[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
       
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                 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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