going to look at it in the same manner.
        Senator Hirono. That is good because I think that there
    will be some long-term health issues, and there is a provision
    in the PACT Act that directs the Department to study the
    impacts of jet fuel exposure. So I assume that you are doing
    that and I would welcome information on how that is going.
        Dr. Hastings. Absolutely. The Office of Health Outcomes
    Military Exposures started looking at fuels and jet fuels
    exposures about 2 years ago. We have already completed some of
    that preliminary work, and thank you very much for the PACT Act
    that expands that and allows us to work with the National
    Academy. We are very excited by this work. It is important. Jet
    fuels, you know, are what the military runs on, and we have to
    know more about them, and we are doing that.
        Senator Hirono. Definitely, because I hear from individuals
    and families who had all kinds of health issues, that clearly
    needs to be tracked. So we do not want to end up with a
    situation that resulted in our having to pass the PACT Act,
    where exposures going back decades have to be somehow, you
    know, we have to figure out the cause and effect. So what you
    are doing right now is very important.
        I also want to mention that the vacancy rate of VAPIHCS,
    which is the VA health care system that covers Hawaii and the
    greater Pacific, has been at about 19 percent, and we have made
    various efforts through this Committee, and more recently
    through the PACT Act to provide a lot more flexibility to the
    VA to hire people. And I am just wondering whether there are
    unique circumstances in Hawaii that makes it that much harder
    to hire and retain people.
        So have you given some thought to it is a not a one-size-
    fits-all situation, that Hawaii poses maybe very unique
    challenges, to get this 19 percent vacancy rate down? You look
    as though you are wanting to say something, Mr. Secretary.
        Dr. Elnahal. Yes, Senator. I had this conversation with Dr.
    Anderson and his team, who did mention that the health care
    labor market is particularly difficult. And as you mentioned,
    that is borne out in the data.
        Ms. Therit summarized all of the exciting new authorities
    that will allow us to pay people much more competitively but
    also to retain them, with the ability for larger retention
    bonuses. Again, thanks to you and this Committee we now have
    that.
        I also had a conversation about how we could work better
    with the Tripler Army Base staff and allow even more services
    to be shared with them, and had a chance to come back and
    address with the Health Executive Committee and DoD. And if we
    have time, Mr. Kiyokawa can talk about some of the other
    exciting work we are doing with DoD.
        Senator Hirono. Well, my main question is I think there are
    some very unique circumstances in Hawaii that we have to get
    creative in how you all are going to take care of all the
    veterans, especially as we are expanding the number of people
    who will come for VA care, including specialized care for women
    veterans. And there are whole ranges of different kinds of
    care, and really we need to get this vacancy rate.
        Thank you, Mr. Chairman.
        Chairman Tester [presiding]. Senator Moran.
        Senator Moran. Mr. Chairman, thank you. I understand that
    Senator Blackburn has not yet voted, and I yield my time to
    her, and in return I hope to be later in the hearing.

                        SENATOR MARSHA BLACKBURN

        Senator Blackburn. Thank you very much. Just a couple of
    questions. Secretary Elnahal, I want to talk about the female
    veterans, the post-9/11 veterans, and the rate of breast
    cancer. I have seen some of the data, and those between the
    ages of 18 and 44 are 34 times more likely to develop breast
    cancers.
        So if you would, talk to me a little bit about the outreach
    that you are doing for female veterans, what you are doing to
    build this awareness, to make them aware of services that are
    available, why they need to have regular and ongoing testing,
    and how they are working with the VSO on this.
        Dr. Elnahal. Absolutely, Senator. It is a major focus of
    mine, as you know. The Office of Women's Health reports
    directly to me. We are focused on this. As a result of a lot of
    the authorities that you and this Committee gave us through the
    MAMMO Act, the Deborah Sampson Act, staffing up our facilities
    with enough women's health coordinators and clinicians on the
    front line to be able to meet the needs of these vets.
        I will mention that reproductive cancers, as a category of
    presumptive conditions, will include breast cancer, and so that
    will help from the standpoint of giving even more veterans
    these benefits, especially if they were deployed, and Mr.
    Jacobs and his team can find a way to give them PACT Act
    benefits.
        In terms of outreach, we are doing very targeted outreach
    to women veterans. The Center for Women Veterans is very
    focused on that. Mr. Boerstler probably has more details to
    share on that as well.
        Senator Blackburn. Okay.
