    [House Hearing, 118 Congress]
    [From the U.S. Government Publishing Office]

                      BUILDING AN ACCOUNTABLE VA: APPLYING
                        LESSONS TO DRIVE FUTURE SUCCESS

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

                                     HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED EIGHTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                           TUESDAY, FEBRUARY 28, 2023

                                   __________

                                Serial No. 118-1

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                        Available via http://govinfo.gov

                                  __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    51-535                       WASHINGTON : 2023

    -----------------------------------------------------------------------------------

                         COMMITTEE ON VETERANS' AFFAIRS

                         MIKE BOST, Illinois, Chairman

    AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking
        American Samoa, Vice-Chairwoman      Member
    JACK BERGMAN, Michigan               JULIA BROWNLEY, California
    NANCY MACE, South Carolina           MIKE LEVIN, California
    MATTHEW M. ROSENDALE, SR., Montana   CHRIS PAPPAS, New Hampshire
    MARIANNETTE MILLER-MEEKS, Iowa       FRANK J. MRVAN, Indiana
    GREGORY F. MURPHY, North Carolina    SHEILA CHERFILUS-MCCORMICK,
    C. SCOTT FRANKLIN, Florida               Florida
    DERRICK VAN ORDEN, Wisconsin         CHRISTOPHER R. DELUZIO,
    MORGAN LUTTRELL, Texas                   Pennsylvania
    JUAN CISCOMANI, Arizona              MORGAN MCGARVEY, Kentucky
    ELIJAH CRANE, Arizona                DELIA C. RAMIREZ, Illinois
    KEITH SELF, Texas                    GREG LANDSMAN, Ohio
    JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

                           Jon Clark, Staff Director
                      Matt Reel, Democratic Staff Director

    Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
    hearing records of the Committee on Veterans' Affairs are also
    published in electronic form. The printed hearing record remains the
    official version. Because electronic submissions are used to prepare
    both printed and electronic versions of the hearing record, the process
    of converting between various electronic formats may introduce
    unintentional errors or omissions. Such occurrences are inherent in the
    current publication process and should diminish as the process is
    further refined.

                             C  O  N  T  E  N  T  S

                                  ----------

                           TUESDAY, FEBRUARY 28, 2023

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Mike Bost, Chairman................................     1
    The Honorable Mark Takano, Ranking Member........................     2

                                   WITNESSES

    The Honorable Michael Missal, Inspector General, Office of the
      Inspector General, Department of Veterans Affairs..............     3

    The Honorable Gene Dodaro, Comptroller General of the United
      States, Government Accountability Office.......................     5

    The Honorable Shereef Elnahal, M.D., Under Secretary for Health,
      Department of Veterans Affairs.................................     6

            Accompanied by:

        Mr. Michael Frueh, Principal Deputy Under Secretary for
            Benefits, Department of Veterans Affairs

        The Honorable Matthew Quinn, Under Secretary for Memorial
            Affairs, Department of Veterans Affairs

                                    APPENDIX
                        Prepared Statements Of Witnesses

    The Honorable Michael Missal Prepared Statement..................    37
    The Honorable Gene Dodaro Prepared Statement.....................    47
    The Honorable Shereef Elnahal, M.D. Prepared Statement...........    81

                           Statements For The Record

    Concerned Veterans for America...................................    93
    America's Warrior Partnership....................................    97
    American Federation of Government Employees......................    99
    Student Veterans of America......................................   107

                      BUILDING AN ACCOUNTABLE VA: APPLYING
                        LESSONS TO DRIVE FUTURE SUCCESS

                                  ----------

                           TUESDAY, FEBRUARY 28, 2023

                         Committee on Veterans' Affairs
                                  U.S. House of Representatives
                                                       Washington, D.C.
        The committee met, pursuant to notice, at 2:24 p.m., in
    room 360, Cannon House Office Building, Hon. Mike Bost
    (chairman of the committee) presiding.
        Present: Representatives Bost, Radewagen, Bergman,
    Rosendale, Miller-Meeks, Murphy, Franklin, Van Orden,
    Ciscomani, Self, Kiggans, Takano, Brownley, Levin, Pappas,
    Mrvan, Cherfilus-McCormick, Deluzio, McGarvey, Landsman, and
    Budzinski.

                OPENING STATEMENT OF MIKE BOST, CHAIRMAN

        The Chairman. If we can get our witnesses to come forward.
    If we can have our witnesses come to the witness table, that
    would be fine.
        Good afternoon and thank you all for being here. Welcome to
    the House Committee on Veterans Affairs' first Oversight
    Hearing of the 118th Congress. I am honored to be the chairman
    of this important committee and leading a group of great
    members. Every one of these members, Republican and Democrat,
    is here because they believe in President Lincoln's promise. We
    all have the responsibility, every man and woman who has served
    in our armed forces, to craft laws that deliver veterans the
    care and benefits they have earned.
        This starts by overseeing VA to make sure that those laws
    are carried out as intended. Unfortunately, VA at times has
    fallen short of that promise to the veterans. And last year
    Inspector General Michael Missal, who is here with us today,
    put it plainly. While discussing the tragic incidents of the VA
    medical centers in Arkansas and West Virginia, Mr. Missal
    stated these failures were the consequences of ``disengaged
    leadership and dangerous culture that is fostered when leaders
    are not attentive to or invested in their staff and the
    veterans they serve.'' Mr. Missal, those were powerful words.
    They ring in my ears. They echo in this room. I hope they keep
    those failed leaders up at night.
        Sadly, they are not the only instances of failed
    leadership. Recently, we have seen veterans denied access to
    community care in direct defiance of the Mission Act
    guidelines, poor care coordination, and delayed diagnoses,
    resulting in low quality care for veterans. VA improperly
    rejecting 31,000 disability claims submitted through its own
    website, senior leaders ignoring disciplinary recommendations,
    and failing to hold management accountable. The Electronic
    Health Record (EHR) Modernization Program is on its fourth
    director in 5 years and continues to burn money and distribute
    care and disrupt care. The VA prioritizing employee
    productivity at the expense of veterans receiving compensation
    and pension benefits.
        Strong, engaged, and thoughtful leadership is the single
    most important factor needed to successfully run an
    organization of any size, be it a family owned trucking company
    like the one I used to run, or one of the largest departments
    of the Federal Government. I am confident that every member of
    this committee agrees with me. All of the examples I just
    listed are areas where leadership failed.
        However, they are not the end of the story. We can and we
    must learn from these failures to deliver a VA that is worthy
    of veterans' service to our great country. This is how we will
    drive VA toward success. Like medical facilities' empowered
    employees to identify and address issues without fear of
    punishment. Helping over 2 million veterans secure housing with
    a VA home loan over the last 2 years, saving over 200,000
    veterans from having their houses foreclosed on during record
    high inflation caused by the Biden administration, and ensuring
    that veterans receive a dignified burial.
        There are all these successes that we can be proud of, but
    unfortunately, they are not yet the norm. VA is simply not
    where it should be. Bringing VA into the 21st Century for
    veterans is my No. 1 priority. With engaged and accountable
    leadership on every level, VA can get to where our veterans
    need it to be. That starts today. We can get there with tough
    but fair oversight, common sense legislation, a commitment from
    VA leadership to always put veterans at the forefront of their
    decisionmaking process. With that, I thank our witnesses for
    being here today. I now recognize ranking member Takano for his
    opening comments.

            OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER

        Mr. Takano. Well, thank you, Mr. Chairman. You and I have
    served together on this committee for more than 8 years now.
    While we may have our differences from time to time, and while
    there are certain issues on which we will never see eye to eye,
    one thing I have appreciated about working with you is that
    whenever possible, we have done our best to find common ground.
    I think one of the most fundamental things we agree on is our
    obligation to hold VA accountable for achieving its sacred
    mission of caring for and honoring our Nation's veterans and
    their families, caregivers, and survivors.
        The last 4 years were busy and productive ones for this
    committee. We saw 36 bills enacted into law, including
    legislation that will address the effects of toxic exposure,
    improve veterans mental health, and reduce suicide, strengthen
    delivery of health care and benefits to women veterans, support
    veterans experiencing housing insecurity, and strengthening
    VA's IT modernization efforts and cybersecurity.
        Dr. Elnahal, Mr. Frueh, and Ms. Quinn, you hold a
    tremendous amount of responsibility. We know you and Secretary
    McDonough are facing many challenges as VA strives to meet its
    mission. One such challenge, a substantial one to be sure, will
    be implementing the Honoring our PACT Act, the landmark
    legislation I championed that finally recognizes the effects of
    toxic exposure as a cost of war. Because of the PACT Act, more
    than 3.5 million veterans are newly eligible for VA health care
    and disability benefits, the most significant VA eligibility
    expansion in decades.
        Like the witnesses, this committee also holds a tremendous
    amount of responsibility. We must conduct rigorous oversight to
    ensure the Department faithfully implements new legislation
    like the PACT Act, while also holding VA accountable for
    efficiently and effectively delivering all other health care
    and benefits veterans have earned.
        Fortunately, we have with us today two of our Nation's
    foremost experts in accountability. VA's Inspector General, Mr.
    Michael Missal and Comptroller General Gene Dodaro of the
    Government Accountability Office. Together, they bring to the
    witness table at least 80 years of collective experience in
    conducting independent, nonpartisan oversight, and
    investigations. As such, they will be able to speak extremely
    knowledgeably about what it takes to ensure accountability at
    VA, the extent to which the Department is successfully meeting
    its mission, and what, if anything, Congress can do to support
    improved accountability across VA.
        It is clear from their testimony that both Inspector
    General Missal and Controller General Dodaro believe strong,
    stable leadership is the foundation upon which accountability
    is built. Having served on this committee since my first year
    in Congress, I could not agree more. Mr. Missal and Mr. Dodaro,
    Chairman Bost, and I have all been in our current roles since
    the Obama administration and have witnessed numerous transition
    in VA leadership during our tenure.
        I am sure today's hearing will provide many opportunities
    for us to examine the negative effects of leadership
    instability on VA's programs. In addition, I anticipate today's
    hearing will also provide an opportunity to examine other major
    management challenges at VA, including persistent staffing
    shortages, antiquated information technology, an aging
    infrastructure, and the extent to which VA is equipped to
    address them.
        I look forward to engaging with our witnesses this
    afternoon and to beginning the work ahead of our committee,
    this Congress. Thank you, Chairman Bost, and I yield back.
        The Chairman. Thank you, Ranking Member Takano. We will now
    turn to our witnesses' testimony. Testifying before us today,
    we have Hon. Michael Missal, Inspector General of the
    Department of Veterans Affairs, Hon. Gene Dodaro, Comptroller
    General of the United States, and Hon. Shereef Elnahal,
    Undersecretary for Health and VA. Now, he is joined by Mr.
    Michael Frueh, Principal Deputy Undersecretary for Benefits at
    the VA, and Hon. Matthew Quinn, Undersecretary for the Memorial
    Affairs at VA. Mr. Missal, you are recognized for 5 minutes.

                      STATEMENT OF MICHAEL MISSAL

        Mr. Missal. Thank you, Chairman Bost, Ranking Member
    Takano, members of the committee, I appreciate the opportunity
    to discuss how the Office of Inspector General's (OIG) work
    enhances VA's accountability. The OIG shares this Committee's
    goal to conduct effective oversight of VA so that it can better
    serve our veterans, their families, and caregivers. Our
    dedicated staff is passionate about their work and committed to
    our mission of meaningful independent oversight.
        In Fiscal Year 2022, our office released more than 250
    oversight publications with 894 recommendations to VA. We made
    over 230 arrests and more than 180 convictions. We had a
    monetary impact of more than $4.5 billion, in addition to the
    invaluable work of our healthcare inspectors that enhance
    patient care and safety. These efforts to improve benefits and
    services for veterans and their families would not be possible
    without the funding and support we receive from Congress.
        Our office appreciates the work VA does every day on behalf
    of veterans. We have regular interactions that we have--we
    value the regular interactions that we have with Secretary
    McDonough and other senior leaders to discuss their concerns
    and priorities. We generally get very good cooperation from the
    Department.
        In addition, we have a strong and collaborative
    relationship with Comptroller General Dodaro and his staff. We
    coordinate efforts with the Government Accountability Office
    (GAO), which promotes more consequential oversight. Our
    oversight work has identified at least five principles that are
    foundational to accountability, and there are examples of each
    in my written testimony.
        They are, first, strong governance and clarity of roles and
    responsibilities. We have found tension between VA offices that
    have policy and oversight functions and leaders in the field
    who are not accountable to those offices. In other cases, staff
    do not understand their roles and responsibilities, or there is
    outdated or conflicting guidance.
        Second, adequate and qualified staffing to carry out those
    duties. VA faces high staff vacancy rates across its programs
    and operations, especially within Veterans Health
    Administration (VHA). These long-standing shortages make it
    challenging for VA to carry out its many programs and
    functions.
        Third, updated IT systems and effective business processes.
    VA is in the process of modernizing a number of significant
    systems that are critical to its operations. We have been
    proactively overseeing VA's implementation of these systems.
    This includes publishing 14 reports on the transformation of
    VA's electronic health record system alone.
        Fourth, effective quality assurance and monitoring to
    detect and resolve issues. VA often lacks controls that
    effectively and consistently ensure that quality standards are
    met. Breakdowns in routine monitoring and workarounds undermine
    efforts to ensure eligible veterans and their families receive
    timely services and benefits.
        Fifth, stable and effective leadership. Frequent turnover,
    vacancies, and long-term use of leaders in acting positions
    have significant negative consequences. Stable and dedicated
    leadership fosters open communication, collaboration,
    psychological safety, and responsibility among all staff.
        I would like to emphasize that OIG report findings and
    recommendations directed to a singular facility, system, or
    program are typically a roadmap to help prevent or correct
    similar problems. These problems are often undetected or
    unaddressed in other facilities or offices across VA. I hope
    that this committee will join me in encouraging leaders at
    every level of VA to review our work proactively to determine
    if findings and recommendations are applicable to their areas
    of responsibility.
        We recognize that VA is working to develop these
    foundations of accountability. We routinely observe personnel
    committed to providing the highest quality care, benefits, and
    services to veterans and their families, despite obstacles. The
    OIG will continue to provide practical and meaningful
    recommendations to help VA remove these obstacles and to
    improve its programs and operations.
        Chairman Bost, and members of the committee, this concludes
    my statement. I look forward to answering any questions that
    you may have.

        [The Prepared Statement Of Michael Missal Appears In The
    Appendix]

        The Chairman. Thank you, Mr. Missal. Mr. Dodaro, you are
    now recognized for 5 minutes.

                        STATEMENT OF GENE DODARO

        Mr. Dodaro. Good afternoon, Mr. Chairman, Representative
    Takano, ranking member, and members of the committee. I am very
    pleased to be here today to talk about GAO's work regarding the
    Veterans Administration. The VA is filled with talented people
    dedicated to their noble mission of serving our veterans.
    However, they work in an unwieldy, highly decentralized
    organization where efforts to bring about positive change are
    extremely difficult to happen. In fact, many initiatives to
    make improvements result in little, if any, meaningful change
    within the Department.
        As a result of observing this over a number of years, I
    added a number of VA areas to a list we keep for the Congress
    of what we consider to be high risk programs and activities.
    These are programs where there is waste, mismanagement, or in
    need of broad-based transformation. We have added veterans'
    healthcare, the acquisition management area, and disability
    exams to this area.
        Now, in the healthcare area, there are a number of things
    we pointed out. First, there is a need for better standards and
    measures to ensure timely access of veterans to the care that
    they need. Also, in the mental health and behavioral health
    area, more analysis to provide services targeted to veterans in
    need of intensive medical health services could be improved,
    particularly for rural veterans. Also, efforts to integrate
    behavioral healthcare into primary health services, which is
    one of VA's strategies, has been hampered by a lack of staff
    shortages, and more attention needs to be put in that area.
    Also, oversight of long-term care facilities needs to be
    improved, both in the oversight of State nursing homes that VA
    provides funds to, as well as VA's own community living
    centers.
        There also needs to be greater attention to ensure there
    are enough providers in the networks to provide care, and also
    that ineligible providers are rooted out, and not allowed to
    provide care in the system, and that employees really pass the
    background screening investigations that they must pass in
    order to ensure the care of veterans and protect our veterans.
    Also, as Mr. Mitchell mentioned, there is a need for much more
    disciplined management practices to ensure the effective
    implementation of the electronic healthcare record system.
        Now, in the acquisition management area, this area, there
    needs to be better strategies to purchase medical and surgical
    supplies in a much more efficient manner than there has been.
    There needs to be attention to supply chain management, so not
    only what is purchased, but how it is managed to get to the
    right places at the right time. Also, to make sure you have an
    adequate workforce in the acquisition area that is trained and
    competent to carry out their responsibilities, to provide the
    support necessary to give medical care to our veterans.
        In the disability exams area, this is one of long-standing
    concerns. You know, we are still using the Veterans Department,
    you know, medical criteria and earnings loss information based
    on a 1940's model. This needs to be improved. VA has been
    working on it. They are 8 years behind schedule. While there
    have been studies, there have not been improvements to this
    system. Also, there is a big backlog. There is about 80,000
    cases from their legacy appeals process, which on average is
    taking 7 years to render an appeal. There is a 380,000 backlog
    in appeals under the new five option appeals process that they
    have.
        As a result of these legacy issues, they are not as well
    positioned as I believe they need to be and could be in order
    to implement the PACT Act. Now that is going to be a heavy lift
    for them and they need to learn from some of these past areas
    where they are not applying best management practices to
    effectuate a good, efficient disability system that ensures
    timely processing of original claims, as well as the appeals
    process going forward.
        We are dedicated at GAO to working with the Inspector
    General with the Veterans Department. I have noticed some
    improvement lately in our efforts to get agreement of what
    needs to be done with the Department. I see some glimmers of
    progress, but that is only the beginning, and there is a long
    way necessary to really bring about the type of change that our
    veterans deserve. I would be happy to answer questions at the
    appropriate point.

        [The Prepared Statement Of Gene Dodaro Appears In The
    Appendix]

        The Chairman. Thank you, Mr. Dodaro. Dr. Elnahal, you are
    recognized for 5 minutes.

                      STATEMENT OF SHEREEF ELNAHAL

        Mr. Elnahal. Thank you, Mr. Chairman, Ranking Member
    Takano, members of the committee for this opportunity to appear
    before you today to discuss the Department of Veterans Affairs
    and our accountability efforts. I am joined today by my
    colleagues from the National Cemetery Administration, Mr.
    Matthew Quinn, Undersecretary for Memorial Affairs, and Mr.
    Michael Frueh, Principal Deputy Undersecretary for Benefits.
        The three of us have had the pleasure to lead a workforce
    that goes above and beyond to serve our Nation's veterans.
    Linda Nair, a licensed practical nurse in Lewistown, Montana,
    demonstrated that dedication when she traveled through two feet
    of snow to ensure veterans receive care during inclement
    weather recently. She does not believe she did anything
    special, but I believe that she demonstrates our employees'
    dedication at every level of the organization. I am sure Mr.
    Quinn and Mr. Frueh can provide similar examples of staff who
    go the extra mile for veterans.
        I want to express gratitude for the PACT Act, the largest
    expansion of benefits and care to veterans in a generation, and
    the Consolidated Appropriations Act of 2023, which provided
    additional authorities and funding to advance our mission. VA
    is also grateful for the partnership with independent
    investigators that improve the way that we serve veterans. Our
    transparency and accountability efforts are significantly
    enhanced by the Government Accountability Office, Office of the
    Inspector General, Office of the Special Counsel, and
    accreditation organizations.
        Thus, I have made it a practice to meet regularly with OIG,
    and I have met directly with GAO officials like Mr. Dodaro and
    his healthcare team multiple times to proactively identify
    opportunities for improvement. As a high reliability
    organization, or HRO, our goal is to enhance the overall
    culture of safety and decrease patient harm events across the
    organization. The HRO accountability framework involves
    instituting a just culture which balances individual
    accountability with systems thinking.
        Patient safety literature has shown that system
    vulnerabilities account for the vast majority of patient safety
    events and lapses in care, and it is incumbent upon staff and
    leadership alike to report and respond to systems issues.
    However, the framework also allows for individual culpability
    in cases of malfeasance, neglect, or instances where leaders
    fail to learn from or respond to patterns of problems when they
    arise.
        Accountability is also a culture and not a specific
    instance of wrongdoing. At VHA, our healthcare operations
    center has established a system to track implementation of our
    priorities. Review of key performance indicators in every
    facility and Veterans Integrated Service Network (VISN) allow
    us to understand which regions are exceeding expectations,
    which have made significant improvements, and which could
    benefit from additional support to ensure every veteran
    receives the care they deserve, regardless of where they live.
        Recently, the Office of Accountability and Whistleblower
    Protection, or OAWP, has undertaken a significant outreach in
    education strategy that involves onsite visits by OAWP senior
    leaders, and more widespread, tailored training. All three VA
    administrations have embraced these efforts and are working
    with OAWP to extend their reach.
        My colleague, Mr. Quinn, is ensuring that our national
    cemeteries are held to a standard befitting of a national
    shrine. Each year, cemetery directors conduct self-assessments
    of their cemeteries to ensure compliance with established
    standards. National Cemetery Administration (NCA) teams also
    conduct meticulous onsite reviews of selected cemeteries, and
    sites are required to develop plans to address any areas noted
    for improvement.
        Recently, NCA achieved an index score of 97 on the American
    Customer Satisfaction Index, the highest score ever achieved by
    any organization, public or private. My colleagues, Mr. Frueh
    and Mr. Josh Jacobs, are ensuring that veterans receive
    appropriate and timely benefits. I am proud to say, as their
    colleague, due to the efforts of dedicated Veterans Benefits
    Administration (VBA) employees, VBA processed a record number
    of claims in fiscal years 2021 and 2022. We have already
    processed more claims so far in Fiscal Year 2023 than we have
    at the same point last year.
        In addition to increasing total production, VBA employees
    also increased productivity in fiscal years 2021 and 2022,
    completing more rating claims per Full Time Equivalent (FTE)
    than ever before. Further, of the more than 320,000 PACT Act
    related claims received since the PACT Act was signed into law,
    nearly 140,000 claims have been processed, and 1,500 terminally
    ill veterans have been granted presumptive service connection.
        VA continues to conduct compliance and quality reviews to
    ensure leaders are accountable for quickly and accurately
    providing veterans the benefits they have earned. The Legacy
    Appeals Inventory has been reduced to just over 25,000 cases,
    representing a 92 percent reduction. Caring for our country's
    veterans and their families is a mission that unites us all. I
    am honored to work with this committee, Congress as a whole,
    and our many other partners to embrace our collective
    responsibility to serve veterans.
        Chairman Bost and Ranking Member Takano, thank you for the
    opportunity to appear before you today, and we look forward to
    your questions.

        [The Prepared Statement Of Shereef Elnahal Appears In The
    Appendix]

