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


                         LEGISLATIVE HEARING ON
 H.R. 41; H.R. 562; H.R. 808; H.R. 754; H.R. 693; H.R. 1089; H.R. 366; 
                          H.R. 542; H.R. 1256

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION
                               __________

                       WEDNESDAY, MARCH 29, 2023
                               __________

                            Serial No. 118-7
                               __________

       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
                    
51-951                     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

                         SUBCOMMITTEE ON HEALTH

               MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

AUMUA AMATA COLEMAN RADEWAGEN,       JULIA BROWNLEY, California, 
    American Samoa                       Ranking Member
JACK BERGMAN, Michigan               MIKE LEVIN, California
GREGORY F. MURPHY, North Carolina    CHRISTOPHER R. DELUZIO, 
DERRICK VAN ORDEN, Wisconsin             Pennsylvania
MORGAN LUTTRELL, Texas               GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

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

                              ----------                              

                       WEDNESDAY, MARCH 29, 2023

                                                                   Page

                           OPENING STATEMENTS

The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
The Honorable Julia Brownley, Ranking Member.....................     2
The Honorable Mark Takano, Ranking Member, Full Committee........     4
The Honorable Frank Mrvan, U.S. House of Representatives, (IN-1).     5

                               WITNESSES

The Honorable Brian Mast, U.S. House of Representatives, (FL-21).     6

The Honorable Jim Baird, U.S. House of Representatives, (IN-4)...     7

The Honorable John Moolenaar, U.S. House of Representatives, (MI-
  2).............................................................     8

The Honorable Steve Womack, U.S. House of Representatives, (AR-3)     9

The Honorable Debbie Lesko, U.S. House of Representatives, (AZ-8)    10

Mr. Alfred Montoya, Deputy Assistant Under Secretary for Health 
  for Operations, Office of the Deputy Under Secretary for 
  Health, Veterans Health Administration, U.S. Department of 
  Veterans Affairs...............................................    11

        Accompanied by:

    Dr. Scotte Hartronft, Executive Director, Office of 
        Geriatrics & Extended Care, Veterans Health 
        Administration, U.S. Department of Veterans Affairs

    Mr. David Perry, Chief Officer, Workforce Management, 
        Veterans Health Administration, U.S. Department of 
        Veterans Affairs

Mr. Jon Retzer, Assistant National Legislative Director, Disabled 
  American Veterans..............................................    20

Ms. Tiffany Ellett, Deputy Director of Health Policy, The 
  American Legion................................................    21

Mr. Morgan Brown, National Legislative Director, Paralyzed 
  Veterans of America............................................    23

                                APPENDIX
                    Prepared Statements Of Witnesses

Mr. Alfred Montoya Prepared Statement............................    33
Mr. Jon Retzer Prepared Statement................................    49
Ms. Tiffany Ellett Prepared Statement............................    56
Mr. Morgan Brown Prepared Statement..............................    66

                       Statements For The Record

Veterans of Foreign Wars.........................................    71
Student Veterans of America......................................    73
Elizabeth Dole Foundation........................................    74
The American Association of Retired Persons......................    78

 
                         LEGISLATIVE HEARING ON
 H.R. 41; H.R. 562; H.R. 808; H.R. 754; H.R. 693; H.R. 1089; H.R. 366; 
                          H.R. 542; H.R. 1256

                              ----------                              


                       WEDNESDAY, MARCH 29, 2023

              U.S. House of Representatives
                             Subcommittee on Health
                             Committee on Veterans' Affairs
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 1:30 p.m., in 
room 2253, Rayburn House Office Building, Hon. Mariannette 
Miller-Meeks [chairwoman of the subcommittee] presiding.
    Present: Representatives Miller-Meeks, Radewagen, Bergman, 
Murphy, Van Orden, Brownley, Deluzio, and Budzinski.
    Also present: Representatives Takano, and Mrvan.

   OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

    Ms. Miller-Meeks. Good afternoon. The legislative hearing 
of the Subcommittee on Health of the Veterans Affair Committee 
will now come to order.
    First, I want to welcome all the members of the 
subcommittee, both new and those returning. I am extremely 
excited to be able to work with each and every one of you this 
Congress.
    I ask unanimous consent that our fellow committee member, 
Representative Mrvan, be allowed to sit in at the dais to 
participate in today's proceed.
    Hearing no objection, so ordered.
    Before we get started, I would like to take a moment to 
introduce myself. My name is Mariannette Miller-Meeks, and I 
proudly serve the people of Iowa's First congressional 
District. Most importantly, as a member of this committee, I 
serve all of those veterans who rely on the VA for their care 
and benefits. I am also a 24 year Army veteran and an 
ophthalmologist and I am married to a 30 year Army veteran. Six 
of the eight children in my family served in the military, as 
well as my father, uncles, and grandfather. I also formerly 
served as the director of Iowa's Department of Public Health.
    As a veteran myself, and one who has worked as both a nurse 
and a physician at the VA hospital, I have seen firsthand both 
the strengths and weaknesses of our VA hospitals and clinics. 
Veterans deserve the care of utmost quality, and I work will 
work tirelessly to ensure that they get the care that they have 
earned.
    We have a responsibility also in Congress to hold the VA 
accountable. I am honored to serve as the chairwoman of this 
subcommittee. The House Committee on Veterans Affairs has a 
reputation for operating in a bipartisan manner. I look forward 
to continue working closely with Ranking Member Brownley and 
all of our members on both sides of the aisle.
    Turning to today's hearing, we are here to discuss nine 
bills that would address a number of issues impacting America's 
veterans and the healthcare services they receive from the VA.
    I would first like to express my frustration that we did 
not receive VA testimony until late yesterday. We requested 
that the testimonies be sent to us 48 hours in advance, and 
that simply was not the case. The list of bills we are 
discussing today were first sent to the VA on February 28. That 
gave the VA ample time to review, and it makes our jobs that 
much more difficult. I look forward to the VA submitting their 
testimony on time at the next hearing.
    I want to reiterate that one of my top priorities that I 
know is shared by many, if not all, of my colleagues is to 
ensure timely and quality care to veterans. As a member of a 
rural district, I know the challenges that come with meeting 
that goal.
    The nine bills before us today address scheduling 
appointments in a timely manner, ensuring veterans have 
available patient advocates, ensuring veterans access to home 
based long-term care, and creating a stable leadership 
environment within the Veterans Health Administration. I cannot 
ignore the significance of the Toxic Exposure Fund, also called 
TEF, and how it impacts the legislation we are discussing 
today. Health programs are now subject to mandatory funding and 
scoring based on a percentage of the overall estimated cost. 
The work of this subcommittee will soon come to a halt if we do 
not work together to address this funding issue.
    I look forward to our discussion on the merits and 
challenges of all the legislation before us today, and I am 
looking forward to the input from the VA and from other 
stakeholders, and thank you all for being here.
    I now yield to Ranking Member Brownley for her opening 
remarks.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Chairwoman Miller-Meeks, and I am 
looking forward to working closely with you. It is a pleasure 
to be here as our subcommittee begins its important work for 
the 118th Congress.
    It has been my greatest honor to serve on the Health 
Subcommittee for more than 10 years now, since my very first 
term in Congress. This will be my sixth term serving as either 
the ranking member or chair of the subcommittee. We have been 
through a lot and accomplished a great deal during the time all 
of us have served. In just the last few years, we passed the 
Deborah Sampson Act and the Promise to Address Comprehensive 
Toxics (PACT) Act, two comprehensive laws that will greatly 
improve access to VA healthcare services for women veterans and 
veterans with toxic exposure.
    Together with VA, we faced a once in a century global 
pandemic, a crisis that the VA healthcare system managed very, 
very well. However, there is one key area where I wish I could 
say that more progress has been made, and that is the extent to 
which VA is enabling veterans to age at home and avoid spending 
the last years of their lives in nursing homes or other 
institutional care settings. I doubt there is a person here 
today who has not grappled with a decision of how best to care 
for an aging or disabled loved one.
    Roughly 90 percent of aging adults would prefer to remain 
at home versus being admitted to a long-term care facility if 
they can absolutely avoid it. Veterans are no different. Over 
the last couple of decades, we have seen states place greater 
emphasis on investment in home and community based services, 
helping Medicaid beneficiaries prevent or delay admission to 
nursing homes. Studies have shown that these rebalancing 
efforts have saved money, provide better health outcomes, and 
allowed Medicaid programs to serve more beneficiaries.
    As of Fiscal Year 2019, Medicaid expenditures for home and 
community based services accounted for about 59 percent of the 
state's total long-term care spending. However, as of Fiscal 
Year 2022, VA's investments were nearly the opposite of that, 
with VA allocating about 65 percent of its overall geriatrics 
and extended care budget to institutionalized care, a category 
of spending that now accounts for about 10 percent of Veterans 
Health Administrations (VHA's) total annual budget. This is not 
sustainable. Aside from the budgetary implications, there 
simply are not enough beds or staff in institutional care 
settings inside the VA or in the community to meet the expected 
need, particularly as Vietnam War era veterans enter their 
later years.
    More importantly, this is not what veterans, their 
caregivers, or their families want. That is why I am pleased 
the subcommittee is considering my bill, the Elizabeth Dole 
Home Care Act, as part of today's agenda. Among other things, 
it will require VA to offer the Veteran Directed Care program, 
the Homemaker and Home Health Aid program, the Homebased 
Primary Care program and the Purchase Skilled Home Care Program 
at all VA medical centers within 2 years of enactment. 
Currently, they are only available at medical centers that have 
chosen to implement them. These programs help veterans with 
activities of daily living, allowing them to receive primary 
care at home and provide skilled nursing care for veterans with 
higher levels of need. Our bill will also expand access to 
respite care for caregivers of veterans in these programs.
    Under this legislation, VA will be required to improve 
coordination between the Program of Comprehensive Assistance 
for Family Caregivers and VA's other home based care programs. 
If a veteran does not meet the enrollment criteria for the 
Caregiver Support Program, the VA will proactively assess the 
veteran and their caregiver for enrollment in other home based 
programs.
    General Bergman and I first introduced the Elizabeth Dole 
Home Care Act just over a year ago in February 2022. Very 
quickly, this bill achieved the rare feat of bipartisan 
bicameral support, with Senators Moran and Tester introducing a 
Senate companion a few weeks later. Unfortunately, we were 
unable to enact this bill before the end of last year, but I am 
very hopeful that we will get it across the finish line during 
this Congress. To do that, however, we will have to overcome a 
major hurdle, which is the Congressional Budget Office's (CBO) 
score for the bill, which, to be quite frank, does not make a 
whole lot of sense to any of us.
    In late November 2022, CBO issued a cost estimate that far 
exceeded our expectations. We were given a preliminary estimate 
in the hundreds of millions, but were shocked when the final 
estimate came back at $24.6 billion over a 10 year period. We 
are engaged in ongoing discussions with CBO about how they 
arrived at that estimate, and we are actively working to help 
them refine it. Today's hearing will help inform these efforts, 
so I thank our witnesses for being here and for offering their 
expertise.
    I also look forward to discussing many of the other bills 
on today's agenda and to continuing the important work of the 
Health Subcommittee during the 118th Congress.
    With that, I yield back, Chairwoman Miller-Meeks.
    Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
    We are having a video issue for live stream, but we are 
going to go ahead and continue the meeting with respect for 
everyone's time.
    We have a very full agenda today, so I will be holding 
everyone to 3 minutes per bill so that we can get through it 
all.
    I am honored to be joined this afternoon by several of my 
colleagues who are going to be testifying about the bills on 
our agenda. I appreciate the steadfast dedication that each of 
you have made to help our veterans.
    With this committee this afternoon are Representative Brian 
Mast from Florida, Representative James Baird, a fellow veteran 
from Indiana, Representative John Moolenaar from Michigan, 
Representative Steve Womack, another fellow veteran from 
Arkansas, and Representative Debbie Lesko from Arizona.
    First, I would like to recognize Ranking Member Takano for 
3 minutes.

    STATEMENT OF MARK TAKANO, RANKING MEMBER, FULL COMMITTEE

    Mr. Takano. Thank you, Chairwoman Miller-Meeks, for the 
courtesy. I thank you for inviting me to today's hearing. I am 
proud to be here to discuss my bill, the Korean American Valor 
Act, H.R. 366.
    This legislation will provide eligibility for VA healthcare 
to veterans who served in the Armed Forces of the Republic of 
Korea as allies of the United States during the Vietnam War who 
have since become naturalized U.S. citizens. This will be done 
through a reciprocal agreement. Korea would reimburse the 
United States for the healthcare services VA furnishes to these 
Korean American veterans. In exchange, the United States will 
reimburse Korea for health care it provides to veterans of the 
U.S. Armed forces residing in Korea.
    My bill would provide some measure of long overdue parity 
for Korean American Vietnam War veterans who, up to this point, 
have never been eligible for VA healthcare services. This 
stands in stark contrast to veterans from European countries 
that were United States allies during World War I and World War 
II, who have had access to VA healthcare for decades.
    Since 1958, through its Allied Beneficiary Program, VA has 
had the authority to treat veterans who have served in the 
Armed Forces of nations that were allied with the United States 
during World War I and World War II. These veterans do not need 
to be U.S. Citizens, and VA has the authority to treat veterans 
of any combat era. In 2022, VA provided care to 1,360 Allied 
Beneficiaries, 1,153 of whom were under the age of 65. VA 
furnishes this care through reciprocal agreements which have 
been established with the United Kingdom, Australia, New 
Zealand, Canada and South Africa. In 1976, VA's Allied 
Beneficiary program was extended to certain veterans who had 
served in the armed forces of Czechoslovakia or Poland during 
World War II or World War I and who subsequently became U.S. 
citizens, because this authority was established when these two 
nations were still under Communist rule, the Czech Republic, 
Slovakia, and Poland do not have reciprocal agreements with the 
United States.
    Today is National Vietnam War Veterans Day, and it is the 
50th anniversary of the date of the last combat troops left 
Vietnam. Let this serve as a call to action. It is far past 
time for our Nation to properly honor the service of these 
Korean American veterans who serve side by side with American 
troops. It is the United States' obligation as a long time ally 
of the Republic of Korea and as a beneficiary of these 
veterans' sacrifices during the Vietnam War to ensure they 
finally receive the same respect and consideration that their 
European counterparts have received for generations. The needs 
of Korean American veterans and of the Vietnam War are no 
different from those of U.S. born veterans. From Agent Orange 
exposure to coping with complex injuries and mental illnesses, 
these veterans deserve the specialized care and services that 
VA can provide.
    Am I going over time? I will stop there. I think you got 
the point.
    Thank you very much.
    Ms. Miller-Meeks. Thank you, Representative Takano.
    Representative Mrvan, you are now recognized for 3 minutes.

                    STATEMENT OF FRANK MRVAN

    Mr. Mrvan. Thank you, Chairwoman Miller-Meeks, for inviting 
me today. I greatly appreciate being at the hearing.
    I am pleased to be here to discuss my recently introduced 
bill, the VHA Leadership Transformation Act, H.R. 1256. My bill 
will extend the term of appointments to the VA's undersecretary 
of health, or USH, for 5 years. It also removes existing 
statutory restrictions on the number of assistant 
undersecretaries for health that VHA can have, and it 
eliminates the requirement that all but two of them be 
physicians or dentists.
    The intent of my bill is to provide greater leadership 
stability at VHA by shielding the agency from leadership 
turnover with every change in Presidential administrations. It 
will also help address governance challenges that have impeded 
oversight and accountability and empower VHA to more 
effectively address veterans health care needs.
    Now, I know what you may be wondering, why should VA make 
these changes, and would not this cause VHA to operate 
differently from other Federal agencies? As to why now, we only 
need to look back at the last 6 years or so. With the 
confirmation of Dr. Elnahal in July 2022, VHA got its first 
Senate confirmed undersecretary for health since January 2017. 
Between January 2017 and July 2022, six different individuals 
rotated through this office, either acting as or performing the 
delegable duties of the undersecretary of health. Long-time 
observers of the VA healthcare will recall that the incredible 
transformation that occurred between 1994 and 1999 under the 
leadership of Dr. Kenneth Kizer. He was a visionary who led the 
VHA away from being a system heavily focused on delivering 
inpatient care in old, often under utilized hospitals to one 
that is now largely focused on delivering primary care and 
preventative care through the vast network of outpatient 
clinics. The VA that so many veterans and employees now and 
love today simply would not be what it is were it not for the 
steady leadership of Dr. Kizer.
    I will also add that there are a number of other positions 
across the Federal Government with 5 year terms, including the 
Social Security Administrator, the Federal Aviation 
Administrator, and the IRS Commissioner. The Director of the 
FBI Services serves for 10 year terms. If any incoming 
President wants to replace any of these officials prior to the 
expiration of their term, the President has the authority to do 
that, and in my bill, would allow the same for VA's 
undersecretary for health. Removing statutory restrictions on 
how many assistant undersecretaries for health VHA can have and 
what their professional backgrounds may be will allow VA's 
healthcare system to adapt to the way healthcare is delivered 
today and enable VA to recruit and attract the best qualified 
candidates.
    As a new ranking member of the Oversight and Investigation 
Subcommittee, I firmly believe--I am so sorry.
    Ms. Miller-Meeks. You are over time.
    Mr. Mrvan. Okay. I did not have--yes. Okay.
    With that, I am pleased to have this testimony, and I yield 
back.
    Ms. Miller-Meeks. Thank you, Representative Mrvan. 
Representative Mast, you are now recognized for 3 minutes.