        Mr. Boerstler. Thank you, Senator. In terms of digital ad
    campaigns we are specifically targeting different customer
    personas, including Vietnam veterans, post-9/11 veterans, and
    but also women veterans that may be exposed to all these toxins
    as well. And we have seen some significant successes, reached
    over 42 million just in the recent weeks since the passage of
    the bill. And we think that, obviously, for post-9/11 veterans,
    that digital advertising works very well.
        We want to make sure, though, that we are also hitting
    radio and TV and having our facilities out in the field,
    engaging with as many of the women veterans who may not yet be
    enrolled in VA. And if you came to VA 10 years ago, come back
    and try us again. The women's clinics, especially, are some of
    the most incredible programs. We see, in terms of our trust
    scores, the fact that women can access the clinics from a
    different location or different entrance at the hospitals. They
    are incredible.
        Also the use of telehealth and virtual health has really
    enabled. We have seen the trust scores for women veterans in
    particular that access VA health care services really go,
    quarter over quarter, over the course of the pandemic. So we
    are doing everything we can to increase access and improve
    outcomes for our women veterans.
        Senator Blackburn. Okay. I appreciate that. I think that we
    all know, with breast cancers, with reproductive cancers, that
    early detection is primary, so this outreach and getting our
    female veterans enrolled is going to be important.
        I had one other question. The Camp Lejeune Act. We have had
    so many questions about how Section 804 and how they are going
    to deal with the awards from the lawsuits and how that is going
    to deal with the offsets. Mr. Jacobs, I think this maybe comes
    under your jurisdiction.
        Our veterans, there is a lot of confusion around this, with
    these awards. Can you speak to that for us?
        Mr. Jacobs. Absolutely. Thank you, Senator. This is a
    question we are continuing to get and we are trying to clarify
    and communicate. There is a lot of confusion. I have been told
    is about $1 billion worth of advertising on the lawsuit. So it
    is top of mind for many.
        We want to make sure veterans and their family members make
    an informed choice. We are not going to persuade or dissuade
    them from seeking justice in the courts. But we do want
    veterans and their families to understand if they are
    successful and they receive an award through the judicial
    system that award will be offset by the amount of VA benefits
    they are receiving for their specific Camp Lejeune benefits
    that they are receiving from VA.
        So we are not making that determination. We are going to
    share information with the Department of Justice and the
    courts, and they will determine the total amount of the offset.
    And then, of course, the offset will also have to take into
    account whatever lawyers' fees are part of that, from my
    understanding.
        Senator Blackburn. Okay. Thank you for the clarification. I
    think the sooner you can get us something in writing, the
    better it will be.
        Mr. Jacobs. Absolutely. This is a complicated piece of
    business and I want to make sure it is crystal clear and that
    it has gone through our counsel's review, and that we make sure
    we are clearly communicating so veterans can make an informed
    choice. And we also want veterans to apply for benefits if they
    have not done so, if they have been affected by Camp Lejeune
    contaminated water.
        Senator Blackburn. Thank you. Thank you, Mr. Chairman.
        Chairman Tester. Senator Hassan.

                      SENATOR MARGARET WOOD HASSAN

        Senator Hassan. Well, thank you, Mr. Chairman and Ranking
    Member Moran. Thank you to our witnesses for being here today.
    And look, up in New Hampshire the veterans I have talked with
    over the last few months are really excited about the passage
    of the PACT Act and the opportunities it provides to veterans.
    Understandably, at the same time, they really also have
    questions about the implementation and how the benefits are
    going to be delivered.
        So I just want to focus on some of those concerns and I
    will start with a question to both of you, Dr. Elnahal and Mr.
    Jacobs. I appreciate the outreach that the VA has already done,
    both directly and through veteran service organizations, and it
    has been important. It has let veterans know about the new
    benefits and health care that they may be eligible for under
    the act. I continue to hear from veterans in New Hampshire,
    especially the VSOs, about how helpful those communications
    have been, so thank you.
        But there is a concern that veterans who are not already
    connected to the VA, or the broader veteran community, are not
    getting the information that they need. And we have talked a
    little bit about that up here, but I want to drill down on a
    couple of things. In particular, I want to make sure that the
    VA is targeting outreach to servicemembers who will be
    separating or retiring from the military in the future but
    likely are not actively connected with VA services today.
        You talked a little bit about information about the PACT
    Act in the Welcome Kit, but how are you coordinating with the
    DoD to make sure that this population learns about the PACT Act
    now so that they can be better prepared when it comes time for
    them to enroll in health care or disability claims?