        The Chairman. Thank you, Dr. Elnahal. We are going to now
    go to questions, and I would like to recognize myself first for
    5 minutes.
        Dr. Elnahal, on January 31 of this year, Dr. Miller-Meeks
    and I sent a joint letter to you asking regarding data
    regarding abortion provided by the VA. We requested that you
    would provide us that data by February 10, 2023. However, my
    office is still waiting for your response. Can we get a
    commitment from you that we can get that response by March 3?
        Mr. Elnahal. Chairman, we will certainly respond to the
    letter. We have to make sure that our response respects the
    safety and privacy of the veterans we serve.
        The Chairman. Right. Believe me, in the letter, we were not
    asking for names. We are asking for numbers. That is what we
    are asking for. Also, with that, we are asking the procedures
    and at what point these were done.
        No private information. We are not wanting any private
    information. We are looking at this as a whole. Also, we are
    needed to ask also if you could respond to the quarterly
    request for data starting on March 31, because we know there is
    pending suits over this. We are just wanting to know where we
    are at as far as your mission and the procedures that you are
    doing without names.
        Mr. Elnahal. I understand, Mr. Chairman. We are committed
    to getting you a response to that letter.
        The Chairman. All right, thank you. Also, I need to applaud
    VHA for their efforts to create an environment where any
    employee can raise their hand and report a problem. We
    appreciate that. However, too often I hear from employees who
    have reported harassment and hostile work environments, but
    nothing happens. We are losing good employees because we are
    not removing bad ones. How do we turn that around? That is for
    you, doctor.
        Mr. Elnahal. Mr. Chairman, I think the initiative that we
    are undertaking around high reliability speaks exactly to what
    you are asking about. We want every single employee in our
    healthcare system and beyond to understand that they have the
    right to raise a voice and in fact, that they should be
    encouraged to raise issues when they see them without fear of
    retaliation and in a manner that protects whistleblowers so
    that we can respond effectively to improve the system on behalf
    of veterans. That is the core of the high reliability effort,
    which started years ago and is now in place at every single
    facility as of September of last year.
        The Chairman. I really do believe that you as an
    administration and the Secretary are trying to do that. I do
    believe that there are certain administrators at different
    facilities that maybe do not encourage that as much. We want to
    work with you to make sure that when we get those reports, that
    we make sure that the employees understand we want them to come
    forward, because it is about the veterans. It is not about the
    management of any one facility.
        Mr. Missal, you have been the Inspector General since 2016.
    Your statement about disengaged leadership is very powerful. Do
    you believe VA leadership is up to the task of running the one
    of the largest departments in the Federal Government?
        Mr. Missal. We have found that the very senior leadership
    at VA is very engaged, and they understand the importance of
    oversight. They work with us very closely. However, all levels
    of leadership need to be engaged to have the highest
    functioning operation. What we have found in our reports is
    that a root cause toward many of the problems is due to some
    failure of leadership at some level.
        Getting back to your last question about what can be done.
    If VA does not hold people accountable for issues that they
    have, it is really hard to improve the culture, and it is
    really hard to improve leadership.
        The Chairman. I understand. Mr. Frueh, VBA is faced with a
    growing backlog of disability claims. How are you working to
    build trust with veterans that VA will decide their claim
    correctly the first time?
        Mr. Frueh. Excuse me?
        The Chairman. Yes.
        Mr. Frueh. We take our mission very seriously to provide
    benefits to veterans, to all veterans, and we do not want any
    veteran to wait to access the benefits they have earned. We
    have positioned ourselves in the last several years with a
    series of people, process, technology changes throughout our
    organization. In terms of people, hiring more people in the
    last several years. In terms of technology, providing more
    enabling technology so we can quickly gather information and
    reach a decision, whether it is for a compensation claim, or an
    education claim, or a certificate of eligibility for a loan
    guarantee. Through processes trying to find a way to get
    feedback from our people to the people that design the
    processes to say that is not working as well as we can.
        We have been changing dramatically over the last several
    years, and the results have shown that we have been able to
    increase our production and deliver more quickly, more benefits
    to more veterans, more equitably than we ever have in the past
    before. I hope veterans judge us by what they see through the
    service we deliver.
        The Chairman. Thank you for those answers. With that, I
    will yield back and now recognize the ranking member, Ranking
    Member Takano.
        Mr. Takano. Thank you, Mr. Chairman. Dr. Elnahal, House
    Republican leaders recently announced their intent to cap
    Fiscal Year 2024 discretionary spending at the Fiscal Year 2022
    enacted level. For VA, this would mean a cut of at least $31
    billion in funding for veterans health care because Congress
    approves funding levels for VA medical programs one Fiscal Year
    in advance.
        I expect this committee will have a much more robust
    discussion about this at our annual budget hearing later this
    spring. Since the topic of today's hearing is applying lessons
    learned to drive future success, please tell us what a $31
    billion cut would mean for VA's future success.
        Mr. Elnahal. Well, if that were to happen, Mr. Ranking
    Member, I would be deeply concerned about resourcing the health
    care needed, not only for our existing base of veterans, but
    for veterans who are expected to increase their reliance on
    healthcare within the VA, including the aging veterans already
    enrolled in VA Healthcare, but also the veterans who are
    standing to benefit from the PACT Act, both new enrollees and
    veterans currently enrolled who stand to increase our priority
    group after they apply for additional benefits from VBA.
        On top of that, we have a situation where we expect demand
    to grow significantly year to year. We need more funding and
    more support, not less. I would be very concerned about
    resourcing the care needed for veterans.
        Mr. Takano. Well, thank you. Beyond the fact--thank you for
    that response--beyond the fact that this would destroy your
    ability to prepare for the up to 3.5 million PACT Act eligible
    veterans to enter the VA health care system, and I mention that
    because Inspector General Missal just cited in one of his five
    concerns about the success of VA is the understaffing, the
    chronic understaffing. VA is already chronically understaffed.
    Can you comment about what this $31 billion cut would mean for
    VA's ability to staff up just in the professional arena? The
    professional providers or medical providers what this would
    mean to be able to staff up for the 3.5 million veterans we
    anticipate entering into the system?
        Mr. Elnahal. I think it is a very good question, Mr.
    Ranking Member. Certainty to at least to the greatest extent
    possible on funding in the out years is really important when
    it comes to the hiring mission. Of course, we need the funding
    to start paying for new employees now as we bring them on. We
    brought on a record of 18,500 additional employees within the
    healthcare system in the first quarter of this fiscal year. If
    you ask our operational leaders in the field, as I do every
    time we meet in our governing board about concerns they have
    for funding into the future, this is an FTE base that we hope
    continues into the out years. The need to be able to pay these
    employees to meet the veteran mission will continue into the
    out years. We do hope that we continue to see the generous
    funding that Congress has been able to provide VA.
        Mr. Takano. Well, you know, what programs or operations
    could withstand a cut of this magnitude? Are there any at VHA?
        Mr. Elnahal. I can not think of one, Mr. Ranking Member.
        Mr. Takano. Thank you. Dr. Elnahal, I am sure you are aware
    the Drug Enforcement Administration (DEA) proposed two rules
    relating to prescribing controlled substances via telemedicine.
    These rules are urgently needed because we are rapidly nearing
    the end of the COVID-19 public health emergency, which for
    almost 3 years now, has waived requirements for patients to
    have in person evaluations with their prescribers prior to
    receiving controlled substance prescriptions. Very quickly, I
    do not have much time, will VA commit to providing a bipartisan
    briefing for committee staff no later than this Friday so we
    can better understand the potential effect of this rule for our
    veterans?
        Mr. Elnahal. We will definitely brief you, Mr. Chairman,
    when it comes to the implication for veterans. I am very
    pleased to see that DEA put this rule out. We were very
    concerned about the ability to initiate new prescriptions for
    controlled substances, which not only include pain medications
    like opioids, but also immunosuppressants, for example,
    critical medications for conditions that veterans commonly
    face. We do hope this rule comes into effect, of course, before
    the public health emergency ends, so that we do not see any
    lapses in care for veterans getting care through telehealth.
        Mr. Takano. Yes, well, thank you for that. We only have 30
    days to comment on the rule, as you know. We are already
    hearing from some stakeholders that DEA's rules are still too
    strict and could present unnecessary barriers for patients who
    need these medications to treat pain, substance use disorder,
    and other mental health conditions. You just mentioned
    immunosuppressants. It is not just about controlling opioids.
    We got to make sure that our patients in rural areas remain
    capable of being able to get these medications without undue
    burdens. I yield back, Mr. Chairman.
        The Chairman. Thank you, Ranking Member. I now recognize
    General Bergman for 5 minutes.
        Mr. Bergman. Thank you, Mr. Chairman. We will get right to
    it, folks. Mr. Frueh, I would like to ask you about the current
    flaws in the VA accreditation system for agents who are
    assisting veterans in obtaining disability benefits. Under the
    current model, accredited agents cannot charge fees for
    assisting in an initial claim, but instead collect on the back
    pay after the process is complete. Do you agree that this
    creates a financial incentive for those accredited agents to
    drag out the process as long as possible instead of getting
    things right initially?
        Mr. Frueh. As I said before, I do not want any veteran to
    wait to receive their benefit. In terms of accredited agents,
    agents are not allowed to charge a veteran for submission of a
    claim before VA. They are able to charge for an appeal, but not
    for an initial claim.
        Mr. Bergman. The agent benefits if there is an appeal.
        Mr. Frueh. We always recommend to veterans to look for----
        Mr. Bergman. Let me cut to the point here. I guess the goal
    is, when do the veterans benefit, because we can talk about
    things like efficiency and effectiveness. You can be very
    efficient. You can answer 1,000 emails today. What was the
    effectiveness to the, if you will, the end game in this case,
    benefiting the veteran if none of those emails resulted in a
    positive outcome for them?
        Remember, last time I checked, we are all on this earth on
    a timeline. It is God's timeline. It is not anybody else's. The
    point is, a moment lost is lost forever. I would suggest to you
    that when you think about the requirement in the mission
    statement and the culture at the VA, and I applaud all of you,
    I applaud all of you for doing what is right for the veterans
    because they did what is right for our country through their
    service.
        We need to understand that to delay outcomes for the wrong
    reason is then hurting the veterans in the long term. I will
    just, you know, I could probably talk about that for a long
    time and give examples, but time is of the essence for any
    veteran.
        Dr. Elnahal, we continue to receive reports from veterans
    and providers alike that VHA referrals for community care are
    still taking excessive time to be approved and processed. Why
    is this? What is the Agency doing to alleviate this, and better
    adhere to Mission Act guidelines for providing veterans care as
    timely as possible? Remember, time is of the essence. Sir.
        Mr. Elnahal. Thank you, General, for the question. It
    speaks to my priority around ensuring veterans the soonest and
    best care possible, including in the community. Frankly, the
    time it takes on average for our system to schedule
    appointments in the community, as you mentioned, is much too
    long. It is an average of about 28 days. From the time that a
    veteran knows they need an appointment to the time that they
    receive a confirmed appointment in the community, we have to
    reduce that timeframe.
        That is why it is one of our True-North metrics that we are
    monitoring across the system, facility by facility, VISN by
    VISN, and tracking over time to reward the high performers and
    top improvers in improving their processes, but also to
    recognize the folks that need help and have the system come to
    their assistance.
        We are also making sure that we look at new scheduling
    systems to assist our offices of community care across the
    system. In fact, we have a request for information for a
    commercial off the shelf solution that should help with
    scheduling.
        Finally, we are also introducing an initiative to have
    veterans schedule their own appointments as an option should
    they choose to do so, as we have seen in pilots across the
    country, that it dramatically improves the time it takes for a
    veteran to receive a confirmed appointment, after which the
    veteran circles back to us so that we can ensure that care is
    coordinated. I want to make sure this is an option available
    across the country, General.
        Mr. Bergman. Thank you. I know my time is about to run out,
    but that is an example of giving the veterans control of their
    future outcomes, just like giving them control of who they can
    work with for disability claims, for getting care in the
    community, for anything. Enable the veterans, and they are
    going to get into it, and the VA will be better. Thank you, Mr.
    Chairman. I yield back.
        The Chairman. Thank you, Mr. Bergman. Ms. Brownley, you are
    recognized for 5 minutes.
        Ms. Brownley. Thank you, Mr. Chairman. First, Dr. Elnahal,
    I just wanted to express my strong support for the interim
    final rule around reproductive healthcare and your department's
    efforts to ensure access to a full complement of healthcare. I
    really want to compliment the team that you have put on. We
    have had several meetings with them to follow up, and I just
    appreciate your diligence on that, your team's diligence. I
    just want to say, for the record, abortion is healthcare. Thank
    you. Thank you very much.
        You know, this is a broad hearing. I am going to ask a
    broad question. Dr. Elnahal, what do you think VA is doing well
    with regards to serving women veterans? This is a broad
    question, but I want to know what the answer is with regard
    throughout the entire enterprise. I am not really interested in
    that, you know, perfect pilot program that is out there that is
    doing really well or a certain area that is just providing
    outstanding healthcare to our women. You know, what is VA doing
    well with regards to serving women? What do you think VA has
    the most opportunity for improvement?
        Mr. Elnahal. Well, I share your prioritization,
    Congresswoman, of better serving women veterans every day in
    this organization. The fastest growing demographic of veterans
    by far, accounting for 30 percent of new enrollees in our
    healthcare system every year. We are seeing some positive
    signs, certainly with the capacity building we have been doing.
        We have women's health program coordinators now at every
    major medical center within the system. We have women's health
    mini residency programs to be able to train every primary care
    provider that we can in comprehensive women's health. Some of
    these providers have been seeing mostly men for many years. We
    want to make sure they have that updated education about how to
    treat women veterans with the full scope of care. Of course, we
    are working as hard as we can to hire more gynecologists and
    specialists on women's health.
        I think where we have some room to grow is the trust among
    women veterans. That has everything to do with making sure our
    space is accommodating. We provide more and more dedicated
    entrances to women veterans in facilities. That is an
    infrastructure challenge. Making sure our programming across
    the board is meeting women veterans' needs.
        Ms. Brownley. Thank you for that. Just to follow up, I
    think with the Inspector General here, I know that one issue
    that he has pointed out are Military Sexual Trauma (MST)
    coordinators across the enterprise. I guess, you know, I should
    ask you or ask the Inspector General, you know, what is it
    going to take to get--the intention of an MST coordinator is to
    have a full-time MST coordinator in all of those areas where
    the demand is. I know that there can be some exceptions to that
    out in a rural area somewhere where they are just not servicing
    women veterans. I get that. What is it going to take to get to
    a, you know, full FTE MST coordinator throughout the VA? Is it
    going to require the fact that we mandate that so the local
    medical centers do not have control over their resources with
    regards to deciding if it is going to be 1/10 of an FTE or 50
    percent of an FTE, et cetera?
        Mr. Missal. Well, certainly our reports on MST, we have got
    multiple reports on MST certainly show that more can be done in
    this area. I know we have had discussions with Dr. Elnahal and
    his staff about this. I think they recognize a need. As you
    pointed out, it could very well just be a resource issue. We
    agree that more attention needs to be given to this area.
    Hearings like this and the previous hearing that we had, I
    think, really shine the proper spotlight on it.
        Ms. Brownley. Dr. Elnahal, in the last women's veterans
    task force that we had, we had a roundtable to look at the
    implementation of Deborah Sampson. It was really pointed out to
    us by women veterans representing lots of different agencies,
    and Veterans Service Organizations (VSOs), and, you know,
    across the country as well, really stating that this issue
    around sexual harassment and assault within the VA is still
    problematic, that it is implemented in some places, and not in
    others, and it is slow moving. That they cited examples of
    women being really retraumatized for reporting these incidences
    and coming to the VA to report them.
        I will just say I do not have any time left, but, you know,
    we have got to be vigilant across the entire enterprise to make
    sure that if any woman walks into the VA that they will be free
    from any kind of harassment or sexual assault. Thank you, Mr.
    Chairman. I yield back.
        The Chairman. Thank you, Ms. Brownley. Mr. Franklin, you
    are recognized for 5 minutes.
        Mr. Franklin. Thank you, Mr. Chairman. Mr. Frueh, my first
    question would be for you. In the last Congress, I served on
    the Oversight and Reform Committee. Part of that oversight
    involved the National Personnel Records Center. One of the big
    concerns we had at that time was with those employees working
    remotely and so many of the medical records not being
    digitized, we had a huge backlog of veterans unable to verify
    eligibility for VA benefits and that sort of thing. Wondering
    what the impact is currently on you, what is the backlog, and
    what do you see coming down the pike? How can we fix that
    problem faster?
        Mr. Frueh. The backlog today is just over 200,000, 201,000
    out of 750,000 claims. It is about 26 percent, which is a
    fairly standard amount. In terms of National Personnel Record
    Center (NPRC), that is actually a very good story where
    National Archives and Records Administration (NARA) personnel
    came to us for vaccination through VHA several years ago. We
    placed three different shifts of VBA personnel in the Personnel
    Record Center so that we could pull files.
        After the first few months of the pandemic, that led to a
    backlog in their records retrieval, which hurt us in terms of
    operations.
        Within a few months, we returned to two-to-three-day
    responsiveness in retrieving records from the NPRC. I would say
    that is no longer an impact in our operations. What we see now
    is the impact in the number of claims that are ready for
    decision, where they were in gather evidence mode before, now
    we see a lot more claims in the ready for decision, which is
    the last stage before we complete a claim.
        The production of records from NPRC is no longer an issue.
    We are actually scanning every PACT veteran's records into NPRC
    and eventually every veteran's records, living and dead. When
    someone files a claim, they will not have to wait a second for
    us to get access to their information. We provide those files
    to NPRC or NARA so they can access them as well to deliver to
    their customers.
        Mr. Franklin. I have a company in my district, a private
    company, that is been contracted to digitize those. What I do
    not know, I am not sure the timeline. When do you anticipate
    all those records being fully digitized?
        Mr. Frueh. We are talking about 46 million or so records.
    That will be many, many years. The PACT records, the veterans
    that we believe fall in the PACT cohort I think it is about a
    year and a half is when we expect to have all of them
    digitized.
        Mr. Franklin. All right, thank you. Dr. Elnahal, as the
    greater veteran population continues to age, the importance of
    noninstitutional or home and community-based services becomes
    more important. What are you all doing to ensure that veterans
    get the care and support that they need, whether it is through
    the VA or the community, especially for veterans living in
    rural areas?
        Mr. Elnahal. It is a big priority for us, Congressman,
    especially as we see the veteran population aging and more in
    need of homebased care where we can. We in fact have an
    initiative called the Aging In Place Initiative to see the full
    scope of options available to vets and to extend all of them
    where we can. We, of course, have our community care-based home
    services. We also have our Caregiver Support program, which we
    are investing in more and more, and we are reevaluating our
    eligibility criteria for that, while we have a 3-year
    moratorium on legacy participants in the caregiver support
    program, particularly the Parent Child Assistance Program
    (PCAP) program.
        Then finally, we are expanding the Veteran Directed Care
    initiative to every single facility within 2 years, which is an
    acceleration of the original 5-year timeframe. Because we know
    that so many veterans have been able to benefit from this by
    basically asking a loved one or close, someone close to them to
    be their caregiver and allow them to have that financial
    support. We are pushing hard on expanding that capacity, and we
    share your prioritization of this important issue.
        Mr. Franklin. Very good. Thank you, Mr. Chairman. I go
    back.
        The Chairman. Thank you, Mr. Franklin. Mr. Levin, you are
    recognized for 5 minutes.
        Mr. Levin. Thank you, Mr. Chairman. Mr. Frueh, I appreciate
    that VA's testimony addressed the Veterans Rapid Retraining
    Assistance Program, or VRRAP program, which was established to
    help retrain veterans who were unemployed due to the pandemic.
    You may remember I was pretty vocal last year about using as
    much of the $386 million appropriated for the program to
    benefit veterans before the program expired.
        In early September 2022, which was 16 months into the
    program, VA had only allocated around 56 percent of the funds.
    I was surprised, pleasantly surprised, that VA was ultimately
    able to obligate 98 percent of these funds by mid-December. My
    question for you, Mr. Frueh, is how was VA able to drastically
    accelerate veteran participation in the span of 3 months?
        Mr. Frueh. I think a lot of that went to consummate
    awareness. Not to use the word advertising in the traditional
    sense but getting the word out to veterans and getting the word
    out to schools, because two of the issues we had with VRRAP
    were supply and demand. The number of programs that were
    willing to say, I want to operate under this payment structure
    of VRRAP was hard to get off the--to get off the ground at the
    beginning, but by the end, we had 1,300 programs enrolled in
    the VRRAP program.
        Then awareness to veterans because the restriction on who
    is eligible to be certified for enrollment where you had to be
    unemployed due to a COVID related circumstance and have not
    received any Federal or State aid, and not have any remaining
    Vocational Rehabilitation and Employment (VRE) or education
    entitlement, it made it difficult at first to get the wheels
    rolling. As we got the word out, as people started to go
    through the programs, we got a lot more. I think eventually we
    had 30,000 applicants almost for the program, of which 4,300
    graduated through the program, and we are very happy that we
    got more through.
        Mr. Levin. That is a good segue to my next question, which
    is about the data. I understand that the data on all the
    outcomes is not available, as lots of veterans are still
    enrolled in programs or within the 180-day mark for certifying
    employment.
        We do have some data. To the best of my knowledge, as of
    January 3, VA had verified that 818 veterans who participated
    in VRRAP had secured employment. By comparison, 2,744 veterans
    had not secured employment. Mr. Frueh, to what factors does VBA
    attribute this relatively low success rate? What is VA doing to
    improve outcomes for veterans who are still participating in
    VRRAP?
        Mr. Frueh. Well, one, we have a lot of experience in VRE in
    terms of working with employers and future employers, and the
    Vet Tech program is a good analog to this in a different
    sector, in Science, Technology, Engineering and Mathematics
    (STEM) related or cyber related things. We have an employer
    consortium in that area which we work with to find suitable
    employment as quickly as we can afterwards.
        One of the tenets of VRRAP that I like, that I think we are
    starting to see some benefit from is the payment to the program
    upon employment. Programs are getting better at recruiting for
    their students. As of now, we are at, I think, 1,000 employees.
    We have gone up a few hundred in the last several weeks. We
    will see as we get through the next four to 6 months after more
    of the people in the program complete the program. I think a
    lot of it is relying upon the programs themselves to push for a
    positive outcome at the end.
        Mr. Levin. What are any other important lessons that you
    might have learned as a result of this program, and
    specifically, how will you incorporate the lessons that you
    have learned in similar programs in coming months and years?
        Mr. Frueh. I think the pay for performance is a nice
    feature of it from the terms of make sure people do not just go
    through the program. Our programs just do not apply to get
    Federal aid without any positive outcomes at the end. I think
    that feature is something that was a deterrent at the
    beginning, but as we worked our way through it, we got a lot
    more programs involved.
        I think starting earlier, getting the word out a whole lot
    earlier would have enabled us to get more programs involved
    earlier, which would, of course, then enable more enrollment by
    veterans in those different programs.
        Mr. Levin. Mr. Missal and Mr. Dodaro, do you have anything
    you would like to add to anything that has been said?
        Mr. Missal. No, I mean, we looked just very broadly at that
    program, but not in any detail. Obviously, you know, we looked
    very closely at all the VBA programs to see whether or not we
    should be doing projects in them, and we are always open to
    looking even more.
        Mr. Dodaro. I do not have anything to add.
        Mr. Levin. Well, I am out of time. I would just hope that
    the next time we stand up a program, that it does not take so
    long to really get things rolling, and that you have hopefully
    learned some lessons from that initial year where very little
    was happening. I am sure it will be talking about it, although
    I hope it is nothing like a pandemic or anything like that. I
    know we will be having new programs in the years to come, so I
    appreciate the work you are doing, and I will yield back.
        The Chairman. Thank you, Mr. Levin. Mr. Rosendale, you are
    recognized for 5 minutes.
        Mr. Rosendale. Thanks so much, Mr. Chair. General Quinn, it
    is so good to see you.
        Mr. Quinn. Congressman, good seeing you.
        Mr. Rosendale. Dr. Elnahal, I have got a couple of
    questions for you. On September the 9th 2022, the VA published
    an interim final rule titled Reproductive Health Services to
    immediately amend its regulations to remove the exclusions on
    abortion and abortion counseling. As you well know, I was
    deeply disturbed by that. I was proud to co-sponsor a
    resolution of disapproval being led by Congressman Cloud and
    Chairman Bost.
        This rule is in clear violation of Section 106 of the
    Veterans Healthcare Act of 1992, which restricts abortions. The
    administration's explicit decision to violate the law is a slap
    in the face to Congress and the separation of powers.
    Specifically, the rule would direct the VA to provide abortions
    when health of the mother would be endangered. This rule also
    directs the VA to provide abortion counseling. While you and I
    may disagree on this issue, the taxpayers deserve to know how
    their dollars are being spent. With that being said, how many
    abortions has the VA provided since September 2022?
        Mr. Elnahal. Congressman, I appreciate the question. It is
    actually a number that is small enough to possibly allow for
    triangulation and identification of veterans and clinicians
    involved. I think in this public forum, it would be quite risky
    to communicate that information. We are happy to work with you.
    Of course, the Chairman's letter response will be important in
    getting feedback back to this committee.
        Mr. Rosendale. We certainly want to make sure that we do
    get that information. How many dollars has the VA spent
    providing abortions since 2022?
        Mr. Elnahal. What I can say, Congressman, is that we
    projected in the impact analysis of the interim final rule that
    we are talking about less than 1,000 veterans per year based on
    how we restricted the ultimate abortion service latitude in
    cases of the life of the veteran, the health of the veteran,
    rape, and incest. It was really the impetus was around veteran
    safety in the wake of the Supreme Court decision that no longer
    made abortion a constitutional right.
        Mr. Rosendale. Dr. Elnahal, I understand our differences of
    opinion and what may or may not happen and the definition which
    provides for this to be allowable. What is the dollar amount
    spent providing these abortions?
        Mr. Elnahal. All of that is to say that the number of
    veterans is quite small. The dollar amount is compared to, of
    course, our total appropriation a very small number.
        Mr. Rosendale. I see you will not answer the first two
    questions. How many veterans have received abortion counseling
    since September 2022? Can we answer that one?
        Mr. Elnahal. For the same reasons I mentioned before,
    Congressman, with all due respect, I think we would have to
    look at the implications of veteran safety before communicating
    that in the public forum.
        Mr. Rosendale. Okay, well, we will look forward to getting
    that information in a more private setting. Even more
    egregious, there are no conscious protections for VA medical
    staff. A VA nurse practitioner, army veteran Stephanie Carter,
    asked the VA for religious accommodations, but allegedly was
    told by the Department that there is no process that exists to
    review such requests. The Department says that it does allow
    employees to opt out of providing certain services based on
    their religious beliefs. Yes or no? Can the VA medical employee
    opt out of providing abortions or abortion care?
        Mr. Elnahal. Yes, Congressman. In fact, we have made that
    policy clear very shortly after the release of the interim
    final rule through an all-employee message. As of earlier this
    year, we put out specific, clear guidance on how staff and
    physicians alike can opt out of doing these types of services.
    We want to respect points of view on this and personal values
    and religious beliefs. That is a core principle that we are
    following.
        Mr. Rosendale. Thank you. I would like to see that actually
    placed into the rule to avoid any confusion. If we could make
    sure that that happens as we go forward. I want to jump to
    another subject real quick.
        I am glad to see literally everyone here in the room today
    with no facial coverings. We can actually see what you look
    like. I wrote the VA a letter last week regarding a veteran who
    contacted my office in regards to being denied service at a
    Montana VA clinic for refusing to wear a mask. It is outrageous
    to deny anyone, particularly a veteran, medical care over a
    personal decision. The Biden administration announced that the
    public health and national emergencies would terminate on May
    the 11th 2023. While the date is very arbitrary, even the
    President recognizes he can no longer hold the public hostage
    with these executive powers. Do you support denying veterans
    care over their unwillingness to wear a mask?
        Mr. Elnahal. Well, Congressman, I will say that we have
    looked at this recently as the pandemic has evolved into a much
    better place. Just as of this week, we have taken the
    opportunity to maximally relax the masking restrictions in our
    facilities according to Centers for Disease Control and
    Prevention (CDC) guidelines based on transmission levels
    locally. We are bound to follow CDC guidelines. We think it is
    important to be consistent with those guidelines, but we are
    trying to be as open as possible to veteran, and clinician, and
    staff preferences alike on this.
        Mr. Rosendale. When do you anticipate lifting these masking
    requirements, period?
        Mr. Elnahal. Well, again, Congressman, we work with the CDC
    on this. We not only follow their guidelines, we partner with
    them regularly. As the pandemic evolves, we will see what comes
    next.
        Mr. Rosendale. Thank you, Mr. Chair. I yield back.
        The Chairman. Thank you, Mr. Rosendale. Mr. Pappas, you are
    recognized for 5 minutes.
        Mr. Pappas. Thanks very much, Mr. Chairman. I want to
    direct my first question to Mr. Frueh. There has been a little
    bit of a conversation here about claims backlogs, and I just
    want to draw your attention to one specific issue. The
    committee has received several inquiries regarding delays in
    processing aid and attendance pension claims, and I am
    wondering if you can shed any light on those backlogs and what
    steps are being taken to address it.
        Mr. Frueh. It is almost like I am on my computer. Aid and
    attendance backlog, there is a slight backlog in aid and
    attendance. There are several thousand claims, and I now
    actually have numbers here, which probably easier if I get to
    you there. Our average days to complete aid and attendance is
    hovering around 110 days, I think, now. The reasons for
    backlogs are varied, you know, in the claims portfolio. It is
    because of the large volume of claims and the lack of ability
    to produce documents back in time in aid and attendance. It is
    a smaller volume of work, but in a commensurately smaller
    organization. I do not know how large the backlog is. I would
    be happy to dig into that with you further, but anything we can
    do. As I said before, I do not want any veteran to wait for a
    benefit.
        Mr. Pappas. That is helpful. Maybe we can dig into the
    specific issues that we have been hearing about and see if
    there is anything that is materially changed around that and
    just see what attention can be drawn to it.
        I am wondering if you could answer an additional question.
    Last Congress, the Disability Assistance and Memorial Affairs
    Subcommittee, of which I am now the ranking member, had a
    hearing regarding VA's outreach to survivors and dependents. I
    think everyone was surprised at the lack of personnel and
    resources that has been dedicated to important tasks, including
    the proactive communication with new survivors. I am wondering
    if you can talk about what action has been taken since that
    hearing to bolster outreach and any steps that have been taken
    to address this issue for survivors' independence and make them
    aware of benefits that are available through VA.
        Mr. Frueh. Awareness is one of the most key elements of
    enabling veterans to access their benefits. For survivors, we
    have an Office of Survivor Assistance that is, you know, within
    VBA, but it is for the entire department. We also have an
    Office of Outreach and the Office of Outreach and Office of
    Survivor Assistants work together with Public and
    Intergovernmental Affairs and others to get word out. For
    example, with the new PACT Act, we reached out to every former
    Dependency and Indemnity Compensation (DIC) applicant who was
    denied to say, please apply again. There is new rules. There is
    a new legislation you might be able to apply for.
        We work with the branches of the military casualty
    assistance officers, and we work through county VSOs, State
    VSOs, and big national VSOs to amplify our message to
    eventually get to the people who need the information. I can
    say as a son of a deceased veteran whose mother, my mother did
    not know about benefits were eligible she was eligible for. I
    hated not knowing what was eligible for her and I worked at VA.
    I am more educated now in the benefits. And I want to make sure
    that there is no survivors like my mother that are unaware of
    the benefits that can help them with their lives.
        Mr. Pappas. Well, thank you for that commitment. One final
    question for you. Last year, the Department announced that it
    is closing a gap in survivor benefits for certain LGBTQ-plus
    veterans, specifically those who are unable to get married
    before the 2015 Obergefell decision. I am wondering if you can
    provide a status update on VA's benefits for these same sex
    surviving spouses and how many survivors have applied for
    benefits through VA so far.
        Mr. Frueh. That is something I will definitely have to talk
    to you offline. I do not have the numbers on veterans who have
    applied for those benefits, but our goal for that was to act as
    if those survivors were in the same if they were in a State
    that did not allow a marriage between a same sex couple, we
    wanted them to have access to the same benefits as if they
    were. The opening of that was geared around equity to veterans
    in different groups. The numbers I will have to work with you
    offline for.
        Mr. Pappas. Okay, thank you. We will follow up on that. I
    yield back, Mr. Chair.
        The Chairman. Thank you. I now recognize Representative Van
    Orden for 5 minutes.
        Mr. Van Orden. Thank you, Mr. Chairman. Thank you all for
    coming here today. I appreciate it greatly. I am a 100 percent
    service-connected disabled veteran, and I get all of my
    healthcare through the VA. I want to share with you and preface
    these comments, my comments that the vast majority of my
    experiences at the VA have been overwhelmingly positive. I am
    very grateful for the staff throughout Western Wisconsin,
    including La Crosse and the medical center in Tomah. I am very
    proud of them.
        However, we can all do better. That is what we do as
    Americans. We continuously seek improvement. In that spirit,
    Dr. Elnahal, I want to share with you how I spent my first day
    in Congress. I got sworn in and I received an email, and I am
    going to read it to you. Right now. My wife and I tonight
    attended my brother's visitation, and I will be attending
    tomorrow his funeral. He passed away on Wednesday before
    Thanksgiving. He is a Wisconsin born, recently retired from the
    army after 22 years, currently residing in North Carolina. He
    leaves behind a beautiful wife and three beautiful young
    children. He went to the VA for help for mental health issues
    and was turned away. He took his life the Wednesday before