                    STATEMENT OF BRIAN MAST

    Mr. Mast. Thank you, Chairwoman.
    I want to talk about the Improving Veterans Access to 
congressional Services Act and I guess just tell you a story 
about it.
    This is not a new program, this has been tested since 2017. 
I opened up the first office in the West Palm Beach VA Medical 
Center. After that, other colleagues from Florida in my area 
surrounding the West Palm Beach VA Medical Center started doing 
the same thing in the same space. We shared a space in the VA 
where we met with our veteran constituents inside of the 
hospital. We met with them to deal with their issues. In that 
time, my office alone opened up more than 500 individual 
casework and dealt with them. At the time, Representative Lois 
Frankel, Representative Ted Deutch, Representative Alcee 
Hastings, they also worked for their veteran constituents at 
the same time. In this very moment I am not given access to the 
Department of Veterans Affairs to have a space to meet with my 
veteran constituents, but at this very moment representatives 
in Orlando, in the VA there, are given access to the VA 
hospital to meet with their veteran constituents, which I am 
glad of, because it gives them the opportunity to be the 
loudest patient advocates that any Member of Congress could be, 
because they are present. You want to be in a fight, you got to 
be present for it. It gives them the opportunity to be the best 
overseers of the Department of Veterans Affairs because they 
are inside of the VA on a weekly basis. Darren Soto, who has 
been doing this almost as long as I have, is inside of the VA 
on a weekly basis seeing what goes right, seeing what goes 
wrong.
    Through this program of allowing to be having access to 
serve our veterans inside of the VA, we have been able to take 
veterans and help them get appointments, we have been able to 
take veterans who had their appointments canceled and were in 
moments of crisis that sent them into situations where they 
wanted to take their lives, and help them work through that, we 
have been able to take them to see the director of the VA 
hospital so they know that they could be heard at the highest 
level of the hospital, we have been able to witness things that 
were just out of place and demand that they be fixed. Like in 
my local hospital, at a bathroom in the main entrance of the 
facility, there was no push button to allow people in 
wheelchairs to have the door open automatically. We have been 
able to look at places where there should be security but was 
not and demand that there was. We have been able to serve our 
veterans at a higher level. There has only been positive 
outcomes for Democrats and Republicans and to my knowledge, not 
one report of misuse ever taking place.
    My ask is for the support of this committee to help all 
Members of Congress be the loudest patient advocates and the 
best possible overseers of the Department of Veterans Affairs 
and be able to serve our veterans at the highest level by 
hearing that space in the VA.
    I look forward to answering any questions you all might 
have.
    Thank you.
    Ms. Miller-Meeks. Thank you, Representative Mast. As a 
fellow veteran, I know that serving veterans in your community 
is your highest priority.
    Representative Baird, you are now recognized for 3 minutes.

                    STATEMENT OF JAMES BAIRD

    Mr. Baird. Thank you, Chairwoman Miller-Meeks and Ranking 
Member Brownley. I also want to thank the committee and its 
staff for holding this hearing and considering my bill, H.R. 
41, the VA Same Day Scheduling Act. This is an important piece 
of legislation that I was proud to reintroduce this Congress 
and I am hopeful that together we can get it across the finish 
line.
    In President Lincoln's second inaugural, he affirmed that 
this Nation would care for those who shall have borne the 
battle. His words have stood the test of time and stand as a 
solemn charge as we do our work here, ringing true today as it 
did back then. This bill is one more step toward fulfilling 
that promise.
    The veterans on this subcommittee alone have about 120 
years of military service. That is something to be proud of. We 
also know too well there are millions of veterans left in limbo 
when it comes to making appointments for healthcare. With about 
19 million veterans in the United States, timely and reliable 
care are essential to those who serve. The VA Same Day Service 
Scheduling Act would improve veterans experiences with the VA 
by prioritizing the customer service. They served our country, 
and now it is time to serve them.
    This common sense measure guarantees that any veteran who 
makes a phone call and is requesting care is able to schedule 
their appointment during that phone call. In too many 
instances, we have seen setbacks to the VA patient scheduling, 
often to tragic consequences because of delays in call-back 
times to schedule these appointments.
    My bill is narrow but targeted in scope to guarantee 
priority for those that established the VA patients.
    With that, I see I am out of time. No, I am not. I got 
another 55 minutes. Sorry.
    Ms. Miller-Meeks. Sorry, I was going to let you know you 
had some more time. I will give you five more seconds.
    Mr. Baird. Okay. My bill is narrowed, but it is targeted to 
scope of the guaranteed priority for those already established 
as VA patients. It is specific to care administered by the VA 
to avoid issues carried out by this task related to the 
community care system. We must remove any uncertainty in 
scheduling VA provided care over the telephone for our 
veterans.
    Additionally, it provides for the Department considerable 
flexibility by making the bill applicable 120 days after 
enactment and allows sufficient time for the VA to set 
appropriate standards after the adoption of this law.
    I see amount of time now, so thank you, Madam Chair, and I 
yield back.
    Ms. Miller-Meeks. Thank you, Representative Baird.
    Representative Moolenaar, you are now recognized for 3 
minutes.

                  STATEMENT OF JOHN MOOLENAAR

    Mr. Moolenaar. Thank you and good afternoon, Chairwoman 
Miller-Meeks and Ranking Member Brownley, distinguished members 
of the committee, thank you for the opportunity to come before 
you today to discuss the Veterans Patient Advocacy Act.
    After putting their lives on the line in service to our 
country, our veterans deserve the best care from the VA, and I 
think that is something we can all agree with. Yet when I am 
back in Michigan, I often hear from veterans that there are 
simply not enough patient advocates at the VA. They tell me 
they struggle getting appointments, feel the VA is letting them 
down, and think the Federal Government does not care about 
them. Patient advocates are specifically trained professionals 
that play a vital role in helping our veterans with problems 
related to their care. Whether it is assisting with paperwork 
or an appeal, patient advocates are there to help. 
Unfortunately, there are not enough of them.
    In a recent report on the Patient Advocacy Program, the 
Government Accountability Office found staffing concerns, 
massive backlogs, and veterans calls going unanswered. The 
Veterans Patient Advocacy Act would address this problem 
directly. It would require the VA to increase the number of 
patient advocates available to serve veterans. Specifically, it 
would mandate that there is at least 1 patient advocate for 
every 13,500 veterans enrolled in the system. This would amount 
to 78 new patient advocates to help veterans. These new patient 
advocates can address the backlogs and assist our veterans to 
ensure they receive the care they need.
    This is bipartisan legislation. I have worked on it with 
Congresswoman Debbie Dingell. It is also supported by the 
Veterans of Foreign War (VFW) and Student Veterans of America.
    I hope you will join us all in supporting it as well.
    Thank you.
    Ms. Miller-Meeks. Thank you, Representative Moolenaar.
    Representative Womack, you are now recognized for 3 
minutes.

                   STATEMENT OF STEVE WOMACK

    Mr. Womack. I thank the chairwoman. Chairwoman Miller-
Meeks, Ranking Member Brownley, and distinguished members of 
the subcommittee, thank you for considering my bill, H.R. 693, 
the VA Medical Center Absence and Notification Timeline Act or 
VACANT Act. I also want to express my appreciation for allowing 
me to speak in support of this bill.
    The VACANT Act is a straightforward and common sense piece 
of legislation that will strengthen congressional oversight of 
the Veterans Health Administration's leadership selection 
process and ultimately improve care for veterans. My bill 
simply requires the VA to notify the congressional Veterans 
Affairs Committees when a medical center director is detailed 
to a different position within the Department and when an 
acting medical center director is appointed. The bill also puts 
a limit on the amount of time a director can be detailed before 
returning to their medical center.
    This legislation, which I am proud to lead with my friend 
Senator John Boozman, highlights the value of effective, stable 
leadership at VA medical centers. Like the chair, I have 
commanded military units, and I fully appreciate how leadership 
drives culture. Unfortunately, we also both understand how poor 
leadership or no leadership can harm an organization, and that 
organizations will not operate at peak effectiveness when there 
is a rotating cast of leaders.
    Until recently in Arkansas, we faced these leadership 
issues with the Veterans Healthcare System of the Ozarks going 
almost 2 years without a permanent Director. Although our 
acting directors were managing the best they could, it is 
understood that organizations need stable leadership to be as 
supportive as possible for our veterans. This legislation is an 
important step to ensuring no other VA medical center is left 
without a permanent director for a significant amount of time.
    Large, complex organizations require effective leadership. 
Effective leaders drive change. They are proactive. Failure to 
appoint a permanent medical center director was a hardship for 
the Veterans Healthcare System of the Ozarks. I am committed to 
ensuring our VA support systems are prepared to meet their 
daily challenges. The VACANT Act is an important step in this 
direction.
    Once again, it is an honor for me to speak in support of my 
legislation today. With your help, we will move this 
legislation closer to enacted law.
    Thank you so much, and I yield back the balance of my time.
    Ms. Miller-Meeks. Thank you, Representative Womack.
    Representative Lesko, you are now recognized for 3 minutes.

                   STATEMENT OF DEBBIE LESKO

    Ms. Lesko. Thank you, Chairwoman Miller-Meeks and Ranking 
Member Brownley, for inviting me to testify in front of the 
subcommittee on my bipartisan bill, VA Medical Center Facility 
Transparency Act, H.R. 1089. I would also like to thank Nevada 
Congresswoman Susie Lee for being the prime lead on this bill 
with me.
    It is hard to believe that it is been almost 10 years since 
the Phoenix VA Medical Center was on national news because of 
huge wait times for our veterans seeking care. This bill is 
critical to helping our veteran constituents by increasing 
transparency between VA medical facilities, Congress, and the 
veterans themselves.
    As the representative of over 50,000 veterans in my 
district, I believe we must ensure that VA medical facilities 
are acting in the best interests of their patients. 
Transparency and accountability are key to building trust and 
confidence among veterans and their families who rely on VA 
medical facilities for their healthcare needs. When VA medical 
facilities are open and transparent about their practices, 
policies, and outcomes, quality of care will increase, which is 
what our veterans deserve and what we promise to deliver.
    My bill requires each director of a VA medical center to 
submit an annual, concise, easy to read fact sheet containing 
statistics regarding the number of veterans treated, the number 
of appointments conducted, the most common illnesses or 
conditions treated, the satisfaction of the veterans who are 
treated at each facility, and a description of any successes or 
achievements experienced by such facilities. The bill also 
requires a quarterly fact sheet that provides the average wait 
time for veterans to receive treatment at the medical facility. 
This information is critical to ensuring that our veterans 
receive timely medical care.
    It is important to note that many of the Nation's veterans 
have unique needs. That is why this bill requires a description 
of special areas of emphasis or specialization by such 
facilities. The VA Medical Center Facility Transparency Act is 
critical to ensuring that our veterans receive the best medical 
care possible. By increasing transparency and accountability of 
medical centers, we can improve access to timely and high 
quality medical care for our Nation's heroes.
    I urge all the members of this committee to support this 
important legislation.
    On behalf of myself and Congresswoman Susie Lee, I thank 
you.
    Ms. Miller-Meeks. Thank you, Representative Lesko.
    As is our process, we will forego a round of questioning 
for our members. You are now excused.
    We will take a slight recess or break for about 5 minutes 
while we get situated for the next panel, and I invite the 
second panel to the table.
    [Recess]
    Ms. Miller-Meeks. Now that we are situated, thank you all 
very much.
    I would like to thank the Department of Veterans Affair for 
joining us today. The members of the VA Administration that are 
here are Alfred Montoya, who is deputy assistant undersecretary 
for health for operations in the Office of the Deputy 
Undersecretary for Health. Accompanying Mr. Montoya today are 
Dr. Scotte Hartronft, the executive director for the Office of 
Geriatrics and Extended Care, and Mr. David Perry, the chief 
officer with the VHA's Workforce Management.
    Mr. Montoya, you are now recognized for 5 minutes to 
present the Department's testimony.

                  STATEMENT OF ALFRED MONTOYA

    Mr. Montoya. Good afternoon, Chairwoman Miller-Meeks, 
Ranking member Brownley, and other members of the subcommittee.
    First, I would like to apologize formally for the lateness 
of our testimony. We certainly do heed your comments about that 
in the beginning, and certainly we will work toward getting our 
testimony in on a more timely fashion. Thank you for those 
comments.
    Thank you for inviting us here today to present our view on 
several bills that would affect VA programs and services. 
Joining me today are Mr. David Perry, chief officer of 
Workforce Management and Consulting, and Dr. Scotte Hartronft, 
executive director, Geriatrics and Extended Care.
    VA is grateful for the committee's dedication to providing 
VA the authority and resources related to access, eligibility, 
and staffing. H.R. 41 would require VA to ensure that whenever 
a covered veteran contacts VA by telephone to request the 
scheduling of an appointment, the scheduling for the 
appointment occur during the telephone call. VA does not 
support this bill. VA already has the authority to do what this 
bill proposes, and it does so whenever possible. However, 
requirements for clinical review and determinations of 
eligibility are not always possible nor desired by the veteran 
at the time of a phone call to complete simultaneous 
appointment scheduling. Additionally, some types of care 
require specific eligibility, and it is not always possible to 
know that information during a telephone call.
    H.R. 366 would add a new subsection that would State that 
persons VA has determined served in Vietnam as a member of the 
Armed Forces of the Republic of Korea between January 9, 1962 
and May 7, 1975, would be eligible for benefits as a discharged 
member of the Armed Forces of a government. VA does not support 
this bill. In addition to a technical concern and equity 
concerns for other nations, there is also a concern about 
expanding healthcare eligibility to persons who served in Armed 
Forces of other nations before we can fully address expanding 
eligibility to veterans and priority groups not covered within 
our own current veteran population.
    We appreciate the close collaboration in addressing some of 
the concerns VA identified with previous versions of H.R. 542. 
We believe the current version is much improved and is a 
demonstration of the benefits of VA and Congress working 
together. VA generally supports this bill if amended, although 
our positions vary, as noted in my written statement.
    H.R. 562 would require VA to permit a Member of Congress to 
use a VA facility for the purposes of meeting with 
constituents. VA opposes this bill because we object to the 
prescriptive requirements of the bill. Facilities also raise 
unique concerns that would make placement of an office for a 
Member of Congress inappropriate.
    H.R 693 would require VA to notify Congress within 90 days 
of detailing a Veterans Affairs Medical Center (VAMC) director 
to a different position in VA. VA supports this if amended. If 
unamended, this bill may impact continuity of operations, as 
well as ongoing projects and initiatives that require a VAMC 
director's leadership.
    Section 2 of H.R. 754 would establish a commission on 
eligibility to examine eligibility for VA healthcare. VA has 
concerns with the proposed bill and opposes it as currently 
written. We appreciate the committee's interest in assessing 
eligibility for VA healthcare. Eligibility determinations can 
be quite complex because veterans and other beneficiaries may 
qualify for the same or similar services under multiple laws.
    H.R. 808 would require VA to ensure that there is not fewer 
than one patient advocate for every 13,500 veterans, and that 
highly rural veterans may access the services of patient 
advocates. Over the last few years, the role of patient 
advocates has expanded, and we are working to identify the best 
approach to ensuring veterans can access patient advocacy 
services as needed to support the delivery of their care.
    Section 2 of H.R. 1089 would require VA to ensure that each 
medical center director submits to the Secretary the Committees 
on Veterans Affairs of the House of Representatives and the 
Senate and the appropriate Members of Congress an annual fact 
sheet with certain statistical information with respect to the 
year covered by the annual fact sheet. VA does not support this 
bill. We understand the fundamental interests or concern of the 
bill, but VA already provides significant information online 
about patient experience, wait times, and quality for each 
medical center. The requirements for each director to submit to 
Congress directly on an annual basis these fact sheets would be 
very involved, requiring each facility to establish redundant 
processes and systems and incur significant additional costs.
    Finally, VA supports section 2 of H.R. 1256. Setting a 5 
year term could provide VA with continuity of operations when 
there is a change in Presidential administrations and could 
allow VA to continue providing support and care to our Nation's 
veterans without interruption. It would also give VA the 
flexibility to recruit and retain highly qualified executives 
with various experience to fill these critical leadership 
positions.
    This concludes my statement.
    We would be happy to answer any questions you or members of 
the subcommittee may have. Thank you.