        Dr. Elnahal. I am happy to start, Senator. This is a major
    area of focus for us. The critical period of transition into
    civilian life for veterans is a very vulnerable one, and it is
    a perfect opportunity for us to introduce VA writ large but
    also the benefits under the PACT Act. We are making use of the
    Transition Assistance Program, TAP, and many other ways of
    doing that.
        I will ask either Mr. Kiyokawa or Mr. Boerstler to give us
    some more details on that.
        Senator Hassan. Yes, and I get the focus on transition, but
    even before transition, what is happening?
        Dr. Elnahal. Well, in the first instance we are actually
    collaborating with DoD on outreach. So we have already had
    excellent meetings centrally with the DoD's Public Affairs
    Office. DoD has regularly events for military outreach,
    everything from fleet weeks, air shows, military bands, base
    openings, ship christenings. We are really going to be at as
    many of those events as possible, and also invite our DoD
    stakeholders to the 50 events during PACT Act Week of Awareness
    on December 10th.
        I don't know if any of my colleagues want to supplement.
        Mr. Jacobs. I can also add we have a pretty robust
    governance process where we partner with DoD. It is led by
    Deputy Secretary Remy. That is part of the Joint Executive
    Committee. Underneath it there is the Health Executive
    Committee and the Benefits Executive Committee. I co-chair the
    BEC. I will be at a meeting with my DoD colleagues on Friday,
    and one of the key points I will be raising is how do we get
    the word out, how do we continue to put our foot on the gas,
    communicate to transitioning servicemembers before----
        Senator Hassan. Well, that is helpful, and I thank you, and
    I will encourage you to continue planning for and supporting
    this group of veterans. I would also like to note that the
    calls made as part of the Solid Start Program to newly
    separated and retired veterans can be an effective tool as
    well.
        Let me move on to one other issue in my remaining time, and
    this is to Dr. Elnahal. As you know, the VA needs to increase
    its workforce to provide veterans with their new benefits under
    the PACT Act. This need is particularly acute in rural
    communities in New Hampshire and across the country, where
    attracting health care providers is a challenge.
        Section 901 of the PACT Act requires the VA to develop and
    implement a national rural recruitment and hiring plan for
    health care professionals to better reach these underserved
    communities. I am glad to hear that you are already working on
    this plan and you expect to complete it, I think, by early
    2024, if I understand the testimony.
        How is the VA developing the plan, and are there any
    details from the plan so far that you can share with us?
        Dr. Elnahal. That is right, Senator. It is a really
    important part of what we need to do to target our hiring
    efforts more effectively in rural areas. As you know, these are
    more difficult health care labor markets. It is harder to get
    folks recruited for these critical positions.
        We are actually approaching this in, I think, an innovative
    way. We are taking our experts in workforce management and
    human resources and combining them with our implementation
    science researchers to collate the data that is available to
    understand what a targeted outreach plan could look like and
    make that actually an evidence-based effort.
        I will ask Ms. Therit if you want to provide more details.
        Senator Hassan. Thank you.
        Ms. Therit. Thank you, Senator. So we have an integrated
    project team that meets on a weekly basis and we update the
    status of this. I will be candid and say that we focused on the
    workforce authorities that we could implement right away,
    knowing that this had the 18-month time frame to submit the
    report. But we can provide you and your staff with updates as
    we develop the plan and really focus on what we can do to get
    the workforce that we need in those locations.
        Senator Hassan. That would be great. Thank you so much, and
    again, thank you all for your work.
        Chairman Tester. Senator Moran.
        Senator Moran. Mr. Chairman, thank you. Dr. Elnahal,
    welcome. I am worried about the VA, the job that needs to be
    done to take care of those veterans who are not currently
    enrolled in the VA, and we have got a couple of windows in
    which they have an opportunity to do so. The one that is most
    pressing is October 1st, we began enrolling, and there is a 1-
    year opportunity. How many veterans have enrolled under that 1-
    year window thus far, and how many, in total, are eligible to
    enroll between now and October 1, 2023?
        Dr. Elnahal. Senator, it is a big priority for us to get
    the word out, especially to post-9/11 veterans who have that 1-
    year window and may have been discharged between 2001 and 2013,
    and I think that is the cohort you are speaking of.
        We are making updates to our health care eligibility system
    so that we can accurately parse out which of these health care
    eligibility applications are clearly connected to that window
    and the benefits under the PACT Act more generally. I do not
    have these numbers with me now, but we are happy to take this
    question for the record and get you more accurate information
    about that.
        Senator Moran. How, generally, does the VA market benefits
    and health care to those who are not enrolled in the VA?