    Thanksgiving. Two days later, a letter from the VA came in the
    mail accepting him. It was too late. His name is Retired Major.
    I will not read that publicly.
        It should be illegal for the VA to refuse a soldier who is
    retired or active duty trying to get help from getting
    admitted. I am requesting for you to work with your
    counterparts in North Carolina on some kind of legislation to
    prevent this from happening to another soldier or veteran
    again.
        I spent my first day as a United States Congressman calling
    the brother of this dead soldier, calling the father of this
    dead soldier, calling the widow of this dead soldier, and
    apologizing profusely for the Federal Government's inability to
    schedule a medical appointment. It sits on my desk with this
    sticky pad and it said, this is why I am here.
        I know you have got a tough job. I know that sometimes we
    can be distracted by the events, especially when you are
    leading a huge bureaucracy like the VA. I prepared this for
    you. Will you bring that to him, please? Will you bring that to
    the doctor? This is a copy of this letter, sir. You can put
    that on your desk or you can hang that on your wall. There is a
    blank sticky pad there. I think it would do us all well if you
    wrote on there why you are here, and to never forget that.
        Things are going to be dark some days. People are going to
    get on you. I understand that. Every day when you wake up in
    the morning, me and my fellow millions of veterans throughout
    the United States of America would be deeply grateful for you
    if you remember why you are here. With that, I yield back.
        The Chairman. Cherfilus-McCormick, Congresswoman Cherfilus-
    McCormick, you are recognized. I am sorry.
        Ms. Cherfilus-McCormick. Thank you, Mr. Chair. My first
    question is for Mr. Dodaro. In 2008, the National Defense
    Authorization Act directed VA and the Department of Defense
    (DoD) to develop and implement systems that would allow for
    interoperable electronic patient healthcare information
    exchange between the Department. After numerous starts, stops,
    and failure attempts, that requirement has not been achieved.
    Now, both departments are working in deploying Cerner
    Corporation's EHR platform across the respective healthcare
    systems.
        Mr. Dodaro, does GAO have an estimate of the VA's
    expenditures on failed EHR modernization efforts before the
    current Cerner EHR project? We are very concerned that the
    total cost for the Electronic Health Record Modernization
    (EHRM) project remains to be seen. It would be helpful for the
    committee to know the running total for taxpayer spending on
    past EHR modernization efforts.
        Mr. Dodaro. The cost that we estimate is over $1.7 billion
    for failed predecessor electronic healthcare record systems
    that either failed or did not come to fruition.
        Ms. Cherfilus-McCormick. Thank you so much. My next
    question is for Dr. Elnahal. Dr. Elnahal, the EHRM program is
    in the midst of another pause, presumably to address some of
    the system's long standing technical and design issues. What
    has your office's participation been in this evaluation, and do
    you think this pause is going to positively impact the
    direction of the program? If so, how?
        Mr. Elnahal. Well, Congresswoman, that was the exact intent
    of doing the pause. We called it the assess and address period,
    because that is exactly what we have been engaged in diligently
    since we announced it. We are looking specifically at the
    system configuration issues, but also people and process
    matters that led to our need to disclose to tens of thousands
    of veterans that their care may have been delayed or affected
    by the implementation of this system. We took that
    responsibility very seriously.
        In the coming weeks, we are going to be releasing the
    results of that work to include not only Oracle Cerner's
    responsibility to fix the configuration of the system, but also
    our own and making sure our people and process matters continue
    to improve. We are very dedicated to that.
        Ms. Cherfilus-McCormick. Thank you. My last question for
    you. The total number of veterans enrolled in the VA's health
    system increased from 7.9 million in 2006 to about 9.2 million
    in 2022. This increase in beneficiaries needs to be matched
    with an increase in providers to meet the need of every
    veteran. What steps has the VA taken to ensure that there are
    enough healthcare providers to care for our veterans and ensure
    that the veterans of Color receive cultural competence and
    trusted care from providers that look like them and understand
    their healthcare needs?
        Mr. Elnahal. I absolutely agree, Congresswoman. It is why
    the first and most important priority that I have set for the
    healthcare system is hiring faster and more competitively. We
    absolutely need to be staffing our hospitals and clinics, but
    also our support personnel to the greatest extent possible, not
    only to serve our existing base of veterans, but to, for
    example, meet the need of all the new enrollees we expect to
    see from the PACT Act. That includes the staff that you are
    talking about, and we have already hired more than 18,500 staff
    in the first quarter of this year. We have also seen a higher
    retention rate compared to January of last year when we had a 4
    percent loss rate. We only had a 2 percent loss rate just last
    month. The combination of greater retention and greater hiring
    has led to 388,000 employees on board. That is an end strength
    that we think will continue to get better throughout the year
    because of our attempts to improve hiring.
        Ms. Cherfilus-McCormick. Thank you so much. My next
    question is for Inspector General Missal. One of the final
    hearings the committee held while Democrats were still in the
    majority in December 2022, was an oversight hearing on the VA's
    progress in implementing the PACT Act. This hearing provides a
    significant opportunity to get updates on the VA's progress,
    meeting major milestones outlined in the law.
        VA has processed PACT Act claims on January 1, 2023,
    according to the data committee received from the VA this week,
    since the law's enactment in August 2022. More than 309,000
    veterans and survivors have submitted PACT Act related claims.
    In your role as the Inspector General, what oversight do you
    have in processing the PACT Act claims? How can we ensure
    veterans are having a streamlined process while awaiting
    confirmation of benefits?
        Mr. Missal. Well, as previously noted, the PACT Act was one
    of the most significant increases in VA benefits in its
    history. We recognize the importance of it. They are just
    starting to process those claims at this point. We have already
    put together a team of people to address it from a number of
    different areas, including the people, the staff that they are
    needing to hire, the processes, how they are processing the
    claims, and the technology, what they are doing along
    technology lines as well. We expect to have a vibrant
    oversight, just given the importance and the amount of money at
    issue.
        Ms. Cherfilus-McCormick. Thank you so much for your
    responses, Mr. Chairman. I will yield back.
        The Chairman. Thank you. The gentlelady yields back.
    Representative Ciscomani, you are recognized for 5 minutes.
        Mr. Ciscomani. Thank you, Mr. Chair. I serve a community in
    Southern Arizona in the Tucson area where the VA hospital there
    serves two military bases, Davis-Monthan (DM) Air Force Base
    and Fort Huachuca Army Base in Sierra Vista. Therefore, I serve
    a large veteran community. I do hear constant good feedback and
    a lot of improvement, and specifically the VA hospital. I, like
    my good friend Congressman Van Orden, also believe that there
    is room for improvement, like, in anything.
        My question is also in the same vein as my colleague. Dr.
    Elnahal, Chairman Bost sent a letter to the Secretary weeks ago
    asking the Agency to expand on its methodology for counting
    veteran suicide deaths. An issue that concerns me is that a
    large number of these deaths are ruled accidental or
    undetermined by our coroners, and as opposed to suicide or
    homicide. Many of these undetermined veteran deaths are drug
    overdose deaths as well.
        Does the VA have any intention of examining these deaths
    due to overdose or risky behavior within the context of suicide
    prevention? Could the VA include this type of data in its
    suicide report? This is a real issue that we see on the rise
    more and more, unfortunately, among our veteran population, and
    one that I hear from my community constant, and specifically
    after this example from the Congressman, I think it deserves
    weighted attention on this.
        Mr. Elnahal. I agree, Congressman, and we are always open
    to feedback and input about how we calculate veteran suicide
    information. Every year, we work with the CDC closely on this,
    medical examiners across the country, our methodology is
    published online. I want to say that we are not only focused on
    veteran suicide, which is my top clinical priority and has been
    for the Agency for years, but also the various different inputs
    into deaths that some folks may be trying to categorize, or are
    giving us feedback, saying that we should categorize or
    consider doing so for suicide.
        For example, substance use disorder. We have extensive
    programming to include residential treatment, medication
    assisted treatment, and various programming for veterans
    suffering from that. Also, the broad scope of our mental
    healthcare services continue to expand. We are doing more
    telemental health care than we have ever done before. We have
    more than 17,000 providers across the system providing these
    services.
        We are, of course, dedicated to expanding that capacity as
    much as possible. To Congressman Van Orden's request of me, I
    will keep this on my desk, and I will always remember that
    story. I will make sure that we continue to try and do better
    and better to prevent this scourge and to deal with this
    pressing, pressing public health issue.
        Mr. Ciscomani. Thank you. I yield back.
        The Chairman. Mr. McGarvey, you are recognized for 5
    minutes.
        Mr. McGarvey. Thank you, Mr. Chairman. I appreciate it.
    Thank you, gentlemen, for being here today. I echo the comments
    of some of my colleagues, Mr. Ciscomani, Mr. Van Orden. I also
    suggest that cutting $31 billion in the VA budget is not the
    way to best address some of those problems in the next year.
        I want to switch to something going on in my district,
    specifically. In August 2022, the VA OIG issued a report about
    issues with Camp Lejeune processing, the claims processing, a
    topic of which I hear about a lot from my veterans at home. Mr.
    Missal, this one is going to be for you. It was in a report
    that the VA OIG recommended that the VBA consider centralizing
    all Camp Lejeune related processing claims in the VBA's
    Louisville Regional Office.
        As you are likely aware, compared to other regional
    offices, the Louisville Regional Office actually had a much
    lower error rate. They processed a lot of claims. They only had
    an 8 percent error rate. That is compared to a 40 percent error
    rate of all the other offices combined. 40 percent for all the
    others, 8 percent for Louisville. In response to those
    recommendations, the VBA said it would assess all of the
    regional office's accuracy of processing Camp Lejeune related
    claims over time. If the accuracy has not shown consistent
    improvement, that VBA would consider further centralization. My
    question is, what progress has the VBA made on determining the
    need for centralizing the processing of Camp Lejeune claims
    since the report was published?
        Mr. Missal. As you correctly pointed out, there were
    significant problems with the processing of the Camp Lejeune
    claims. We projected out of the 37,000 during a 4-year period,
    21,000 were not processed properly, 17,000 of those, 21,000
    were prematurely denied because they did not have enough
    information. One of our recommendations involved the
    centralization of the claims. My understanding is that VBA is
    going to centralize it, but before we close out that
    recommendation, we want to see that it is actually done and how
    it is working. Then there is a second recommendation from that
    report that remains open as well.
        Mr. McGarvey. I appreciate that because it does seem like
    there is some hesitancy in moving forward with that
    recommendation on centralization. I guess for maybe Mr. Frueh,
    what I would say is we do have spaces in the VA that deal with
    this already. We have teams at VBA that currently specialize in
    processing certain types of claims such as military, sexual
    assault, trauma. Why is there a hesitancy in going ahead and
    centralizing those claims in the Louisville office?
        Mr. Frueh. I would say that the issue with specialization
    versus generalization is there is a lot of different
    disabilities and there is a finite capacity to centralize into
    different areas. It is not a lack of desire to get better. It
    is not a lack of desire to find that the answer of
    centralization will answer this because if we did that with all
    of the disabilities, we would run out of offices to do the
    centralization.
        Our goal and what I consider a quality organization is a
    veteran that applies from any State through any modality,
    through any external help, whether it is a VSO accredited
    representative or us has access to the same outcome.
    Centralizing makes that more likely because you are looking at
    one place to enforce outcomes. We do have a distributed
    workforce and we do do a lot of work around the Nation, and our
    goal is to make that as high quality as we possibly can across
    the Nation.
        Mr. McGarvey. Well, you know, I am not saying
    centralization is necessarily the answer. I think the numbers
    that Mr. Missal gave illustrate the real problem that
    potentially tens of thousands of Camp Lejeune related
    disability claims have been subject to processing errors. The
    most important thing here are the men and women who served who
    are not potentially getting the care, the treatment, the
    resources they need. Mr. Frueh, what is the VBA doing to
    proactively identify those claims that were processed
    incorrectly, to notify the veterans of the error, and to allow
    them to update their claims accordingly?
        Mr. Frueh. I would have to go back to the report. The last
    time I looked at it was a few months ago. When we got the
    identification of claims that the IG said were processing
    error, we did reach out to everyone. We did relook at every
    single claim. When we found a claim that we did find an
    erroneous answer. Some that were process and error that were
    prematurely decided, when we looked at them again, they came to
    the same conclusion. The answer was still the same answer that
    we got before. When we get to a claim that we readjudicate and
    we get a different answer, then we reach out to that veteran
    and reopen the claim and work with them to the ultimate
    conclusion.
        Mr. McGarvey. I am out of time, so I yield back.
        The Chairman. Thank you. Representative Self, you are
    recognized for 5 minutes.
        Mr. Self. Thank you, Mr. Chairman. My issue is the director
    of the Dallas VA Center. You are free to select your senior
    leadership any way you will. I believe that you have damaged
    your relationship with your stakeholders. The Dallas VA Center
    is not in my district, but the Metroplex is a large place, and
    that VA Center is the second largest in the country I
    understand. You are free to select your director, but the
    deputy was not considered for the job. Highly qualified. He had
    been the deputy for the second largest center in the Nation for
    a number of years. The man that was selected to be the director
    came from a very small center, and the deputy was not
    considered at all.
        If I go through the other, central Texas conducted a full
    and open interview process. Amarillo was full and open. El Paso
    was full and open. You did not even post the position in the
    second largest center in the Nation. Again, I believe that you
    have damaged your relationship with the stakeholders, with the
    veterans in the area. Believe you me, there are a lot of
    veterans in the Dallas Metroplex and in North Texas. My
    questions are, did Mr. Jones, is it Dr. Jones, the H.R.
    director? Mr. Jones, Dr. Jones, your H.R. director, did he
    follow proper protocol when considering the new executive
    director of the North Texas Dallas VA? Then the real question I
    have is, does it make sense that he would select a candidate
    from a clinic of 17,000, move him to the second largest in the
    country, with a budget of roughly 20 billion?
        Mr. Elnahal. Congressman, I had a chance to visit the
    Dallas VA Medical Center. I met the individuals that you are
    talking about. Wendell Jones is the network director across
    VISN 17 for Texas. I think it is an extraordinary asset for the
    veterans and the community.
        Personnel decisions are always very difficult. Before I
    signed off on this action, I checked with our Office of General
    Counsel, and they determined that the process was within the
    scope of the law. What I can tell you is we have a commitment
    to ensuring that the entire team there is supported to meet the
    mission on behalf of veterans in the Dallas area.
        Mr. Self. In your mind, you signed off of it. You just gave
    me a legal process. How about the personnel process? Did you
    hire the best man for the job or woman for the job? We are not
    discussing names here. Did you hire the best person for the
    job----
        Mr. Elnahal. In my discussion----
        Mr. Self [continuing]. realizing that the deputy had been
    there for a number of years in this second largest VA center in
    the Nation?
        Mr. Elnahal. Well, candidly, Congressman, there are a lot
    of inputs that go into these very difficult decisions about
    picking our leaders in the organization. After I consulted with
    Mr. Jones on this, we came to the determination that we did.
    That is not a disparagement at all of anybody else who wanted
    that job. What I am committed to doing is making sure that we
    are meeting the mission on behalf of veterans in every
    performance indicator we can in the Dallas VA.
        Mr. Self. Understand, the deputy was not considered, as far
    as anyone knows. I think that you have some work to do to
    regain the trust of the stakeholders and the veterans in the
    Metroplex area, in the North Texas area.
        With that, I would like to move to a different issue. Mr.
    Quinn. In 2021, the VA IG reported that NCA could better ensure
    that VA grant funded State veterans cemeteries were maintained
    according to national shrine standards. How has the NCA
    improved the oversight over those State veterans cemeteries?
        Mr. Quinn. Congressman, thanks for the question. I will
    make sure I have a voice through this hearing. We have looked
    very closely at that State in particular that was mentioned in
    the IG report. We have gone back for additional assistance
    visits with that State, and we have done an additional
    inspection of that State, and we do that with all states. We
    want to make sure that this partnership between the Federal
    Government and the State, Tribal, territorial, grant funded
    cemeteries are out there, that we maintain national shrine
    standards. The veterans deserve that. The family members
    deserve that. We will take every step necessary to make sure
    that those are national shrines.
        Mr. Self. You are assuring me that it is meeting the
    traditional national shrine standards today?
        Mr. Quinn. Congressman, we are still working with that
    State to ensure that they meet national shrine standards. Yes,
    sir.
        Mr. Self. Thank you, sir. I yield back, Chairman.
        The Chairman. Thank you, Mr. Mrvan.
        Mr. Mrvan. Thank you, Chairman Bost. This week, I am
    introducing the VHA Leadership Transformation Act, a bill I
    believe will help address some of the leadership and governance
    challenges that are described in the Inspector General Missal's
    and Comptroller General's Dodaro's testimony. First, my bill
    will establish a 5-year term for the Undersecretary for Health
    in order to provide greater leadership, stability, continuity
    within the Veterans Health Administration. Second, my bill will
    remove existing statutory limitations on the number of
    Assistant Undersecretaries for Health that VHA can have, as
    well as the requirement that nearly all of them be doctors.
        This will give VA greater flexibility to determine its
    organizational structure and expand the pool of healthcare
    executives who can be considered for these senior leadership
    positions. Mr. Missal and Mr. Dodaro, what are your thoughts on
    the idea of depoliticizing the appointment of the
    Undersecretary for Health? What would be the potential benefits
    of greater leadership, stability, and continuity at VHA? Third,
    and could VHA benefit from having greater flexibility to design
    its organizational structure?
        Mr. Dodaro. First, I think there are tremendous benefits to
    be gained of sustained leadership and stability over a period
    of time, provided it is the right person in the leadership job.
    In fact, the criteria that we have for getting off GAO's high
    risk list, the very first criteria is sustained leadership.
    That is pivotal. Without that, you are not going to make
    progress.
        There are a number of other positions across government
    with 5-year terms. The Internal Revenue Service (IRS)
    Commissioner within the Treasury Department. The FAA Administer
    in the Department of Transportation, Small Business, or excuse
    me, Social Security Administration has a 5-year term.
    Unfortunately, two of those, all three are vacant right now, so
    they are trying to be filled.
        I believe that with the right person, sustained leadership
    is important, particularly at VA, where if you want to have
    change of the magnitude that is needed there, you need to have
    stability over time to guide it to a successful conclusion. I
    also think it is important to consider people who have
    management skills, as well as medical skills in order to
    effectuate the type of change that is needed over at the VHA. I
    would submit to you, although you did not ask me, that the same
    thing should be true for VBA and the Benefits Administration to
    have that stable leadership over a period of time when you have
    such important functions that we have and these are functions
    that need to be performed. To be successful, you need to have
    continuity over time.
        Mr. Missal. I would just add second what Mr. Dodaro said
    about leadership. Effective leadership and stable leadership is
    so critical, particularly for an organization as large,
    complex, and decentralized at VHA. I have been the IG for a
    little more than six and a half years. In my time at VA, there
    have been six people who have sat in the undersecretary's chair
    at VHA, either an acting basis or as a Senate confirmed
    position. I know that the Commission on Care in 2016
    recommended 5-year terms for the VHA. I think they called it
    the executive director, with the possibility of being
    renominated for it. I agree with Mr. Dodaro that anything that
    gets stability within these very important positions would be
    very helpful.
        Mr. Mrvan. Then, Dr. Elnahal, do you have any views to add?
    Do you think by making the statue less restrictive, VHA could
    recruit the kind of senior healthcare executives it needs?
        Mr. Dodaro. Yes. I think you--oh, I am sorry. Was it to me
    or to the doctor?
        Mr. Mrvan. To the doctor.
        Mr. Dodaro. Okay, I am sorry.
        Mr. Mrvan. No, problem, sir.
        Mr. Elnahal. Thank you. I am glad we agree.
        Mr. Mrvan. I am just going to direct all my questions to
    you.
        Mr. Dodaro. No, I am sorry. I am sorry.
        Mr. Mrvan. Thank you, sir, very much.
        Mr. Elnahal. Thank you, Congressman. Of course, as we do
    with proposed legislation analyzing the implications of such a
    bill, we have not had a chance to come to a position yet as an
    agency or administration. I would just concur in principle with
    my colleagues that continuous leadership is really important. I
    am very focused, for example, on filling our medical center
    directors and VISN directors with permanent folks and making
    sure we utilize every single PACT Act authority, and hiring
    authority, and retention authority that we have to sustain that
    leadership.
        I am very sensitive to the oversight of my colleagues, the
    colleagues to my right in various reports about the risks of,
    you know, continuously transitioning leadership. It is hard to
    sustain initiatives. It is hard to hold folks accountable. It
    really sets a path for continuous improvement that is
    consistent with our high reliability effort to have continuous
    leadership.
        Mr. Mrvan. With that, I yield back my time. I thank you
    very much.
        The Chairman. Dr. Murphy, you are recognized for 5 minutes.
        Mr. Murphy. Thank you, Mr. Chairman, gentlemen, thank you
    for coming today. I represent North Carolina's 3rd
    congressional District. One-seventh of my constituents are
    veterans or active-duty military. It is a heavily populated
    military district. Our veterans issues are, very, very
    important to me. I have also been a physician for 30 years plus
    now. The trials and tribulations that go on in the VA are not
    lost on me. To your point of stability, trying to fill doctors
    in, I get it, because we in the civilian world are facing a
    cataclysmic fall in physicians, even more so with surgeons. I
    know sometimes recruiting is very difficult in rural areas and
    especially in VA areas. Any help that we can do in that regard,
    you have to let us know because that is a big deal for our
    veterans. They signed on the dotted line to serve and sacrifice
    for us. As far as I am concerned, the day they come home is the
    time for us to turn our attention on the second part of that
    contract.
        Veteran suicide is a big problem. Dr. Elnahal, I wish you
    could speak to that and what improvements, where you see this
    going, because we are at now, what, 22, 24 a day? Absolutely
    unacceptable. What are we doing? What are we doing in the VA to
    change that? How can we help or what fires do we need to light
    to make a difference?
        Mr. Elnahal. Well, Congressman, I share your priority
    around preventing veteran suicide. It is my top clinical
    priority for the healthcare system and it has been so for the
    Agency for years. We will simply not be satisfied until we
    bring that number to zero.
        Every veteran suicide is a tragedy. We are focused with a
    comprehensive public health approach, everything from ensuring
    access to crisis care, both through our veteran crisis line and
    urgent care through our emergency settings, to lethal means
    safety, to ensuring same day access to care and continuous
    mental healthcare. Very importantly, community-based
    organizations need to be our partners in this to include, of
    course, our veteran service organizations. We have put in more
    than $50 million in this Sergeant Parker Gordon Fox grant
    program to fund community-based organizations in partnership
    with us.
        We just announced $20 million in funding to innovative
    organizations, startups, community-based organizations alike
    through our Mission Daybreak program. We are simply not going
    to stop until we get to zero.
        Mr. Murphy. Thank you. I appreciate that. That said, we are
    not bending the needle. We are not changing things. I
    appreciate the work. It is a hard-to crack. I am not belaying
    that whatsoever, especially in today's society when you wake up
    and you do not know who you are, which whatever you pick these
    days, and there is so much pressure by society to be something
    different. I get it. No wonder suicide rate is up, actually
    across all age groups, primarily with young girls. That is a
    different issue.
        I will tell you this, and I need your help with this, and I
    need your opinion on this I have, as a surgeon, I have worked
    with wound care for over 30 years, wounds that will not heal. I
    have found absolute and repeatable excess with hyperbaric
    oxygen. I will tell you, I have studied the literature. It is
    somewhat controversial. I will readily admit, being an
    objective scientist. I will tell you, I have known many well,
    several veterans who I know, who have undergone hyperbaric
    oxygen at their last thread, and it has saved their life. I
    want your opinion, and I really want a commitment that the VA
    is going to really put some effort into this for a last thread.
    If we are going to really do everything, if we are not going to
    leave anything on the table, we have to explore this option.
        Mr. Elnahal. The first thing I will say is I fully respect
    your perspective, Congressman, as a surgeon and a physician
    yourself, and appreciate that you have seen the benefits of
    this yourself. We do allow for referrals for hyperbaric oxygen
    therapy in the community. That is a patient by patient,
    physician by physician, or provider determination at the point
    of care.
        Mr. Murphy. Does the VA pay for this?
        Mr. Elnahal. Yes, the VA does pay for that therapy in the
    community. If the referral is made at the front line and the
    clinical determination is made.
        Mr. Murphy. Okay, that is news to me, because that is not
    the word that I am getting back. I will take you for what you
    said, and that is in the record, and we will go from there. Mr.
    Chairman, I am done. Thank you all for what you do for our
    veterans. It is critical. I just say this, we do not go to bed
    without something worrying about what the next thing is. I
    expect you guys to not go to bed every night not worrying about
    that next veteran. Thank you, sir. I will yield back.
        The Chairman. Ms. Ramirez, you are recognized for 5
    minutes.
        Ms. Ramirez. Thank you, Chairman. Before I went into the
    State legislature, for a very long time, I was the executive
    director of a social service agency. We worked primarily with
    people experiencing homelessness. Many of them were men
    experiencing homelessness, and about 20 percent of them were
    veterans. Being on this committee is first an honor and a
    privilege, and certainly, there is a lot of work to be done as
    we talk about housing insecurity and the connections between
    mental health and housing insecurity.
        Mr. Frueh, as we have thought about access to permanent
    stable housing and particularly even as we think about
    homeownership, I know that recently the VA, in coordination
    with a broader White House initiative, announced it was
    enhancing its oversight procedures to better identify and act
    against discriminatory bias in VA home loan appraisals. VA is
    also recommending that all VA fee panel appraisals and all
    lenders staff appraisal reviewers take training on appraisal
    bias, fair housing, and fair lending. Can you tell me how VA--
    can you tell me if the VA has already removed any appraisers
    under its newly enhanced oversight process for detecting bias
    and discrimination?
        Mr. Frueh. First, I would say thank you so much for
    focusing on housing and housing America's most vulnerable
    population. From our perspective, every benefit, every veteran
    deserves access to their benefits, not some veterans. We want
    to make sure we root out discrimination wherever it is from the
    loan guarantee program and the new focus on finding bias in
    appraisals, I do not think that it is yet identified bias. I
    think it is a new program that is still being implemented. I
    would be happy to talk with your staff and you about this as we
    go forward with it. I do not yet have any results from that
    work.
        Ms. Ramirez. You are still in the process of putting
    together the program and the training itself, is that correct?
        Mr. Frueh. I believe so. I know it is in its infancy.
        Ms. Ramirez. Okay. For the record, I would like to be able
    to work with you and closely learn how the training program is
    being designed and then how we are going to be enforcing it. I
    think the last thing I would say is I started as a case worker,
    actually as a mail lady, when I worked at the Social Service
    Agency. I started at the age of 17. I remember I was a senior
    in high school, and I would run right after school to the
    shelter to help distribute mail to people that did not have a
    permanent mailing address. As young, as naive as I was, I sat
    in a room and I heard people who have dedicated their life, who
    died in service, who nearly died in service, talk to me about
    the traumas they had experienced, trauma that I could not
    connect with. I kept asking myself, how could you have fought
    for our country and now be in a church basement with no access
    to supports?
        I would say to you that I have been honored to work on some
    of the affordable housing initiatives on veteran housing in the
    State of Illinois. I really want to put on record how
    incredibly important it is, as you have said, that we continue
    to prioritize housing as we see the housing crisis across this
    country, veterans, both women and men, are struggling between
    paying for their rent and paying, in some cases, for either
    utility bills or rising costs of other things.
        I am grateful that the healthcare system within the VA
    continues to improve, but we still have a long way to go. I
    just want to make sure that as we talk about mental health, as
    we talk about trauma, that we understand that there is an
    intersection between housing, employment, supports for family,
    and that we continue to work to make housing a top priority for
    veterans. I look forward to working with all of you to make
    that happen. Thank you. I yield back, chairman.
        The Chairman. Thank you. Ms. Budzinski, you are recognized
    for 5 minutes.
        Ms. Budzinski. Thank you, Mr. Chairman. Good afternoon. My
    name is Nikki Budzinski. I have the honor and privilege of
    representing Illinois 13th congressional District, which is in
    central and southern Illinois, a little further south of
    Congresswoman Ramirez. I have two VA clinics, one in Decatur,
    one in Springfield, that I have the honor of getting to work
    with and represent. I also have a lot of constituents that are
    serviced by a VA hospital in St. Louis, as the district is
    quite long and reaches over there.
        I am really excited. I am the granddaughter of two World
    War II veterans to get to serve on the Veterans Affairs
    Committee and help my constituents, including many of those
    that are servicemen and women. As a new member and as a part of
    the Veterans Affairs Health Subcommittee, I look forward to
    helping to ensure our veterans have access to the highest
    quality and affordable healthcare. This includes, for me,
    really prioritizing issues around expanding access to
    telehealth, supporting, and helping to recruit the workforce of
    the VA. I know a number of members have spoken to shortages and
    looking at how I can be helpful in that area and ensuring that
    Americans have--our veterans--excuse me, have access to
    behavioral health services, something that I know a number of
    other members on the committee have also spoken to. Because my
    district is predominantly rural, as you know, there are a lot
    of specific challenges that rural communities face when trying
    to tackle some of these priorities.
        I believe our veterans have sacrificed so much for our
    country, and it is our duty as a member, as Members of
    Congress, to work together to find the best solutions. Another
    point I would make is I am honored to serve on this committee,
    which has a long history of bipartisan working together to
    service our men and women that are veterans. I am committed to
    working with my colleagues to do just that.
        I just want to say a thank you to all of your honor being a
    part of this panel. This was very informative, and I am sorry,
    with our schedules, that we have to kind of come back and
    forth, in and out of our committee hearing. I did want to ask
    specifically to Dr. Elnahal, you know, with the ongoing work of
    the PACT Act, which is, I think, very exciting for our veterans
    in this country, I am very specifically interested in how
    specialized care can be expanded through the work of the
    implementation of the PACT Act. Then as a second part of that
    same kind of question around the PACT Act is how you are
    looking at the unique challenges that implementation in rural
    communities, how you are going to be tackling those.
        Mr. Elnahal. Well, thank you, Congresswoman. We share your
    dedication, of course, to providing the highest quality, best
    care we can, including to rural veterans. I think the most
    enabling thing we have to do to fully implement the PACT Act to
    its fullest extent is to hire enough talented, quality
    providers to be able to do so. The PACT Act actually affords us
    the requirement, frankly, to do a study on making sure we
    maximize all of the tools we have to be able to recruit
    specific staff to be able to meet the needs of rural veterans.
    We have already commenced with that important work. We are, of
    course, also trying to maximize, as you mentioned, the use of
    telehealth, because that just makes care more accessible,
    especially to rural veterans.
        We have a partnership with the Federal Communications
    Commission, the FCC, to be able to extend wireless and
    broadband access. We are handing out tablets as well, and
    devices for folks in rural areas to be able to receive that
    care. We are making sure they are trained to be able to do so,
    including training and supporting caregivers. Across the
    spectrum, hiring the number of providers we need to hire,
    making sure we are as productive as we can be with our clinics,
    with various initiatives to be able to improve productivity,
    but also extending connectivity and telehealth to meet rural
    veterans' needs.
        Ms. Budzinski. Thank you, Mr. Chairman. I will yield back
    my time. Thank you.
        The Chairman. Thank you. That concludes all of the people
    who are having questions. Ranking Member Takano, do you have
    closing remarks?
        Mr. Takano. Yes, just briefly, Mr. Chairman, thank you for
    putting this hearing together and calling all the witnesses. I
    want to extend my deep sympathy and condolences to
    Representative Van Orden for the tragic loss of it was your
    brother. Unfortunately, this event occurred at a time when VA
    had not implemented the recent COMPACT Act. I want to use this
    opportunity because I think we might want to get this message
    out to folks that the COMPACT Act was implemented on December
    17--January 17, January 17 of this year. It was a bill that I
    introduced and carried and very proud of it. What that bill
    does is it says that a veteran can call 988, the crisis
    hotline, and be evaluated and be immediately referred,
    immediately referred to a mental health practitioner. It could
    be inpatient or outpatient, and it could be in VA or out of VA,
    wherever it is, whatever is the pathway. This eligibility
    extends to anyone who wore the uniform. Even if you are not
    eligible for VA and you are going through an emergency health
    mental health crisis, you can call 988 and press 1 and be
    connected.
        I wish it had been implemented earlier, but I am very
    grateful Dr. Elnahal, that we have it implemented now. I just
    want to take this moment to make sure that people know about it
    and all our offices can be involved, making sure our veterans
    know about it. Since I took over the chairmanship in 2017,
    suicide prevention has been my No. 1 priority.
        I want to thank you. Many of the new Members of Congress
    coming in, new people coming onto the committee have made it
    their top priority. I agree with Dr. Elnahal, we will not rest
    until that number is zero. Thank you.
        The Chairman. I want to thank the ranking member for
    bringing that up, because it is vitally important that all of
    our members know and understand what that is. The outreach can
    be quick and that no one would be denied.
        I do want to thank all of our witnesses for being here
    today. I think it is clear that VA has a lot of work to do. We
    can get VA to where it needs to be by going back to the basics
    and conducting thorough oversight of VA and the Biden
    administration and where fixes are needed to be made. We will
    work hard to enact thoughtful, necessary legislation that puts
    veterans first and fiscally responsible. We will propel VA into
    the future, force it to keep pace with the modern healthcare
    systems for this generation of veterans and the next. Our
    veterans deserve no less than that but the best in exchange for
    their service. The VA, they use day in and day out should
    reflect that. I look forward to working with the honorable
    members of this committee and our stakeholders to accomplish
    these objectives.
        Again, I want to thank you for being here today. Now, I ask
    unanimous consent that all members shall have 5 legislative
    days in which to revise and extend their remarks and include
    extending their material. Hearing no objections, so ordered.
    With that we are adjourned.
        [Whereupon, at 4:16 p.m., the committee was adjourned.]
    =======================================================================