    [The Prepared Statement Of Alfred Montoya Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you for your testimony, Mr. 
Montoya.
    I will now yield myself 5 minutes.
    Mr. Montoya, currently, when a veteran contacts the 
Department by telephone to request the scheduling of an 
appointment and the request cannot be accommodated during that 
phone call, what is the typical process for follow up?
    Mr. Montoya. Chairwoman, thank you so much for that 
question.
    When we look at scheduling and when a veteran calls in, I 
will actually use some of my own examples as a veteran who gets 
100 percent of my care in the VA. As that veteran calls in, if 
they are not able to make that appointment for one reason or 
another, that eligibility or determination of the clinical 
reason would then go on to another provider or clinical staff 
to be able to help schedule that appointment.
    A good example of this would be dental. Dental is one of 
those very intricate appointment types where there needs to be 
some evaluation of the benefit as well as the clinical 
application of the appointment.
    Ms. Miller-Meeks. On average then how long does it take for 
a veteran to schedule that scheduled appointment?
    Mr. Montoya. Yes, I am very happy to actually share some of 
our wait time data that we do have for the community. For the 
exact timeframe as far as when it takes a veteran to get their 
appointment scheduled, I will certainly get back to you on that 
one for the record.
    I will tell you, in some cases we do this already the same 
time that that veteran calls in. It is a very basic appointment 
such as primary care and mental health. In many cases, we can 
do that the same day. In some cases we actually have a clinical 
contact center that does that 24/7, 365 days a year.
    Ms. Miller-Meeks. I will let you know that I am a physician 
and when patients call me to schedule an appointment, we 
schedule that appointment the same day. We do not have them 
call back. If they walk in, I see them. I do not ask for their 
insurance or what their benefits are. I take care of that 
patient.
    In addition to which, I understand the challenges that you 
are having, but there are often times when veterans have 
extreme need and need to be addressed. We know one of those 
because we have a bill named after a veteran who committed 
suicide who could not get into the VA and was declined service 
or not made an appointment in a timely fashion.
    It is a bill that I support. I understand the challenges 
that you face at the VA, but I think that sometimes when there 
is a will, there is a way and perhaps we need to give the VA 
the will to make the way happen.
    When a veteran contacts a call center, should not they be 
able to complete that scheduling request in a single call? It 
sounds like you are supportive of that.
    Mr. Montoya. Yes, ma'am. Thank you for that.
    As I did mention in my previous answer, many of our basic 
appointments, such as primary care or mental health, those are 
scheduled on the same day. In fact, when veterans do call into 
our clinical contact centers, they are able to schedule those 
appointments.
    Where it does actually present an opportunity or a 
challenge is when there are some of those more complex medical 
appointments, such as cardiology or dental, as I mentioned with 
my previous example, where it does take more time to dig into 
what the eligibility is, what the clinical concern is, to make 
sure that we are scheduling the right appointment for that 
veteran at the right time.
    Ms. Miller-Meeks. In your view, how would veterans benefit 
from having representatives of their Members of Congress 
available in VA facilities during business hours?
    Mr. Montoya. Yes, thank you so much for that question.
    As well, as a former medical center director of three 
different stations, I can not underscore enough the importance 
of the relationship with our congressional stakeholders in the 
community. Often times we hear those concerns from them first 
and foremost about our veterans. When they are in the facility, 
we actually run into a couple of concerns. First and foremost, 
our primary reason for our medical centers is to provide that 
space for clinical care. Often times in our medical center, 
there is not enough space to be able to do that. We do feel 
that having that blanket requirement to provide office space 
would detract from that clinical care or the potential for that 
clinical care to be provided.
    Additionally, when you look at it, there are other things 
that come alongside that, such as parking, the flow, going into 
the campuses and the like that tend to be a little detracting.
    Ms. Miller-Meeks. Your conference rooms are full? 24/7?
    Mr. Montoya. They are not. In fact, thank you for that, 
because I think there are the opportunities for our 
congressional members to, on an ad hoc basis, to be able to 
coordinate space within those medical centers. All they have to 
do is reach out to their medical center director, and they can 
work through the process of making that happen.
    Ms. Miller-Meeks. Thank you very much.
    As a fellow veteran, I think sometimes it is good to go 
into the VA hospital when you are unannounced and not having an 
officially guided tour.
    Thank you.
    I am going to yield 5 minutes to Ranking member Brownley.
    Ms. Brownley. Thank you, Madam Chair. I appreciate it.
    Dr. Hartronft, I wanted to ask you a couple of quick 
questions here at the beginning, and I would just appreciate if 
you could just answer yes or no, okay.
    Is home and community based care good for veterans? Do 
veterans who use home and community care generally have 
positive experiences and good health outcomes?
    Dr. Hartronft. Yes, ma'am.
    Ms. Brownley. Is home and community based care usually less 
expensive than institutionalized care?
    Dr. Hartronft. Yes, ma'am, in most cases.
    Ms. Brownley. How many veterans does VA expect would 
benefit by increasing--in section 2 of the bill--by increasing 
the cap to 100 percent?
    Dr. Hartronft. We do not have the exact number, but the 
populations that are primarily affected by the current cap are 
veterans with Amyotrophic Lateral Sclerosis (ALS) and also some 
spinal cord injury and disorder patients, especially when they 
need ventilator care 24/7 care, the primary population that 
most likely has issues with the cap.
    Ms. Brownley. In no way does the bill say that every 
veteran who receives home based care would use the full amount?
    Dr. Hartronft. No, ma'am.
    Ms. Brownley. It would be a much smaller amount.
    Dr. Hartronft. We would estimate that.
    Ms. Brownley. Yes. Well, you estimated approximately $1.2 
billion in terms of the cost.
    Mr. Montoya, maybe you know this, but there had to be some 
kind of an assumption of how many veterans would utilize the 
cap at 100 percent. Roughly, 200, 500?
    Dr. Hartronft. I can bring those to--for the record, exact 
numbers. Again, we were primarily looking at those populations 
that were specifically hitting the cap.
    Ms. Brownley. Okay, I am looking for like exact numbers 
because we have some work to do with CBO. I would definitely, 
definitely, definitely like those numbers.
    Do you think the way CBO--because CBO did score this at 
roughly $24 billion, which is, you know, quite different from 
your $1.2 billion. That is quite a difference. Do you think 
that what they did was they assumed that everyone, every 
veteran that would utilize the homebased care, they scored it 
at 100 percent? Do you think that is how they possibly came up 
with a $24 billion figure?
    Dr. Hartronft. My apologies, but I can not really comment 
on the CBO's estimates.
    Ms. Brownley. The secretary said the same thing.
    Dr. Hartronft. Yes, ma'am.
    Ms. Brownley. If you are not going to comment on this, then 
I need you to comment on how you came to your conclusion of 
what you think the bill costs.
    Dr. Hartronft. Yes, ma'am.
    Ms. Brownley. We have got to figure out this discrepancy, 
okay. Yes, okay.
    I guess then I would just go on to ask if did the CBO ask 
the VA for data to make their assessments of cost?
    Dr. Hartronft. I am unaware and can not comment on how much 
they reached out.
    Ms. Brownley. Are you unaware or you can not comment?
    Dr. Hartronft. I am unaware.
    Ms. Brownley. Okay, good. All right. So, unaware. We have 
just got to kind of get to the bottom of this. I know on the 
Senate side of the bill, they are equally as interested in 
figuring this out. I know this is a section of the bill that 
the VA absolutely supports.
    Again, if you can give me the exact numbers for the record, 
I would appreciate it.
    With that, I yield back.
    Ms. Miller-Meeks. Thank you, Representative Brownley.
    I would now like to recognize General Bergman for 5 
minutes.
    Mr. Bergman. Thank you, Madam Chairwoman.
    As you all know--I guess let us start with first things 
first. To any of our fellow Vietnam veterans, March 29, several 
years ago, was designated Vietnam Veterans Day. Welcome home. I 
would like to extend that welcome home to all our fellow 
brothers and sisters and for all of you in the Veterans Service 
Organizations (VSOs) and the VA community who serve, in my 
case, my generation of veterans. It is not too little, too 
late, but it was too late for some. And as we look at providing 
care for veterans now in their seventies and eighties, that the 
dynamics of healthcare have changed.
    The reason I would start with that is that With H. 542, the 
Elizabeth Dole Community Based Services for Veterans And 
Caregiver Act, Mr. Montoya, what does VA consider to be the 
cost of 100 percent institutional care? Now, I know it could 
possibly vary by geography or that cost of living, whatever, 
but what factors go into determining that cost?
    Mr. Montoya. Yes, General, thank you so much for that 
question.
    For that, I am going to actually turn to my colleague, Dr. 
Hartronft to be able to answer this.
    Dr. Hartronft. Yes, sir.
    It does vary from region to region, as you are aware, but 
what we usually look at is the average cost for region for the 
VA Community Living Center is kind of what we look at. Then we 
adjust that cap with a 65 percent with the average. That is 
kind of how we peg to that.
    Mr. Bergman. When we are costing out, then what we are 
going to do with, if you will, Community Based services, do you 
feel that you have really here is the cost of providing this in 
Roanoke, Virginia or Escanaba, Michigan, that you can compare 
and contrast the costs associated with home based healthcare, 
that we are not using a metric that does not really match the 
geographic area, you can determine how much this is going to 
cost.
    Dr. Hartronft. That is why we currently support not only 
the 100 percent, but then also the waiver availability, for 
both certain conditions that exceed that. Yes, we would be 
interested in meeting and going specific into VA methodologies 
in more detail if you are----
    Mr. Bergman. We accept and understand that there could be 
cost variances in different parts of the country. Unless VA 
can, through your procedures for evaluating cost, give us as 
Members of Congress who would appropriate money to the VA for 
general funds or specific programs, sometimes we get a little 
nervous that we are throwing--we are not getting the right cost 
benefit for the dollar.
    I for one like to see numbers and I am not afraid of cost 
comparisons, because either it is worth the value or it is not. 
How do we balance that spectrum of care? If we--and we--and 
this is kind of a partnership between the House and VA, do not 
have our fiscal act together when it comes to implementing good 
programs for care, the confidence that the veterans and their 
families and even within your systems, within your Veterans 
Integrated Services Networks (VISNs), one might feel 
handicapped by the numbers, other one might feel advantaged by 
the numbers because it came out in their favor.
    I see my time is running out here. Anything that the VA can 
do to give realistic numbers for all of us to take a look at as 
we make these decisions is going to be helpful in the end to 
the care we provide for the veterans, and in the end, all of 
us--all of us will be proud of what we did. It will vary a 
little bit.
    I just wanted to say thank you for all you do and let us 
not quit because we got a lot of veterans out there and their 
families who are counting on us.
    With that, Madam Chairwoman, I yield back.
    Ms. Miller-Meeks. Thank you.
    The chair now recognizes Representative Budzinski from 
Illinois for 5 minutes.
    Ms. Budzinski. Thank you, chairwoman.
    It is great to be with all of you. Thank you for being 
here.
    I actually had a question I wanted to ask about H.R. 542, 
the Elizabeth Dole Home Care Act, introduced actually by 
Ranking Member Brownley. I have heard from many of the veterans 
back in my district and from several VSOs on the need to enable 
elderly and disabled veterans to be able to enjoy a higher 
quality of life at home as they age, as well as the increasing 
need to support their caregivers. According to the VA Geriatric 
and Gerontology Advisory Committee, over half of the VHA 
enrolled veterans are 65 or older, and this population is only 
increasing, meaning we need to take immediate action to support 
long-term care and invest in VA's home and community based 
services, especially those in rural areas like the district 
that I represent, where health care options are already 
limited.
    Really, my first question is for anyone on the panel, what 
challenges do current caregivers and elderly veterans face and 
how do you think this bill in particular works to address some 
of those concerns?
    Dr. Hartronft. Thank you for that question, ma'am.
    Actually, this bill has been very helpful in us aligning 
our timelines. As you all may be aware, we currently had had a 
multi year expansion for many of our programs and home 
community based. Due to feedback--and we had previously said we 
were going to make that directed care be available at all VA 
over 5 years, but recently, due to feedback from this 
subcommittee and others and external stakeholders, we have 
actually compressed that now to where we are going to do it 
over eight quarters. We are going to go from 71 sites that were 
available in 2022 to where we are going to add 70 more sites 
over the next 8 quarters. We also were expanding number of home 
based primary care and also medical foster home, which is not a 
program that is well known.
    Right now we have also made homemaker home health care, 
purchased skilled home care, and home based primary care is now 
available at all VAs. Now we are working on getting that vet 
directed care, medical foster home to all VAs, as well as 
trying to make veterans known.
    I think some of the barriers, of course, is especially in 
rural areas, and it is a problem for all the American 
demographics, not just for veterans, in the sense that there 
may not be many vendors or home healthcare agencies in many of 
the rural areas or highly rural areas. That is why many people 
really like the veteran directed care program where they can 
hire a family member, neighbor, and others to fill in that gap. 
That has really helped us in many significant rural areas.
    We are also trying to push the limits when it comes to 
telehealth and other modalities to really kind of improve 
access to our rural veterans and others who can not get it by 
traditional means.
    Ms. Budzinski. Right. That is great to hear. I actually 
have a follow-up question.
    In the same vein, there is also critical need to address 
the complex and unique mental health concerns, of course, of 
aging vets. Again, for anyone on the panel, how can this bill 
help address the behavioral health concerns older veterans are 
facing today?
    Dr. Hartronft. I think for us, especially with behavioral 
health and mental health covers many aspects unique to veterans 
as well as that of aging in itself, with whether you have 
dementia or other reasons. We work closely with the Office of 
Mental Health and Suicide Prevention and we look at both how we 
can improve both the home care level, as well as making sure 
that our institutional facilities are aware of veteran specific 
unique needs as well as behaviors, especially as you see in 
certain populations of aging veterans with dementia and other 
disorders. A lot of it is education, training, availability of 
services, and us working closely with the Mental Health Program 
office.
    Ms. Budzinski. Great. Thank you.
    I guess I would just last like to say I am really a proud 
co-sponsor of the Elizabeth Dole Home Care Act, and I am 
grateful to my colleagues on both sides of the aisle because it 
does have a lot of really great bipartisan support.
    Thank you again for being here today.
    I yield back my time.
    Ms. Miller-Meeks. Thank you.
    The chair now recognizes Representative Van Orden from 
Wisconsin for 5 minutes.
    Mr. Van Orden. Thank you very much, Madam Chairman.
    Write this down. I agree with Congressman Takano. I think 
that is a first. He is right. These Korean War veterans served 
alongside my Uncle Bob, Robert Francis Mulligan, who was nearly 
killed by a Chinese Communist grenade thrown into his pit. They 
became American citizens. These are not just random people on 
the street.
    I completely disagree with you, Mr. Montoya. These people 
deserve the respect that they earned fighting next to our 
relatives.
    Did you say you support H.R. 1256? I did not hear that. 
That is the 5 year term and that sort of stuff.
    Mr. Montoya. Yes, sir, we do.
    Mr. Van Orden. Okay, thank you.
    I want to talk to you about H.R. 562. I am 100 percent 
disabled, service-connected disabled veteran. My care has been 
outstanding. The one issue that I have had consistently with 
the VA is the bureaucracy involved with it. I noticed that your 
testimony was requested a month ago. We got it last night. 
Could you say that your testimony was lost in the bureaucracy? 
Probably. Okay, let us put that one there.
    Senior Chief Mike Day committed suicide 2 days ago. He was 
shot 27 times in Iraq. His primary weapon was disabled. He drew 
his pistol and he killed the 3 people in the room that shot him 
27 times.
    We have to have an on ramp into the VA. I have had good 
experiences with the VA, but a lot of people wearing the same 
hat that I got back there did not. I will tell you why. It is 
because you walk into the VA and you do not know anybody. You 
do not. If we are able to walk into the VA and see someone who 
was sent by them to represent them, that is a friendly agent. I 
will do anything I possibly can to prevent another damn veteran 
suicide. By excluding us from sitting in a room, and I have 
been to I do not know how many VA facilities, so that we can be 
the friendly on ramp for our veterans so they can get into the 
system and not kill themselves, is imperative. I am concerned 
because I do not believe what you just testified. I do not 
believe that you think there is not enough room for this. I do 
not believe that. What I do believe is that your agency is 
concerned about having on the ground oversight by congressional 
people who control your budget. That is unacceptable. That is 
putting your job and the jobs rest these cats herein front of 
my brothers and sisters in arms, and I will not accept that. So 
you guys need to change your opinion on that.
    H.R. 1256 says can allow for more flexible numbers of 
assistant undersecretaries, correct?
    Mr. Montoya. That is correct.
    Mr. Van Orden. You are capped at eight, right? Can you 
envision any scenario, if you have flexible options that that 
number would become seven?
    Mr. Montoya. Thank you very much for that question, sir.
    For that I am going to turn to Mr. Perry to be able to 
answer.
    Dr. Perry. Yes, sir, thank you for that question.
    I think what we are looking for is the flexibility to not 
have a predefined number of assistants.
    Mr. Van Orden. I get you. I am just asking you a pretty 
clear question, Mr. Perry. You are capped at eight right now. 
Can you envision that ever becoming seven?
    Dr. Perry. It could potentially, yes.
    Mr. Van Orden. Well, I could potentially grow my hair back, 
but the chance of that happening are zero, right? No, this is 
the problem here. The only one of these things that you 
vigorously supported was growing the bureaucracy. The only 
reason your testimony was a month late is because of your 
bureaucracy. The only problem I have ever had with the VA is 
with your bureaucracy. We got to stop this. I am not going to 
vote to grow the bureaucracy. I will vote to refine the 
bureaucracy. I will vote to make sure that you are empowered to 
do your job better, that my fellow reps on this panel have the 
ability to conduct oversight so it can become more efficient, 
but I am not voting for this. It is inappropriate. I mean, my 
goodness, this whole pack of them, the only thing you supported 
was growing your bureaucracy. That is not good. We cannot have 
another veteran commit suicide because of bureaucracy. There is 
a framed letter on my desk from a veteran, his brother, who 
wrote me, who committed suicide and they got the letter 2 days 
later that he got accepted to the VA because of the 
bureaucracy. His request was lost with your testimony, and we 
have had enough of that.
    With that, I yield back.
    Ms. Miller-Meeks. Thank you, representative.
    On behalf of the committee, I thank all of our witnesses 
for their testimony and for joining us today. You are now 
excused. We will wait a moment as the third panel comes to the 
witness table.
    [Recess]
    Ms. Miller-Meeks. Welcome everyone, and I thank you for 
your participation today. On our third panel we have Mr. John 
Retzer, assistant national legislative Director with Disabled 
American Veterans, Mrs. Tiffany Ellett, the deputy director of 
health policy for the American Legion, and Mr. Morgan Brown, 
national legislative director of Paralyzed Veterans of America.
    Mr. Retzer, you are now recognized for 5 minutes.