        Dr. Elnahal. It is really important for us, Senator, to
    reach out to the entire complement of veterans across the
    country, and the PACT Act is a way to do that because we do
    expect new enrollees to qualify. So as Mr. Boerstler mentioned,
    we are making sure we use as many media outlets as possible,
    social media, radio, print ads, trying to get in front of folks
    with the avenues that they normally see. And Mr. Boerstler, if
    you have more details specifically for that cohort of folks not
    associated with the VA, that would be helpful.
        Mr. Boerstler. Absolutely, and this goes back to a lot of
    our data-sharing with the Defense Department. You know, we get
    the contact information and we are able to still target those
    veterans who have not enrolled in our programs because we are
    able to see in our system, Senator, when they enroll in our
    programs and what programs they are enrolled in. So proactive
    outreach is always top of mind for us, especially when we think
    about our vet resources, e-newsletters that go out on a weekly
    basis, that incorporate not just VA information but other
    information from our partners.
        We have also simplified the enrollment, a 10-10EZ
    enrollment form, for those that are already rated at a certain
    percentage, so that they can get to enrollment faster.
        But the untethered population is a big focus for us in
    making sure that they get the information on the benefits and
    the care that they have earned.
        Senator Moran. Dr. Elnahal, you and others here today, if
    you have suggestions for how I, as a Member of Congress, a
    Kansan, can help educate and bring in people in my State,
    veterans who would qualify, I would welcome that. I would guess
    my colleagues would be happy to be advocates for veterans that
    maybe continue to fall through the cracks.
        Let me turn to resourcing. One of the things that I have
    heard from one of our staff at one of our VA hospitals in
    Kansas is they cannot keep up with the pace of pay increases in
    the surrounding labor market. Even though they have the
    authority to increase clinicians' pay when the market pay
    increases, they say that by the time VHA human resources
    completes all the necessary reviews and signoffs the private
    sector has already begun another pay increase before the VA can
    match the first. They are always at least one pay increase
    behind what they should be.
        Your thoughts on how that is or can be corrected?
        Dr. Elnahal. Senator, I think consistent and full
    implementation of all of the new PACT Act hiring, recruitment,
    and retention authorities in the first instance is the best way
    to do that. And it is our job to take the excellent work of Ms.
    Therit and her team, our workforce management teams who are
    working rapidly to finalize these policies and make sure that
    every single network in our system is utilizing every
    possibility to do all of the new ways we can pay folks,
    recruitment and retention incentives, but also student loan
    repayment, and so many of the other options that we have.
        I will say that we have a legislative proposal in the
    President's budget that I think is really important, especially
    for rural areas, to allow us to surpass the $400,000 cap for
    physicians in particular. I will just reiterate that in order
    to recruit the right folks on the physician, dentist, and
    podiatrist side it is becoming much more difficult, especially
    in rural areas, as salaries go up and the health care labor
    market becomes more difficult. And we would be able to pay more
    innovatively as well to incent the right behavior among these
    clinicians if we were able to get that. So I humbly request
    your consideration of that as well.
        Senator Moran. Thank you for highlighting that. I am going
    to conclude, Mr. Chairman--I will not necessarily ask a
    question, or I will ask a very short question, to Mr. Jacobs.
        One of the things that, again, I have heard in Kansas,
    there is a frustration for veterans who end up in a category
    called ``ready for decision'' status, but then discover that it
    still takes months or even a year for the decision to occur. It
    seems to me that we may be increasing expectations beyond our
    capabilities, and is there a plan to try to better inform a
    veteran how he or she may--what wait there may be?
        Mr. Jacobs. Yes, thank you very much for that question. I
    would say right now we are unbalanced in terms of the
    distribution of the workload across the claims lifecycle. So it
    is kind of a pig-in-a-python situation, where during the
    pandemic we were not able to get certain veteran records, we
    were not able to provide C&P exams, so we had no claims in the
    ``ready for decision'' cycle. As we have brought down the
    backlog by 100,000, we now have been getting that evidence, and
    it is coming into the ``ready for decision'' cycle.
        There are too many claims, simply put, there right now.
    Since the beginning of November we have brought it down by 5,
    almost 6 percent, and we need a targeted and consistent
    approach to continue to bring that down. And we are going to be
    able to free up some staff to do just that. And so I would say
    right now we need to do a better job managing expectations
    while we are working to bring that particular area into focus
    and get the decisions made for veterans. Thank you.
        Chairman Tester. Senator Blumenthal.

                       SENATOR RICHARD BLUMENTHAL

        Senator Blumenthal. Thanks, Mr. Chairman. Thank you all for
    being here, and thank you to the VA for its work on reducing
    the backlog of claims from 175,000 now to 140,000. I understand
    there are 137,000 new PACT Act claims.