                             A  P  P  E  N  D  I  X

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

                        Prepared Statements of Witnesses

                                  ----------

                      Prepared Statement of Michael Missal

        Chairman Bost, Ranking Member Takano, and Committee Members, thank
    you for the opportunity to discuss how the Office of Inspector
    General's (OIG) work enhances VA's accountability and continuous
    improvement efforts for its services, programs, and operations. The
    OIG's mission is to serve veterans and the public by conducting
    meaningful independent oversight of VA. Our more than 1,100 staff
    conduct and support accurate, fair, and impactful audits, reviews,
    healthcare inspections, and investigations across the Nation. In just
    this past fiscal year, the OIG produced 250 oversight publications with
    894 recommendations for corrective action. Our personnel have made over
    200 arrests, fielded more than 36,000 contacts to our hotline, and
    testified before congressional committees on 14 occasions, including 10
    before this committee or its subcommittees. Our work has resulted in a
    monetary impact of more than $4.5 billion for VA. This would not be
    possible without the funding and other support we receive from
    Congress.
        The OIG appreciates the work VA does every day on behalf of
    veterans. Secretary McDonough, other VA leaders, and the vast majority
    of personnel with whom the OIG staff engages recognize the benefits of
    meaningful, independent oversight and have been very responsive to our
    requests for information. We also value the regular interactions we
    have with senior leaders to understand their concerns and priorities.
    In addition, we have a strong and collaborative relationship with
    Comptroller General Dodaro and his staff and our work often complements
    and builds on their oversight.

    FOUNDATIONS OF ACCOUNTABILITY

        The OIG's oversight reports reveal recurring themes and
    deficiencies that often center around key elements of accountability.
    They are routinely shared with VA leaders across the enterprise to
    encourage positive change and efficiencies within their respective
    programs and operations. OIG recommendations that focus on even a
    single medical facility or benefits process are often a road map for
    other facilities and offices across VA to help prevent or correct
    similar problems that have gone undetected or unaddressed.

        The OIG's work often focuses on five components of accountability:

            1. Strong governance and clarity of roles and responsibilities

            2. Adequate and qualified staffing to carry out those duties

            3. Updated information technology (IT) systems and effectual
            business processes to support quality healthcare delivery,
            accurate and timely benefits, and efficient operations

            4. Effective quality assurance and monitoring to detect and
            resolve issues

            5. Stable leadership that fosters responsibility for actions
            and continuous improvement

        The OIG reports referenced below help illustrate how weaknesses in
    any of these areas of accountability can negatively affect veterans,
    their families, and caregivers and can waste or misuse taxpayer
    dollars.

    Strong Governance and Clarity of Roles and Responsibilities

        Misconduct, failures to take appropriate action, and persistent
    problems are often the result of VA personnel or contractors not
    understanding their roles and responsibilities. In other cases, they
    understand their duties, but simply do not or cannot fulfill them. This
    may be due to outdated policies and procedures, conflicting guidance,
    or a lack of clear decisionmaking--often with those best positioned to
    act lacking the authority to do so.
        Some oversight reports reveal the tension between program offices
    that may have the policy and oversight functions but lack the authority
    to direct staff in the field. OIG reports have noted this, for example,
    in the governance structure for VA police.\1\ An OIG audit conducted in
    response to concerns about accountability found VA did not have
    adequate and coordinated governance over its police program, due in
    part to confusion about police program roles and authority and lack of
    centralized management. Governance of the police program has been
    divided between the Veterans Health Administration (VHA), whose medical
    facility directors directly supervise police assigned to their
    facilities, and the Office of Security and Law Enforcement (OSLE) that
    oversees police policy and inspections. In this structure, OSLE had the
    authority to inspect medical facility police programs but no authority
    to ensure the problems they detected were promptly fixed.
    ---------------------------------------------------------------------------
        \1\ VA OIG, Inadequate Governance of the VA Police Program at
    Medical Facilities, December 13, 2018; VA OIG, VA Police Information
    Management System Needs Improvement, June 17, 2020.
    ---------------------------------------------------------------------------
        An OIG healthcare inspection described concerns with the oversight
    and supervision structure for military sexual trauma (MST)
    coordinators.\2\ The VHA Office of Mental Health and Suicide Prevention
    oversaw and provided funding for the national MST Support Team that was
    tasked with facilitating communications among regional staff, MST
    coordinators, and other VA staff. Yet funding for MST programs at the
    facility level was allocated by facility leaders, resulting in MST
    coordinators having to compete against other medical facility needs for
    support. The OIG found that inadequately protected administrative time,
    insufficient support staff, and deficient funding were among the
    problems that challenged MST coordinators' ability to fulfill their
    responsibilities to patients. The OIG made one recommendation to the
    under secretary for health to evaluate the guidance and operational
    status and take necessary actions.
    ---------------------------------------------------------------------------
        \2\ VA OIG, Challenges for Military Sexual Trauma Coordinators and
    Culture of Safety Considerations, August 5, 2021.
    ---------------------------------------------------------------------------
        A review of the Intimate Partner Violence Assistance Program
    (IPVAP) revealed personnel at both the Veterans Integrated Service
    Network (VISN) and facility levels were confused about their roles and
    responsibilities, impeding the progress of this program.\3\ In
    interviews, VISN champions expressed the need to clarify their
    responsibilities and those of VISN lead coordinators. Almost half of
    the IPVAP facility coordinators described inadequate resources to
    fulfill their responsibilities. Fourteen percent of IPVAP facility
    coordinators reported that their facilities did not implement routine
    screening to help detect and offer services and supports to patients
    who might be subjected to intimate partner violence. Although IPVAP
    facility coordinators are identified as responsible for program
    evaluation, the OIG found that VHA had not established standardized
    program evaluation methods or measures.
    ---------------------------------------------------------------------------
        \3\ VA OIG, Intimate Partner Violence Assistance Program
    Implementation Status and Barriers to Compliance, September 28, 2022.
    VA has divided the country into 18 regional systems of care referred to
    as Veterans Integrated Services Networks. See www.va.gov/HEALTH/
    visns.asp.
    ---------------------------------------------------------------------------
        Confusion over roles and decisionmaking that is not fully informed
    can affect patient care and business operations on even the most
    routine operations. The OIG review on the cause of a backlog of mail at
    the Atlanta VA Health Care System (HCS) in Decatur, Georgia, revealed
    that the HCS and VHA's Payment Operations and Management (POM) office
    mismanaged incoming mail from November 2020 to September 2021, causing
    a backlog of more than 17,000 mailed items.\4\ The mail included
    veterans' medical records, claims for payment from veterans and
    community care providers, and checks totaling nearly $207,000. The
    cause was traced to a verbal agreement that transferred POM's
    responsibility for mail management to HCS personnel, without engaging
    HCS staff expected to take on this work. HCS leaders lacked a clear
    understanding of the additional workload they assumed and did not
    ensure enough staff were adequately prepared for managing the influx of
    mail. POM officials were later reluctant to help, citing the transfer
    of their responsibilities in a verbal agreement. VA concurred with the
    OIG's five recommendations, including one recommendation focused on
    addressing all negative consequences, but that recommendation remains
    open.
    ---------------------------------------------------------------------------
        \4\ VA OIG, Atlanta VA Health Care System's Unopened Mail Backlog
    with Patient Health Information and Community Care Provider Claims,
    April 27, 2022.
    ---------------------------------------------------------------------------
        Similarly, OIG reports on Veteran Benefits Administration (VBA)
    claims-processing deficiencies identified the tension and disconnect
    between VBA's Office of Field Operations (OFO) and Compensation Service
    office. OFO manages the employees who process veterans' claims, sets
    production goals, and oversees personnel management. Compensation
    Service provides the ``how to'' guidance, training, and quality
    assurance checks. The disconnect between the two offices is illustrated
    through the deficiencies involving MST-related claims processing. The
    OIG issued two reports on the processing of MST claims, one in 2018 and
    a follow-up in 2021, which actually showed an increase in incorrect
    claims processing following the ineffective implementation of OIG
    recommendations.\5\ In the follow-up report, the OIG found that the
    Compensation Service and OFO did not communicate effectively to resolve
    claims-processing problems identified in 2018 and managers and claims
    processors were not being held accountable for adhering to updated VBA
    policies and procedures. Communication and cooperation between these
    offices is crucial to successfully overseeing the processing of claims,
    and the OIG recommended that VBA develop, implement, and monitor a
    written plan that requires these two offices to strengthen
    communication, oversight, and accountability.
    ---------------------------------------------------------------------------
        \5\ VA OIG, Denied Posttraumatic Stress Disorder Claims Related to
    Military Sexual Trauma, August 21, 2018; VA OIG,Improvements Still
    Needed in Processing Military Sexual Trauma Claims, August 5, 2021.
    ---------------------------------------------------------------------------
        The OIG report, Improvements Needed to Ensure Final Disposition of
    Unclaimed Veterans' Remains, demonstrates the repercussions of having
    27 program offices with responsibilities related to unclaimed
    remains.\6\ This led to inadequate and ineffective administration and
    oversight of benefits and services by VHA, VBA, and the National
    Cemetery Administration. The OIG team obtained more than 9,000 records
    from a Department of Justice database and found more than 400 matches
    of individuals whose remains were unclaimed that appeared to be
    veterans based on a search of full names and dates of birth and
    death.\7\ Additionally, the team identified multiple instances of
    individuals who may be veterans interred in mass graves as well as
    those with final interments delayed as long as 44 years. There were
    three key areas in which VA governance of benefits and services for
    deceased veterans whose remains are unclaimed was not effective: (1)
    insufficient outreach to funeral homes and other custodians of
    unclaimed remains and collaboration with external entities to locate
    deceased veterans and facilitate their burials; (2) a financial
    oversight structure that did not support cross-administration or VA-
    wide reconciliation of payments made for these deceased veterans; and
    (3) inadequate oversight across and within VA's three administrations.
    ---------------------------------------------------------------------------
        \6\ VA OIG, Improvements Needed to Ensure Final Disposition of
    Unclaimed Veterans' Remains, December 15, 2021.
        \7\ The National Missing and Unidentified Persons System (NamUs) is
    the Department of Justice data base used. The review team referred all
    NamUs-matched records to VA for follow-up to conclusively identify
    veterans and eligible dependents, which may require coordination with
    the medical examiner, coroner, or law enforcement agency that has
    custody of the remains.
    ---------------------------------------------------------------------------
        The problematic decentralized nature of governance is also seen in
    VA's financial management structure. Under the Chief Financial Officer
    (CFO) Act, the VA CFO has the responsibility for establishing financial
    policy, systems, and operating procedures for all VA financial
    entities. VA administrations and other offices are responsible for
    implementing those policies and producing financial information, but
    they are not under the supervision of the VA CFO. This fragmented
    structure has been a consistent concern and finding in the audit of
    VA's consolidated financial statements.\8\ Without active involvement
    from VA's senior leaders to overcome organizational silos and ensure
    collaboration, problems at the administration level may not be elevated
    for resolution.
    ---------------------------------------------------------------------------
        \8\ VA OIG, Audit of VA's Financial Statement for Fiscal Years 2022
    and 2021, December 7, 2022.

    ---------------------------------------------------------------------------
    Adequate and Qualified Staff

        VA faces high vacancy rates across its programs and operations,
    especially within VHA. These long-standing shortages of qualified
    personnel make it difficult for VA to carry out its many goals and
    functions, impeding its ability to serve the Nation's veterans. Having
    the right people in the right positions committed to doing the right
    thing is essential to building a culture of accountability.
        To address these staffing shortages, VA has engaged in surge hiring
    and other recruitment strategies under their expanded authority. While
    expedient hiring is critical, VA cannot lower its standards for
    suitability and expertise. A report released last week focuses on
    suitability (background) checks. It was prompted in part by the
    recognition that nursing assistant Reta Mays, convicted for murdering
    seven patients in a West Virginia VA medical center, had not undergone
    a timely background check that might have prevented her from attaining
    her position.\9\ In the course of auditing the personnel suitability
    process across all VA medical facilities, the OIG detected problems
    with how this process was being conducted at the VA medical center in
    Beckley, West Virginia. In addition to finding that suitability
    personnel support was significantly understaffed at Beckley, the review
    of the facility revealed a need to tighten controls for ensuring
    individuals are suited for their positions. Thankfully, no patient harm
    was detected and all affected personnel had either left VA or were
    successfully cleared. Making certain that staff are and remain
    competent to do their jobs is central to the quality assurance issues
    discussed below as well.
    ---------------------------------------------------------------------------
        \9\ VA OIG, Personnel Suitability Process Concerns at the Beckley
    VA Medical Center in West Virginia, February 23, 2023.
    ---------------------------------------------------------------------------
        As for persistent shortages, VA is not alone. Medical systems
    across the country are facing challenges in finding and retaining
    qualified personnel. The OIG is required by law to conduct an annual
    review to identify clinical and nonclinical VHA occupations with the
    largest staffing shortages within each VHA medical center.\10\ In the
    Fiscal Year 2022 review, the OIG found that all 139 VHA facilities that
    were surveyed reported at least one severe occupational staffing
    shortage.\11\ The total number of their reported severe shortages was
    2,622. Twenty-two occupations were identified as a severe occupational
    staffing shortage by at least one in five facilities, including the
    medical officer and nurse occupations, which have been reported as
    severe shortages every year since 2014. Practical nurse positions were
    the most frequently identified ``clinical severe occupational staffing
    shortage'' in Fiscal Year 2022 (62 percent of facilities), with
    custodial worker and medical support assistance positions being the
    most frequently reported nonclinical and ``Hybrid Title 38'' shortages,
    respectively.\12\ The total number of severe occupational staffing
    shortages increased by 22 percent from the prior year. This was also
    the first Fiscal Year that facilities identified more than 90
    occupations as severe shortages.
    ---------------------------------------------------------------------------
        \10\ VA Choice and Quality Employment Act, Pub. L. No. 115-46, 131
    Stat. 958 (2017).
        \11\ VA OIG, OIG Determination of Veterans Health Administration's
    Occupational Staffing Shortages Fiscal Year 2022, July 7, 2022.
        \12\ In 2003, Public Law 108-170 provided for 21 Title 5
    occupations to be converted to ``Hybrid'' 38 positions, including
    psychologists, respiratory and physical therapists, and medical
    technologists. This conversion provided greater benefits related to
    appointment, advancement, and some pay matters, while retaining some
    traditional Title 5 employment provisions, including performance
    appraisals, leave, work schedule, and retirement benefits. See 38
    U.S.C. Sec. Sec.  7403 and 7405.
    ---------------------------------------------------------------------------
        In a recent inspection, the OIG found that inadequate staffing
    within the Martinsburg, West Virginia, VA medical center's Care in the
    Community (CITC) Service led to delays in scheduling community consults
    (referrals).\13\ Sixty-two percent of the COVID Priority 1 cardiology
    consults during a one-year period were scheduled more than 30 days
    beyond the clinically indicated date, which is the date the patient
    needs to be seen based on their clinical status. To meet workload
    demands, the CITC Service at the facility needed a minimum of 23
    schedulers and 11 clinical employees. At the time of the inspection,
    they had only 10 scheduling and four clinical staff, with facility
    leaders reporting significant staff turnover and a lack of training as
    contributing factors.
    ---------------------------------------------------------------------------
        \13\ VA OIG, Care in the Community Consult Management During the
    COVID-19 Pandemic at the Martinsburg VA Medical Center in West
    Virginia, February 16, 2022.
    ---------------------------------------------------------------------------
        In another recent report, the OIG team focused on VA's
    accountability for the physical security of its medical facilities.\14\
    The report identified multiple security vulnerabilities and
    deficiencies at the time of the review, most notably staffing shortages
    that contributed to the lack of a visible and active police
    presence.\15\ To meet VA's established security requirements,
    facilities need to fill police officer vacancies to correct security
    weaknesses. Other measures facilities can take to improve campus
    security include increasing security personnel resources, such as
    suitable police operations rooms; operable surveillance cameras with
    consistent monitoring; and adequate equipment. Moreover, the report
    found that facilities need to do a better job securing doors and
    restricting public access to high-risk areas. VA concurred with the
    OIG's six recommendations, which included delegating a responsible
    official to monitor and report monthly on facilities' security-related
    vacancies; authorizing sufficient staff to inspect VA police forces;
    and ensuring medical facility directors appropriately assess VA police
    staffing needs, authorize associated positions, and leverage available
    mechanisms to fill vacancies.
    ---------------------------------------------------------------------------
        \14\ VA OIG, Security and Incident Preparedness at VA Medical
    Facilities, February 22, 2023.
        \15\ Police staffing shortages have remained in the top 10 most
    frequently reported positions with severe shortages annually in the
    OIG's annual survey of occupational shortages. VA OIG, OIG
    Determination of Veterans Health Administration's Occupational Staffing
    Shortages Fiscal Year 2022.
    ---------------------------------------------------------------------------
        In addition to addressing staffing shortages, VA should also make
    sure that its existing personnel are equipped and prepared to do their
    jobs. The OIG recently reviewed whether staff at VBA were correctly
    following procedures when requesting medical opinions, a process that
    is vital to ensuring veterans receive the benefits to which they are
    entitled.\16\ The review found that claims processors did not
    consistently identify relevant medical evidence for the examiner's
    review, did not always use clear and accurate language, did not
    regularly request all warranted medical opinions, and sometimes
    requested unnecessary medical opinions. One contributing factor to
    these issues was inadequate training. The mandatory training for claims
    processers on making medical opinion requests did not explain how to
    correctly complete the requests using VBA's electronic systems,
    including what information to input in particular fields. The training
    also did not describe what constitutes relevant evidence for a medical
    examiner's review or provide examples of what language should be used
    to ensure requests are adequate and well written. These failings can
    lead to inaccurate medical opinions, incorrect decisions on veterans'
    claims, delayed decisions for veterans, as well as an inefficient use
    of resources (such as when the medical opinion requires rework).
    ---------------------------------------------------------------------------
        \16\ VA OIG, VBA Could Improve the Accuracy and Completeness of
    Medical Opinion Requests for Veterans' Disability Benefits Claims,
    September 7, 2022.

    ---------------------------------------------------------------------------
    Modernizing IT Systems and Business Processes

        VA is in the process of modernizing a number of significant systems
    that are critical to its operations. The OIG has been proactively
    overseeing VA's implementation of these crucial systems. However, as
    the OIG has detailed in multiple reports, VA has had significant
    troubles with upgrading or replacing key systems that support patient
    care, supply management, benefits to veterans and their families, and
    the stewardship of taxpayer dollars. These issues must be resolved for
    VA to remain accountable for the care, services, and benefits it
    provides. VA's process for replacing crucial IT systems, however, faces
    significant ongoing challenges. Major plans to modernize electronic
    health records, supply chain management, claims processing, and
    financial management systems have been marked by critical missteps.
    These have typically included weaknesses in planning, lack of stability
    in leadership positions, insufficient stakeholder engagement, failures
    to promptly fix known issues, and program management or coordination
    deficiencies. The OIG recognizes the tremendous complexity and cost of
    these efforts and continues to provide recommendations that are as
    practical and actionable as possible to support VA personnel working
    tirelessly to ensure patient safety and to deliver benefits and
    services to eligible veterans.
        Perhaps the largest contract in VA history, and one that affects
    patient care, is VA's Electronic Health Record Modernization (EHRM)
    program. Key objectives of the new system include achieving
    interoperability of VA and DoD systems to provide complete health
    records for veterans and enhancing the ability to exchange records with
    external healthcare providers.\17\ Essential to implementing and
    budgeting this multibillion-dollar effort, VA needs a high-quality,
    reliable, integrated master schedule to ensure all tasks are properly
    and fully completed and accounted. An OIG audit found, however, that
    this foundational master schedule had significant reliability
    weaknesses, including missing tasks, no baseline schedule, and no risk
    analyses.\18\ Without remediation, VA cannot offer reliable assurances
    on timelines and costs. Further, the OIG has estimated that any delay
    in the program's completion would cost about $1.95 billion a year.
    ---------------------------------------------------------------------------
        \17\ VA OIG and DoD OIG, Joint Audit of the Department of Defense
    and the Department of Veterans Affairs Efforts to Achieve Electronic
    Health Record System Interoperability, May 5, 2022.
        \18\ VA OIG, The Electronic Health Record Modernization Program Did
    Not Fully Meet the Standards for a High-Quality, Reliable Schedule,
    April 25, 2022.
    ---------------------------------------------------------------------------
        Overall, the OIG has released 14 reports on VA's rollout of the new
    electronic health record system that identify critical missteps and
    lack of remediation. Of the 68 recommendations issued to date, 24 have
    not yet been implemented--with 12 open for more than a year and two
    open nearly three years. The open recommendations include VA minimizing
    the number of required mitigation strategies healthcare providers must
    use when the system goes live, determining if veterans' appointments
    are being scheduled correctly, and addressing unresolved issues related
    to medication management and care coordination. These reports have also
    been highlighted in seven congressional hearings in which the OIG
    testified.\19\ Unless VA more effectively engages and coordinates all
    affected offices and contractors, IT solutions will continue to be
    delayed, more cost overruns will occur, and the risk to patients and VA
    operations will increase.
    ---------------------------------------------------------------------------
        \19\ Prior EHRM congressional statements can be found at
    www.va.gov/oig/publications/statements.asp.
    ---------------------------------------------------------------------------
        Although VA paused its EHRM rollout in June 2022, users of the new
    system continue to raise troubling complaints that the system hinders
    the delivery of prompt, high-quality patient care. The effects on
    staff, workload, and the risks for errors are also concerning. The OIG
    is continuing its oversight, including an examination of system
    degradations and outages.
        Similarly, there are other key systems essential to maintaining
    effective and efficient VA operations in other areas that are also in
    critical need of updates or replacement. In March 2019, VA decided to
    modernize and standardize its supply chain management, replacing up to
    12 legacy systems with a system already in use at DoD--the Defense
    Medical Logistics Standard Support (DMLSS) system. The OIG reviewed
    VA's oversight and coordination of the system's implementation at the
    pilot site to identify challenges that could affect supplies getting to
    where and when they are needed and to inform future deployments.\20\
    The OIG found that the system did not meet more than 40 percent of the
    high-priority essential business requirements identified by VA medical
    facility staff at the pilot site. This occurred because the VA
    Logistics Redesign (VALOR) program manager did not follow VA's
    acquisition framework as required. After months of trying to determine
    the way ahead, VA announced in December 2022 that it will not deploy
    the DMLSS multibillion-dollar supply chain management system across the
    department's health and medical services.\21\ In considering next
    steps, supply chain modernization is not just about the system; it is
    about the people, processes, and technology limitations. Without clear
    roles and responsibilities, business requirements, and effective tools,
    VA will struggle to achieve accountability for its multibillion-dollar
    logistics portfolio.
    ---------------------------------------------------------------------------
        \20\ VA OIG, DMLSS Supply Chain Management System Deployed with
    Operations Gaps That Risk National Delays, November 10, 2021.
        \21\ Edward Graham, ``VA Cancels Future Deployments of New Supply
    Chain Management System,'' Nextgov, December, 13, 2022, https://
    www.nextgov.com/technology-news/2022/12/va-cancels-future-deployments-
    new-supply chain-management-system/380841/. The article states that the
    decision to abandon DMLSS deployment followed the OIG report findings.
    ---------------------------------------------------------------------------
        Making sure veterans are promptly and accurately provided benefits
    is one of VA's most important responsibilities, yet it is often
    hindered by outdated IT systems and unclear or complex business
    processes. For example, VA improperly created debts in veterans'
    accounts when reducing disability levels. In a national review of the
    issue, the OIG found instances in which VA employees retroactively
    reduced disability levels and erroneously created debts without always
    informing veterans--in part due to system limitations. Based on the
    review of a statistical sample, the OIG estimated errors resulting in
    incorrectly created veteran debts totaling about $13.4 million.\22\
    ---------------------------------------------------------------------------
        \22\ VA OIG, VBA Improperly Created Debts When Reducing Veterans'
    Disability Levels, July 28, 2022.
    ---------------------------------------------------------------------------
        The OIG has also released a series of reports on GI bill benefits
    in response to concerns that eligible beneficiaries were not getting
    payments owed to them or were being underpaid.\23\ Starting with an
    issue statement in 2019, the OIG identified delays in system
    modifications needed to satisfy the statutory requirements, in part due
    to the lack of an accountable official to oversee the project.\24\ The
    OIG team found that approximately 10 months passed from the time
    Congress enacted the Forever GI Bill until VA received the initial
    software development release and began testing the system
    modifications. VA's testing of the software development release
    identified defects, prompting the development of additional versions.
    Based on interviews, when user testing occurred, there were failures
    related to scenarios that VBA did not account for when personnel
    developed the business requirements. In a recent report on the Post-9/
    11 GI Bill, the OIG found errors in VBA's processing of school vacation
    breaks due to the process being entirely manual, resulting in about
    $624,000 in underpayments to beneficiaries for monthly housing
    allowances and college funds.\25\
    ---------------------------------------------------------------------------
        \23\ VA OIG, Forever GI Bill: Early Implementation Challenges,
    March 20, 2019; VA OIG, Controls Appear to Have Addressed Prior
    Overpayments of Post-9/11 GI Bill Monthly Housing Allowance, June 23,
    2020; VA OIG Management Advisory Memorandum, Post-9/11 GI Bill Non-
    College Degree Entitlement Calculations Lead to Differences in Housing
    Allowance Payments, January 19, 2021; VA OIG, Processing of Post-9/11
    GI Bill School Vacation Breaks Affects Beneficiary Payments and
    Entitlement, May 3, 2022.
        \24\ VA OIG, Forever GI Bill: Early Implementation Challenges.
        \25\ VA OIG, Processing of Post-9/11 GI Bill School Vacation Breaks
    Affects Beneficiary Payments and Entitlement.
    ---------------------------------------------------------------------------
        Another report indicated improper payments were being made to
    veterans who were deceased because VA needed to better monitor its
    death match records automated process, and VBA missed opportunities to
    discontinue payments by not coordinating with and obtaining data from
    VHA.\26\ In one case, payments continued to be improperly paid to a
    veteran who was deceased for a total of about $99,000.\27\ An automated
    system also was to blame for improper processing of pension reductions
    as detailed in a 2021 report, leading to veterans not being notified
    that their benefits were being reduced or given the information
    necessary to appeal those reductions. All of the estimated 13,100 cases
    contained notification errors that made it difficult for beneficiaries
    to determine what action they should take, such as submitting evidence
    that the benefit should not be reduced or requesting a hearing. Errors
    identified were the result of inadequate planning and implementation of
    the automated pension reduction process.\28\
    ---------------------------------------------------------------------------
        \26\ VA OIG, Additional Actions Can Help Prevent Benefits Payments
    from Being Sent to Deceased Veterans, April 21, 2022.
        \27\ In a recent OIG criminal investigation, the daughter of a
    deceased widow who had been receiving VA survivors benefits continued
    to receive those benefits even after her mother passed by forging her
    mother's signature and fraudulently filing VA paperwork to make it
    appear as if her mother was still alive. The daughter was ordered to
    pay restitution of almost $462,000. VA OIG, Monthly Highlights, January
    2023.
        \28\ VA OIG, Improper Processing of Automated Pension Reductions
    Based on Social Security Cost of Living Adjustments, October 28, 2021.
    ---------------------------------------------------------------------------
        VA has also been struggling since the early 2000's to replace its
    financial management system. After several failed attempts in 2004 and
    2010, VA used the lessons learned and established the Financial
    Management Business Transformation (FMBT) program. The program's
    mission is to increase the transparency, accuracy, timeliness, and
    reliability of financial information across VA, ultimately resulting in
    improved care and services for veterans and accountability to
    taxpayers. Central to the FMBT program's modernization efforts is the
    multiyear, phased deployment of the Integrated Financial and
    Acquisition Management System (iFAMS) beginning with NCA. In September
    2021, the OIG issued a management advisory memorandum on inadequate
    business intelligence reporting capabilities in iFAMS that hindered
    NCA's ability to easily monitor its budget and operations.\29\ In June
    2022, the OIG issued another memorandum on the results of a consulting
    engagement related to financial reporting controls for iFAMS at
    NCA.\30\ This memorandum identified risks that could lead to inaccurate
    financial reporting, including interface errors, more manual data
    entry, and the lack of automated controls. VA is currently reviewing a
    draft report related to the deployment of iFAMS at NCA that discusses
    issues that should be addressed as VA moves forward with further
    deployment of iFAMS.
    ---------------------------------------------------------------------------
        \29\  VA OIG, Inadequate Business Intelligence Reporting
    Capabilities in the Integrated Financial and Acquisition Management
    System, September 8, 2021.
        \30\ VA OIG, Results of Consulting Engagement Related to Selected
    Financial Reporting Controls for the Integrated Financial and
    Acquisition Management System at the National Cemetery Administration,
    June 15, 2022.