                    STATEMENT OF JON RETZER

    Mr. Retzer. Chairwoman Miller-Meeks, Ranking Member 
Brownley, and members of the subcommittee, thank you for 
inviting Disabled American Veterans (DAV) to testify at this 
legislative hearing.
    I will focus my remarks on the bills under consideration 
today that most affect service disabled veterans.
    DAV is pleased to support H.R. 542, the Elizabeth Dole Home 
Care Act. By 2037 the age cohorts are the greatest need for 
long-term care, veterans who are at least 85 years and those 
who have disability ratings of 70 percent or higher, which 
guarantees mandatory long-term care, is expected to grow by 
almost 600 percent. Cost of long-term care services support 
must double by 2037 just to maintain our current services.
    In order to meet the overwhelming increasing demand for 
long-term care needs for the veterans in the years ahead, VA 
must significantly expand and fund home and community based 
services as proposed in H.R. 542. The programs are not only 
more affordable, but often preferred by veterans and their 
families.
    We also support the increasing of the expenditure cap for 
home and community services to create the financial incentives 
to expand these important services.
    DAV is pleased to support H.R. 41, the Same Day Scheduling 
Act. In the recent years, the Government Accountability Office 
and others have reviewed VA scheduling process and identified 
very specific challenges that the Veterans Health 
Administration has in ensuring all appointments, including 
those at community care, are scheduled in a timely manner. This 
legislation would require VA to schedule an appointment during 
the veterans telephone call, regardless of the prospective date 
of the appointment being scheduled. This would improve the 
current scheduling procedures at the VA and provide more 
accurate waive time data.
    DAV also supports H.R. 808. The bill would improve the 
patient advocates program at VA medical facilities by ensuring 
there are no fewer than one patient advocate for every 13,500 
veterans. Patient advocates play a critical role in assisting 
veterans to get the care they need. They have direct effect, 
the ability to address veterans' complaints and resolve issues 
with access to care. Importantly, patient advocates also assist 
veterans with clinical appeals. Advocates should be able to 
provide timely assistance to veterans in accessing health care 
and the clinical appeals process..
    Therefore, we recommend additional research be conducted to 
ensure that the ratio of patient advocate to veterans is 
adequate and balanced.
    DAV supports H.R. 693, the VACANT Act, legislation that 
would limit the detailing's of the VA medical center director 
to the different deposition within the Department. Staffing 
shortages and vacancies in the VA healthcare system, especially 
the critical management positions, can impede the delivery of 
care for veterans who rely on VA for their care. This 
legislation would help improve accountability to sustain needed 
leadership, to ensure VA healthcare runs seamlessly during a 
period of transition and that veterans continuity care and 
benefits are not disrupted.
    H.R. 1256 would extend the term of appointment for the 
undersecretary for health to 5 years and remove restrictions 
for the number of assistant undersecretary for health that can 
be appointed. We understand the intent of this bill is to 
provide greater leadership stability at VHA and believe it 
would empower the undersecretary for health to more effectively 
manage and carry out their responsibilities to ensure veterans 
health care needs are met. While DAV does not have a resolution 
that speaks to this issue, we have no objections to moving this 
bill forward.
    The final bill I will comment on is H.R. 754. This 
legislation would establish a commission to examine policies 
guiding veterans health care eligibility and make 
recommendations, if advisable, make changes. DAV is concerned 
that previous reform efforts have proposed to diminish the size 
and scope of the veterans health care system, whether by 
proposing changes in eligibility to limit the number of 
veterans who may have received care or by pressing for 
privatization of the VA medical services.
    Historically, Congress has made thoughtful decisions about 
assigning priority for care and eligibility for various veteran 
groups. Most recently, Congress expanded eligibility for 
veterans who experienced combat and were exposed to toxic 
exposures or radiation under the PACT Act, veterans in mental 
health crisis under the Comprehensive Prevention Access to Care 
and Treatment (COMPACT) Act. Rather than a commission, we, 
believe Congress should continue to make these decisions in the 
best interest of veterans by conducting oversight of VA 
healthcare eligibility and legislating the changes that are 
deemed necessary.
    Chairwoman Miller-Meeks, this concludes my statement. I am 
happy to address questions you or the members of subcommittee 
may have.

    [The Prepared Statement Of Jon Retzer Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Mr. Retzer.
    The chair now recognizes Ms. Ellett. You are recognized for 
5 minutes.

                  STATEMENT OF TIFFANY ELLETT

    Ms. Ellett. I sit before you today as a disabled veteran, a 
VA patient, and a veteran advocate. I receive all of my care 
through the Department of Veteran Affairs and have personally 
experienced the evolution of the VA benefit and healthcare 
system since my separation from the United States Army in 2013.
    It is through this lens that I am able to see what our 
members see, to feel the frustrations and aggravation they 
exude when discussing obtaining an appointment, navigating the 
system, and receiving appropriate care. With their voices in 
mind, I would like to take this opportunity to touch on a few 
points.
    Chairwoman Miller-Meeks, Ranking member Brownley, and 
distinguished members of the subcommittee, on behalf of our 
National Commander Vincent ``Jim'' Troiola, and our more than 
1.6 million dues paying members, we thank you for inviting the 
American Legion to testify today.
    VA has made a number of changes to appointment scheduling 
through their website, healthcare facilities, and updated 
Internet applications. However, there are still veterans having 
difficulty scheduling an appointment within the setting of a 
phone call to their VA facility. With the current process for 
appointment scheduling via phone, many veterans are able to 
successfully obtain an appointment in that timeframe. However, 
others are told they will need to be contacted at a later date, 
with some going weeks without follow up. At times, this can 
make a simple task tedious and cause frustrations.
    In Dorn VA, Columbia, South Carolina, there is a pilot 
program where staff can schedule an appointment without 
spending time on technical issues or information searching. 
Instead, all necessary information for scheduling is in a 
single sign on interface. In this one screen, the scheduler can 
see all open appointment times and days for not only VA 
providers, but also for the community care provider to which 
the veteran was referred. With this type of system, scheduling 
an appointment takes an average of about 7 minutes. This is 
ideal for simplifying the scheduling needs of a veteran. The 
American Legion supports the VA Same Day Scheduling Act of 2023 
and its intent to increase and simplify access to veterans 
care.
    Separately, in 2003, the American Legion dubbed the VA 
healthcare system a system worth saving, and in doing so, 
created a program where veterans and local VA medical center 
staff could meet with us to discuss the challenges and 
successes in delivering and receiving efficient health care. In 
the last three trips we have conducted, the American Legion has 
found that VA patient advocates are utilized by both veterans 
and VA with the same goal in mind, successful navigation 
through the VA Healthcare system.
    As expected, with the increase of veterans enrolling in VA 
care, the patient advocates have a heavy workload and at times 
are not able to assist veterans to the extent needed. The 
American Legion supports the Veteran Patient Advocacy Act and 
the improvements it will bring through establishing a standard 
of at least one advocate per 13,500 veterans. We are also 
encouraged to see an increase in access to patient advocates 
for veterans in rural communities. The availability of patient 
advocates is a priority of the American Legion and will 
continue to be a focal point when speaking with veterans about 
their representation as a VA patient.
    Finally, I would like to address the Elizabeth Dole Home 
and Community Based Services for Veterans and Caregivers Act of 
2023. Recently, our national commander testified that there is 
a concern for caregivers and their health. Often, caregivers 
will put their veterans health and care above their own, 
leading them toward poor health and burnout. The American 
Legion is pleased to see that respite care is addressed in this 
legislation, as it is beneficial to caregivers, their families, 
and the veterans they care for. We are also pleased to see 
consideration given to caregivers in terms of support services 
and education on possible benefits. We also agree that 
successful transition and care are critical to the overall 
well-being of both the caregiver and the veteran.
    As consistently stated by Secretary McDonough, VA has a 
priority of providing timely world class health care to 
veterans. The American Legion supports the necessary 
legislation to help VA accomplish this endeavor. We have seen 
VA work to identify deficiencies, and we have seen Members of 
Congress work with VA to create solutions. The American Legion 
supports VA as they continue to evolve. We also call upon 
Congress to pass legislation such as these to allow for and 
encourage VA's evolution toward health equity for veterans.
    I conclude by thanking Chairwoman Miller-Meeks, ranking 
member Brownley, and this subcommittee for your incredible 
leadership and for always keeping veterans at the forefront of 
your mission.
    It is my privilege to represent the American Legion for the 
subcommittee, and I look forward to answering any questions you 
may have.

    [The Prepared Statement Of Tiffany Ellett Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Ms. Ellett.
    The chair now recognizes Mr. Brown. You are recognized for 
5 minutes.

                   STATEMENT OF MORGAN BROWN

    Mr. Brown. Thank you. Chairwoman Miller-Meeks, Ranking 
member Brownley, and members of the subcommittee, Paralyzed 
Veterans of America (PVA) thanks you for this opportunity to 
present our views on pending legislation impacting the 
Department of Veterans Affairs that is before the subcommittee.
    My written statement covered PVA's positions on the nine 
bills being reviewed today, so in the interest of time, I am 
going to focus on the one bill that most directly impacts our 
membership.
    PVA gives its strongest endorsement to H.R. 542, the 
Elizabeth Dole Home Care Act, which would make urgently needed 
improvements to VA's home and community based services, 
including several that target our concerns about current 
program shortfalls. VA projects the demand for long-term care 
will continue to increase, driven in part by growing numbers of 
aging veterans and veterans with service-connected 
disabilities. Expenditures for long-term care will increase as 
well and are projected to double by 2037. While greater 
investment in the Department's long-term care infrastructure is 
badly needed, VA must also expand veterans access to 
noninstitutional programs when appropriate to prevent or delay 
nursing home care and to reduce costs. Fixing VA's challenges 
to meet veterans long-term care needs will be difficult because 
it is a multidimensional problem that requires a comprehensive 
solution.
    Section two of this bill raises the cap on how much VA can 
pay for the cost of home care. Currently, VA is prohibited from 
spending more than 65 percent of what it would cost to care for 
the veteran in a nursing home. When VA reaches this cap, the 
Department can either place the veteran into a VA or community 
care facility at a significantly higher cost or rely on the 
veteran's caregivers, who are often family members, to bear the 
extra burden. Depending on the services available in their 
area, some veterans must turn to their state's Medicaid program 
to receive the care they need, even for service-connected 
disabilities.
    Last month, the Senate Veterans Affairs Committee advanced 
a similar version of this bill without the language raising 
VA's cap on care, primarily due to its cost. CBO score for this 
section is perplexing because only a few hundred veterans are 
currently exceeding the 65 percent threshold. Some may need 
rates to be raised to the full cost of nursing home care, but 
the majority would not.
    VA is committed to enhancing and maintaining the quality of 
life for veterans, but the current limitations on the cap of 
services is contrary to this vision. Nothing in this 
legislation expands the number of veterans in this category and 
the number of them in this situation is relatively stable from 
year to year. We recommend the subcommittee work with CBO and 
your Senate counterparts to review the current calculations to 
determine their accuracy.
    Section Four of the bill requires the VA to administer 
programs like Veterans Directed Care (VDC) at all VA medical 
centers within 2 years. The VDC program allows veterans to 
receive Home and Community Based Services (HCBS) in a consumer 
directed way and is designed for veterans who need personal 
care services and help with their activities of daily living. 
Last year, the VA announced plans to expand the VDC program to 
75 additional sites over a 5 year period, and we were pleased 
when VA's undersecretary for health recently directed VHA to 
accelerate that timeline. We understand several sites may be 
ready to launch their programs but lack the financial resources 
to do so. We urge Congress to provide the necessary funding so 
every VA medical center can offer a robust VDC program as 
quickly as possible.
    And, finally, even when veterans have access to programs 
like VDC or Homemaker Home Health, it can be challenging to 
find home care workers. One PVA member told us he regularly 
spends weekends in bed because no staff is available to assist 
him, and he is depressed and frustrated because he can not find 
the direct care workers he needs.
    The shortage of caregivers or direct care workers is not 
unique to VA. Across the country, there is an increasing 
shortage of direct care workers, and a national effort is 
needed to expand and strengthen the workforce. We believe the 
pilot program established in section seven would lessen the 
difficulty in finding direct care workers at the sites VA 
selects and may reveal additional ways the VA could alleviate 
this problem for many veterans nationwide.
    I close again by stressing that this important bill 
addresses several major concerns for catastrophically disabled 
veterans, and we urge Congress to pass the Elizabeth Dole Act 
this year.
    I thank you again for this opportunity to share our views 
on this legislation, and I am happy to answer any questions you 
may have.