        Do you have an estimate on what the total universe of
    claims likely to be made over the next 6 months, over the next
    year?
        Mr. Jacobs. Thank you very much, Senator, for that
    question. We are anticipating upwards of 700,000 claims, PACT
    Act-specific claims, in this fiscal year. I think we have to
    wait and see what the total number ultimately is. In part, that
    is going to be dependent on our continued focus on outreach and
    trying to get the word out.
        We have received, as of this Saturday, about 146,000 PACT
    Act claims. And so we are continuing to try to get the word
    out, and it is really important for us to communicate to
    veterans that we want them to file this year. If they file
    before August 10, 2023, they are going to be able to preserve
    the earliest possible effective date. So we want veterans to
    come in, we want them to understand the potential benefits that
    are provided in the PACT Act, and we want them to either file
    directly online, va.gov/PACT, or with an accredited
    representative, with one of our VSO partners. They do
    incredible work. They can help inform veterans about how to
    apply, and they can be good allies and advocates along with us.
        Senator Blumenthal. Let me ask you specifically about
    screening. I understand that screening became a possibility for
    everyone as of last Tuesday, a week ago yesterday. Could you
    talk about what kind of outreach you are doing specifically on
    screening?
        Dr. Elnahal. Thank you, Senator. We are really excited
    about our progress with toxic exposure screenings. I mentioned
    earlier that in just over a week we have already conducted over
    166,000 of those screenings. And a really important piece of
    data is that about 38 percent of veterans are indicating that
    they may have been exposed to one of the toxins relevant to the
    PACT Act.
        This is a screening that is now available in primary
    clinics in every medical center across the country, which is
    why the numbers are climbing so quickly. As we see every
    veteran who has not yet been screened, we are screening them,
    and they will be screened every 5 years as part of their
    normal, routine care.
        We think this is really important to capture, at the very
    least, the cohort of veterans who are already eligible for
    health care, and they may be eligible if we do a warm handoff
    successfully to VBA, which Mr. Jacobs and I are working on
    diligently, for a priority group increase or even more benefits
    that they may not have had before.
        Senator Blumenthal. And how did you develop the protocol
    for the screening? Is it uniform to every instance of screening
    or does it differ at all across the country with different
    individuals, different exposures?
        Dr. Elnahal. It is uniform across the entire country,
    Senator. We have had diligent training on the screening itself,
    so we are training providers across the country. We have done
    so since the legislation was passed and even before that,
    anticipating that we would get the authority to do this.
        But also we are making sure that the electronic health
    record is the place where this information is stored in a
    structured way. So really the prompt is quite easy. It is
    basically a module within the health record. The two standard
    questions are there, and the drop-downs continue, based on what
    the veteran's answers are to these questions.
        So that is structured data that we hope to be able to use
    for all sorts of reasons, whether it is toxic exposure research
    or handing over to VBA.
        Senator Blumenthal. What is the next step, if you find,
    among those 38 percent, that there was exposure?
        Dr. Elnahal. Well, the first and most important step is
    that referral to VBA for possibly enhanced benefits. That is
    how the veteran is going to benefit from this. And as I
    mentioned, having that data clearly documented for every
    veteran who is screened will allow us to gain even more
    insights on the relationship between exposures and health
    outcomes.
        Senator Blumenthal. But your goal in screening is to
    prevent more egregious or serious illnesses, and how do you
    assure that those steps are taken?
        Dr. Elnahal. Well, in the context of a primary care visit,
    Senator, the revelation of a possible exposure naturally leads
    to more questions that physicians and providers may ask in the
    primary care clinic, would perhaps lead to different
    investigations that may not have otherwise occurred. And so on
    a very individual level, to a veteran this is important because
    we can ask about symptoms related to common conditions related
    to exposures. The research that Dr. Hastings and her office
    does has informed us diligently about that. And of course the
    legislation provides us guidance as well.
        Senator Blumenthal. Thanks, Mr. Chairman.
        Chairman Tester. Senator Sullivan.

                          SENATOR DAN SULLIVAN

        Senator Sullivan. Thank you, Mr. Chairman. I would like to
    follow up on a little bit of what Senator Blackburn was talking
    about. A gigantic concern of mine, that we all saw coming, I
    think you saw it, the Biden administration saw it, we saw it
    but we did not do anything about it. I wanted to do something
    about it. Senator Inhofe wanted to do something about it.