    ---------------------------------------------------------------------------
    Quality Assurance, Monitoring, and Reviews

        VA often lacks controls that effectively and consistently ensure
    quality standards are met. Routine monitoring breakdowns and
    workarounds undermine efforts to ensure eligible veterans and their
    families receive timely quality services and benefits. Failures in
    quality assurance and monitoring relate not just to systems and
    processes, but to personnel as well--particularly in areas such as
    credentialing, privileging, and monitoring of healthcare personnel
    entrusted with veterans' care.
        VBA and VHA programs have various types of quality assurance
    programs; however, they are not consistently and effectively
    implemented and the results are not always clearly communicated or
    resolved. Among the many reports the OIG has published, a series of
    four focused reports and a roll-up report have been released on VBA's
    multifaceted quality assurance program.\31\ The program is managed by
    VBA's Compensation Service but VBA's OFO is responsible for ensuring
    regional office employees adequately address claims-processing
    deficiencies routinely identified by the quality assurance program. The
    individual reports on elements of the quality assurance program
    identified weaknesses in the program, and the summary report identified
    systemic weaknesses in OFO's oversight and accountability. Two aspects
    of the quality assurance program are the STAR Program and the Quality
    Review Team Program. However, OIG staff have observed those programs
    focus on an overall statistical sample of completed disability
    compensation claims. That means that complex claims, such as claims for
    military sexual trauma and ALS (Lou Gehrig's disease), are not the
    focus of the sample. Processing deficiencies related specifically to
    these complex claims may go undetected if they are simply grouped with
    claims at lower risk for error. Without more focused sampling, quality
    assurance results provide incomplete information to VBA on how well
    staff are processing claims more vulnerable to error.
    ---------------------------------------------------------------------------
        \31\ VA OIG, The STAR Program Has Not Adequately Identified and
    Corrected Claims-Processing Deficiencies, July 22, 2020; VA OIG,
    Deficiencies in the Quality Review Team Program, July 22, 2020; VA OIG,
    Site Visit Program Can Do More to Improve nationwide Claims Processing,
    August 18, 2020; VA OIG, Greater Consistency Study Participation and
    Use of Results Could Improve Claims Processing nationwide, September
    29, 2020; VA OIG, The Office of Field Operations Did Not Adequately
    Oversee Quality Assurance Program Findings, May 18, 2021.
    ---------------------------------------------------------------------------
        One of the OIG's reports on VBA's quality assurance program
    examined VBA's site visit program of regional benefits offices, which
    is designed to not only correct deficiencies at individual regional
    offices, but also to identify error trends across multiple regions that
    could be used to drive nationwide improvements in claims processing.
    The OIG reviewed the site visit reports for 47 regional offices and
    found that almost 50 percent had deficient workload management plans,
    36 percent had no plans at all to clear the backlog of errors pending
    correction identified by quality review teams, and 23 percent were
    deficient in MST claims processing.\32\ While the site visit program
    identified these and other frequently recurring deficiencies, OFO did
    not require all offices across the country to apply the information to
    ensure widespread improvements. As a result, VBA missed opportunities
    to provide impactful oversight and drive positive change, which could
    ultimately improve the accuracy and consistency of veterans' disability
    benefit decisions. Until VBA leaders ensure improvements are made,
    veterans may not get the benefits to which they are entitled.
    ---------------------------------------------------------------------------
        \32\ VA OIG, Site Visit Program Can Do More to Improve nationwide
    Claims Processing.
    ---------------------------------------------------------------------------
        VA has identified patient safety as a top priority.\33\ Healthcare
    facilities committed to patient safety routinely follow protocols that
    prioritize high-quality care and have a structured and proactive
    quality and safety management oversight team. OIG reports, however,
    routinely identify instances in which staff fail to adhere to policy or
    to take actions that ensure a culture of patient safety. For example, a
    recent OIG report found that the Tuscaloosa VA Medical Center and VISN
    7 had insufficient oversight of the facility's Patient Safety
    Program.\34\ The OIG received a VHA Issue Brief identifying concerns
    with the program's management not completing the required patient
    safety root cause analyses and risk assessments, and the former Patient
    Safety Manager (PSM) not attending meetings with facility and VISN
    committees. These concerns followed the extended leave and abrupt
    retirement of the former PSM. The OIG substantiated the concerns and
    identified other issues with program oversight and the facility's
    culture of safety. According to the report, the facility and VISN
    leaders did not take appropriate action. Facility leaders failed to
    fully engage with Patient Safety Program staff and did not sufficiently
    use available tools to assess and evaluate reported concerns related to
    patient safety, putting patients at unnecessary risk.
    ---------------------------------------------------------------------------
        \33\ See, e.g., VA, ``Patient safety a primary concern at VA,''
    March 15, 2021, https://news.va.gov/85809/patient-safety-primary-
    concern-va/, and ``VHA National Center for Patient Safety'' (web page),
    VA, https://www.patientsafety.va.gov/about/approach.asp.
        \34\ VA OIG, Deficiencies in the Patient Safety Program and
    Oversight Provided by Facility and VISN Leaders at the Tuscaloosa VA
    Medical Center in Alabama, February 27, 2023.
    ---------------------------------------------------------------------------
        Ensuring high-quality patient care was also identified in a report
    on the Columbia VA Health Care System in South Carolina.\35\ That
    report focused on adverse clinical outcomes for three patients. While
    reviewing the allegations related to those patients, the OIG found
    weaknesses in the peer review and quality management processes. The
    peer reviews and the peer review committee practices were inefficient
    and there was a delay in the initiation of an institutional disclosure
    to the patient's family and completion of a root cause analysis of the
    problem. All seven of the report's recommendations remain open,
    including three focused on the facility's quality management program.
    ---------------------------------------------------------------------------
        \35\ VA OIG, Surgical Adverse Clinical Outcomes and Leaders'
    Responses at the Columbia VA Health Care System in South Carolina,
    September 27, 2022.
    ---------------------------------------------------------------------------
        Proper documentation practices are an important aspect of
    accountability in both benefits and healthcare settings. Those
    practices help VA and oversight entities ensure that policies and
    requirements are being met. In healthcare settings, proper
    documentation is especially critical as it communicates to members of
    an integrated healthcare team critical data that are necessary to
    ensure coordination and collaboration. For example, in an inspection of
    the VA Pittsburgh Healthcare System, the OIG found that failures in
    completing a thorough assessment and documentation may have contributed
    to a lack of appropriate intervention and ultimately an adverse
    clinical outcome for a patient.\36\ A behavioral health nurse
    practitioner did not document a comprehensive suicide risk assessment
    for eight patients, even though this was required based on their
    positive screen for suicidal ideation. The nurse practitioner also
    failed to consistently document intent, risk and protective factors,
    and a mitigation plan for the patients. The OIG also found that a nurse
    manager who was responsible for conducting ongoing professional
    practice evaluations (OPPE) had given this nurse practitioner a
    ``satisfactory'' rating for the ``safety plan completion for high risk
    for suicide patients'' and ``copy and paste use'' elements--even though
    the nurse manager admitted to not reviewing these elements of
    documentation. In fact, the inspection team found that the nurse
    practitioner not only failed to complete a safety plan for eight
    patients, but also inappropriately copied and pasted significant
    sections of notes from prior documented clinical encounters. The OIG's
    recommendations centered on the improvement of assessment and
    documentation practices, verification of the review of performance
    elements in OPPEs, and manager oversight of those OPPEs.
    ---------------------------------------------------------------------------
        \36\ VA OIG, Deficiencies in a Behavioral Health Provider's
    Documentation and Assessments, and Oversight of Nurse Practitioners at
    the VA Pittsburgh Healthcare System in Pennsylvania, May 3, 2022.
    ---------------------------------------------------------------------------
        Quality controls and process monitoring must be coupled with
    ensuring the competency of personnel to meet the requirements of their
    position and their commitment to serving veterans. Delayed responses to
    concerns related to the competency of healthcare providers cannot only
    put patients at risk and compromise the trust of staff, but can
    negatively affect the skills and practices of the providers in
    question. A report on the Richard L. Roudebush medical center in
    Indiana highlights this issue.\37\ The cardiology nursing staff had
    expressed multiple concerns to facility leaders regarding the skills of
    a newly trained interventional cardiologist. As a result, the
    cardiologist's cardiac catheterization laboratory privileges were
    suspended and a factfinding investigation was initiated. However, these
    actions were not completed in a timely manner. The factfinding
    investigation was finalized more than 3 months after the cardiologist's
    suspension, and it took almost another three months for the
    cardiologist's privileges to be reinstated so that leaders could
    initiate a second observed evaluation of the cardiologist's performance
    in the catheterization laboratory. After 6 months out of practice, the
    cardiologist refused to participate in a practice review and resigned.
    Ultimately, the OIG did not substantiate that the interventional
    cardiologist provided poor quality of care to patients at the facility.
    ---------------------------------------------------------------------------
        \37\ VA OIG, Deficiencies in Credentialing, Privileging, and
    Evaluating a Cardiologist at the Richard L. Roudebush VA Medical Center
    in Indianapolis, Indiana, January 17, 2023.

    Stable Leadership That Fosters Responsibility and Continuous
    ---------------------------------------------------------------------------
        Improvement

        VA leaders at every level often do not get the information they
    need to make effective decisions; some fail to take necessary and
    prompt action, while others struggle to create a culture where every
    employee feels empowered to report problems. The frequent turnover in
    key positions or the long-term use of acting positions exacerbates
    these challenges.
        The OIG's recent report on the mistreatment of a patient admitted
    to the Miles City Community Living Center (CLC), part of the VA Montana
    Healthcare System in Fort Harrison, describes failures in leadership
    that led to several incidents of patient abuse.\38\ The OIG learned
    that nurses and a physical therapist forced a critically ill patient to
    walk after the patient verbally refused and lowered to the floor to
    further refuse participation. Staff reported the physical therapist,
    and a nurse forcefully lifted the patient by the arm to stand and then
    pulled the patient's walker forward and out of reach, compelling the
    patient to walk. A VA police report documented bruises to the patient's
    arms, and staff told the OIG that the patient sustained skin tears
    during this session. The OIG concluded that the physical therapist and
    nurses violated VHA policy by failing to respect the patient's right to
    refuse treatment and subjecting the patient to mistreatment during two
    physical therapy sessions. The OIG also determined that there were
    three previous investigations with confirmed findings of mistreatment
    or abuse in the CLC. Two nurses involved in the mistreatment of this
    patient were also involved in two of the other incidents, one in a 2018
    incident and both in an August 2020 incident. The OIG determined that
    facility leaders did not complete oversight processes for the CLC,
    including intervening in prior findings of CLC patient mistreatment in
    2018 and 2020. Facility leaders also failed to oversee the sole
    physician responsible for the CLC patients. The lack of oversight
    repeatedly placed patients at risk. With a distance of over 350 miles
    to the Fort Harrison facility, staff easily escaped accountability.
    ---------------------------------------------------------------------------
        \38\ VA OIG, Mistreatment and Care Concerns for a Patient at the VA
    Montana Healthcare System in Miles City and Fort Harrison, January 26,
    2023.
    ---------------------------------------------------------------------------
        The Montana case is an example of a culture the OIG has found in
    other facilities that did not foster the prompt and candid reporting of
    concerns. Leaders' failures to create a culture in which personnel feel
    safe in reporting clinical personnel's incompetency or errors can lead
    to tragic outcomes. For example, in a 2021 report, the OIG detailed how
    Dr. Robert M. Levy, the former pathologist at the VA Health Care System
    of the Ozarks in Fayetteville, Arkansas, was found to have been working
    while impaired by substance use and misdiagnosed thousands of patients'
    pathological specimens. His errors resulted in some veterans not being
    diagnosed with cancers for which they needed prompt and tailored
    treatments and others undergoing interventions they did not need--some
    with significant side effects. In addition, in his position as chief of
    pathology, he was able to alter quality management documents to conceal
    his errors.\39\ Dr. Levy was sentenced to 20 years in federal prison
    (including one count of involuntary manslaughter), followed by three
    years of supervised release, and ordered to pay $497,745 in
    restitution.\40\ Like the Reta Mays serial murder case mentioned
    earlier, personnel had concerns regarding the circumstances surrounding
    the hypoglycemic events, but not all personnel promptly reported
    concerns and there were insufficient follow-up actions taken.
    ---------------------------------------------------------------------------
        \39\ VA OIG, Pathology Oversight Failures at the Veterans Health
    Care System of the Ozarks in Fayetteville, Arkansas, June 2, 2021.
        \40\ US Department of Justice, ``Fayetteville Doctor Sentenced to
    20 Years in Federal Prison for Mail Fraud and Involuntary
    Manslaughter,'' January 22, 2021, www.justice.gov/usao-wdar/pr/
    fayetteville-doctor-sentenced-20-years-Federal-prison-mail-fraud-and-
    involuntary.
    ---------------------------------------------------------------------------
        In a number of OIG reports, leaders' stated commitment to
    improvement is not reflected in closing, sustaining, or fully
    implementing recommendations for corrective action.\41\ As stated
    earlier, the OIG has reviewed VBA's processing of posttraumatic stress
    disorder (PTSD) claims related to MST several times due to delays in
    implementing recommendations for improvement or sustaining those
    corrective actions. In August 2018, the OIG found that claims
    processors did not follow the proper procedures for about half of
    denied claims to veterans, resulting in premature denials. The OIG made
    six recommendations including calling for VBA to have MST claims
    handled by a specialized group of claims processors. In response, VBA
    identified a list of designated claims processors and in January 2019
    established a procedure requiring that only designated employees
    process MST claims.\42\
    ---------------------------------------------------------------------------
        \41\ See, e.g., VA OIG, Follow-Up Review of the Accuracy of Special
    Monthly Compensation Housebound Benefits, December 15, 2021.
        \42\ VA OIG, Denied Posttraumatic Stress Disorder Claims Related to
    Military Sexual Trauma.
    ---------------------------------------------------------------------------
        However, in August 2021, the OIG concluded in a followup to the
    2018 report that VBA leaders had not sustained the corrective
    actions.\43\ About 80 percent of claims denied from October 1 through
    December 31, 2019, were processed by one or more VBA employees who were
    not designated MST claims processors. Based on a sample of claims
    processed after VBA acted on the prior OIG recommendations, the review
    team estimated about 620 of 1,100 denied claims (57 percent) were
    incorrectly processed, which was not an improvement from the previous
    error rate.
    ---------------------------------------------------------------------------
        \43\ VAOIG, Improvements Still Needed in Processing Military Sexual
    Trauma Claims.
    ---------------------------------------------------------------------------
        VA has a special obligation to provide veterans who are claiming
    benefits every opportunity to support their claims. Leadership duties
    do not end when the OIG closes a recommendation based on VA-provided
    documentation that demonstrates sufficient plans and steps have been
    taken to address identified issues. Leaders must instill in all VA
    personnel a commitment to continuous improvement, including fully
    addressing and sustaining corrective actions taken in response to OIG
    recommendations.
        A lack of commitment to full transparency in reporting operational
    problems can also hinder OIG and other oversight. In reviewing VA's new
    EHR system at the Mann-Grandstaff VA Medical Center in Spokane,
    Washington, the OIG found that leaders in what was then the VA Office
    of Electronic Health Record Modernization (OEHRM) showed a careless
    disregard for the accuracy and completeness of the information they
    provided, and that those leaders' lack of due care and diligence
    resulted in misinformation being submitted to OIG staff.\44\ The OIG
    recommended that the program's leaders clarify to their personnel that
    all staff have a right to speak directly and openly with OIG staff and
    ensure that direct communication with OIG staff is not impeded when
    needed to clarify requests or responses.\45\
    ---------------------------------------------------------------------------
        \44\ VA OIG, Training Deficiencies with VA's New Electronic Health
    Record System at the Mann-Grandstaff VA Medical Center in Spokane,
    Washington, July 8, 2021. In December 2021, OEHRM was restructured to
    form the Electronic Health Record Modernization Integration Office
    (EHRM IO).
        \45\ VA OIG, Senior Staff Gave Inaccurate Information to OIG
    Reviewers of Electronic Health Record Training, July 14, 2022.

    ---------------------------------------------------------------------------
    Conclusion

        There is no question that the overwhelming number of VA leaders and
    personnel are committed to serving veterans, their families, and
    caregivers, as well as answering the call for assistance from their
    local communities in times of crisis. They often have to navigate
    obstacles and overcome challenges to make certain that patients receive
    prompt high-quality care and that veterans and other eligible
    beneficiaries receive the compensation and services they are owed.
    Unfortunately, the OIG has found that VA has struggled with the
    foundations of accountability, including strong governance and clarity
    of roles and responsibilities; adequate and qualified staffing; updated
    IT systems and effectual business processes; effective quality
    assurance and monitoring; and stable leadership that fosters
    responsibility for actions and continuous improvement. Without a
    greater emphasis on these areas of accountability, VA will not always
    provide the highest-quality care, benefits, and services to veterans
    and their families.
                                   __________

                       Prepared Statement of Gene Dodaro
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                   __________

                     Prepared Statement of Shereef Elnahal

        Our Nation's most sacred obligation is to prepare and equip the
    troops we send into harm's way, and to care for them and their families
    when they return home. VA is honored to fulfill the promise made to
    care for our brave Service members and we will stop at nothing to serve
    Veterans, their families, caregivers, and survivors every bit as well
    as they have served us.
        VA has provided more care, more benefits, and more services to more
    Veterans than ever before. Across the enterprise, VA has achieved
    record-breaking numbers in providing benefits and care. In 2022 alone,
    the Veterans Benefits Administration (VBA) completed more than 1.7
    million disability compensation and pension claims for Veterans, an
    all-time VA record that broke the previous year's record by 12 percent.
    Continued focus on claims processing fundamentals, such as expanded C&P
    examination capacity, digitization of federal records, and ensuring a
    robust hiring and onboarding process, contributed to the agency's
    ability to meet these goals. This resulted in Veterans and survivors
    receiving over $128 billion in disability compensation and pension
    benefits in 2022, including nearly $10 billion in retroactive awards.
        During this same period, the Veterans Health Administration (VHA)
    also provided more than 115 million clinical encounters, with VA
    serving over 6.4 million patients. This included roughly 40 million in-
    person appointments and more than 31 million tele-health and telephone
    appointments and approximately 38 million community care appointments
    in 2022 alone.
        In addition, the National Cemetery Administration (NCA) interred
    nearly 150,000 Veterans and eligible family members in our national
    cemeteries during Fiscal Year 2022--the highest number of annual
    interments VA has recorded. NCA also provided more than 350,000
    headstones, markers and columbarium niche covers around the world. We
    also provided nearly 12,000 medallions in 2022 to mark the privately
    purchased headstones of Veterans. In 2023, VA will continue to deliver
    more care and more benefits to more Veterans than ever before, and
    continue to fight for all Veterans, their families, caregivers, and
    survivors.
        To continue this momentum, VA has a threefold approach. First, VA
    is focused on increasing access to world class health care and earned
    benefits by improving customer service and ensuring that Veterans and
    their families trust VA by expanding outreach to underserved Veterans
    and implementing new authorities (such as the Sergeant First Class
    Heath Robinson Honoring our Promise to Address Comprehensive Toxics
    (PACT) Act to expand services, programs, and benefits.
        Second, VA is investing in its people. This means VA is hiring more
    staff across the Department to ensure that care and benefits are
    delivered in a timely manner. VA is also focused on improving employee
    experience to help improve outcomes for Veterans, their families,
    caregivers, and survivors which makes sure that we keep the Veteran at
    the center of everything we do. Additionally, VA is implementing new
    hiring authorities and new retention authorities to grow and maintain a
    diverse, talented workforce with a shared mission to provide more care
    and more benefits to more Veterans. For example, using the recently
    approved Direct Hire Authority for mission critical occupations, VBA
    was able to increase its total workforce by more than 5 percent (more
    than 1,300 employees) in the first four months of Fiscal Year 23,
    compared to less than 1 percent growth in the workforce over the same
    time period in Fiscal Year 22.
        Third, VA is transforming systems, processes, and infrastructure in
    order to achieve operational excellence, increase productivity, and
    ensure that systems and processes are easy to use by both the staff and
    the Veterans we serve. Outcomes for Veterans drive everything we do -
    because Veterans, not us, are the ultimate judges of our success. The
    proof of VA's ability to deliver on this promise is evident in NCA's
    recent top score in the prestigious American Customer Satisfaction
    Index (ACSI) \1\ ratings. For the second time, NCA has scored 97 (out
    of 100) on the index, which is the highest score ever achieved by any
    organization rated by the ACSI, public or private, including the best-
    known companies in our country. The ACSI survey describes itself as
    ``the only national cross-industry measure of customer satisfaction
    available in the United States.''
    ---------------------------------------------------------------------------
        \1\ In 1999, the federal government selected the ACSI to be a
    standard metric for measuring citizen satisfaction. The ACSI measures
    citizen satisfaction with over 100 services, programs, and websites of
    federal government agencies. The objective of the survey is to measure
    customer satisfaction with a score of 0-100.
    ---------------------------------------------------------------------------
        This is the seventh time NCA has been ranked first in customer
    satisfaction by ACSI. This remarkable achievement is testament to the
    extraordinary hard work that every member of the NCA team puts in every
    day. They are motivated every day to ensure that Veterans receive the
    final honor they have earned from our grateful Nation - a place of
    eternal rest in a National shrine. NCA's impressive customer
    satisfaction scores are an inspiration for all of us in VA. Every
    employee in VA shares that dedication and motivation to serve our
    Nation's Veterans every day.

    Increasing Access

        Across VA, VHA, VBA, and NCA have focused on increasing access to
    world class health care and earned benefits to all Veterans, their
    families, caregivers, and survivors. We will continue to do so by
    facilitating timely access, focusing on women's health care, and
    expanding mental health care and suicide prevention.