    [The Prepared Statement Of Morgan Brown Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you so much, Mr. Brown.
    I am going to go last as my prerogative. I think my 
predecessor did that as well. I am now going to recognize 
Ranking Member Brownley for 5 minutes.
    Ms. Brownley. Thank you, Madam Chair.
    Mr. Brown, thank you for your testimony. Given the 
population of veterans that PVA serves, I was sadly unsurprised 
to see the significant challenges veterans and their families 
face due to statutory cap on how much VA can spend on home care 
you highlighted in your testimony. For those who did not get a 
chance to read his testimony or review it, would you briefly 
highlight some of those issues and the impact on veterans 
quality of life?
    Mr. Brown. Certainly.
    We have numerous veterans that have--their family is 
attempting to provide their care, and because of the cap and VA 
is limited the number of hours, they have to make a choice 
basically. They are forced to choose between going into either 
a VA facility or into a local facility, which often times 
provides them a lesser quality of care, or to have the family 
assume that burden. In many cases, it is the family that is 
attempting to do the right thing here and to care for their 
loved one in the home. Many of these veterans, and I believe it 
was touched on earlier, are veterans with ALS that are in their 
final years in life. It is a great disappointment to us that we 
cannot figure out a way to provide them the full care that they 
earned and deserve.
    Ms. Brownley. Thank you for that.
    You mentioned in your testimony that you thought there 
would just be really there is a couple of hundred veterans, you 
believe?
    Mr. Brown. Yes, ma'am. It is our understanding that it is 
only a few hundred veterans that are currently exceeding the 
cap, and that not all would require 100 percent. You may have 
some that maybe need 70 percent, some that need 80. Certainly 
there are some that would need the full increase.
    Ms. Brownley. Very good.
    Mr. Brown. The number is stable from year to year.
    Ms. Brownley. Very good. Where did you get that data from?
    Mr. Brown. From talking with our own members and then with 
conversations with VA.
    Ms. Brownley. Okay, very good. Well, the VA has promised me 
those numbers on the record.
    Mr. Brown--really this is a question for all three of you. 
There is a section in the bill, I think, that the VA is not 
necessarily supporting, and that is about transparency and 
having a singular website with all of these services together 
on a website so a veteran knows where to go and does not have 
to go to five or six different sites to figure out what 
programs and services are out there--one centralized location 
on a website to get that information. Do you think that is a 
good idea?
    Mr. Brown. Absolutely.
    Ms. Brownley. Ms. Ellett.
    Ms. Ellett. Yes, I absolutely think that that is a good 
idea. I was an analyst in the Army and I can find those things 
and I can spend all day on that. I am also a veteran advocate, 
so it is kind of my job. My wife has five head injuries, and 
for her, if she is going to find--if she is going to look for 
any resources, if she has to go past two clicks, it is not 
going to work. In order to benefit our caregivers and our 
veterans, I think that it is not a hard ask to have them all in 
one location.
    Ms. Brownley. Yes. Very good.
    Mr. Retzer. Yes, we agree too. I think the veterans 
experience, as VA speaks about it, should be as simple and easy 
and streamlined in the virtual world along with the VA 
healthcare that they get.
    Ms. Brownley. Yes, I think, Mr. Brown, in your written 
testimony, I think you had a case where there was a veteran, 
was associated with a medical center that had the directed care 
program, he needed that program, but the two never came 
together.
    Mr. Brown. That is correct. Actually, that was our national 
president.
    Ms. Brownley. Oh, my goodness.
    Mr. Brown. He is currently in home health program. It was 
not until last year that we realized that Veterans Directed 
Care was available at the facility that serves him. He had a 
little bit of difficulty contacting the staff, but when he did 
and inquired about why he was not offered that program, they 
told him that they felt that he probably would have difficulty 
finding the workers that he needs to care for him, but in fact, 
the opposite was true. He actually had people that were willing 
to step forward and care for him and it would have been an 
ideal situation for him to participate in that program.
    Ms. Brownley. Terrific. Thank you so much.
    I yield back, Madam Chair.
    Ms. Miller-Meeks. Thank you, Representative Brownley.
    I now recognize Representative Van Orden from Wisconsin for 
5 minutes.
    Mr. Van Orden. The angry senior chief. I am just kidding, 
man.
    Mr. Retzer, I understand you support the bill that I do 
not. It is not that I do not support the whole thing, it is 
just I do not want to grow the bureaucracy. Having a term 
longer for the secretary I think, is a great thing because it 
does get rid of that gap. Again, we need to work for 
efficiencies.
    Ms. Ellett, is your wife a vet?
    Ms. Ellett. Yes, sir.
    Mr. Van Orden. Is she getting taken care of now?
    Ms. Ellett. Yes, she is.
    Mr. Van Orden. Where does she get seen?
    Ms. Ellett. We both go to Richmond VAMC. We are also rural 
veterans.
    Mr. Van Orden. So am I.
    Ms. Ellett. It takes us about 45 minutes to get to a local 
Community Based Outpatient Clinics (CBOC)----
    Mr. Van Orden. Okay.
    Ms. Ellett [continuing]. and about an hour and a half to 
get to the VA medical center. When we make appointments, we 
make them all day, make them for the whole day, and it is the 
day trip for the both of us.
    Mr. Van Orden. Have you had problems getting access to 
community care?
    Ms. Ellett. Yes and no. Some of the community care 
providers are very--we get the referral quickly, and some of 
the community care providers are very helpful and very willing 
to work--working through a third-party administrator is a 
little bit difficult because they have you on the phone and 
they have somebody else on the phone. We have had those same 
day struggles, however, when we do schedule for like our CBOC, 
it is immediate. We can call and schedule an appointment like 
that. It is the community care appointments that have a real 
problem with the same day scheduling.
    Mr. Van Orden. Okay, well, thank you for that.
    You know that you have friends here on this committee, 
right?
    Ms. Ellett. Yes, sir.
    Mr. Van Orden. Okay. I am a Legionnaire myself.
    H.R. 562. Does anybody on this panel believe that the VA 
cannot find space for us to see veterans that come in to visit 
to hopefully get care and benefits?
    Mr. Retzer, I will start with you.
    Mr. Retzer. DAV is a resolution based organization. We do 
not have a resolution that supports that. However, in our 
experiences that we have, I think that is something that 
Congress can definitely look into with the administration to 
see what spaces they have. We know that they have some 
challenges with regards to some localities not having the 
conference rooms available and things of that nature. But 
definitely we would be willing to work with you to see if we 
can assist that process.
    Mr. Van Orden. Yes. Okay.
    Ma'am. Army guy. Were you an intelligence analyst? You said 
you are an analyst.
    Ms. Ellett. Yes, I was an intelligence analyst.
    Mr. Van Orden. What was your Military Occupational 
Specialities (MOS)?
    Ms. Ellett. 35 Fox.
    Mr. Van Orden. Okay, roger that. Did you go to Huachuca?
    Ms. Ellett. I did.
    Mr. Van Orden. Okay, check. Do you think we should be able 
to see our fellow vets?
    Ms. Ellett. We have a lot of veterans that--first, thank 
you for that question.
    Mr. Van Orden. You are welcome.
    Ms. Ellett. We have a lot of veterans who do communicate 
with our Congress individuals, especially our rural veterans. 
They would like to interact more due to more representation, 
more representation opportunities. However, we do not have a 
specific position on that. We are talking about taking it back 
to our members. It would be nice to have that kind of direct 
communication.
    As far as space, I know that I have been to quite a few VA 
facilities, and they are struggling to find space for their 
services. However, it is going to be a compromise. If that is 
how they move forward, then I am sure that we can all figure it 
out.
    Mr. Van Orden. It would be awesome if you brought that back 
to our fellow Legionnaires.
    Ms. Ellett. Absolutely.
    Mr. Van Orden. I honestly believe I think they are afraid 
of oversight
    Sir. Mr. Brown.
    Mr. Brown. So availability, space is always a perennial 
concern in VA. It sounds like we are all in agreement here. PVA 
did not take a formal position on this bill.
    Mr. Van Orden. I read your stuff.
    Mr. Brown [continuing]. I am really supportive of it.
    Mr. Van Orden. Okay.
    Mr. Brown. Like DAV, we certainly would hope that the 
committee and VA will be able to work something out.
    Mr. Van Orden. Excellent. Thank you.
    I would like to go on a record again to say that the vast 
majority of my healthcare provided by the VA is excellent. I am 
incredibly proud of my local office in La Crosse. I also go to 
Tomah. That is where that whole--the drug stuff started. I am 
very, very proud of them. I am also very proud of you. It takes 
a lot of guts to come here and speak in front of these 
committees. You are doing a good thing, and you are helping my 
brothers and sisters, of which you are also. God bless you guys 
and you take care and take care of your wife, will you.
    All right, with that, I yield back.
    Ms. Miller-Meeks. Thank you, Representative Van Orden.
    I now recognize myself for 5 minutes.
    I will just go down the panel.
    Do VSOs have space in VA medical centers, Mr. Retzer?
    Mr. Retzer. For the DAV, we are fortunate to have space 
where we have our transportation program that is in there with 
our hospital service coordinators. At the same time, many of 
times, we have the Veterans Affairs Medical Regional Office 
Centers (VAMROCs) (phonetic 1:35:49), which have National 
Service Officers co-located inside, or we have National Service 
Officers that are close by at Federal buildings.
    Ms. Miller-Meeks. Ms. Ellett.
    Ms. Ellett. Thank you.
    Yes, s we do have some space. We share typically with other 
VSOs. We have our representatives or our Service Officers that 
do have space in most VAs, usually with DAV or PVA in the same 
office?
    Ms. Miller-Meeks. Mr. Brown.
    Mr. Brown. Yes, ma'am, PVA does have space in many VA 
facilities. The majority of those are the spinal cord injury 
centers and the hub locations.
    Ms. Miller-Meeks. Having been a nurse who worked on the 
neurosurgery floor at Walter Reed, I am glad that you have some 
space. It also seems to me that if VSOs have space in VA 
medical centers, that Members of Congress who want to meet with 
their constituents and fellow veterans should also.
    Thank you for your candid answers.
    Ms. Ellett, in your testimony, you mentioned that many 
medical centers are trying to make the scheduling process 
easier, but it varies from VISN to VISN. What are your members 
experiences when trying to schedule an appointment via a call 
center?
    Ms. Ellett. Typically call centers will have to--they have 
to log out of one VAMC and into another area, which usually 
takes more time. There is also more confusion with that. Like I 
said, there is a pilot program that is--I think it is VISN 
eight, and it is a call center that has that one screen, and it 
is able to combine 14 VA instances. A person does not have to 
log out of one and log into another. It makes it a lot easier, 
but it depends on the VISN. There are some that are very 
responsive, there are individuals that are very willing to 
assist and move mountains to help make those appointments 
happen, and there are others that are less motivated.
    Ms. Miller-Meeks. Thank you.
    I also provided community care and took care of veterans as 
part of my practice. You had mentioned that many community care 
referrals require multiple phone calls to establish an 
appointment. How can this bill impact that process? Is there 
anything we need to add?
    Ms. Ellett. We are hoping that with that bill, there is 
more of the technology of--the pilot might happen and you would 
also have the buy in with the community care providers. I think 
with this legislation that we do not want to get lost in making 
an appointment happen that day or scheduling an appointment 
that day, but losing any quality. We do not want to lose any 
quality of care or anything to take care of the veteran. We do 
not want anything negative, any negative impact with it. That 
is what we are concerned about.
    Ms. Miller-Meeks. Understood.
    With the PACT Act increasing eligibility, I am even more 
concerned about scheduling processes and delays in cares. Many 
veterans prefer online portals and direct scheduling. Even so, 
these sites often require veterans to follow up with phone 
calls. If you miss the phone call, sometimes you miss an 
appointment.
    Does the bill require any additional language to apply to 
these types of scenarios? What type of oversight would be 
required to make sure the VA implements this bill if passed? 
Like I said, sometimes when you create the will, they find a 
way.
    Ms. Ellett. Thank you for that.
    I think maybe adding an additional timeline for a follow up 
to allow that room for those specific ones. I know that 
personally, getting community care for Gastrointestinal (GI) 
appointment is impossible to schedule the same day. I think 
that having a timeline for any follow ups and then keeping 
oversight of those tracking, that is where kind of the 
Transparency Act would come in.
    Ms. Miller-Meeks. Excellent. Thank you so much.
    I yield back the remainder of my time.
    Ranking member Brownley, do you wish to make any closing 
remarks?
    Ms. Brownley. Well, thank you for that.
    No, I do not really have any closing remarks, except I am 
excited about this hearing. I am excited about the Elizabeth 
Dole bill, obviously, but there are many other good bills here. 
I thank the chairwoman for making this hearing happen so we can 
begin to move these bills along in the 118th Congress.
    Thank you.
    Ms. Miller-Meeks. Thank you. I look forward to working 
through these issues and many more with the Department, with my 
colleagues, and with the ranking member, and the members of 
this subcommittee.
    The complete written statements of today's witnesses will 
be entered into the hearing record. I also thank all of the 
witnesses for making the time and the effort to appear before 
us.
    I ask unanimous consent that all members have 5 legislative 
days to revise and extend their remarks and include extraneous 
material.
    Hearing no objections, so referred.
    I thank the members and the witnesses for their attendance 
and participation today. This hearing is now adjourned.
    [Whereupon, at 3:09 p.m., the subcommittee was adjourned.]

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                         A  P  P  E  N  D  I  X

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                    Prepared Statement of Witnesses

                              ----------                              


                  Prepared Statement of Alfred Montoya

    Chairwoman Miller-Meeks, Ranking Member Brownley, and other Members 
of the Subcommittee, thank you for inviting us here today to present 
our views on several bills that would affect VA programs and services. 
Joining me today is Dr. Scotte Hartronft, Executive Director, Office of 
Geriatrics and Extended Care and Mr. David Perry, Chief Officer, 
Workforce Management.

H.R. 41 VA Same-Day Scheduling Act

    This bill would redesignate current 38 U.S.C. Sec.  1706A as Sec.  
1706B and create a new Sec.  1706A regarding timely scheduling of 
appointments at VA facilities. Specifically, it would require VA to 
ensure that whenever a covered Veteran contacts VA by telephone to 
request the scheduling of an appointment, the scheduling for the 
appointment occur during that telephone call (regardless of the 
prospective date of the appointment being scheduled). ``Covered 
veterans'' would be those enrolled in VA health care. These amendments 
would apply with respect to requests for appointment scheduling 
occurring on or after the date that is 120 days after the date of 
enactment.

    VA Position: VA does not support this bill.

    VA already has the authority to do what this bill proposes, and it 
does so whenever possible. However, requirements for clinical review 
and determinations of eligibility are not always possible, nor desired 
by the Veteran, at the moment of a phone call to complete simultaneous 
appointment scheduling. Some specialty care appointments require 
referrals to be reviewed by a Referral Coordination Team with a Veteran 
before an appointment is scheduled; this would make this section, as 
written, difficult or even impossible to meet. The text provides no 
flexibility in terms of VA's requirement to schedule an appointment 
during the call itself, which could result in non-compliance through no 
fault of VA (if, for example, the call was interrupted, or the Veteran 
chose to end the call before VA could schedule an appointment). It also 
does not acknowledge the growing number of Veterans who prefer to self-
schedule appointments. The text also does not contemplate a Veteran who 
is eligible for community care and may prefer instead to seek care 
under the Veterans Community Care Program.
    Additionally, some types of care, such as dental care, require 
additional eligibility be met, and it is not always possible to know 
that information during a telephone call. We are already pursuing 
information technology solutions that will improve tracking timely 
scheduling of appointments for Veterans.

    We do not currently have a cost estimate for this bill.