        Unfortunately, some of my colleagues on the other side of
    the aisle did not, and it is this--unscrupulous trial lawyers
    who are now preying on Marines on this Camp Lejeune issue and
    are likely to make millions, if not billions of dollars, and
    the sick Marines are going to get crumbs. Okay? We knew it. A
    lot of these guys are unscrupulous, some of them are blood-
    suckers, and they are doing it. Okay? We all see it. Every day.
    You cannot turn on any TV station in America without these ads.
    Okay?
        Here is what the American Legion recently put as a
    resolution. ``Whereas predatory law firms charging exorbitant
    fees''--I am hearing 40 to 50 percent contingency fees. Sick
    Marines, you do not get anything. Trial lawyers get really
    rich. That is happening. It is happening.
        American Legion, ``predatory law firms charging exorbitant
    fees have engaged in aggressive marketing campaigns to include,
    but not limited to, television advertisements, social media,
    digital marketing campaigns, targeting veterans through
    sponsored content. Therefore, be it resolved they are asking us
    for serious oversight with regard to these unscrupulous lawyers
    on the Camp Lejeune Justice Act.''
        Here is why it could have been avoided. The Biden
    administration, to its credit--Mr. Chairman, I would like to
    submit this for the record.
        Chairman Tester. Without objection.

        [Documents submitted by Senator Sullivan appear on pages
    59-76 of the Appendix.]

        Senator Sullivan. This is the technical assistance from the
    Department of Justice to the Biden administration, warning us
    that this was going to happen, and saying if you do not cap the
    contingency fees on these unscrupulous lawyers they are going
    to get all the money. Inefficient delivery will be costly for
    servicemembers--this is the Biden administration Justice
    Department--as well as the Federal Government.
        It went on to explain how they thought there should be a 2
    percent fee cap for filing paperwork and a 10 percent
    contingency cap for trial lawyers. That was the Biden
    administration.
        Senator Inhofe had a bill to do that. My Democratic
    colleagues blocked it.
        So what is happening? The trial lawyers are making millions
    and billions and sick Marines are going to get crumbs. We all
    knew it. Even the Biden administration knew it.
        So what I am going to do is I am going to resubmit the
    Inhofe legislation and try to UC it, and I hope every Senator
    on this Committee supports it, because it is sickening to
    enrich trial lawyers at the expense of sick United States
    Marines. And as a United States Marine I take a little bit of
    umbrage about this.
        So I know that the panelists have had similar concerns, and
    I know your phones are blowing up just like mine. So would you
    support my legislation to do what the Biden administration
    Justice Department told us to do? But, you know, the trial
    lawyers say ``jump'' and certain members of this Committee and
    this body say ``how high.'' So they did not do it. No caps. And
    trial lawyers are getting rich and sick Marines are not getting
    anything.
        I would like any of you to take that one and see if you
    would support what the Biden administration supports. Any
    takers? Are you upset about this just like I am?
        Mr. Jacobs. I am incredibly concerned about the confusion
    that exists amongst the veterans who are seeing these ads.
        Senator Sullivan. Millions and millions of dollars of ads,
    by the way.
        Mr. Jacobs. I have heard a billion dollars.
        Senator Sullivan. Oh, I do not doubt it because they are
    going to make billions.
        Mr. Jacobs. Yes, I would be happy to take that for the
    record. I think we will likely have to----
        Senator Sullivan. Do you agree that this Committee and this
    Senate and this Congress has to do something soon to stop the
    trial lawyers from getting all the money that is supposed to go
    to sick Marines? Would you agree with me, sir?
        Mr. Jacobs. I agree we need to make sure that veterans are
    well informed about the implications of the decisions that they
    make.
        Senator Sullivan. Why do you think trial lawyers are
    spending a billion in advertising?
        Mr. Jacobs. I think there is a clear incentive.
        Senator Sullivan. To get rich at the expense of U.S.
    Marines?
        Mr. Jacobs. I would say that there is a history of
    injustice here that they are working to address, and I think
    that what I would say is if you are a veteran who served in
    Camp Lejeune and that has been affected by contaminated water,
    we at VA want you to file a claim. We have presumptive service
    connection, thanks to Congress. We want veterans to come and
    get the benefits that they have earned.
        And I would also say we want those veterans and the family
    members to understand the implications of the decisions that
    they make when they are considering whether or not to seek
    justice through the courts.
        Senator Sullivan. With a trial lawyer who is going to
    charge them a 60 percent contingency fee and get all the money.
    Correct?
        Mr. Jacobs. I do not know.
        Senator Sullivan. I mean, that is a concern, right?