    Access to the Soonest and Best Care

        Providing Veterans access to the best care in a timely way is at
    the core of our mission. Over the last 2 years, VA has delivered more
    care to more Veterans through both VA and community care providers than
    during any time in our Nation's history. Veterans completed more than
    73 million outpatient appointments in VA and another 38 million
    community care outpatient appointments in calendar year 2022. While
    enrolled Veterans continue to receive the majority of their outpatient
    care in VA, more than 3.5 million Veterans have completed at least one
    outpatient appointment with a community care provider since we
    implemented the VA MISSION Act of 2018. As such, more than 1/3 of all
    Veterans enrolled in VA health care have been eligible for and chosen
    to elect to receive at least one community care appointment at some
    point in the last five years.
        Veterans today have more options for care than ever. VA has more
    than 1,100 medical centers and community-based outpatient clinics for
    Veterans to receive their care. VA offers care in-person, over the
    phone or through video appointments as clinically appropriate. VA's
    community care network has more than 1.3 million community care
    providers across all 50 States and U.S. Territories. Enrolled Veterans
    also have access to community urgent care, and all Veterans have access
    to emergent suicide care.
        Veterans' trust levels for VA health care exceed 90 percent
    nationally, whether care is received in VA or through a community
    provider. Veterans believe VA health care is getting better, according
    to studies by the Veterans of Foreign Wars, more than 90 percent of
    Veterans surveyed say they would recommend VA care to other Veterans.
    VA is seeing more patients than ever before and studies show VA
    compares favorably to the private sector for access \2\ as well as
    quality of care \3\ - and in many cases exceeds the private sector.
    ---------------------------------------------------------------------------
        \2\ Comparison of Wait Times for New Patients Between the Private
    Sector and United States Department of Veterans Affairs Medical Centers
    : Health Care Quality : JAMA Network Open : JAMA Network
        \3\ VA Health System Generally Delivers Higher-Quality Care Than
    Other Health Providers : RAND

    ---------------------------------------------------------------------------
    Women's Health Care

        VA remains committed to providing high-quality, equitable care to
    women Veterans at all sites of care. More women are choosing VA for
    their health care than ever before, with women accounting for over 30
    percent of the increase in Veterans served over the past 5 years. The
    number of women Veterans using VHA services has more than tripled since
    2001, growing from 159,810 to more than 600,000 today.
        To provide the highest quality of care to women Veterans, VA offers
    women Veterans trained and experienced designated Women's Health
    Primary Care Providers (WH-PCP). National VA satisfaction and quality
    data indicate women who are assigned to WH-PCPs have higher
    satisfaction and higher quality of gender-specific care than those
    assigned to other providers. Importantly, we also find women assigned
    to WH-PCPs are twice as likely to choose to stay in VA health care over
    time. Designated WH-PCPs are available across all VA health care
    systems. VA tracks sites with fewer than two WH-PCPs to enhance
    national training and local hiring initiatives in rural areas and in
    additional areas where we have gaps in capacity to treat women.
        While maternity care is not provided in VA facilities, a
    significant number of Veterans use maternity services provided through
    VA-authorized care in the community. Pregnant and postpartum Veterans
    continue to receive care in VA for other conditions and may also need
    primary care, emergency care and require coordination of Community Care
    services. To support pregnant and postpartum Veterans, VA has developed
    a Maternity Care Coordination (MCC) program in all VA health care
    systems to ensure coordination of care both in VA and in the community.
    To further support our Veteran population and in response to Public Law
    (P.L.)116-79, Protecting Moms Who Served Act of 2021, VA is expanding
    the maternity care coordination program to follow pregnant Veterans for
    one year postpartum, a particularly vulnerable time for families. VA
    MCCs support pregnant Veterans through every stage of pregnancy and
    postpartum. MCCs help pregnant Veterans navigate health care services
    both inside and outside of VA, connect to community resources, cope
    with pregnancy loss, connect to needed care after delivery and answer
    questions about billing. MCCs screen Veterans for intimate partner
    violence, perinatal mental health conditions, substance use disorders,
    homelessness and food insecurity and ensure Veterans are connected to
    appropriate resources and needed services.
        VA is focusing on enhancing care coordination for preventive care,
    such as breast and cervical cancer screening. VA is actively
    implementing the Dr. Kate Hendricks Thomas Supported Expanded Review
    for Veterans In Combat Environments (SERVICE) Act. Beginning in March
    2023, VA will be providing breast cancer risk assessments, including
    toxic exposure risk assessments, to Veterans eligible under the SERVICE
    Act with referral for mammography as clinically indicated. Breast and
    cervical cancer screening programs require meticulous tracking to
    ensure that all eligible Veterans receive appropriate screening and
    receive results of screening tests, and that followup care is arranged
    as needed. To ensure accuracy, timeliness and reliability, VA tracks
    the provision of breast and cervical cancer screening and the
    availability of breast and cervical cancer care coordinators across the
    system.

    Preventing Suicide

        Preventing Veteran suicide is a top priority, and VA has
    implemented a comprehensive public health approach to reach all
    Veterans. This approach is in full alignment with the President's
    national strategy, Reducing Military and Veteran Suicide \4\, advancing
    a comprehensive, cross-sector, evidence-informed public health approach
    with focal areas in lethal means safety, crisis care, and care
    transition enhancements, increased access to effective care, addressing
    upstream risk and protective factors, and enhanced research
    coordination, data sharing, and program evaluation efforts.
    ---------------------------------------------------------------------------
        \4\ Military-and-Veteran-Suicide-Prevention-Strategy.pdf
    (whitehouse.gov)
    ---------------------------------------------------------------------------
        With the goal to reach Veterans both inside and outside VA care, VA
    launched Suicide Prevention 2.0 (SP 2.0). SP 2.0 is a population-based,
    public health model of intervention. SP 2.0 includes community-based
    prevention strategies and evidence-based clinical strategies that
    empower action at National, regional, and local levels. To accomplish
    the goal of working toward ending suicide among all 20 million U.S.
    Veterans, a comprehensive approach to suicide prevention that blends
    community-based prevention and clinically based interventions is
    needed. The model works to reach Veterans in the community and those we
    currently serve in VA with evidence-informed community-based prevention
    strategies combined with strategies with known outcomes for reducing
    suicide and suicide attempts based upon the VA-Department of Defense
    (DoD) Clinical Practice Guidelines.
        Another tool VA actively uses to combat suicide is the Veterans
    Crisis Line (VCL), which offers support to Veterans who reach out for
    help. Since July 16, 2022, the VCL has been easily accessible via 988,
    and pressing 1. The new, shorter number, implemented thanks to the
    National Suicide Hotline Designation Act of 2020, directly addressed
    the need for ease of access and clarity in times of crisis, both for
    Veterans and non-Veterans alike. Between 2007 and October 2022, VCL has
    taken more than 6.4 million calls, 269,000 texts, 772,000 chats and
    provided more than 1.2 million referrals. Since the official launch of
    988 through February 5, 2023, VCL has seen a 12.35 percent increase in
    call volume and 25.46 percent increase in text volume compared with
    last year. Average calls per day exceeded 2000 between July 15, 2022,
    and February 5, 2023. Additionally, VCL campaigns are designed to raise
    awareness of call, chat, and text supports for Veterans in crisis. The
    campaign also provides social media, web, print and video resources
    that can be broadly shared through the Spread the Word Initiative .
        In partnership with the Department of Health and Human Services'
    Substance Abuse and Mental Health Services Administration, VA is
    facilitating State-level efforts to prevent Veteran suicide with the
    Governor's Challenge to all States and territories. The Governor's
    Challenge advances a public health approach to suicide prevention by
    bringing together key State leaders to develop strategic action plans
    focused on Veteran suicide prevention. As the President announced in
    the State of the Union address, VA is working with the Departments of
    Health and Human Services and Defense to work with the States and
    territories through the Governor's Challenge. VA is launching a new $10
    million program to further bolster these efforts. We appreciate
    Congress' support in this regard. Additionally, with the launch of
    Mission Daybreak, VA invited innovators across the country to
    participate in a $20 million challenge to help VA develop suicide
    prevention strategies for Veterans. VA received over 1,300 submissions
    and recently announced 2 Grand Prize Winners as well as second and
    third place prize winners. The prize winners have at least one element
    in common: they each reflect various innovative approaches to clinical
    and community-level suicide prevention and intervention and they each
    are well-positioned to be deployed across a variety of settings and
    communities as part of our collective suicide prevention efforts.
        VA is expanding outreach to Veterans like never before. To reach
    Veterans wherever they are, VA has emphasized paid media campaigns to
    facilitate suicide prevention awareness. These include: 1) Don't wait.
    Reach out; 2) Keep it Secure; and 3) the Veterans Crisis Line. To
    develop the ``Don't Wait. Reach Out'' campaign, VA entered into an
    agreement with the Ad Council, a national non-profit organization that
    uses donated communication industry resources to elevate messaging. The
    campaign strategy was informed by extensive research with Veterans and
    portrays real Veterans in all videos. For the Don't Wait, Reach Out
    Campaign, from October 2021-July 2022, we have had over 1 billion
    impressions with over $10 million in donated media value.
        The Keep it Secure campaign is a national public health campaign,
    launched in September 2021, focused on safe storage for firearms during
    times of distress. From launch through January 2023, the campaign has
    garnered over 1.8 billion impressions, and over 20 million website
    visits to access resources and support for safe storage. As part of the
    White House Strategy to Reduce Military and Veteran Suicide, VA will
    continue expansion of this lethal means safety campaign this year with
    new communication endeavors also focused on providers, caregivers, and
    family members of Veterans, encouraging secure storage of firearms and
    medication.
        Finally, the VCL campaign works to reach Veterans and those who
    love them to support them 24/7 during times of crisis. Since the launch
    of the VCL campaign in February 2020 until July 2022, there have been
    nearly 2 billion impressions. When developing these and other
    campaigns, VA strives to represent the demographic and cultural
    diversity of Veterans. Together with ongoing campaigns like AboutFace
    and Make the Connection, VA hopes every Veteran will see themselves
    represented and know VA is here to serve them. VA is also making it
    easier for customers to connect with us with VA.gov and VA's Health and
    Benefits mobile app as our digital front door and 1-800-MyVA411 as our
    telephonic front door.
        With the enactment of the Commander John Scott Hannon Veterans
    Mental Health Care Improvement Act of 2019 (Hannon Act , P.L. 116-171)
    , VA is using new authorities that improve Veterans' mental health and
    substance use disorder care and services through the expansion of
    mental health care options. This includes the Staff Sergeant Parker
    Gordon Fox Suicide Prevention Grant Program (SSG Fox SPGP), which
    awards grants to eligible entities to provide or coordinate suicide
    prevention services to eligible individuals and their families. This
    grant program is the first-of-its-kind effort by VA to provide funding
    for local suicide prevention programs through outreach, suicide
    prevention services, and connection to VA and community resources.
        Through this new program, VA awarded $52.5 million to 80 grantees
    in 43 States, the District of Columbia and American Samoa. Twenty-one
    grantees serve Tribal lands including Navajo Nation, Cherokee Nation,
    Choctaw Nation, Alaskan Native Tribes and others. Funding decisions
    reflect VA's authority to prioritize the distribution of grants to
    rural communities, Tribal lands, Territories of the United States,
    medically underserved areas, areas with a high number or percentage of
    minority Veterans or women Veterans, and areas with a high number or
    percentage of calls to the Veterans Crisis Line.
        In addition to implementation of the authorities in the Hannon Act,
    VA continues to implement several other statutory requirements related
    to mental health care. As of January 17, 2023, as part of the COMPACT
    Act, eligible individuals (including Veterans) in suicidal crisis are
    eligible to receive covered emergency care - including transportation
    costs, inpatient or crisis residential care--from any health care
    facility, whether at VA or in the community. Inpatient care is
    available for up to 30 days, and outpatient care is available for up to
    90 days.

    Access to Burial Benefits

        VA is focused on increasing access to burial benefits as well by
    developing new National cemeteries, developing additional gravesites at
    existing National cemeteries, and establishing and expanding Veterans
    cemeteries through grants to States, territories, counties and Tribal
    organizations. VA has been steadily managing the largest expansion of
    the cemetery system since the Civil War. VA has opened 13 new
    cemeteries in the last decade with one more planned this year. We also
    plan to open one new cemetery in each of the next two years. These
    National cemeteries will provide new or enhanced burial access to over
    3.8 million Veterans and their families.
        VA is also working with States and Tribal authorities to encourage
    the development and placement of VA grant-funded cemeteries in
    locations where Veterans do not have reasonable access to a burial
    option, either in a VA National or VA grant--funded Veterans' cemetery.
    Tribal access is a particular focus for VA. Within the last year, VA
    has engaged directly with the Crow Tribe in Montana, the Pascua Yaqui
    tribe in Arizona and the Sisseton Wahpeton Oyate tribe in South Dakota
    to address challenges and identify potential solutions regarding
    utilization of their grant-funded cemeteries. Similar sessions with
    leaders from the remaining eleven tribes with grant-funded Veterans
    cemeteries are planned.
        In Fiscal Year 2022, VA interred nearly 150,000 Veterans and
    eligible family members in our National cemeteries--the highest number
    of annual interments VA has recorded. Also in Fiscal Year 2022, VA also
    provided more than 350,000 headstones, markers and columbarium niche
    covers around the world, as well as nearly 12,000 medallions to mark
    the privately purchased headstones of Veterans. But these statistics
    reveal a key challenge for VA: ensuring Veterans know about and take
    advantage of interment in a VA national cemetery, or a VA-funded State,
    territorial or tribal cemetery.
        Approximately half of all Veterans are eligible for benefits and
    services, about one third of all Veterans actively use VA health care,
    and 85 percent of eligible Veterans use their GI Bill benefits (either
    themselves or by transferring those benefits to a family member).
    However, only 15 percent of all Veterans who die each year are interred
    in a VA National cemetery, with another 5 percent interred in a VA-
    funded State, territorial or Tribal cemetery. That's why we are
    embarking on a campaign to ensure that Veterans know they have the
    option to Choose VA for their final resting places. To ensure they know
    that VA stands ready to fulfill our solemn obligation to them: to care
    for them and their loved ones in a manner that mirrors their own
    dedicated service and devotion to our Nation - in perpetuity.

    Serving Veterans with Environmental Exposures

        Passage and enactment of the PACT Act marked the largest and most
    significant expansion of Veterans' care and benefits in decades,
    empowering VA to deliver additional care and benefits to millions of
    Veterans and their survivors. VA issued sub-regulatory guidance and
    provided training before going live with nationwide claims processing
    on January 1, 2023. Prior to implementation of the law, the VA used its
    authority under sections 403, 404, and 406 of the PACT Act to treat all
    presumptive conditions newly added as part of the PACT Act as
    applicable as of August 10, 2022, instead of future phased-in dates as
    prescribed by the law, to allow VA to deliver much-needed benefits and
    access to care to Veterans, family members, caregivers, and survivors
    as soon as the law was signed. As of February 4, 2023, VA has received
    nearly 300,000 PACT Act-related claims and completed over 110,000
    claims. Using the new PACT Act authorities, VA has granted presumptive
    service connection for over 1,200 terminally ill Veterans.
        VA immediately began executing a comprehensive, targeted outreach
    effort to encourage Veterans and survivors to apply now for PACT Act-
    related care and benefits. VA hosted 127 PACT Act ``Week of Action''
    events between December 10th and 17th in all 50 States, the District of
    Columbia, and Puerto Rico. Each event was open to Veterans, their
    families, caregivers, survivors, and advocates as well as the press.
    Invitations were also extended to Members of Congress, State Directors
    of Veterans Services, and local officials and stakeholders. More than
    50,000 attendees participated in person or online, VA completed 5,600
    exposure screenings, and received 2,600 claims for benefits, and more
    than 800 applications to enroll for health care. Over the coming weeks
    and months, VA will continue targeted outreach efforts to include
    public service announcements (PSA), advertisements such as the video
    billboard in Times Square, social media posts, and radio, TV, and audio
    streaming.
        One of the biggest challenges VA faces is identifying and
    contacting survivors, even more so now that many more may now be
    eligible for benefits under the PACT Act. We have mailed nearly 300,000
    letters to potentially eligible survivors and are working with Veterans
    Service Organizations and survivor organizations such as the Tragedy
    Assistance Program for Survivors (TAPS) and Gold Star Wives to amplify
    and streamline messaging. VA is also leveraging social media and
    posting YouTube videos to provide easy to read information on PACT Act.
    VA's goal is to provide information on the PACT Act not just to
    survivors themselves, but to anyone who may know a survivor so that
    VA's message can reach as many impacted individuals as possible.

    Toxic Exposure Screenings

        As of February 8, 2023, VA has screened more than 1.78 million
    Veterans for toxic exposure. Of the 1.78 million Veterans screened, 43
    percent required follow-up. This includes both Veterans who reported
    possible exposure, and Veterans who were unsure of potential exposure
    concerns and had additional questions. When the screening is initiated
    by physicians (MD), osteopathic doctors (DO), advanced practice
    registered nurses (APRN), and physician assistants (PA) with
    privileges, 90 percent of followup screenings occur on the same day as
    the initial screening. If a screening is initiated by a staff member
    without clinical privileges (such as the facility Toxic Exposure
    Screening, or TES Navigator), the followup screening is then referred
    to and completed by a clinical provider. This ensures all Veterans with
    health concerns receive appropriate clinical assessment in a timely
    manner.

    Toxic Exposure Research and Registry

        VA has completed a review of the Airborne Hazards and Open Burn Pit
    Registry in light of the 2022 National Academy of Sciences Engineering
    and Medicine (NASEM) 5-year review of the Registry, VA's internal
    Office of Inspector General review and our partnership with DoD to
    better address a Service member's (soon to be a Veteran's) health
    through the separation health assessment done at separation or
    retirement from military service.
        Title V of the PACT Act elevates the timely progress of exposure
    science through a whole-of-government approach. VA, in collaboration
    with the heads of other Federal entities, will establish an
    interagency, mission-aligned toxic exposure research working group with
    the goal of collaboratively developing and executing a 5-year strategic
    research plan on the health consequences of toxic exposures experienced
    during active military, naval, air, or space service, as required by
    section 501 of the PACT Act. VHA's Office of Research and Development
    met with other Federal agencies on February 2, 2023, to address section
    501 of the PACT Act, and establish an interagency Toxic Exposure
    Research Working Group, which will, in part, identify collaborative
    research activities and resources available among entities represented
    by members of the Working Group to conduct collaborative research
    activities and develop a 5-year strategic plan for such entities to
    carry out collaborative research activities.

    Ending Veteran Homelessness

        VA has made significant progress in preventing and ending Veteran
    homelessness and VA remains focused on ending homelessness for all
    Veterans. Since 2010, the number of Veterans experiencing homelessness
    in the United States has declined by more than 55 percent. More than
    1,000,000 Veterans and their family members have been permanently
    housed, rapidly rehoused, or prevented from falling into homelessness
    through VA's homeless assistance programs. VA housed over 40,000
    homeless Veterans in 2022. This accomplishment along with VA's ongoing
    collaborative efforts with the Departments of Housing and Urban
    Development and Labor and the U.S. Interagency Council on Homelessness,
    are anticipated to further reduce the overall number of Veterans
    experiencing homelessness.

    Supporting Transitioning Service Members

        VA is charged with ensuring that every Veteran is aware of and
    understands the benefits they have earned as they transition from
    military service. In Fiscal Year 2022, VA conducted 6,467 Transition
    Assistance Program (TAP) briefings to over 164,000 Service members and
    provided 58,356 one-on-one counseling sessions.
        The VA Solid Start program which launched in December 2019 has
    successfully connected with 315,604 (66.4 percent) eligible Veterans
    and provided information about, and access to, the benefits and
    services they have earned. Additionally, to reduce the Veteran suicide
    risk and to ensure continuity of care, VA Solid Start provided priority
    contact to those Veterans who met certain risk criteria. Since the
    program launched, VA Solid Start has successfully connected with 53,220
    (78.9 percent) priority Veterans supporting a successful transition to
    VA mental health care treatment.
        VA has begun work with DoD on a TAP Military Life Cycle (MLC)
    module with Other than Honorable (OTH) discharge as the topic focus.
    Further, VA will look to update OTH information in the VA TAP Benefits
    and Service Participant Guide beginning in March 2023. VA has found
    Veterans with an OTH character of discharge did not receive adequate
    information or support to connect with the VA benefits and services for
    which they are eligible, which may have detrimental downstream effects
    on a population already prone to crisis situations (mental health
    emergencies, joblessness, suicidality, homelessness, etc.).
        VA has a special commitment to understanding and supporting the
    unique needs of women Veterans. The Women's Health Transition Training
    Program is a critical resource tool that provides a comprehensive
    holistic approach to help transitioning Service women and recently
    separated women Veterans understand their VA health care benefits and
    services. In concert with our TAP interagency partners, VA has worked
    diligently to promote the Women's Health Transition Training Program
    through TAP and other means to make sure every Service woman is aware
    of this specialized course and is able to participate in this effective
    learning opportunity through five modules.

    Improving Economic Opportunity

        VA is dedicated to improving the economic opportunity of
    Servicemember, Veterans and their families. VA has undertaken a number
    of improvements with the Veteran Readiness and Employment (VR&E)
    Program, Education Program, Home Loan Guaranty Program and Insurance
    Service to ensure that Veterans have an opportunity to achieve suitable
    employment, attain an education, obtain affordable housing, and
    maintain life insurance for themselves and their families.
        In Fiscal Year 2022, VA implemented a six-point plan to improve
    outcomes for Veterans participating in the Veteran Readiness &
    Employment (VR&E) Program. This plan includes implementing a new
    comprehensive data management system (RES), formerly known as the Case
    Management System (CMS); implementation of e-VA, electronic document
    signing, and other system enhancements; enhancements to the Veteran
    Success on Campus (VSOC) program; Employment Services; Quality Review
    Teams; and increased Vocational Rehabilitation Counselor (VRC)
    recruitment and retention.
        VA continues its efforts in realigning the services provided by the
    VSOC program. VSOC counselors have taken on increased workload allowing
    for more Veterans to be served in a counseling capacity at the school
    to which they are assigned. Therefore, an updated position description
    has been classified, removing the positive education requirement, which
    ultimately expands the population of individuals who can qualify to
    work as a VSOC counselor.
        Through the Digital GI Bill (DGIB), the VA is also transforming how
    GI Education Benefit Claims are submitted, reviewed, and processed
    using a multi-prong strategy - with the intent of enhancing the Veteran
    and beneficiary education experience. In August 2022, for the first
    time, Veterans were able to submit original Post-9/11 GI Bill
    applications could through an automated system. Applicants receive a
    head start by having pre-filled service history information which leads
    to quicker eligibility decisions, including as soon as the same day
    instead of more than 10 days on average.
        In support of the DGIB, the Office of Information and Technology
    (OIT) has worked with its VBA partners to successfully deploy ``My
    Education Benefits'' through va.gov, allowing the automated processing
    of original claims for the first time ever. The DGIB team has also
    moved the DGIB Application to production, saving the government
    millions in infrastructure costs for cloud computing and storage. DGIB
    is ready to deploy the ``Enrollment Manager'' and Chatbot to over
    45,000 school certifying officials around the world, which will improve
    the user experience for schools and increase automation of claims. This
    allows for the decommissioning of the VA-Once legacy application. In
    addition, VA has refined the rules so that Supplemental Automation has
    consistently been above 50 percent and as high as 62 percent. Last, the
    DGIB team deployed text messaging (with opt-in rates above 90 percent)
    and email services, enabling faster communication with VA that allows
    Veterans and beneficiaries to easily verify their enrollment in college
    courses.
        The Veterans Rapid Retraining Assistance Program (VRRAP) was
    enacted on March 11, 2021, under the American Rescue Plan to support
    Veterans seeking retraining and economic opportunities in response to
    the effects of the COVID-19 pandemic. VA worked on a highly effective
    PSA campaign with over 29 million impressions on television and radio,
    as well as a robust social media campaign to increase Veteran and
    eligible schools' awareness and participation in VRRAP. VA processed
    over 5,600 enrollments in less than 90 days. These actions were vital
    in allowing VA to obligate 98 percent of the $386 million available for
    Veterans to train and find suitable employment.
        The Veteran Employment Through Technology Education Courses (VET
    TEC) is a 5-year pilot program for eligible Veterans to help them
    secure meaningful employment in the technology sector. VET TEC pairs
    eligible Veterans with market-leading training providers offering
    sought after high-tech training and skills development. Since the
    program started, over 93,000 Veterans have applied for VET TEC with
    64,463 receiving Certificates of Eligibility. 9,075 Veterans have
    graduated from a VET TEC training program and 4,089 have found
    meaningful employment with an average salary of $65,118. The VET TEC
    Employer Consortium helps Veterans bridge the gap between program
    completion and meaningful employment, it also fosters a network of
    employers and training providers for graduates to leverage at the
    beginning of, and throughout, their careers.
        VA is dedicated to protecting Veterans as they pursue higher
    education. The Department of Education (ED) recently announced final
    rules that will better protect Veterans and Service members from
    predatory recruitment practices. These regulations implement an
    important change made by the American Rescue Plan, closing a
    longstanding loophole in the Higher Education Act of 1965 that allowed
    for-profit colleges to aggressively recruit Veterans and Service
    members because they could count money from Veteran and Service member
    benefits toward their 10 percent revenue requirement (other than
    Federal assistance). VA worked with ED on this effort and is assisting
    schools in maintaining compliance with ED's 90/10 rule, by providing
    training on how to obtain reports from VA detailing GI Bill payments.
        Since 1944, VA's home loan program has helped almost 28 million
    Veterans achieve the dream of home ownership. This program continues to
    maximize opportunities for Veterans, Service members, and surviving
    spouses to obtain, retain and adapt their homes. Veteran households
    have higher homeownership rates than the general population and, for
    many Veterans, VA's home loan program is the most advantageous mortgage
    option. Veterans make up approximately 6 percent of the U.S.
    population, but VA home loans account for 13 percent of the current
    mortgage market. VA's home loan program is popular because Veterans
    receive competitive interest rates, pay limited closing costs, and
    avoid private mortgage insurance requirements--usually without having
    to make a down-payment. Due to efforts of the Loan Guaranty Service to
    improve the program, even in today's higher interest rate environment,
    rates for 30-year, fixed-rate VA home loans currently average nearly
    one-half of 1 percent (or 50 basis points) lower than rates on
    conventional loans. Another specialized feature of the home loan
    program is the individualized service VA loan technicians provide to
    Veteran borrowers facing financial difficulty.
        VA continues to look for opportunities to improve the homebuying
    process for Veterans and their families. Through people, process, and
    technology enhancements, 76 percent of home loan certificates of
    eligibility (COE) are issued instantaneously. Appraisal timeliness has
    shown steady improvement, with average business days to completion
    decreasing from 10.4 business days in October 2021 to 6.7 business days
    in January 2023. As a member of the Property Appraisal and Valuation
    Equity (PAVE) Task Force, supporting Veterans' ability to utilize their
    home loan benefit without bias or racial impacts is of utmost
    importance. VA's commitment is further augmented by the fact that VA is
    the only agency that maintains and oversees an independent appraisal
    panel. VA recently announced advanced oversight procedures to improve
    methods of screening for potential appraisal bias and discrimination.
        VA remains committed to expanding opportunities for homeownership
    to Native American Veterans residing on trust land. VA is providing
    expansion through increased outreach to and collaboration with the 574
    federally Recognized Tribes. VA has signed 111 memoranda of
    understanding allowing the signatory Tribes to participate in the
    Native American Direct Loan (NADL) program. We continue to work with
    stakeholders in the State of Alaska to expand this vital direct loan
    program for Native American Veterans residing in Alaska.
        At the start of the COVID-19 pandemic, VA proactively announced
    numerous flexibilities in servicing guidelines to help Veterans with VA
    home loans. Since the start of the pandemic, VA's loss mitigation
    options have helped more than 200,000 Veterans remain in their homes,
    with more than 30,000 Veterans assisted through VA's temporary home
    retention options, the COVID-19 Veterans Assistance Partial Claim
    Payment, and the COVID-19 Refund Modification programs. As the COVID-19
    national emergency nears an end, VA continues to explore changes in
    servicing policies and home retention options to assist Veteran
    borrowers.
        As VA celebrates the 75th anniversary of the Specially Adapted
    Housing (SAH) grant program this year, it is worth reflecting on the
    nearly 50,000 grants that have been awarded under this program since
    inception. Each SAH grant represents VA's enduring commitment to
    assisting the Nation's most severely disabled Veterans live
    independently in their homes. The enactment of the Ryan Kules and Paul
    Benne Specially Adaptive Housing Improvement Act of 2019 led to
    expanded SAH assistance, with nearly $250 million in grant approvals in
    fiscal years 2021 and 2022.
        VA Insurance Service provides 5.7 million Veterans, Service
    members, military families and survivors insurance coverage totaling
    over $1.45 trillion with Servicemembers Group Life Insurance (SGLI)
    coverage increasing to $500,000, the highest level ever. This makes VA
    the Nation's 12th largest American life insurer. Additionally, on
    January 1, 2023, VA launched VALife, a whole life policy which
    eliminates time barriers and medical underwriting for all service-
    connected Veterans with any rating (0-100 percent) aged 80 and under.
    VALife offers automated online applications and instant approvals even
    through a smart phone and at the most competitive rates which will
    never increase.

    Supporting Family Caregivers

        VA expanded its Program of Comprehensive Assistance for Family
    Caregivers (PCAFC) to eligible family members and Veterans of all eras
    on October 1, 2022, and has received over 44,300 applications as of
    February 8, 2023. Previously, PCAFC was only available to eligible
    Veterans who served on or after September 11, 2001. On October 1, 2020,
    VA expanded the program to eligible Veterans who served on or before
    May 7, 1975, or on or after September 11, 2001. Currently, there are
    over 44,800 Veterans participating in the PCAFC across the country,
    including territories. As of February 8, 2023, 98 percent of PCAFC
    applications are dispositioned in under 90 days.
        VA is not only adding to the services and supports that we offer
    our caregivers but focusing on how VA offers it. Additionally, VA is
    enhancing and expanding the types of resources provided to caregivers,
    including enhanced respite, mental health services, and the caregiver
    and Veteran experience. The Caregiver Support Program has partnered
    with the Office of Mental Health and Suicide Prevention to fund 54
    mental health clinicians who will be dedicated to providing mental
    health services for our Family Caregivers through clinical resource
    hubs. In addition, VA is funding 14 respite liaisons to assist
    caregivers in experiencing a smooth and seamless respite experience.
        VA has trained over 120 staff at 54 sites to be health and well-
    being coaches for Caregivers. These coaches focus on providing
    individualized personal care plans on areas that matter most to
    caregivers. By the end of this fiscal year. VA will have staff trained
    at every VA medical center in this model. VA has also trained over
    7,271 staff through the Campaign for Inclusive Care, which seeks to
    move from caregiver support to caregiver integration, making the
    caregiver an integral part of the Veteran's treatment team.
        In addition, caregivers participating in PCAFC will have access to
    services such as household budget planning, debt management, retirement
    planning review and education, and assistance with advanced directives,
    power of attorney, simple wills, and guardianship.