H.R. 366 Korean American Vietnam Allies Long Overdue for Relief (VALOR) 
Act

    H.R. 366 would amend 38 U.S.C. Sec.  109 by adding a new subsection 
(d) that would State that persons VA has determined served in Vietnam 
as a member of the armed forces of the Republic of Korea between 
January 9, 1962, and May 7, 1975 (or such other period determined 
appropriate by VA for purposes of this subsection), would be eligible 
for benefits under subsection (a) to the same extent and under the same 
conditions (including with respect to applicable reciprocity 
requirements) as a discharged member of the armed forces of a 
government specified in such subsection who is eligible for such 
benefits under such subsection.
    Currently, 38 U.S.C. Sec.  109(a) authorizes VA, upon request of 
the proper officials of the Government of any Nation allied or 
associated with the U.S. in World War I (except any nation which was an 
enemy of the U.S. during World War II), or in World War II, to furnish 
to discharged members of the armed forces of such Government, under 
agreements requiring reimbursement in cash of expenses so incurred, at 
rates and under such regulations as VA may prescribe, medical, 
surgical, and dental treatment, hospital care, transportation and 
traveling expenses, prosthetic appliances, education, training, or 
similar benefits authorized by the laws of such Nation for its 
Veterans, and services required in extending such benefits. 
Hospitalization in VA facilities is not allowed except in emergencies, 
unless there are available beds surplus to the needs of the Veterans of 
this country. VA may also pay the court costs and other expenses 
incident to the proceedings taken for the commitment of such discharged 
members who are mentally incompetent to institutions for the care or 
treatment of the insane. VA may contract for necessary services with 
private, State, and other Government hospitals in carrying out this 
authority. All amounts received by VA as reimbursement for such 
services must be credited to the current appropriation from which 
expenditures were made under section 109(a).

    VA Position: VA does not support this bill.

    We appreciate that this version of the bill generally subjects 
these benefits to the same terms and conditions as is available to 
allied beneficiaries in that benefits and services must be furnished 
only upon request of the proper officials of the Korean Government and 
under agreements requiring reimbursement. These changes address some of 
the equity concerns VA identified with an earlier version of this bill 
in the previous Congress (H.R. 234). However, H.R. 366's amendments to 
38 U.S.C. Sec.  109 still raise some concerns. While the bill's 
addition of a new subsection (d) would seemingly authorize the 
provision of benefits notwithstanding the current limitations in 
subsection (a), we believe the bill should be clearer as to how these 
authorities can be reconciled.
    VA is in the process of expanding health care eligibility to 
Veterans who served in Armed Forces as authorized by the PACT Act (Pub. 
L. 117-168). As Congress considers this and other legislation, we note 
our concern that VA will need adequate appropriations to ensure that we 
can deliver on the promise of VA benefits and services for all eligible 
Veterans.

    VA does not currently have a cost estimate for this bill.

H.R. 542 Elizabeth Dole Veterans Home-and Community-Based Services for 
Veterans and Caregivers Act of 2023, or the Elizabeth Dole Home Care 
Act

    We appreciate the close collaboration of Committee staff, the 
Elizabeth Dole Foundation in addressing some of the concerns VA 
identified with previous versions of this legislation in the prior 
Congress (H.R. 6823). We believe the current version is much improved 
and is a demonstration of the benefits of VA and Congress working 
together.

    VA Position: VA generally supports this bill if amended, and 
subject to the availability of appropriations, although our positions 
vary as noted below; more specific discussion of each provision appears 
below.

    We estimate the bill, overall, would cost $74.4 million in fiscal 
year (FY) 2023, $105.1 million in FY 2024, $536.2 million over five 
years, and $1.23 billion over 10 years. Much of this projected cost is 
attributable to section 4(b) of the bill. As included in the FY 2024 
President's Budget, a portion of these costs may be paid for from the 
Cost of War Toxic Exposures Fund, as authorized in the Sergeant First 
Class Heath Robinson Honoring our Promise to Address Comprehensive 
Toxics Act of 2022 (Public Law 117-168; PACT Act), and the remaining 
portion from discretionary appropriations.
    Section 2(a) of the bill would amend 38 U.S.C. Sec.  1720C(d) to 
increase the maximum percentage of the total cost of providing services 
or in-kind assistance to Veterans eligible for medical, rehabilitative 
and health-related services in non-institutional settings for Veterans 
who are eligible for and in need of nursing home care. Specifically, it 
would increase this amount from 65 percent of the cost that would have 
been incurred by the Department during that fiscal year if the Veteran 
had instead been furnishing nursing home care under section 1710 to 100 
percent of that cost. Further, it would authorize VA to exceed 100 
percent of the cost that would have been incurred under section 1710 if 
the Secretary determines, based on a consideration of clinical need, 
geographic market factors and such other matters as VA may prescribe 
through regulation, that such higher total cost is in the best interest 
of the Veteran. Section 2(b) would provide that the amendments made by 
section 2(a) would apply with respect to fiscal years beginning on or 
after the date of enactment.

    VA Position: VA strongly supports section 2.

    VA strongly supports increasing the allowable amount to cover 100 
percent of the cost of nursing home care that would otherwise have been 
incurred. This is one of the Department's legislative proposals for the 
FY 2024 budget. We appreciate that this text includes criteria VA would 
consider in exceeding 100 percent of the cost of care while still 
providing discretion to VA, through regulation, to consider other 
factors as well. These changes should make it much easier for VA to 
administer this authority consistently and fairly. We are experiencing 
situations where Veterans with serious medical conditions, such as 
amyotrophic lateral sclerosis (ALS), that can be managed safely in a 
non-institutional setting are being forced to transition to 
institutional care because VA is no longer able to provide support 
within this statutory cap. This institutional care is both less 
clinically appropriate and more expensive. A change to the authorized 
cap, as section 2 would do, would allow these Veterans to remain in 
their homes and with their loved ones. VA does not have any other 
option in these situations given its current statutory authority, which 
is why we strongly support this legislation. While this likely only 
affects a small number of Veterans (particularly those in need of 
ventilator care), we believe their unique circumstances justify this 
type of exception and support from Congress and VA. We know that 
several States with similar caps have included exceptions that permit 
these Veterans to remain in their homes, but we believe all Veterans 
deserve this same opportunity.
    VA estimates that it would exercise this new authority within its 
current budget authority and so would result in no additional costs. 
This estimate is consistent with the estimate for VA's legislative 
proposal in the FY 2024 budget request. This section could 
theoretically cost more due to the ability to exceed 100 percent of the 
cost of care in this bill. However, it is difficult to predict how many 
Veterans would qualify for rates in more than 100 percent of the cost 
of care. VA has used other strategies, such as the combination of 
Veteran-Directed Care and VA Home-Based Primary Care, for many Veterans 
to remain below the cap, and while this does not work for every 
Veteran, it does work for many of them. Further, and as noted above, by 
reducing the need for institutional care, VA will save money in this 
regard, so even being able to pay for non-institutional care at a 
higher rate would still likely result in a budget neutral result. We 
have not had an opportunity to develop a full methodology showing these 
cost tradeoffs, but we would appreciate the opportunity to discuss 
these matters more with the Committee to ensure that the Congressional 
Budget Office estimate for this provision reflects an accurate 
estimate.
    Section 3 of the bill would further amend section 1720C by creating 
a new subsection (f). This subsection would provide that in furnishing 
services to a Veteran under this section, if a VA Medical Center (VAMC) 
through which such program is administered is located in a geographic 
area in which services are available to the Veteran under the Programs 
of All-Inclusive Care for the Elderly (PACE) Program, VA would have to 
seek to enter into an agreement with the PACE Program operating in that 
area for the furnishing of such services.

    VA Position: VA supports the PACE Program and has no objection to 
this provision.

    We appreciate that this version of the bill has addressed VA's 
prior concerns regarding the use of the term ``partnership''; the bill, 
by requiring VA to seek to enter into an agreement, provides greater 
flexibility and should ensure that this authority could be exercised 
consistent with other programs, in particular the Veterans Community 
Care Program that VA operates under 38 U.S.C. Sec.  1703. We do note 
that there may be some locations where the PACE Program would be unable 
to offer convenient care for Veterans, and so while VA would seek to 
enter into agreements in these locations, it may be inadvisable to do 
so.
    Section 4(a) would create a new 38 U.S.C. Sec.  1720K governing 
home-and community-based services and programs. Proposed section 
1720K(a) would provide that in furnishing non-institutional 
alternatives to nursing home care pursuant to section 1720C or any 
other authority, VA would have to carry out each of the programs 
specified in the new section 1720K in accordance with such relevant 
authorities, except as otherwise provided in this section.

    VA Position: VA generally supports section 4(a) if amended; we 
recommend clarifications as noted in detail below.

    We generally appreciate the interest and emphasis of this bill on 
VA's existing programs, which are critical to ensuring that Veterans 
can live where they want and in settings that are appropriate to them. 
We interpret proposed section 1720K, as would be added by section 4 of 
the bill, to codify existing practice, rather than to replace VA's 
existing programs of the same names with new programs with different 
rules or requirements. We appreciate the proposed rule of construction 
in proposed section 1720K(g), which would clarify that nothing in the 
proposed section 1720K could be construed to limit VA's authority to 
carry out programs providing home-and community-based services under 
any other provision of law. This change would ensure that VA could 
continue to develop and implement innovative programs that meet the 
needs of Veterans.
    Proposed section 1720K(b) would require VA, in collaboration with 
the Department of Health and Human Services (HHS), to carry out a 
program known as the Veteran Directed Care program under which VA could 
enter into agreements with an Aging and Disability Resource Center, an 
area agency on aging, a State agency, a center for independent living 
or an Indian Tribe or Tribal organization receiving assistance under 
title VI of the Older Americans Act of 1965 (42 U.S.C. Sec.  3057 et 
seq.) to provide to eligible Veterans funds to obtain such in-home care 
services and related items as may be appropriate (as determined by VA) 
and selected by the Veteran, including through the Veteran hiring 
individuals to provide such services and items or directly purchasing 
such services and items. In carrying out the Veteran Directed Care 
program, VA would have to administer such program through each VAMC, 
seek to ensure the availability of the program in American Samoa, Guam, 
the Commonwealth of the Northern Mariana Islands, the Commonwealth of 
Puerto Rico, the U.S. Virgin Islands and any other territory or 
possession of the United States. VA also would have to ensure the 
availability of the program for eligible Veterans who are Native 
American Veterans receiving care and services furnished by the Indian 
Health Service (IHS), a Tribal health program, or an Urban Indian 
organization. VA also would have to ensure the availability of the 
program for eligible Native Hawaiian Veterans in a Native Hawaiian 
health care system, to the extent practicable. If a Veteran 
participating in the Veteran Directed Care program were 
catastrophically disabled, the Veteran could continue to use funds 
under the program during a period of hospitalization in the same manner 
that the Veteran would be authorized to use such funds under the 
program if the Veteran were not hospitalized.
    Veterans participating in the Veteran Directed Care program hire 
their own workers to provide personal care services in their homes and 
communities. This program is managed by local aging and disability 
network providers (e.g., area agency on aging), who support the 
Veteran, their caregiver and families. This support includes managing 
employer paperwork, filing taxes and paying workers. In addition, case 
managers in the community help Veterans develop a plan for hiring 
workers, monitor the care being delivered and facilitate delivery of 
other community services to meet their needs.
    Currently, there are approximately 6,300 Veterans participating in 
this program at 71 VAMCs. Research has shown that Veteran Directed Care 
is a critical resource for VAMCs in supporting Veterans at risk of 
hospital and nursing home placement who may be able to receive 
necessary care and support in non-institutional alternatives. Veterans 
in Veteran Directed Care are typically sicker, more service-connected, 
more likely to live in rural areas, younger and have more chronic 
conditions compared to Veterans participating in other VA personal care 
services programs. In addition, an evaluation of Veteran Directed Care 
has shown even though the needs of Veterans in Veteran Directed Care 
are more complex, it is more effective at reducing hospital and nursing 
home use and improving patient outcomes when compared to other VA 
personal care services. Because Veterans, their caregivers and families 
can make decisions about where and how to receive their care, Veteran 
Directed Care also increases overall satisfaction and improves trust 
with VA for Veterans. Given this, we support continued operation of the 
Veteran Directed Care program. We also support the provision that would 
allow catastrophically disabled Veterans to continue using funds during 
a period of hospitalization in the same manner the Veteran would use 
such funds if they were not hospitalized. This provision would provide 
needed consistency and assurances for such Veterans.
    We appreciate the bill providing flexibility to VA given the 
significant challenges in ensuring these programs are available in some 
of the U.S. territories with small Veteran populations and limited-
service availability. Some U.S. territories may lack nursing homes in 
the first place, and their ability to offer non-institutional 
alternatives likely is limited as well. We note that Puerto Rico and 
the Commonwealth of the Northern Mariana Islands operate a Veteran 
Directed Care program, while the U.S. Virgin Islands is scheduled to 
adopt the program later this year.
    Proposed section 1720K(c) would require VA to carry out a program 
known as the Homemaker and Home Health Aide program under which VA 
would be able to enter into agreements with home health agencies to 
provide to eligible Veterans such home health aide services as may be 
determined appropriate by VA. VA would have to ensure this program was 
available in the same territories and for the same populations as the 
Veteran Directed Care program under proposed section 1720K(b).
    VA's Homemaker and Home Health Aide program has been in operation 
for approximately 30 years. The program uses licensed and Medicare-and 
Medicaid-certified agencies to provide care to Veterans needing 
assistance with activities of daily living (e.g., bathing and dressing) 
and instrumental activities of daily living (e.g., meal preparation). 
VA purchases Homemaker and Home Health Aide services from approximately 
6,000 agencies, mostly through Community Care Network (CCN) contracts. 
In FY 2022, nearly 149,000 Veterans were served in this program.
    We note that the proposed legislation, in proposed 1720K(b)(3)(B), 
clearly requires VA, to the extent practicable, to seek to ensure the 
availability of the Veteran Directed Care program in the territories 
and possessions of the U.S. We believe the incorporation by reference 
proposed in section 1720K(c)(2)(A) is intended to and could be 
interpreted to extend the same flexibilities to the Homemaker and Home 
Health Aide program, but we recommend further clarification on this 
point. As discussed above regarding the Veteran Directed Care program, 
we are also concerned that the requirement to ensure the availability 
of this program in all U.S. territories would be difficult to meet.
    Proposed section 1720K(d) would require VA to carry out a program 
called the Home-Based Primary Care program, under which VA could 
furnish to eligible Veterans in-home health care, the provision of 
which would be overseen by a VA physician.
    VA's Home-Based Primary Care program furnishes primary care to 
Veterans in their homes. A VA physician leads the interdisciplinary 
health care team that provides comprehensive longitudinal health care. 
This evidence-based program is for Veterans who have complex health 
care needs for whom routine clinic-based care is not effective. This 
program is already available at every VAMC.
    Proposed section 1720K(e) would require VA to carry out the 
Purchased Skilled Home Care program under which VA could furnish to 
eligible Veterans such in-home care services as may be determined 
appropriate and selected by VA for the Veteran.
    VA's Purchased Skilled Home Care program uses licensed and 
Medicare-and Medicaid-certified agencies to provide care to Veterans 
with short-term and long-term skilled care needs. Approximately 75 
percent of the Veterans served in the program have short-term, post-
acute needs. The remaining 25 percent of Veterans require care for a 
longer period for conditions such as non-healing wounds, long-term 
catheter management, medication management and ventilator care. VA 
purchases skilled home care services from approximately 4,000 agencies, 
mostly through CCN contracts. In FY 2022, approximately 171,000 
Veterans were served in the Purchased Skilled Home Care program.
    Proposed section 1720K(f)(1) would provide that, with respect to a 
resident eligible caregiver of a Veteran participating in a program 
under this section, VA would have to, if the Veteran meets the 
requirements of a covered Veteran under section 1720G(b), provide to 
such caregiver the option of enrolling in the program of general 
caregiver support under section 1720G(b), provide to such caregiver not 
fewer than 30 days of covered respite care each year and conduct on an 
annual basis (and, to the extent practicable, in connection with in-
person services provided under the program in which the Veteran is 
participating) a wellness contact of such caregiver. Under proposed 
section 1720K(f)(2), covered respite care could exceed 30 days annually 
for resident eligible caregivers if such extension is requested by the 
resident caregiver or Veteran and determined medically appropriate by 
VA.
    We agree that informing caregivers of the option to enroll in the 
program of general caregiver support under section 1720G(b) is 
advisable, and our current efforts have focused on ensuring that 
caregivers participating in the general caregiver program under current 
section 1720G(b) are provided robust support. We focus on educating 
caregivers of Veterans in current programs and referring those 
caregivers to the general caregiver support program when they are 
interested.
    Several aspects of existing section 1720G(b) are not consistent 
with proposed section 1720K(f)(1). It is not clear whether Congress 
intends to alter section 1720G(b) for caregivers under section 
1720K(f). There is no requirement in existing section 1720G(b) that the 
caregiver reside with the Veteran, unlike proposed section 1720K(f)(1). 
Nor does VA currently administer in-home wellness contacts of 
caregivers under the general caregiver program in section 1720G(b), but 
VA would be required to do so per proposed section 1720K(f)(1)(C). We 
suggest clarifying any differences between the support VA provides to 
caregivers who under section 1720G(b) generally relative to those 
caregivers who provide care under proposed section 1720K.
    We also note that under our existing authorities, VA offers at 
least 30 days of respite care to primary family caregivers of covered 
Veterans under section 1720G and up to 30 days of respite care each 
year for other caregivers. The utility of codifying 30 days is not 
apparent.
    Proposed section 1720K(g) would establish a rule of construction 
that nothing in this section could be construed to limit VA's authority 
to carry out programs providing home-and community-based services under 
any other provision of law.