        Mr. Jacobs. I do not know the amount. What I will tell you
    is we are concerned. I am not talking specifically about trial
    lawyers, but we are concerned about predatory actors who are
    seeking to take advantage of veterans, and that is why we are
    consistently trying to refer our veterans to work with an
    accredited representative, to work with one of our VSO
    partners. They know the system. They have been accredited. They
    are going to do it for free when they come to seek VA benefits.
    We want to make sure that veterans understand that there are
    resources. You can file directly with us. If you are filing for
    a VA claim you can work with----
        Senator Sullivan. You do not need a predatory law firm, as
    the American Legion said. Correct?
        Mr. Jacobs. I defer specific questions about the lawsuits
    to DOJ.
        Senator Sullivan. Okay. So Mr. Chairman, this is a huge
    issue. There are going to be billions of dollars going to these
    predatory law firms at the expense of United States Marines.
    This was predicted. This is now happening. The American Legion
    is raising the alarm bell. The VA is raising the alarm bell.
    The Biden Justice Department raised the alarm bell. And
    unfortunately this Committee did not do anything. As a matter
    of fact, some of you guys blocked it.
        So we need to fix it, and I want to work with the VA, the
    Justice Department to fix it. But U.S. Marines who are sick
    should not have to go begging to unscrupulous trial lawyers who
    are going to take all the money. A billion dollars in
    advertising. The only reason they are doing that is they think
    they are going to make tens of billions at the expense of the
    Marines, and right now they are set to do that.
        So I appreciate your comment. I look forward to working
    with you on this. But it is--this is despicable. Despicable.
    And some of us saw it coming, the Biden Justice Department, for
    God's sakes, saw it coming, and now it is happening. We have
    got to fix it.
        Thank you, Mr. Chairman.
        Chairman Tester. Thank you, Senator Sullivan.
        Mr. Jacobs, I want to talk a little bit about something you
    talked about in your opening statement. It was automation. Now
    the VA is not automating the final decision, but it is instead
    automating prep work, as I understand it, to help with the
    human claims processing to make a final decision.
        Can you tell us about the effectiveness of that automation
    and, quite frankly, is it saving us man hours in the end, and
    do you have any sort of update you could give us on that?
        Mr. Jacobs. Yes. Thank you very much, Mr. Chairman, for
    that question. I think the work that we are doing with
    automated decision support is groundbreaking. It is very early
    in the process, so I think there is still a lot more to do. We
    are currently working on this technology at four of our
    regional offices. We only have run this through a very small
    number of claims because we are investing a significant amount
    of time working with our frontline staff to get their feedback
    on how the system is working, how it is enabling them to make
    more timely and accurate and consistent decisions, and also how
    the user interface is designed. And so it is actually, right
    now, taking us more time to do these decisions because we are
    stopping the claim, we are interviewing the employee.
        We have only made, I think we have only run about 7,000
    claims through the process, and I will turn it over to Rob, who
    has been leading the charge on this effort. I will say it is
    early, but there is great promise.
        Mr. Reynolds. Thank you, Mr. Jacobs, and yes sir, it is
    early in the process, as was mentioned. We started with a
    single claim for increase, so we really have not gotten into
    the presumptives yet.
        But what I can tell you is what we are seeing on that front
    end of the development lifecycle of the claim is that we are
    reducing the average touches of a claim by about 44 percent,
    and 63 percent of claims are processed with no development at
    all, meaning they are going right to the rater.
        And a couple of the key points that we are doing in this
    automated decision support is really what was realized from the
    global pandemic, when we had trouble getting Federal records,
    and/or getting some of our most vulnerable veterans to medical
    appointments. We are leveraging that data. If we have
    sufficient medical evidence, we do not necessarily need to
    order an exam. We have got evidence that can rate the claim.
        So, the technology is really realizing the efficiencies on
    the front-end part, but as Mr. Jacobs said, our VSRs, the
    raters, have been critical in that human-centered design piece
    of it. While we are not seeing the lift or efficiency yet, we
    are less than a year into the process. It is very early, but it
    looks promising.
        Chairman Tester. Thank you. The PACT Act also mandates that
    the VA conduct several large-scale research studies into toxic
    exposure. These studies will depend heavily on VA researchers
    and collaborative efforts with other Federal agencies.
        Recent guidance from the Department of Justice puts
    hundreds of VA researchers who received compensation for
    research conducted outside their work with the VA at risk of
    criminal prosecution. So what impact does this guidance have on
    VA's research, and does it hinder VA's ability to complete the
    research mandated in the PACT Act?