    Investing in Our People

        Providing Veterans, their families, caregivers, and survivors
    access to world class health care, timely access to earned benefits,
    and when the time comes, a final resting place is only possible with an
    enterprise-wide team of the best and brightest in their respective
    fields. VA is investing in our people by dramatically increasing
    hiring, holding onboarding surge events to onboard staff more quickly,
    increasing the use of incentives for recruitment and retention,
    maximizing pay authorities and scheduling flexibilities, expanding
    scholarship opportunities, and providing more education loan repayment
    awards than ever before.

    Veterans' Health Administration

        In Fiscal Year 2022, VHA nearly doubled the number of scholarships
    for clinical education offered to employees and increased the number of
    Education Debt Reduction Program (EDRP) awards to over 3,000.
    Additionally, the percentage of staff receiving recruitment, retention,
    and relocation incentives (3Rs) more than doubled from 5.9 percent to
    12.2 percent. At rural facilities, the use of 3Rs increased from 4.3
    percent to 18.9 percent. And for some critical shortage occupations,
    such as housekeeping aides (10.5 percent to 35 percent) and food
    service workers (2.1 percent to 18.7 percent), the use of 3Rs increased
    even more dramatically. These incentives assisted with the reduction of
    loss rates for critical shortage occupations in those areas to address
    increased competition for health care and entry level staff.
        The nationwide onboarding surge event that occurred in November
    2022 resulted in onboarding more new staff in VHA in the first quarter
    of Fiscal Year 2023 (12,900 staff) than first quarter onboarding in any
    previous year, this was 86 percent higher than the typical number
    onboarded in the first quarter. Onboarding continued to be high in
    January 2023 (5,603 new staff onboard, approximately 600 more than last
    January). VHA's emphasis on hiring has also resulted in a net increase
    in onboard staff of 2.1 percent as of January 31, 2023. This is already
    two-thirds of our end strength goal of 3 percent growth just 4 months
    into the fiscal year.

    Veterans Benefit Administration

        Through the implementation of the PACT Act, VA has actively engaged
    the workforce through a variety of avenues and solicited feedback.
    Since the enactment of the PACT Act, VA has hosted open townhalls with
    VA leaders, hosted local townhalls led by the Regional Office Directors
    and engaged with both labor partners and claim processors to ensure the
    workforce is equipped with the necessary information to process PACT
    claims and to resolve concerns. VA created a PACT Act inquiry tool to
    allow regional offices direct access to policy experts for questions
    about process and policy. In response to feedback on training, VA
    hosted additional live training sessions and created additional tools
    to aid processors in understanding how to implement the law.
        These investments in employee engagement are critical as we look to
    hire more employees than ever before. Under the initial Toxic Exposure
    Funding (TEF) spend plan approved on October 6, 2022, VA allocated
    1,871 positions toward claims processors and supporting staff. As of
    February 21, 2023, VA has hired 1,257 of the 1,871 positions (67.2
    percent).
        Currently, VA is hosting in Salt Lake City the 7th in-person PACT
    Act Career and Hiring Fair of the month. These events have been a
    resounding success with thousands of candidates coming in-person to
    learn about available jobs, participate in onsite interviews, conduct
    suitability assessments, and complete fingerprinting, resulting in
    hundreds of candidates receiving tentative job offers the same day. VA
    is leveraging all available hiring options to ensure we meet our PACT
    Act hiring goals - including the use of expanded hiring authorities
    provided in Title IX of the PACT Act.
        VA continues to partner with military installations to recruit
    military spouses and transitioning Service members. The Secretary
    visited the VA Intake Center at Fort Hood and discussed the total
    rewards of a VA career directly with Service members. Additionally,
    during the Waco hiring fair, the Secretary spoke directly to candidates
    interested in career opportunities with VA. Fiscal Year 2022 was a
    record year for VA hiring and by the second quarter of Fiscal Year
    2023, we are pleased to report that we have already surpassed 60
    percent of Fiscal Year 2022 total hires.

    National Cemetery Administration

        Developing our staff is a critical investment for all of VA. The
    Cemetery Director Development Program trains the next generation of
    leaders at NCA by teaching them how to lead, manage burials, conduct
    maintenance, and manage administrative operations at a national
    cemetery. The Cemetery Caretaker/Representative is the face of VA to
    grieving families at our National cemeteries and VA has recently
    upgraded the position to increase recruitment and retention of these
    important staff and to provide them with advancement opportunities.

    Transforming Systems, Processes, and Infrastructure

        VA has strengthened its capital construction project change
    management processes for Major Construction, Major Lease, and CHIP In
    Act (Community Helping Invest through Property and Improvements Needed
    for Veterans Act of 2016) projects. This has been accomplished through
    regular engagement on projects at both the local and national levels,
    collaborative review of decision event documents, and synchronization
    of the VA change management processes for these programs. Over time,
    this will improve VA's ability to deliver large projects within budget
    and on schedule, and to be good stewards of taxpayer investments while
    bringing modernized health care infrastructure to support care for the
    Nation's Veterans.
        Authorities in Title VII of the PACT Act have already helped
    further our infrastructure further improvement in our infrastructure
    All 31 leases authorized by the PACT Act are in development, with some
    already in the solicitation phase. The revised approval and budget
    authorities for leases allow VA much greater flexibility than in the
    past, particularly accelerating timelines for leases that fall below
    the new Major Lease threshold but above the previous threshold. VA is
    in active discussion with multiple academic affiliates and multiple DoD
    entities on opportunities enabled by new authorities in the PACT Act,
    and both are already informing our Fiscal Year 2025 Strategic Capital
    Investment Process currently underway.
        VA is making progress in upgrading its facility infrastructure to
    correct deficient building systems, such as horizontal cabling and
    electrical upgrades, that will support modernized technologies such as
    the electronic health record, financial management, and supply chain
    management systems. This needed investment in facility infrastructure
    will allow timely and efficient future deployments of these modernized
    systems. The increase in non-recurring maintenance funding in recent
    fiscal years has allowed VA to make bigger investments per project and
    allowed many more projects to be funded. These improvements will help
    VHA address more of the Facility Condition Assessment backlog than has
    been possible previously.
        The modernization of VA's electronic health record (EHR) system is
    a highly complex clinical and business transformation endeavor, with
    the opportunity to standardize and optimize clinical operations for VA
    health care personnel, support delivery of consistent, high-quality
    care for Veterans, and ensure interoperability with the DoD and the
    broader health care community. In October 2022, VA delayed upcoming
    deployments until June 2023 to address challenges with the system. VA
    has been focusing on assessing and remediating identified issues at the
    five current sites where the system has been implemented and has been
    planning for future sites. VA is committed to continuous improvement of
    the electronic health record and associated health information
    technologies, even while executing ongoing deployments across the
    health care system in the years to come. VA continues to develop and
    finalize a new deployment schedule and remains fully committed to
    implementing a modernized electronic health records system, in service
    of providing the best possible care for our Veterans.
        Our national cemeteries are also transforming and evolving with the
    rest of the agency to meet Veterans' expectations in the modern, cyber-
    driven world. Beyond merely establishing the physical burial locations,
    NCA has embraced technology and made significant improvements to its
    digital landscape to better serve Veterans and their families. The
    Veterans Legacy Memorial (VLM) continues to expand its reach among
    Veterans, their families, and friends. Loved ones and others can upload
    tributes, photos, and other items to a Veteran's VLM page, hosted on
    NCA's public-facing webpage. The number of VLM pages, for those
    individuals buried in National and VA grant-funded cemeteries,
    increased to 4.4 million pages in 2022. This year VA is planning to add
    VLM pages for those interred in 28 DoD-managed cemeteries, including
    Arlington National Cemetery, 18 Army post cemeteries, 5 Navy
    cemeteries, and 4 Air Force cemeteries. VLM was awarded three industry
    awards last year, further highlighting its unique position in honoring
    the lives and legacies of Veterans.
        NCA is also preparing to meet the changing needs and preferences of
    Veterans and their families in the 21st century. With the enactment of
    the National Cemeteries Preservation and Protection Act of 2022 (P.L.
    117-355), NCA will soon begin piloting green burials at the Pikes Peak
    National Cemetery with potential expansion to other locations. Green
    burial sections will include a natural appearance of the grounds, with
    a design and grounds maintenance plan based on the cemetery's
    geographic location, which may include use of natural prairie and
    meadow grasses and wildflower mixes.

    The Path Forward

        As described throughout this statement, there are many joint
    concerted efforts to address every domain of Veterans, their families,
    caregivers, and survivors' lives. While many of these efforts are still
    in early stages, we commit to a continued partnership of transparency
    and accountability to ensure VA is doing right by those we serve. VA is
    a Veteran-centric, collaborative and transparent organization dedicated
    to serving more Veterans than ever before.

                           Statements for the Record

                                  ----------

              Prepared Statement of Concerned Veterans for America
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                   __________

              Prepared Statement of America's Warrior Partnership
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                   __________

       Prepared Statement of American Federation of Government Employees

        Chairman Bost, Ranking Member Takano, and Members of the Committee:
        The American Federation of Government Employees, AFL-CIO (AFGE) and
    its National Veterans Affairs Council (NVAC) appreciate the opportunity
    to submit a statement for the record on today's hearing titled
    ``Building an Accountable VA: Applying Lessons Learned to Drive Future
    Success.'' AFGE represents more than 750,000 Federal and District of
    Columbia government employees, 291,000 of whom are proud, dedicated
    Department of Veterans Affairs (VA) employees. These include front-line
    providers at the Veterans Health Administration (VHA) who provide
    exemplary specialized medical and mental health care to veterans,
    including those newly eligible for treatment under the Sergeant First
    Class (SFC) Heath Robinson Honoring our Promise to Address
    Comprehensive Toxics (PACT) Act. Furthermore, we represent the Veterans
    Benefits Administration (VBA) workforce responsible for the processing
    veterans' claims, the Board of Veterans' Appeals (Board) employees who
    shepherd veterans' appeals, and the National Cemetery Administration
    Employees (NCA) who honor the memory of the Nation's fallen veterans
    every day.
        With this firsthand and frontline perspective, we offer our
    observations on the problems the VA Employees are facing, many of which
    were created or exacerbated by VA leadership. AFGE provides these
    examples with goal of both urging the VA to address these issues
    administratively and highlight to the House Veterans Affairs Committee
    to use its oversight and legislative authority to better enable VA
    employees, over a third of whom are veterans themselves, to continue
    serving veterans. Specifically, AFGE will identify current issues and
    needed solutions related to:

          Veterans Benefits Administration:

              o Performance Standards, including:

          Counterproductive Frequency of Changes to Processes

          Failure to Award Credit for Each Issue Claimed

          ``Talk Time'' at VBA National Call Centers

              o Addressing the critical need for staffing with the rapid
            influx of new PACT Act claims.

              o Ensuring the training for VBA employees is adequate,
            nationally consistent, and beneficial.

          Board of Veterans Appeals

              o Performance Standards

              o Recruitment and Retention

          Veterans Health Administration

              o Monitoring that VHA has the staff it needs to meet the
            increased demand created by the PACT Act.

              o Ensuring that VHA is using the compensation tools it gained
            in the PACT Act to benefit lower-grade front line clinicians.

              o Ensuring that VHA compensates its employees what they are
            owed.

              o Restoring full HR functioning at the facility level through
            additional hiring, training, and decentralization.

          VA Police

        We hope you find these suggestions constructive, and we stand ready
    to work with the Members of the Committee to make necessary and
    positive improvements to the VA.

    Performance Standards for VBA Employees

        For many years prior to the passage of the PACT Act, AFGE has
    highlighted the many problems with the VBA performance standards faced
    by its employees. Standards are often introduced and implemented for
    VBA staff in a haphazard manner and are overly focused on metrics that
    prioritize quantity over quality, providing a disservice to the
    veterans they are intended to benefit. Unfortunately, these problems
    have not been solved by the PACT Act, but instead further highlighted
    with increased demand from the PACT Act. When asking bargaining unit
    employees in the VA's Regional Offices (VARO) to identify the single
    biggest obstacle they face to successfully performing their duties and
    serving veterans, the universal answer is constantly changing
    performance standards.

    Counterproductive Frequency of Changes to Processes

        A classic example of VBA's constant change to performance standards
    was the implementation of new performance standards for Veteran Service
    Representatives (VSR) and Rating Veteran Service Representatives
    (RVSRs) on October 1, 2020, with a three-month acclimation period.
    Since the implementation of these standards, VBA made changes to these
    standards in November 2020 and December 2020, and then announced at the
    end of the end of December 2020 that it would make more changes leading
    to another three-month acclimation period. These standards were changed
    again in January 2021, again in March 2021, and were finalized on April
    1, 2021. For context, these standards are incredibly complex and take
    time to learn, requiring acclimation periods to allow the employees to
    fully understand them. Having six changes made in six months was
    severely disruptive and made it difficult for staff to perform their
    duties and effectively serve veterans. Had VBA worked collaboratively
    with AFGE representatives from the beginning when changing these
    standards to gain employee perspectives and input, many of these
    problems could have been avoided and VBA would have been able to
    process claims in a more efficient and timely manner.
        The implementation of the PACT Act is leading to changes in
    performance standards for numerous positions throughout VBA, while the
    manual that states correct procedures and provides technical advice is
    updated weekly. Through AFGE's midterm bargaining, AFGE proposed a
    Memorandum of Understanding to allow for a 180-day adjustment period
    for claims processors to learn these new complex procedures and adjust
    accordingly. The VA refused, and instead stated that the 90-day
    adjustment period was non-negotiable. This unnecessary and self-imposed
    obstacle will only continue to stress and pressure VBA employees, lead
    to additional errors, and inadvertently cause errors to veterans'
    claims.
        Furthermore, since the start of 2023, VBA has imposed new standards
    for Authorization Quality Review Specialists, Rating Quality Review
    Specialists, Fiduciary Program Specialists, and Quality Review
    Specialists in the National Call Center. AFGE attempted to reach a
    memorandum of understanding with VBA on these changes prior to their
    implementation on January 1, 2023, rather than VBA unilaterally
    imposing new standards on the workforce. While AFGE was able to bargain
    issues related to appropriate arrangements and procedures with the VBA,
    the VBA refused to negotiate the metrics themselves. These standards
    will lead to additional employee errors, burnout, higher turnover, and
    decreased service to the veterans they serve. As these standards are
    implemented and other performance standards are updated, AFGE urges VBA
    to work in good faith with AFGE to design fair and attainable standards
    that prioritize quality over quantity, and best serve veterans.
    Specifically, AFGE recommends that the VBA offer a more generous grace
    period to learn the evolving complexities in both PACT Act and older
    claims and give employees additional time between manual updates which
    will allow employees to absorb information prior to adjusting to
    changes. AFGE also urges the committee to perform oversight on the
    developments of new VBA production and quality standards in response to
    both older claims and new PACT Act claims to ensure that these
    standards enable employees to serve the best interests of veterans.

    Failure to Award Credit for Each Issue Claimed

        Clearly, every veteran is supposed to be treated equally by the VA,
    but VBA performance standards can cause disparate treatment depending
    on the claim filed. When evaluating claims, VBA does not easily
    distinguish the number of issues or contentions each veteran makes in
    their claim, instead using a complex tier system that unnecessarily
    hurts the ability of VSRs and RVSRs to meet their standards. This is
    arbitrary and punishes employees who get assigned claims with a
    significant number of contentions, but not enough to earn additional
    credit. This can unfairly punish veterans who, through no fault of
    their own for the number of contentions they submit in a given claim,
    realize negative decisions affecting their claims.
        The PACT Act will lead to the filing of many claims with
    significantly more contentions and distinctions. While we have
    advocated repeatedly for a change in employee production standards that
    adequately account for complicated claims, the implementation of the
    PACT Act necessitates a fair and accurate recalibration of standards,
    and new training programs and procedures to factor in the additional
    work and time that will be required to process these new claims and
    urge the committee to monitor the implementation of these performance
    standards.
        We also urge the Committee to monitor the VBA's changes to these
    standards and ensure that they enable employees to best serve veterans,
    instead of meeting arbitrary and self-imposed internal metrics.

    ``Talk Time'' at VBA National Call Centers

        For years, AFGE has raised concerns to this committee about the
    VBA's measure of the timeliness or ``talk time'' component for Legal
    Administrative Specialists (LAS) who answer veterans' questions at
    VBA's eight national call centers. Each LAS is allotted a certain
    amount of time they can be on the phone with a veteran based upon the
    employee's GS level. This can be as little as eight minutes and thirty
    seconds. This is a one size fits all standard that does not consider
    common issues veterans often call in about including a ``first notice
    of death call'' where a veteran's spouse is calling to inform the VA
    that the veteran has passed away. Such a call may take 20-30 minutes.
    The standard also does not take into account the numerous older
    veterans who have difficulty communicating or veterans who have more
    than one question or issue to resolve. It also does not account for a
    veteran not having their VA ``Pin Number'' available and leaving the
    LAS on the phone while they attempt to locate the information.
    Additionally, the standard effectively disincentivizes an employee from
    suggesting to a veteran about a benefit or program he or she may be
    eligible for but does not know to ask about, because it would take more
    time on the phone.
        With passage of the PACT Act, there has been a predictable surge in
    calls to the national call centers with numerous questions for VBA
    employees. Despite the fact this problem that was easily anticipated by
    VBA leadership, employees, including those in the National Call
    Centers, have not been given any additional time to meet their talk
    time standards, and were only provided with a short generic script to
    respond to a veteran's complex questions.
        An employee whose primary responsibility is to answer a veteran's
    questions should not have their performance measured by how quickly
    they can get a veteran off the phone, and the VA should not prioritize
    a contrived metric over providing valuable customer service to
    veterans, especially in the wake of a massive and complex expansion of
    benefits to millions of veterans. VBA should remove Talk Time as a
    critical component of employee performance.
        Furthermore, it has come to AFGE's attention that on October 20,
    2022, VBA instituted new performance standards for the call centers
    that further restricted the use of ``wrap up time'' at the end of the
    day for LASs to input data, prepare mail to veterans and complete other
    tasks that they could not handle during calls. This change was also
    accompanied by a new availability standard that substituted percentages
    for raw minutes, further increasing stress on workers, and
    unnecessarily increasing the difficulty of the job. These rules, which
    result in unnecessarily limiting bathroom breaks, are pennywise and
    pound foolish, and decrease the quality of service that veterans
    receive.

    VBA Staffing and Backlog

        The enactment of the PACT Act has resulted in a need to increase
    the size of the VBA workforce to process the expected surge in claims
    from newly eligible veterans. In a Senate Veterans Affairs Committee
    Hearing on February 16, 2023, Josh Jacobs, the nominee for
    Undersecretary of the VBA stated that VBA expects 700,000 new PACT Act
    claims to be filed in 2023. This in part explains why in a presentation
    made to AFGE representatives, VBA estimated that the current backlog of
    150,000 claims is expected to increase to 450,000 claims in 2023.
    Additionally, according to the data on staff vacancies required by
    Section 505 of the VA MISSION Act, VBA has 2,806 vacancies as of the
    end of the third quarter of Fiscal Year 2022. Despite this, while the
    VA has hired many new claims processors, AFGE has heard reports of slow
    hiring for employees, one example being the Cleveland, Ohio, VARO,
    which is having a delay in hiring candidates who are disabled veterans.
    These delays have taken months, causing some applicants to accept other
    jobs. Additionally, given the months it takes to effectively learn to
    process claims, this delay is worsening the backlog to the detriment of
    veterans. AFGE urges the VBA to continue to quickly ramp up its
    staffing and training of claims processors and allow it to better
    manage the backlog of claims, instead of relying upon mandatory
    overtime, which exacerbates employee burnout.

    Training

        The PACT Act mandates several new VA workforce training
    initiatives. However, the information shared with employees since
    enactment has been greatly inadequate. So far, VBA employee have five
    Talent Management System courses, the vast majority of which last 30
    minutes each, courses and given a new Standard Operating Procedure to
    read. To date, no hands-on training or opportunities to ask questions
    of a live instructor have been offered.
        This will foreseeably create inconsistency in the future with
    different VAROs creating different determinations. AFGE urges the VBA
    to increase training, including ample opportunity to ask questions.
    Specifically, for all training to be effective, including PACT Act
    training, it is essential that management solicit input from the labor
    representatives' rank and file members who are actually working claims
    as to what training would enable them to better serve veterans.
    Furthermore, AFGE recommends that VBA create a team of specialized
    instructors to travel to different to regional offices and provide this
    training to employees while using real claims as examples, giving
    employees the opportunity to ask questions in real time. By using this
    model and not having each Regional Office assemble their own team, this
    will ensure consistency in training across the agency, and create less
    variability between Regional Offices.

    Board of Veterans Appeals

        AFGE is proud to represent the employees who work at the Board of
    Veteran Appeals (Board). This dedicated workforce plays a critical role
    in the final stage of the claims process for claims that require
    additional review. However, there have been recent decisions made at
    the Board that have created negative consequences for Board attorneys
    and the veterans they serve.

    Performance Standards

        Board attorneys, like VBA claims processors, face difficult to meet
    performance standards that cause burnout and harm recruitment and
    retention. Prior to the implementation of the Appeals Modernization Act
    (AMA), Board attorneys were expected to complete 125 cases a year, a
    pace that averaged 2.4 cases per week. Each case, regardless of the
    number of issues decided, carried the same weight toward an attorney's
    production quota. In Fiscal Year 2018, the Board increased its
    production standards from 125 to 169 cases per annum, (or 3.25 cases
    per week), a 35 percent increase in production requirements which was
    overwhelming for Board attorneys. In Fiscal Year 2019, the Board
    created an alternative measure of production for Board attorneys which
    evaluated the total number of issues decided by an attorney, regardless
    of the number of cases completed, setting that number at 510 issues
    decided. AFGE supports the creation of this alternative metric as it
    better accounts for the work required to complete each case. However,
    we caution that measuring the number of issues can also be manipulated
    to create unfair metrics. Unfortunately, this manipulation appeared in
    Fiscal Year 2020, the first full year the AMA was fully implemented,
    because while the case quota remained at 169, the issue quota was
    raised to 566. Finally in Fiscal Year 2021, the quota was changed to a
    more manageable but still difficult 156 cases or 491 issues.
    Unfortunately, AFGE has heard reports that the Board intends to
    increase its production quota for the next Fiscal Year in an attempt
    meet expected appeals as a result of the PACT Act. Simply increasing
    the quota will not increase production and may result in reduced
    quality for veterans who have often waited years to have their appeals
    heard.
        These standards are also harmed by the rule that a Board attorney
    may only receive credit for a case once a judge signs off on the work.
    While this requirement may appear reasonable, delays caused by
    overburdened judges can cause attorneys to miss their quotas through no
    fault of their own. When attorneys are adjudged to be performing poorly
    based on such missed quotas, it violates Article 27, Section 8,
    Subsection E of AFGE's collective bargaining agreement with the VA,
    which states ``When evaluating performance, the Department shall not
    hold employees accountable for factors which affect performance that
    are beyond the control of the employee.'' The VA should adhere to the
    terms of the collective bargaining agreement and not penalize workers
    for no fault of their own. This is especially true since the Board
    recently began the practice of hiring Veteran Law Judges, or Board
    Members, who have no experience in Veterans law, and are simultaneously
    harming employees' performance and slowing down the appeals process for
    veterans who have waited long enough for their claims to be finalized.
    The leadership of the VA and the Board should revert to hiring Board
    Members with significant veteran law expertise and look to current
    Board Attorneys to fill those positions.

    Recruitment and Retention

        To further assist with recruitment and retention, the Board of
    Veterans' Appeals is a place where attorneys should have a path to work
    for their entire careers. To accomplish this goal, the Board needs to
    re-establish a standard career ladder for GS-14 Board Attorney
    positions which had until recently existed for new hires. Eliminating
    this level of growth and compensation for attorneys is a direct way of
    dissuading qualified applicants from joining the Board of Veterans
    Appeals or choosing to stay long term. The VA should reverse this
    shortsighted policy and attract the best candidates to the Board's
    ranks.
        Additionally, AFGE strongly supports the creation of a journeyman
    non-supervisory GS- 15 Board Attorney position. Currently, Board
    attorney grades range from GS-11 to GS-14. Of the 871 attorneys
    currently at the Board, 439 attorneys are at the GS-14 level. While not
    all attorneys would qualify or choose to advance to a GS-15 position,
    creating the possibility for 100 to 200 GS-15 attorneys would help with
    long-term recruitment and retention. It is also important to note that
    there are non-supervisory journeyman GS-15 attorneys within the VA
    Office of General Counsel, thus setting a precedent. As Board attorneys
    are in the Excepted Service, it is within the Secretary's discretion to
    create and fill these new positions. AFGE has and continues to
    encourage the Secretary to create this advancement opportunity and has
    asked Congress to voice its support for this change or pass legislation
    establishing its creation.

    VHA Staffing, Compensation, and Other Workforce Issues

        As a result of the PACT Act, VHA is facing an unprecedented
    increase in demand for medical care. The hiring and training of
    additional health care personnel will be essential to meet the
    screening and treatment needs of newly eligible veterans in virtually
    every medical center service line, in particular primary care clinics,
    emergency rooms (ER), cardiology, pulmonology, urology,
    gastroenterology and dermatology. Unfortunately, an informal survey of
    our members reveals very limited efforts to hire, train or carry out
    other activities for an effective rollout of new PACT Act health care
    initiatives and increased demand for services.

    Staffing

        There is an urgent need for VHA to address the chronic short
    staffing that significantly worsened during the COVID-19 pandemic.
    According to the data on staff vacancies required by Section 505 of the
    VA MISSION Act, VHA had 76,531 vacancies as of the end of the third
    quarter of Fiscal Year 2022. Outpatient clinics are forced to shut
    their doors due to lack of staff.
        Many facilities cannot reopen their hospital beds due to a critical
    nurse staffing shortage, leaving veterans in the ER for up to 48 hours
    waiting to be admitted. AFGE received an encouraging member report from
    a VISN 6 facility that is actively carrying out onboarding events to
    expedite the hiring of more clinical staff, an effort that should be
    replicated across the country. Another VISN 6 provider provided a less
    encouraging report that his facility's management has failed to step up
    recruitment and retention efforts, and in some cases, is actively
    pushing employees to resign.
        AFGE has received very troubling reports from our locals at
    numerous facilities that medical center directors who received
    retention incentive funds provided by the PACT Act have not distributed
    them to front line clinicians even in the face of high vacancy rates.
    Also, the job listings posted by medical centers in many locations
    failed to align with the much higher vacancy rates used to justify
    these retention incentive dollars. More generally, congressional
    oversight of the deeply flawed and unreliable vacancy data that is
    currently collected and published by the VA is badly needed.
        A failed HR modernization effort launched under the Trump
    Administration and continued under the Biden Administration is
    exacerbating staffing shortages. Under this modernization, Human
    Resources (HR) functions traditionally performed by personnel at
    medical centers were centralized at the VISN level. AFGE members across
    VISNs report that lack of coordination between the facilities and the
    VISN are extending the time it takes to hire employees and often leads
    to ``bait and switch'' offers where new employees take jobs based on
    compensation, benefits and duties that change when they begin the job.
    Many qualified candidates lose interest in VA positions or accept a job
    only to quit shortly thereafter when it was not what was agreed upon.
    This situation deteriorates even further for many employees who choose
    to stay, as VA employees also report that HR mistakes create ``debt''
    for employees whose pay is clawed back retroactively. Employees receive
    inadequate information about how they can have this debt waived.
        For an agency that has claimed it wants to recruit the best
    providers possible and that recruitment and retention of employees is a
    top priority, the counterproductive centralization of HR functions away
    from the medical centers must be reversed. Front line personnel and
    their labor representatives need access to knowledgeable HR specialists
    at the facility level to resolve routine personnel matters.