    As stated earlier, we support and appreciate this clarification.

    Proposed section 1720K(h) would define various terms. In 
particular, it would define ``covered respite care'' to have the 
meaning given such term in section 1720G(d) (as would be added by 
section 5(b)(3) of the bill); this would be defined to mean respite 
care under section 1720B that is medically and age appropriate for the 
Veteran (including 24-hour per day care of the Veteran commensurate 
with the care provided by the caregiver) and includes in-home care. 
``Eligible Veteran'' would mean any Veteran for whom VA determines 
participation in a specific program under this section is medically 
necessary to promote, preserve or restore the health of the Veteran and 
who, absent such participation, would be at increased risk for 
hospitalization, placement in a nursing home or emergency room care. 
The term ``resident eligible caregiver'' would mean a caregiver, or a 
family caregiver of a Veteran who resides with the Veteran and has not 
entered into a contract, agreement or other arrangement for such 
individual to act as a caregiver for that Veteran unless such 
individual is a family member of the Veteran or is furnishing caregiver 
services through a medical foster home.
    The definition of eligible Veteran would be broader than our 
current authority by including reference to an increased risk of 
hospital care and emergency room care. Current section 1720C also 
states that Veterans must need nursing home care, rather than simply 
being ``at increased risk for...placement in a nursing home''. We 
continue to not support adoption of the phrase ``resident eligible 
caregiver,'' as this would create a new classification (beyond 
caregivers and family caregivers) that could cause confusion among VA's 
programs. We appreciate various clarifications and revisions made in 
this draft to address some of VA's previous concerns.
    Section 4(b) would require VA to ensure that the Veteran-Directed 
Care and the Homemaker and Home Health Aide programs are administered 
through each VAMC by not later than two years after the date of 
enactment.

    VA Position: VA supports this subsection, which is consistent with 
VA's current timeline for expansion. VA already has a Homemaker and 
Home Health Aide programs at all its VAMCs, and we are working 
diligently to expand the Veteran-Directed Care program to be available 
at all VAMCs by Spring 2025.

    Section 5(a)(1) would amend 38 U.S.C. Sec.  1720G to add a new 
paragraph (14) to subsection (a). This paragraph would State that in 
the case of a Veteran or caregiver who seeks services under subsection 
(a) and is denied such services, or a Veteran or the family caregiver 
of a Veteran who is discharged from the program under this subsection, 
VA would have to, with respect to the caregiver, ensure the caregiver 
is provided the option of enrolling in the program of general caregiver 
support services under subsection (b); assess the Veteran or caregiver 
for participation in any other available VA program for home and 
community-based services for which the Veteran or caregiver may be 
eligible and, with respect to the Veteran, store (and make accessible 
to the Veteran) the results of such assessment in the medical record of 
the Veteran; and provide to the Veteran or caregiver written 
information on any such program identified pursuant to that assessment, 
including information about facilities, eligibility requirements, and 
relevant contact information for each program. For each Veteran or 
family caregiver who is discharged from the program under this 
subsection, a caregiver support coordinator would have to provide for a 
smooth and personalized transition from such program to an appropriate 
VA program (including the programs specified in section 1720K, as added 
by section 4 of the bill). Section 5(a)(2) would provide that the 
amendments made by section 5(a)(1) of the bill would apply with respect 
to denials and discharges occurring on or after the date that is 180 
days after the date of enactment.

    VA Position: VA supports this subsection with amendments.

    We agree with the intent of these provisions, and we appreciate the 
Committee's willingness to receive technical assistance on this bill in 
the previous Congress to ensure VA has the resources and authority to 
successfully assist Veterans and their caregivers. VA is already 
working to enhance our efforts in this area. VA currently offers every 
caregiver who is discharged or denied from the Program of Comprehensive 
Assistance for Family Caregivers the opportunity to participate in the 
Program of General Caregiver Support Services (PGCSS) when appropriate. 
This opportunity is offered in the letter notifying them and often by 
phone. VA also notifies these caregivers of other services and support 
through other programs, but it does not evaluate the caregivers for 
such programs.
    Concerning the timeline established in section 5(a)(2), we 
appreciate that this version would provide VA 180 days to implement, 
but we estimate VA would need at least one year to hire staff and 
develop the systems and training to implement the changes made by 
paragraph (1).
    Section 5(a)(3) of the bill would amend the definitions of section 
1720G(d) to modify the definitions of the terms ``caregiver,'' ``family 
caregiver,'' ``family member'' and ``personal care services'' to refer 
to Veterans denied or discharged as specified in section 1720G(a)(14), 
as added by section 5(a)(1) of the bill.

    We have no objections to these amendments.

    Section 5(b) would make further amendments to section 1720G to 
conform with changes described above regarding respite care benefits.

    VA Position: VA has no objection to section 5(b).

    Section 5(c) would require VA to conduct a review of its capacity 
to establish a streamlined system for contacting all caregivers 
enrolled in PGCSS under section 1720G(b) to provide program updates and 
alerts to such caregivers relating to emerging services for which such 
caregivers may be eligible.

    VA Position: VA does not support this subsection because it is 
unnecessary.

    VA currently has a list-serve with more than 150,000 recipients 
where VA shares information regarding the caregiver program. This list 
is not limited to general caregivers but is available to anyone 
interested in the program. VA also regularly updates its website to 
provide new information or updates. While VA can conduct a review of 
how VA could establish a streamlined system for contacting caregivers, 
we do not believe this subsection is necessary.
    Section 6 would require VA to develop and maintain a centralized 
and publicly accessible internet website as a clearinghouse for 
information and resources relating to covered programs. The website 
would need to include a description of each covered program, an 
informational assessment tool that explains the administrative 
eligibility, if applicable, of a Veteran or caregiver for any covered 
program and provide information, because of such explanation, on any 
covered program for which the Veteran or caregiver (as the case may be) 
may be eligible. It also would have to include a list of required 
procedures for the directors of VAMCs to follow in determining the 
eligibility and suitability of Veterans for participation in a covered 
program, including procedures applicable to instances in which the 
resource constraints of a facility or the community where the facility 
is located may result in the inability to address the health needs of a 
Veteran under a covered program in a timely manner. VA would have to 
ensure the website is updated periodically.

    VA Position: VA does not support this section because it is 
unnecessary.

    VA supports efforts to ensure Veterans and their caregivers are 
aware of our programs. We appreciate the bill's clarification that the 
website need only describe administrative eligibility criteria. VA's 
existing websites (www.va.gov/geriatrics and https://
www.caregiver.va.gov/) provide general information about VA's programs 
and contain resources for additional information. VA has existing 
national policies in place that define how facility directors and staff 
implement these programs.
    Section 7(a) would require VA, within 18 months of enactment, to 
carry out a 3-year pilot program under which VA would provide homemaker 
and home health aide services to Veterans who reside in communities 
with a shortage of home health aides. VA would have to select not fewer 
than five geographic locations in which VA determines there is a 
shortage of home health aides at which to carry out the pilot program. 
VA would be authorized to hire nursing assistants as new VA employees 
or reassign nursing assistants who are existing employees to provide 
Veterans with in-home care services (including basic tasks authorized 
by the State certification of the nursing assistant) under the pilot 
program in lieu of or in addition to the provision of such services 
through non-VA home health aides. Nursing assistants could provide 
services to a Veteran under the pilot program while serving as part of 
a health care team for the Veteran under the Home-Based Primary Care 
program. VA would be required to submit a report to Congress not later 
than 1 year after the pilot program terminates on the result of the 
pilot program.

    VA Position: VA does not support this subsection.

    We agree with the Committee's interest in ensuring that Veterans in 
need of homemaker and home health aide services can access them, 
particularly in areas with shortages of such health aides, but we do 
not believe this pilot program would allow VA to recruit such health 
aides any more effectively than we can today. We currently have several 
pilot programs that are struggling to hire such health aides. We do not 
support this subsection as it seems unlikely to produce the intended 
results.
    Section 7(b) would require, not later than 1 year after the date of 
enactment, VA to provide a report to Congress with respect to the 
period beginning in FY 2012 and ending in FY 2023 containing an 
identification of the amount of funds that were included in a VA budget 
during such period for the provision of in-home care to Veterans under 
the Homemaker and Home Health Aide program but were not so expended, 
disaggregated by VAMC (if such disaggregation is possible). It also 
would have to include, to the extent practicable, an identification of 
the number of Veterans for whom, during such period, the hours during 
which a home health aide was authorized to provide services to the 
Veteran were reduced for a reason other than a change in the health 
care needs of the Veteran and a detailed description of the reasons why 
any such reductions may have occurred.

    VA Position: VA does not support this subsection because it is 
unnecessary.

    We certainly welcome congressional oversight, and we appreciate the 
flexibility this bill would provide relative to prior drafts. However, 
we do not believe this subsection is necessary. VA already has analyzed 
and compared appropriated and obligated amounts (including unused 
funds) related to the Homemaker and Home Health Aide program at an 
aggregate level, and we would be happy to share this information with 
the Committee.
    Section 7(c) of the bill would require VA, not later than one year 
after the date of enactment, to issue updated guidance for the 
Homemaker and Home Health Aide program. This guidance would have to 
include a process for the transition of Veterans from the Homemaker and 
Home Health Aide program to other covered programs and a requirement 
for VAMC directors to complete such process whenever a Veteran with 
care needs has been denied services from home health agencies under the 
Homemaker and Home Health Aide program because of the clinical needs or 
behavioral issues of the Veteran.

    VA Position: VA does not support this subsection because it is too 
prescriptive.

    VA recently published new guidance and procedures relating to the 
Homemaker and Home Health Aide program generally (including the 
transition process), so we do not believe a statutory requirement would 
be beneficial or necessary.
    Section 8(a) of the bill would require the Under Secretary for 
Health (USH) to conduct a review of each program administered through 
the Office of Geriatric and Extended Care (GEC) to ensure consistency 
in program management, eliminate service gaps at the medical center 
level, and ensure the availability of, and the access by Veterans to, 
home-and community-based services. VA also would have to assess the 
staffing needs of GEC, and the GEC Director would have to establish 
quantitative goals to enable aging or disabled Veterans who are not 
located near VAMCs to access extended care services (including by 
improving access to home-and community-based services for such 
Veterans). The GEC Director also would have to establish quantitative 
goals to address the specialty care needs of Veterans through in-home 
care, including by ensuring the education of home health aides and 
caregivers of Veterans in several areas. Not later than one year after 
the date of enactment, VA would have to submit to Congress a report 
containing: the findings of the review of each program, the results of 
the assessment of the staffing needs of GEC; and the quantitative goals 
required in this subsection.

    VA Position: We do not believe this subsection is necessary, but we 
have no objection to it, provided additional resources were made 
available to complete this review.

    Section 8(b) of the bill would require VA to conduct a review of 
the financial and organizational incentives of VAMC directors to 
establish or expand covered programs at such medical centers; any 
incentives for such directors to provide to Veterans home-and 
community-based services in lieu of institutional care; the efforts 
taken by VA to enhance VA spending for extended care by shifting the 
balance of such spending from institutional care to home-and community-
based services; and the USH's plan to accelerate efforts to enhance 
spending to match the progress of similar efforts taken by the Centers 
for Medicare & Medicaid Services Administrator for extended care. Not 
later than one year after the date of enactment, VA would have to 
submit to Congress a report on the findings of this review.

    VA Position: VA does not support this subsection.

    VA has already conducted an analysis of these incentives and does 
not believe this subsection is necessary. We would be happy to brief 
the Committee on the results of our earlier work.
    Section 8(c) of the bill would require VA, not later than two years 
from the date of enactment, to conduct a review of the use, 
availability, and effectiveness of the respite care services furnished 
by VA.

    VA Position: VA does not believe this section is necessary, but we 
have no objection to it.

    Section 8(d) of the bill would require that, not later than two 
years after the date of enactment, VA, in collaboration with HHS, 
submit to Congress a report containing recommendations for the 
expansion of mental health services and related support to the 
caregivers of Veterans. The report would have to include an assessment 
of the feasibility and advisability of authorizing access to Vet 
Centers by family caregivers enrolled in a program under section 1720G 
and family caregivers of Veterans participating in a program specified 
in section 1720K, as added by section 4 of this bill. VA would have to 
develop recommendations in two areas. First, VA would have to develop 
recommendations as to new services with respect to home-and community-
based services. These recommendations would have to be developed in 
collaboration with HHS. Second, VA would have to provide 
recommendations regarding methods to address the national shortage of 
home health aides in collaboration with HHS and the Department of Labor 
(DoL). VA would have to submit to Congress a report containing these 
recommendations and an identification of any changes in existing law or 
new statutory authority necessary to implement these recommendations. 
VA would have to consult with DoL in carrying out these requirements. 
In addition, VA would have to solicit from Veterans Service 
Organizations (VSO) and non-profit organizations with a focus on 
caregiver support, as determined by VA, feedback and recommendations 
regarding opportunities for VA to enhance home-and community-based 
services for Veterans and their caregivers, including through the 
potential provision by the entity of care and respite services to 
Veterans and caregivers who may not be eligible for any program under 
section 1720G or section 1720K but have a need for assistance. VA also 
would have to collaborate with the IHS Director and representatives 
from Tribal health programs and Urban Indian organizations to ensure 
the availability of home-and community-based services for Native 
American Veterans, including Native American Veterans receiving health 
care and medical services under multiple health systems.

    VA Position: VA does not support this subsection.

    VA has no objection to reporting to Congress on the feasibility and 
advisability of authorizing access to Vet Centers by family caregivers, 
but we do not believe it would be appropriate to expand access to Vet 
Centers for family caregivers in the manner intended as the focus of 
Vet Centers is on helping Veterans, Service members, and their families 
cope with deployment-related issues. Currently, Vet Centers provide a 
range of support for family members, including assistance to help loved 
ones cope during a Service member's deployment, bereavement services to 
eligible family members or services in connection with assisting the 
eligible Veteran or Service member in attaining their readjustment 
goals. Prior to providing readjustment counseling services to a family 
member of a Veteran or member of the Armed Forces, Vet Center 
counselors must confirm: (1) that a presenting problem inclusive of 
family relationship problems is clearly linked to the eligible 
Veteran's or Service member's military service and post military 
readjustment and (2) that the severity of the problem, as manifest in 
any family member, is one that can be addressed by Vet Center 
professionals acting within the scope of the Vet Center readjustment 
mission (a non-medical counseling service). The Vet Center facility and 
mission is not designed to address general mental health problems not 
linked to the eligible Veteran's or Service member's readjustment; 
caregivers who require support in relation to an eligible Veteran's or 
Service member's readjustment are already eligible for Vet Center 
services. When a family member, including family caregivers, receives 
readjustment counseling services through Vet Centers, these records are 
included as part of the eligible Veteran's or Service member's record. 
We do not establish separate records for the family members. VA can 
already provide support to such family caregivers in connection with a 
covered Veteran's treatment under section 1782. We are concerned that 
expanded eligibility to family caregivers who do not meet current 
eligibility requirements for family services would result in family 
caregivers presenting issues and concerns that would be outside the 
scope of Vet Center counselors, whose focus is on the effects of 
military service-related trauma and reintegration into civilian life. 
We also are concerned that making this population eligible for Vet 
Center services could result in significant additional demand on Vet 
Centers that would require additional resources to ensure that VA's 
current efforts to support combat Veterans and other eligible 
populations are not diluted.
    VA could develop recommendations regarding home-and community-based 
programs, but we have no expertise in addressing labor shortages of 
home health aides and recommend DoL prepare this report. VA can provide 
information specific to its programs upon request.
    VA regularly meets with VSO and non-profit organization staff on 
operations and improvements for home and community-based services. We 
also solicit Veteran and caregiver feedback through satisfaction 
surveys, listening sessions, a peer support mentoring program and other 
means.
    Section 9 of the bill would define various terms, including 
``covered program'' and ``home-and community-based services.'' The term 
``covered program'' would mean any VA program for home-and community-
based services and would include the programs specified in section 
1720K, as added by section 4 of the bill. ``Home-and community-based 
services'' would mean the services referred to in section 1701(6)(E) 
and include services furnished under a program specified in section 
1720K, as added by section 4 of the bill.