        Dr. Elnahal. I will say, Senator, in general terms, it is a
    big risk for VA and the research that we conduct. We not only
    conduct research for toxic exposures, we are, in many cases,
    the organization that is conducting major clinical trials,
    answering key questions across all of American medicine. And
    what this risks is the participation and employment of these
    physician scientists and our hospitals.
        Thankfully, we have a legislative proposal that I know you
    are considering that will provide us relief on this. It is
    mentioned under the VIPER Act as one of the options. We support
    getting legislative relief on this because I am concerned, writ
    large, about our ability to have enough physician scientists
    and to continue, frankly, already ongoing studies, whether they
    are basic science or clinical, to answer some of these key
    questions.
        I will ask Dr. Hastings if she has other things to add on
    this.
        Dr. Hastings. Mr. Chairman, for the research that is
    specifically in the PACT Act, our epidemiologists are prepared
    to carry it out. I do not see any specific problems with
    regards to this Department of Justice letter for the PACT Act-
    specific research that we have. And I would like to take it for
    the record and explore it a bit more, just to make sure. But we
    are very excited to carry on the research that you have
    directed.
        Chairman Tester. You can take that for the record and get
    back to us. Thank you very much.
        Senator Moran?
        Senator Moran. Mr. Chairman and witnesses, I think I am
    just about done. Let me ask one more.
        I want to make certain that the VA is proactively looking
    at technology-based innovative solutions to provide quality
    customer service and claims accuracy and timeliness. Since
    innovation does not necessarily mean in-house, is the VA
    looking to partner with experts in the field to provide quality
    access and outcomes to veterans when it comes to medical
    disability exams, possible technologies to further enhance
    claim processing automation?
        Mr. Jacobs. Yes, thank you very much for that question. The
    majority of our compensation pension exams are done by
    contractors, by vendors in the community. We do a small number
    with our VHA colleagues, but we are also mindful of allowing
    them to have clinical capacity to deliver health care.
        I would say, to your question, everything is on the table.
    We do not profess to own all of the solutions or the good
    ideas, and we want to work with industry. To the extent that
    there are good ideas and solutions to help us better meet the
    needs of veterans in a more timely, accurate, and equitable
    way, we are all for it. So if you have ideas, we want to hear
    them.
        Senator Moran. Are vendors, are companies bringing you
    those ideas now, like they see an opportunity and they are
    making their case?
        Mr. Jacobs. Oh yes. I will defer to Rob. I am sure his
    inbox is full of requests.
        Senator Moran. I am not surprised.
        Mr. Reynolds. Yes, sir. We get plenty of outreach from our
    vendor partners out there. In fact, some of our contracts that
    we are working on now are professional managed services as
    well, so not in-house folks we have brought in.
        And one key piece that we just put in for the quality
    aspect is an IV&V contractor, to help us look, from an
    independent third-party lens, of what we are doing in the
    automation and that the quality is there as we move forward in
    this. So we are looking at all those outside vendors to help us
    get this right, as well.
        Senator Moran. Thank you all for being here today, and I
    thank you for your efforts. They are appreciated and necessary
    as we work to implement this major piece of legislation to
    benefit a significant number of veterans who desperately need
    timely, quality care and benefits. And so I express my
    gratitude to each of you and to those you work with at the
    Department of Veterans Affairs. And again I would offer, you
    have made a couple of suggestions in legislation and
    appropriations during this hearing, but if there are things
    that need to be addressed to help you accomplish that goal, to
    help us accomplish that goal together, please reach out to me
    and to my colleagues.
        And I would welcome you, Dr. Elnahal, to come to Kansas and
    we will promote the PACT Act and let you see how it is working
    in the field, if that appeals to you. And anybody that has
    suggestions of how I and other can educate our veteran
    population about the opportunities, through our social media
    and other ways that we communicate with constituents, I am
    interested in being helpful. Thank you.
        Chairman Tester. I want to associate myself with the
    closing comments that the Vice Chairman just made. I appreciate
    you guys. We are here to help in any way, whether it is
    education, manpower, whatever it might be, to make this thing
    work. It is a big piece of legislation--we all knew that when
    we passed it--and I think it is an all-hands-on-deck kind of
    scenario. So thank you very much for what you are doing. Thank
    you for being at this hearing.
        We will keep oversighting. We will keep holding you
    accountable. And we will also keep the record open for another
    2 weeks for additional comments.
        With that this hearing is adjourned. Thank you.
        [Whereupon, at 4:27 p.m., the hearing was adjourned.]

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