    Compensation

        Compensation that is not competitive with private pay remains a
    major barrier to both recruitment and retention. The pay grades of a
    number of lower-wage VHA positions, including the nursing assistants
    and licensed practical nurses who make up the core of VA community
    living center workforces, are still too low to recruit and retain
    sufficient staff. Similarly, medical support assistants who handle
    patient scheduling and other critical support functions are already
    working at a low grade that causes a lot of attrition and in some cases
    are facing downgrades to even lower positions.
        According to the VA master agreement, the VA should review wages
    offered by non-VA hospitals in a region to determine if VA pay is
    competitive but often fail to fulfill this obligation. As a result, VA
    employees are often paid based on out-of-date information about local
    wages.
        While it is encouraging that the PACT Act may make it easier to
    hire more housekeepers to keep medical facilities clean and safe, this
    position has had a high attrition rate for many years. VA needs to
    raise their pay grades to make them more competitive with the private
    sector.
        The lack of mobility between grades further worsens shortages as
    employees stymied by lack of opportunity for promotion--even after
    years of experience and/or receiving additional training--leave for
    jobs where their advanced skills are rewarded.

    Collective Bargaining

        In 1991, Congress amended Title 38 to provide medical professionals
    who work at VA facilities with limited collective bargaining rights
    (which include the rights to use the negotiated grievance procedure and
    arbitration) (P.L. 102-40 Sec. 202). Under 38 USC Sec. 7422, covered
    employees can negotiate, file grievances and arbitrate disputes over
    working conditions except ``any matter or question concerning or
    arising out of'':

          professional conduct or competence (defined as direct
    patient care or clinical competence);

          peer review; or

          the establishment, determination, or adjustment of
    employee compensation.

        This has resulted in VA management interpreting these exceptions
    very broadly and refusing to bargain over virtually every significant
    workplace issue affecting Title 38 medical professionals. It is also
    very problematic that VA managers are increasingly asserting ``7422''
    themselves, rather than requesting a 7422 ruling from the VA Under
    Secretary for Health (USH) as required by statute. (The statute
    authorizes the VA Secretary to make 7422 rulings. In a 1992 memorandum,
    the VA Secretary delegated this authority to the USH (formerly called
    the Chief Medical Director.).
        When managers refuse to seek a USH 7422 ruling, the union's efforts
    to enforce the rights of Title 38 professionals are hamstrung because
    nothing prevents the VA medical center from belatedly and retroactively
    obtaining a USH 7422 ruling when the Federal Labor Relations Authority
    (FLRA) threatens the VA with ordering remedial relief for the
    professionals. When local management asserts Section 7422 but does not
    seek an USH ruling, the union is forced to file an Unfair Labor
    Practice (ULP). The FLRA Regions generally decline to take any action.
    However, if the FLRA region starts to pursue an action over the ULP
    charge, the management will then seek an USH ruling even though it is
    late in the FLRA litigation process.
        VA Title 38 medical professionals have extremely limited collective
    bargaining rights in comparison to their counterparts in other federal
    agencies, State and local government systems, and the private sector.
    As a result, Registered Nurses (RNs), doctors and other impacted
    employees at the VA are experiencing increased job stress, low morale,
    and burnout. This in turn, exacerbates the VA's recruitment and
    retention problems. AFGE seeks a legislative fix that would restore
    full collective bargaining rights to title 38 employees. But in the
    absence of this reform, VA should be held accountable for its overuse
    of 7422 exceptions to block workers' right to grieve agency wrongdoing.

    Contract Care Access Standards

        The MISSION Act required the Department to implement access
    standards to determine when veterans should be referred outside the VA
    health care system for care in the private sector through the Veterans
    Community Care Program (VCCP). These standards consider how long
    veterans wait to access VA in-house care and how long it takes for the
    veteran to drive to the closest VA medical facility in order to
    determine if the veteran should be referred to a VCCP provider. If a
    veteran must wait more than 28 days for VA in-house care or drive more
    than 30 minutes for VA in-house primary care or 60 minutes for VA in-
    house specialty care, than he or she can choose to go outside the VA to
    a VCCP provider instead.
        The access standards have caused unprecedented number of VCCP
    referrals. But the double standard on wait times for VA vs. VCCP care
    has resulted in many veterans waiting longer and driving further for
    non-VA care than they would have if they continued receiving VA in-
    house care. A Government Accountability Office analysis of VHA data
    from the third quarter of Fiscal Year 2022 found that VA medical
    scheduled timely referrals for VHA facility appointments more
    frequently than community care.
        The current double standard must be eliminated; a revised access
    standard must be applied equally to the VA and VCCP providers.
    Currently, the access standards do not consider the wait times and
    driving times that veterans will face to access care outside the VA.
        In addition, the driving time component of the access standard is
    not restrictive enough and results in the overuse of contract care even
    when a veteran would be better served by in-house care. VCCP providers
    should be supplementing, not supplanting the VA. Multiple studies have
    shown VA's own care to be of higher quality with better health
    outcomes, and less costly than private sector care.
        The access standards also apply a double standard to care provided
    by telehealth and tele-mental health (``telehealth''). The VA has long
    been recognized as a leading telehealth model by other health care
    systems. Yet, the access standards do not count VA in-house telehealth
    services in determining if the VA has met the standard. As a result,
    veterans who would have not had any wait for VA-provided telehealth
    care are sent to VCCP providers who treat them through telehealth
    programs of unknown quality and at greater cost to taxpayers.
        Last Congress, Secretary McDonough testified before the Senate
    Veterans' Affairs Committee that he was considering revising the access
    standards in order to address the skyrocketing costs of VCCP care. He
    also committed in his testimony to propose changing the way that VA
    telehealth availability is factored in determining eligibility for
    community care. The department has not yet proposed these changes.
        Oversight is needed to ensure that the VA Secretary revises the
    current access standards to increase the drive time limit and count VA
    in-house telehealth when determining whether the VA has met the
    standards. Additionally staffing levels at facilities must be adjusted
    so that veterans' needs for in-house care are not compromised by
    workloads associated with VCCP referrals.

    Privatization

        The VA MISSION Act of 2018 established a nine-member Asset and
    Infrastructure Review (AIR) Commission to make recommendations
    regarding ``closure, modernization and realignment'' of VHA facilities.
    AFGE took a cautious approach at first to the Commission, hoping that
    the process might result in more attention to the VA significant need
    for infrastructure investment and modernization. However, in March
    2022, the VA announced its recommendations to the AIR Commission,
    calling for a vast privatization of VA services through the closure or
    downsizing of nearly 60 VA medical centers, around a third of the total
    across the country. The VA's plan called for transferring these
    functions to new, mostly smaller facilities that had yet to be funded
    or built, or to the private sector, with almost no analysis of the
    quality, cost, or availability of those private services. The VA used
    outdated, pre-pandemic analyses to support its recommendations, an
    approach that was lambasted by its own OIG, the Government
    Accountability Office, and a panel of private experts the VA convened
    through MITRE Corporation. Despite the obvious frailty of the VA's
    process, the MISSION Act established a fast-track process for approving
    the recommendations, with little opportunity for Congress or other
    stakeholders to exert any influence.
        AFGE and the NVAC mobilized across the country in opposition to the
    AIR Commission, holding rallies, contacting Members of Congress,
    publishing articles, and partnering with affected veteran
    organizations. As the result of these efforts, in June 2022 a
    bipartisan group of senators including many from the Senate VA
    Committee announced their opposition to confirming any AIR Commission
    members. In July 2022, a bipartisan House majority voted to strip
    funding from the AIR Commission and to deauthorize the commission in
    the annual NDAA. In December, Congress approved the 2023 omnibus
    spending bill which defunded the AIR Commission and imposed new
    restrictions on the VA ability to close or downsize rural healthcare
    facilities.
        Nonetheless, the threat of privatization persists. A separate
    section of the MISSION Act, unaffected by Congress's recent actions,
    directs the department to conduct strategic infrastructure reviews
    every four years, with the first review expected in 2023. In the late
    summer of 2022, following the collapse of the AIR process, several
    VISN's contacted AFGE locals with plans to continue pursuing the
    hospital closures recommended to the defunct AIR Commission, with no
    apparent attempt to update the discredited market assessments behind
    those recommendations.

    Other VHA Workforce Matters

        Veterans in need of screening and treatment for toxic exposure need
    and deserve the thorough, specialized, comprehensive care that only the
    VA provides. We received a concerning report from VISN 23 that veterans
    may be shortchanged by a new ``bookable hours'' policy that cuts the
    time that a provider can spend to assess a new patient from sixty to
    thirty minutes. Doctors unable to meet this standard must choose
    between working extra hours off the books to compensate for time they
    spend assessing new patients or depriving veterans of the care they
    deserve.
        Our members report that the online training on new screening tools
    that has been provided is a good first start but that more
    comprehensive training is needed to ensure that all clinicians and
    support personnel have a full understanding of the specialized
    screening processes and treatment needs of veterans with toxic
    exposure.

    VA Police

        AFGE is proud to represent the VA Police Officers in facilities
    across the country. As is evidenced by a VA Office of the Inspector
    General (OIG) Report issued February 22, 2023, titled ``Security and
    Incident Preparedness at VA Medical Facilities,'' there are significant
    challenges facing the VA Police Department. As the summary of the
    report states that ``[t]he OIG identified multiple security
    vulnerabilities and deficiencies, most notably staffing shortages that
    contributed to the lack of a visible and active police presence. To
    meet VA's established security requirements, facilities will need to
    fill police officer vacancies, as employing sufficient security
    personnel and correcting security weaknesses are inextricably linked.''
        AFGE agrees with the need to recruit and retain more police
    officers to keep veterans and employees safe at VA facilities.
    Approximately 90 percent of VA police officers are veterans. Its
    officers are highly trained in crisis intervention to de-escalate
    situations at VA facilities, and these officers have unique knowledge
    of the facilities within their jurisdiction and how to interact with
    veterans. However, regardless of the number of officers recruited, if
    the VA cannot retain them, it does not help the agency. As AFGE
    advocated for years, the single biggest change that VA leadership can
    do to help with the recruitment and retention to the VA Police Force is
    to grant the VA Police Officers Law Enforcement Officer (LEO)
    Retirement either through administrative action or by supporting this
    bipartisan legislation.
        AFGE has raised this issue before, including in submitting a
    Statement for the Record on a hearing before the House Veterans Affairs
    Committee Subcommittee on Oversight and Investigations titled
    ``Modernizing the VA Police Force: Ensuring Accountability'' in the
    117th Congress on July 13, 2021. As was stated previously, under 5
    U.S.C 8336(c), any LEO who either serves 25 years or is age 50 or older
    and serves 20 years is entitled to immediate retirement with a full
    pension and has mandatory retirement at age 57 (with few exceptions).
    These are commonly referred to as ``6(c) special retirement benefits''
    (6(c) benefits). However, the definition of LEO relied upon in the code
    (5 U.S.C. 8401(17)) to grant 6(c) benefits does not include VA Police
    Officers, and in turn they do not receive special retirement benefits
    on par with federal law enforcement officers at other federal agencies.
    AFGE has endorsed the ``Law Enforcement Officers (LEO) Equity Act,''
    introduced by Representatives Bill Pascrell, Jr. (D-NJ), Andrew
    Garbarino (R-NY), Gerry Connolly (D-VA), and Brian Fitzpatrick (R-PA)
    (this bill was H.R. 962 in the 117th congress, and is pending re-
    introduction in the 118th Congress). If enacted, this bill would grant
    6(c) benefits to VA Police Officers as well as law enforcement officers
    of other federal agencies who do not have 6(c) benefits, including the
    Department of Defense (DoD), Federal Emergency Management Agency
    (FEMA), and the Federal Protective Service (FPS). In the 117th
    Congress, this legislation earned 105 bipartisan co-sponsors, including
    Chairman Mike Bost (R-IL), Ranking Member Mark Takano (D-CA), and seven
    members of the House Veterans Affairs Committee in the 118th Congress.
        Granting 6(c) benefits to VA Police Officers would significantly
    help the VA Police Force with recruitment and retention. Currently, the
    VA hires many new recruits, sends them to the Law Enforcement Training
    Center (LETC) for training, and sees these officers depart the force
    for other opportunities within the federal government that have 6(c)
    benefits, or to other State and local police departments. If VA Police
    Officers were granted 6(c) benefits it is expected many more would stay
    with the department and feel less financial incentive to leave.
        The continuous turnover of VA Police Officers represents a
    significant cost for the VA. Not only does the VA have to pay for new
    officers to attend LETC to backfill positions, at a cost of thousands
    of dollars per officer, but the VA is spending resources on specialized
    training for its officers who leave the VA. A key example of this is
    the suicide prevention training that was enacted as part of the Johnny
    Isakson and David P. Roe, M.D. Veterans Health Care and Benefits
    Improvement Act of 2020. Because of this law, VA Police Officers who
    serve at VA Medical Centers, Community Based Outpatient Clinics (CBOC),
    or VA Regional Offices are now trained to prevent a veteran in a crisis
    situation from harming himself or herself or others. This is incredibly
    critical and specialized training that the VA invests in to save lives.
    The high attrition rates of VA Police Officers who undergo this
    training puts an added strain on VA resources. Granting 6(c) benefits
    to VA Police Officers will diminish this turnover, and help the VA
    maintain a stronger and better trained police department with higher
    morale. While the ``Law Enforcement Officer (LEO) Equity Act,'' is not
    in the jurisdiction of the House Veterans' Affairs Committee, AFGE
    urges that members of this subcommittee, and consequently the full
    committee, to join their colleagues to become co-sponsors of H.R. 962
    and urge its passage in the House. Additionally, while not a permanent
    solution, AFGE urges Secretary of Veterans Affairs Denis McDonough to
    use his administrative powers to grant 6(c) benefits to the VA Police
    Officers until these benefits can be codified.

    Conclusion

        AFGE thanks the House Veterans' Affairs Committee for the
    opportunity to submit a Statement for the Record for today's hearing.
    AFGE stands ready to work with the committee and the VA to address the
    workforce issues currently facing the department and find solutions
    that will enable VA employees to better serve our Nation's veterans.
                                   __________

               Prepared Statement of Student Veterans of America

        Chairman Bost, Ranking Member Takano, and Members of the Committee:
    Thank you for inviting Student Veterans of America (SVA) to submit a
    statement on the topic of Building an Accountable Department of
    Veterans Affairs (VA).
        Through a dedicated network of campus-based chapters worldwide, SVA
    aims to inspire yesterday's warriors by connecting today's military-
    connected students, student veterans, family members, and survivors
    with a community of dedicated SVA chapter leaders. Every day these
    passionate leaders advocate for the necessary resources anywhere. This
    population is pursuing their education while working to provide support
    through networking and fostering a sense of comradery post-military
    service to ensure student veterans can effectively connect, expand
    their skills, and ultimately achieve their greatest potential.

                        Transparency and Accountability

        SVA firmly believes that transparency and accountability go hand in
    hand. We encourage the Committee to focus on the following topics when
    considering how to build a more transparent and accountable VA so it
    can better serve student veterans and other military connected
    students.

        1. Increase oversight of VA communications with institutions and
    training providers.

        SVA heard growing concerns from School Certifying Officials (SCOs),
    institutions, and training providers recently concerning a lack of
    timely and accurate communications on policy changes and guidance.
        Over the last 3 years, many important and necessary changes have
    been made to laws governing VA education benefits. For instance, the
    landmark Johnny Isakson and David P. Roe, M.D. Veterans Health Care and
    Benefits Improvement Act of 2020--appropriately dubbed by VA as
    ``transformative''--required the Department to implement more than 30
    new provisions.\1\ SVA supported this bill and will be forever grateful
    for this Committee's work. However, based on our conversations with
    SCOs and other institutional representatives, VA has had challenges
    implementing certain aspects of the legislation. This has been
    particularly true when it comes to the Department disseminating clear,
    consistent, and timely guidance to institutions.
    ---------------------------------------------------------------------------
        \1\ Isakson and Roe Veterans Health Care and Benefits Improvement
    Act of 2020, U.S. DEP'T OF VETERANS AFFAIRS, https://benefits.va.gov/
    gibill/isaksonroe.asp (last updated July 18, 2022).
    ---------------------------------------------------------------------------
        Communications issues at VA have also impacted certain aspects of
    its Digital G.I. Bill modernization project. This long-overdue project
    is making significant changes to GI Bill IT systems.\2\ Of course,
    these changes have implications for institutions as well. For instance,
    the Department is about to release its new Enrollment Manager--an
    updated system for SCOs to use when certifying enrollment for students
    using VA education benefits.\3\ SVA believes this is an important
    update and supports the overall effort. Yet, we have been perplexed by
    some of the decisions made by VA and the seeming lack of consideration
    the Department has shown for input from insitutions.
    ---------------------------------------------------------------------------
        \2\  Transforming the GI Bill Experience, U.S. DEP'T OF VETEARNS
    AFFAIRS, https://digital.va.gov/delightful-end-user-experience/
    transforming-the-gi-bill-experience/ (last updated Feb. 22, 2023).
        \3\ Bulletin from Veterans Benefits Administration to School
    Certifying Officials (Dec. 13, 2022), available at https://
    content.govdelivery.com/accounts/USVAVBA/bulletins/33ced9d.
    ---------------------------------------------------------------------------
        Last year, for instance, VA announced plans to transition from the
    current VA-ONCE system to the new Enrollment Manager during arguably
    the busiest enrollment period of the spring semester. This decision
    came despite feedback from SCOs that doing so would have potentially
    disastrous consequences for student veterans and military-connected
    students due to delayed certifications resulting in late benefit
    payments, among other issues. We commend VA for ultimately heeding
    these concerns and delaying the rollout, but we still have reservations
    as to why the original decision was made in the first place and why
    input from SCOs was seemingly not considered earlier in the process.\4\
    At the time of this hearing, VA-ONCE sunset a few days ago, and VA's
    new Enrollment Manager will kick in March 6. SVA stands by to hear
    those using the new system.
    ---------------------------------------------------------------------------
        \4\ See generally Letter from American Council on Education et. al
    to the Hon. Denis R. McDonough, Secretary, U.S. Department of Veterans
    Affairs (Dec. 8, 2022), available at https://www.acenet.edu/Documents/
    Letter-VA-Enrollment-Manager-120822.pdf (explaining institutional
    concerns); see Bulletin, supra note 3 (explaining VA chose to delay the
    rollout to ``optimize functionality.'').
    ---------------------------------------------------------------------------
        SVA often hears from SCOs that they are not receiving the guidance
    they need from their VA Education Liaison Representatives (ELRs). The
    problem has sometimes been attributed to a shortage of ELRs. Though
    based on comments we have heard from VA representatives, it appears the
    Department simply views their ELR structure as in transition. Whatever
    the true nature of the issue, SVA believes ELRs are critical for VA to
    disseminate timely and accurate guidance to institutions. Considering
    what we have heard from SCOs about the current state of VA
    communications and guidance, SVA urges the Committee to explore whether
    ELRs are truly fulfilling their essential duties. If necessary, we ask
    that the Committee intervene to correct deficiencies.
        As a general matter, SVA encourages the Committee to ramp up its
    oversight of VA's communications at all levels with institutions and
    training providers. We ask that the Committee more closely monitor VA's
    communications for timeliness and consult with institutions and
    training providers regularly regarding the clarity, consistency, and
    workability of VA communications, including on policy guidance.

        2. Address concerns with VR&E processes and personnel.

        SVA believes the Committee should focus a brighter oversight
    spotlight on the Veteran Readiness and Employment (VR&E) program.
        In 2021, VA announced a self-identified change in how it assesses
    eligibility for VR&E as it relates to other veterans' education
    benefits. In short, a veteran may use their VR&E eligibility up to a
    36-month cap and then, separately, use another education benefit, such
    as the Post-9/11 GI Bill, up to its own 36-month cap, with a total cap
    of 48 months. SVA would like to commend VA for identifying and changing
    its interpretation. This change provides a greater benefit to eligible
    veterans and complies with the underlying statute.
        To continue this positive trend, SVA encourages the Committee to
    place a focus on ongoing areas of concern with the program that we hear
    about from student veterans, such as the lack of counselors, difficulty
    in contacting VA to determine eligibility, long timelines in the
    assessment process, inconsistent counselor guidance and determinations,
    among many other issues.
        VR&E is one of the most flexible and important programs in VA's
    portfolio. Indeed, in certain scenarios, it provides a vastly greater
    benefit than even the generous Post-9/11 GI Bill. Particularly
    considering the recent change to entitlement charges by VA. It is more
    important than ever to thoroughly review this program for obstacles,
    barriers, and shortfalls that prevent it from fulfilling its true
    potential as a benefit. We look forward to working with the Committees
    on the best path forward for the program.

        3. Support and monitor ongoing improvements to the GI Bill
    Comparison and Feedback Tools.

        The GI Bill Comparison and Feedback Tools are important
    transparency mechanisms that give students critical information to make
    informed choices about where to use their VA education benefits.
    Students can get cost estimates, see if a school has key veteran
    support programs and services, and view complaints against
    institutions, among other things. Yet, the tools also remain a source
    of great untapped potential. We urge the Committee, as we have in the
    past, to consider the following options to improve the GI Bill
    Comparison and Feedback Tools.
        As it stands, the lack of coordination between the Department of
    Education (ED) and VA on College Navigator, College Scorecard, and GI
    Comparison Tool reduces the overall delivery of powerful data to
    veterans.\5\ The Comparison Tool has unique data, justifying itself as
    a separate tool from ED's options, but the underlying data is not being
    shared effectively between these tools, leaving prospective students an
    incomplete view of their options. We encourage members to explore ways
    to better share and integrate the data across ED and VA resources.
    ---------------------------------------------------------------------------
        \5\  See generally College Navigator, NATIONAL CENTER FOR EDUCATION
    STATISTICS, US DEPARTMENT OF EDUCATION, https://nces.ed.gov/
    collegenavigator (last visited March 1, 2020); College Scorecard, US
    DEPARTMENT OF EDUCATION, https://collegescorecard.ed.gov (last visited
    March 1, 2020); GI Bill Comparison Tool, US DEPARTMENT OF VETERANS
    AFFAIRS, https://www.va.gov/gi-bill-comparison-tool/ (last visited Feb.
    24, 2021).
    ---------------------------------------------------------------------------
        SVA also believes student outcome measures should be displayed in
    the GI Bill Comparison Tool. Establishing the appropriate data feeds
    and displaying the information in the tool would require IT upgrades
    that fit neatly alongside those currently happening at VA. In one of
    our most common-sense recommendations, each institution should be
    required to disclose how effective it is at delivering on its promise
    to students. By informing military-connected students, student
    veterans, family members, and survivors about the effectiveness of GI
    Bill-eligible programs, we allow them to make informed decisions about
    how to spend their education benefits.
        Additionally, we ask that the Committee encourage VA to note
    whether an institution participates in the VA VITAL Program. VITAL can
    provide critical mental health support for student veterans, assistance
    with academic accommodations, and foster a more veteran-inclusive
    campus culture. The GI Bill Comparision Tool currently includes a
    section on ``Veteran Programs and Support'' where VA could easily note
    whether the institution participates in VITAL and link to more
    information about the program's benefits.
        The GI Bill Comparison Tool also suffers from a lack of detailed
    information about student complaints. For any given school, the tool
    simply shows a tally of complaints across broad categories. The tool
    also only publishes complaints from the prior 24 months. SVA provided
    specific recommendations to address these issues in a public comment on
    VA's continued collection of information through the GI Bill Feedback
    Tool:

            VA should publish and maintain a comprehensive data base of all
            school-specific complaints submitted through the Feedback Tool.
            Students should be given the option to disclose their narrative
            comments publicly, and those comments should be included in the
            data base. The feedback data base should be presented in a
            familiar interface, preferably one that mirrors other popular
            review websites. This means it should include helpful user
            features like search, filters, and sorting. We further
            recommend the Department include a link on each school's
            profile page in the GI Bill Comparison Tool that directs
            students to a full, detailed list of complaints submitted about
            that institution. This will help students identify and better
            understand the true nature of complaints submitted about each
            school. It will also improve the ability of advocates and
            researchers to monitor and analyze past and present
            institutional compliance with the Principles of Excellence and
            other laws.\6\
    ---------------------------------------------------------------------------
        \6\  SVA Comment on OMB Control No. 2900-0797 Agency Information
    Collection Activity: Principles of Excellence Complaint System Intake,
    STUDENT VETERANS OF AMERICA 3 (2020), available at https://
    www.regulations.gov/comment/VA-2020-VACO-0001-0084.

        To address concerns about fake or inaccurate reports, we believe VA
    should verify that reports come from current or former students of the
    institution for which feedback is being provided and that schools be
    given the opportunity to issue public responses to complaints.
        VA should also place caution flags on schools in the GI Bill
    Comparison Tool that receives an inordinate number of student
    complaints. VA currently only places caution flags on schools with a
    program of education subject to ``increased regulatory or legal
    scrutiny'' by VA or other Federal agencies.\7\ SVA supports this use of
    caution flags, but student veterans also deserve to be alerted when a
    school has received a troubling number of student complaints.
    ---------------------------------------------------------------------------
        \7\  GI Bill Comparison Tool: About This Tool, U.S. DEPARTMENT OF
    VETERANS AFFAIRS (June 11, 2020), https://www.benefits.va.gov/gibill/
    comparison--tool/about--this--tool.asp#sourcedata.
    ---------------------------------------------------------------------------
        SVA also asks that VA develop a mechanism to maintain closed
    schools within the GI Bill Comparison Tool versus having them simply
    disappear. This removal of schools from the tool means associated data
    also disappears, leaving significant gaps in the overall picture of how
    those schools served students. We look forward to working with Congress
    and VA to update this valuable resource so it can better serve student
    veterans, service members, and their families.
        SVA applauds Senators Schatz, Rounds, Portman, and Coon's
    leadership on this issue with their championing of the Student Veterans
    Transparency and Protection Act last Congress. The bill would make
    numerous improvements to the GI Bill Comparison and Feedback tools,
    while also providing entitlement restoration for beneficiaries that are
    the victims of misconduct perpetrated by bad-actor institutions. We
    look forward to that bill being reintroduced this Congress and
    encourage the Committees' members to support it as well as the other
    improvements we have outlined here.
        Finally, SVA acknowledges and applauds VA's ongoing efforts to
    improve the GI Bill Comparison Tool. The Department has made great
    strides in recent years, by adding new information like context about
    accreditation and details on institutional ownership as well as
    important new features like side-by-side comparison and map
    functionality. We look forward to collaborating closely with Congress
    and VA to further refine these important tools.

        4. Establish a Veteran Economic Opportunity and Transition
    Administration with Undersecretary representation for all economic
    opportunity and transition programs.

        For years, SVA and others have called for the creation of a fourth
    administration at VA--a Veteran Economic Opportunity and Transition
    Administration. This new administration would provide VA's economic
    opportunity programs with the dedicated, senior-level leadership they
    deserve. As DAV, PVA, and VFW pointed out in the 2016 Independent
    Budget, a ``new undersecretary for EO would refocus resources, provide
    a champion for these programs, and create a central point of contact
    for veterans service organizations and Congress.'' \8\ If we want to
    ``build a more accountable VA''--especially with regards to economic
    opportunity programs--a fourth administration would do just that.
    ---------------------------------------------------------------------------
        \8\ Id. at 121.
    ---------------------------------------------------------------------------
        As SVA has noted, we believe the greater focus must be placed on
    economic opportunity for veterans, including through higher education.
    This would be best achieved by building on the early success of the new
    office at VA dedicated to transition and economic opportunity and
    elevating it, and Education Service, to its own administration at VA.
    Presently, economic opportunity programs such as the GI Bill, home loan
    guaranty, and many other empowering programs for veterans are buried
    within the bureaucracy of Veterans Benefits Administration and
    functionally in competition against disability compensation policy for
    internal resources.
        Over the past century, VA has focused on compensating veterans for
    loss, but the reality of the 21st century and beyond demands the
    additional goal of empowering veterans to excel post-service and
    improving a veteran's social determinant of health. Critically, this
    will further advance our nation's goals of enhancing economic
    competitiveness and increasing protective factors against suicide. A
    focus on veteran contributions to business and industry, to
    governments, to non-profit organizations, and to communities through
    the best education programs in our country will result in impressive
    returns on the taxpayers' investments and save lives.
        The continued success of veterans in higher education in the Post-
    9/11 era is no mistake or coincidence. In our Nation's history,
    educated veterans have always been the best of a generation and the key
    to solving our most complex challenges. This is the legacy we know
    today's student veterans carry.
        We thank the Chairman, Ranking Member, and Members of the Committee
    for your time, attention, and devotion to the cause of veterans in
    higher education.

                                     [all]