    VA Position: VA has no unique objections or concerns with this 
section.

H.R. 562 Improving Veterans Access to congressional Services

    H.R. 562 would require VA, upon request of a Member of Congress and 
subject to regulations, to permit the Member to use a VA facility for 
the purposes of meeting with constituents of the Member. VA and the 
General Services Administration (GSA) would have to jointly identify 
available spaces in VA facilities for such purposes. Within 90 days of 
enactment, VA would have to prescribe regulations regarding the use of 
facilities by Members of Congress. The regulations would have to 
require that a space within a facility of the Department provided to a 
Member is available during normal business hours, located in an area 
that is visible and accessible to constituents of the Member, and 
subject to a rate of rent that is like the rate charged by GSA for 
office space. The regulations could not prohibit a Member from 
advertising the use by the Member of a space within a VA facility, and 
would have to comply with the Hatch Act (5 U.S.C. Sec. Sec.  7321-7326) 
and 38 C.F.R. Sec.  1.218(a)(14) by prohibiting activities including: 
campaigning in support of or opposition to any political office; 
statements or actions that solicit, support or oppose any change to 
Federal law or policy; any activity that interferes with security or 
normal operation of the facility; photographing or recording a Veteran 
patient at such facility; photographing or recording a patient, visitor 
to the facility, or VA employee without the consent of such individual; 
and photography or recording for the purpose of political campaign 
materials. The regulations also could not permit a Member of Congress 
to use such a facility during the 60-day period preceding an election 
for Federal office in the jurisdiction in which such facility is 
located and could not unreasonably restrict use of a VA facility by a 
Member if there is space in such facility not in regular use by VA 
personnel and if use of such space would not impeded VA operations in 
the facility.

    VA Position: VA opposes this bill both because we can already 
provide space to Members of Congress in VA facilities under certain 
circumstances and because we object to the prescriptive requirements in 
the bill, requirements that could restrict VA's ability to serve 
Veterans effectively.

    Initially, in August 2017, VA's Office of Real Property issued Real 
Property Policy Memorandum 2017-06, Issuance of VA Revocable Permits to 
Members of Congress for Use of VA Space. This Memorandum contains 
helpful information for Members of Congress or their staffs to request 
space in VA facilities for purposes of providing constituent outreach. 
The Memorandum provides VA Form 10-6215 within as Exhibit C to request 
revocable permits. VA Form 10-6215 contains special conditions to 
ensure compliance with the Hatch Act and to protect patient privacy and 
confidential health information; no deviations from these special 
conditions are permitted. Legal review and concurrence from VA's Office 
of General Counsel must also be received prior to issuing a revocable 
permit.
    We object to the bill's requirement for VA to make available space 
in VA facilities for Members of Congress upon their request. Many of 
our facilities do not have space that would be conducive to an office 
for a Member of Congress, let alone multiple Members who may ask for 
office space in the same facility; other facilities raise unique 
concerns (such as medical facilities or cemeteries) that could make 
placement of an office for a Member of Congress inappropriate. In 
addition to the physical imposition on space that could otherwise be 
used for other purposes, such as furnishing health care, we note that 
the ancillary effects such as parking and increased traffic would 
present problems for many facilities that would require additional 
resources (e.g., security, maintenance, etc.). We believe the bill 
could create significant additional demands on our facilities for 
services that may not even be directly related to Veterans' benefits; 
we note the legislation includes no requirement that the constituent 
services provided by the Member of Congress be limited only to VA 
benefits or claims. Additionally, and as noted above, we are concerned 
about the potential Hatch Act complications that could arise from 
guaranteeing the use of VA facility space ``for the purposes of meeting 
with constituents of the Member''. We realize the bill would require 
VA's regulations to comply with the Hatch Act and 38 C.F.R. Sec.  
1.218(a)(14), but these arrangements would create an elevated risk for 
partisan political activities, and VA would have little to no means of 
monitoring compliance. Last, we want to emphasize that VA facilities 
are not public fora, and it is not consistent with VA's mission to 
allow their use for matters not related to VA business, such as general 
press conferences or interviews not related to Veterans or VA.
    The provisions of the bill are particularly problematic for VA 
facilities managed by the National Cemetery Administration. In addition 
to the concerns stated above regarding parking and increased traffic, 
VA national cemeteries have limited office space and are carefully 
designed to maximize burial space for Veterans and other eligible 
individuals. Requiring the national cemeteries to use available office 
space or to increase usable office space for this purpose would 
seriously detract from VA's mission of honoring the memory of those who 
served by providing burial in national shrines. In addition, requiring 
national cemeteries to allow signage that directs constituents to the 
location of a space for congressional consultation could disrupt the 
serenity of the national cemeteries and disturb the quiet contemplation 
of the families who have come to remember their loved ones in these 
solemn spaces.
    On a technical level, we have some concerns regarding the 
requirement to issue regulations under the bill. It is not immediately 
apparent what exactly VA would be regulating; presumably such 
regulations would only govern the process for approving requests or 
conditions on the use of space, but these would seem more appropriately 
established through policy (such as the Memorandum mentioned above) or 
through the permit or agreement allowing the Member of Congress to use 
the facility's space. VA would have no remedy for a violation of the 
regulation beyond terminating the permit or agreement to use space, 
which again could be established through the permit or agreement 
itself. If regulations were required, we caution that 90 days would be 
inadequate to promulgate regulations.
    VA is unable to develop a cost estimate at this time because we are 
unable to determine how many Members of Congress would request to use a 
VA facility or which facilities would be the subject of such requests. 
We believe the costs could be significant if there is great demand 
under this authority by Members of Congress.

H.R. 693 VACANT Act

    H.R. 693, the VA Medical Center Absence and Notification Timeline 
Act (the VACANT Act), would require VA, within 90 days of detailing a 
VAMC director to a different position in VA, to notify Congress of such 
detail. The notification would have to include the location at which 
the director is detailed, the position title of the detail, the 
estimated time the director is expected to be absent from their duties 
at the medical center, and such other information as VA determines 
appropriate. Within 120 days of detailing a VAMC director to a 
different position, VA would have to appoint an individual as acting 
director of such medical center with all the authority and 
responsibilities of the detailed director. Within 120 days of detailing 
a VAMC director to a different position within VA, and not less 
frequently than every 30 days thereafter while the detail is in effect 
or while the director position at the VAMC is vacant, VA would have to 
report to Congress with an update regarding the status of the detail. 
In general, not later than 180 days after detailing a VAMC director to 
a different position within VA, for a reason other than an ongoing 
investigation or administrative action with respect to the director, VA 
would have to return the individual to the position as VAMC director or 
reassign the individual from the position and begin the process of 
hiring a new director. VA could waive these requirements with respect 
to an individual for successive 90-day increments for a total period of 
not more than 540 days from the original date the individual was 
detailed away from the position as VAMC director, but VA would have to 
notify Congress of the waiver and provide to Congress information as to 
why the waiver is necessary not later than 30 days after exercising 
such a waiver.

    VA Position: VA supports, if amended.

    VA can notify Congress when a VAMC director is detailed out of 
their position. VHA immediately identifies and appoints a qualified 
individual to act in a VAMC director position as soon as the position 
becomes vacant. As such, the requirement to detail within 120-days is 
already being done in the agency.
    Submitting updates to Congress every 30-days would be a significant 
administrative burden to implement. VA proposes an amendment to H.R. 
693 that would reduce this burden by removing the requirement for a 30-
day update and replacing it with notification to Congress of any waiver 
of the 180-day limitation by the Secretary of Veterans Affairs.
    VA also proposes to amend H.R. 693 by removing the 540-days 
limitation on details and replacing it with the statutory and 
regulatory limits that govern details in the senior executive service 
(5 CFR 317.903) for positions at the GS-15 level or below or to a 
position with unclassified duties or from a senior executive service 
equivalent excepted service position.
    If unamended, H.R. 693 may imcontinuity of operations as well as 
on-going projects/initiatives that require the VAMC director's 
leadership.

    VA does not have a cost estimate for this bill.

H.R. 754 Modernizing Veterans' Health Care Eligibility Act

    Section 2 of H.R. 754 would establish a Commission on Eligibility 
to examine eligibility for VA health care. For ease of understanding, 
the provisions of this bill will be summarized in terms of their 
requirements related to the appointment of the Commission and other 
personnel matters, then the powers and duties of the Commission.

Appointment and Personnel Matters

    The Commission would be composed of 15 voting members appointed by 
congressional leaders and the President (who would appoint the 
Chairperson). At least one member would have to represent an 
organization recognized by VA for the representation of Veterans under 
38 U.S.C. Sec.  5902; at least one member would have to have experience 
as senior management for a private integrated health care system with 
an annual gross revenue of more than $50 million; at least one member 
would have to be familiar with Government health care systems 
(including those of the Department of Defense (DoD), IHS or federally 
qualified health centers); and at least one member would have to be 
familiar with, but not currently employed by, the Veterans Health 
Administration. The appointment of the Commission members would have to 
be made within 1 year of enactment, and members would be appointed for 
the life of the Commission. If a vacancy arose, it would not affect the 
powers of the Commission and would be filled in the same manner as the 
original appointment. The Commission's first meeting would have to 
occur not later than 15 days after the date on which eight voting 
members have been appointed. The Commission would meet at the call of 
the Chairperson, and a majority of members would constitute a quorum, 
but a lesser number could hold hearings.
    Members of the Commission who are not an officer or employee of the 
Federal Government would be compensated at a rate equal to the daily 
equivalent of the annual rate of basic pay prescribed for level IV of 
the Executive Schedule under 5 U.S.C.Sec.  5315 for each day (including 
travel time) during which such member is engaged in the performance of 
the duties of the Commission. Members of the Commission who are 
officers or employees of the United States would serve without 
compensation in addition to that received for their services as 
officers or employees of the United States. Members of the Commission 
would be allowed travel expenses, including per diem in lieu of 
subsistence, at rates authorized under subchapter I of chapter 57 of 
title 5, U.S.C., while away from their homes or regular places of 
business in the performance of services for the Commission. The 
Chairperson of the Commission could, without regard to the civil 
service laws and regulations, appoint and terminate an executive 
director and such other personnel as may be necessary to enable the 
Commission to perform its duties. The Chairperson could fix the 
compensation of the executive director and staff without regard to 
chapter 51 and subchapter III of chapter 53 of title 5, United States 
Code, except that the rate of pay for these staff could not exceed the 
rate payable for level V of the Executive Schedule under 5 U.S.C. Sec.  
5316. Any Federal Government employee could be detailed to the 
Commission without reimbursement, but such would be without 
interruption or loss of civil service status or privilege. The 
Chairperson could procure temporary and intermittent services under 5 
U.S.C. Sec.  3109(b) at rates for individuals that do not exceed the 
daily equivalent of the annual rate of basic pay prescribed for level V 
of the Executive Schedule under 5 U.S.C. Sec.  5316. The Commission 
would terminate 30 days after the date on which the Commission submits 
its final report. VA would make available to the Commission such 
amounts as the Secretary and Chairperson jointly consider appropriate 
for the Commission to perform its duties under this section.

Powers and Duties

    The Commission would have the power to hold hearings, sit and act 
at such time and places, take testimony and receive evidence as the 
Commission considers advisable. The Commission could secure directly 
from any Federal agency such information as it considers necessary to 
carry out this section, and upon request of the Chairperson, the heads 
of such agencies would be required to furnish such information to the 
Commission. The Commission would be required to undertake a 
comprehensive evaluation and assessment of eligibility to receive 
health care from VA. In undertaking this evaluation, the Commission 
would have to evaluate and assess general eligibility; eligibility of 
Veterans with service-connected conditions; eligibility of Veterans 
with non-service-connected conditions; eligibility of Veterans who have 
other insurance or health care coverage (including Medicare and 
TRICARE); eligibility of Veterans exposed to combat; eligibility of 
Veterans exposed to toxic substances or radiation; eligibility of 
Veterans with discharges under conditions other than honorable; 
eligibility for long-term care; eligibility for mental health care, 
assigned priority for care, required copayments and other cost-sharing 
mechanisms; and other matters the Commission determines appropriate.
    The Commission would submit to the President, through VA, a report 
not later than 90 days after the date of the initial meeting on the 
Commission's findings with respect to the required evaluation and 
assessment and such recommendations as the Commission may have for 
legislative or administrative action to revise and simplify eligibility 
to receive health care from VA. Not later than one year after the date 
of the initial meeting, the Commission would have to submit a final 
report on the findings of the Commission with respect to the required 
evaluation and assessment and such recommendations as the Commission 
may have for legislative or administrative action to revise and 
simplify eligibility to receive VA health care. The President would 
require VA and such other heads of relevant Federal Departments and 
agencies to implement such recommendations set forth in the 
Commission's final report that the President considers feasible and 
advisable and determines can be implemented without further legislative 
action. Not later than 60 days after the date on which the President 
receives a report from the Commission, the President would have to 
submit to the Committees on Veterans' Affairs of the House of 
Representatives and Senate and such other Committees as the President 
considers appropriate, a report. The report would have to include an 
assessment of the feasibility and advisability of each recommendation 
contained in the Commission's final report, and for each recommendation 
assessed as feasible and advisable, whether such recommendation 
requires legislative action (and if so, whether such legislative action 
is recommended), a description of any administrative action already 
taken to carry out a recommendation and a description of any 
administrative action the President intends to be taken to carry out a 
recommendation and by whom.

VA Position: VA opposes this bill.

    We appreciate the Committee's interest in assessing eligibility for 
VA health care. Eligibility is the doorway that allows Veterans and 
other beneficiaries to access VA services, so it is fundamental to 
everything we do. In some respects, though, it is inaccurate to think 
of eligibility as a single door - there are many laws that establish 
eligibility for certain VA benefits and for certain veterans and other 
Veteran affiliated populations. The President believes we have a sacred 
obligation to care for those who we send into harm's way - and to care 
for them and their families when they return home. Eligibility criteria 
for VA benefits are a key enabler of how we do that as a Nation, and VA 
was established out of this sacred obligation. Eligibility for benefits 
have evolved over time as warfare and national security requirements 
have shifted in a manner to support the All Volunteer Force. We 
continue to owe our Nation's Veterans access to world-class benefits 
and services. Eligibility determinations can also be quite complex 
because Veterans or other beneficiaries may qualify for the same or 
similar services under multiple different laws - laws enacted by 
Congress to ensure we meet the needs of a diverse Veteran population. 
As an example, VA recently reviewed its authorities related to the 
provision of mental health care and identified more than 20 different 
statutes that defined eligibility for different services or different 
populations. These varying standards and rules can make for Veterans 
and the public to understand. However, complexity is not necessarily a 
problem if it produces the right results for Veterans. Our primary 
focus, is ensuring that our system is designed to provide what is best 
for Veterans. To the extent Congress believes eligibility has become 
too complex, we believe VA and Congress can work together directly to 
address these issues and that a Commission would be unnecessary.
    VA opposes this bill as currently drafted, due to several concerns. 
First, the intended outcome of the Commission is not clear. As drafted, 
the tasking to the Commission is exceptionally broad and there is no 
language to help direct or frame their review. Depending upon the 
composition and specific focus of the Commission, it may recommend 
narrowing or expanding eligibility (or both, but in different ways or 
for different populations). Given the central role of eligibility in 
accessing VA health care services, proposed changes could have far-
reaching effects and unintended consequences, including effects on the 
amount of resources VA needs to execute its responsibilities. We are 
particularly mindful of the potential effects changes to eligibility 
may have on current beneficiaries. We would appreciate the opportunity 
to discuss with the Committee the underlying concerns motivating this 
bill, as we may be able to identify alternatives to strengthen the 
system. As noted earlier, VA is authorized to provide forms of mental 
health care under more than 20 different authorities. Addressing some 
of these areas first could have a more immediate beneficial impact.
    There are elements of the Commission on Eligibility's duties that 
we believe should be reconsidered as well. First, we note that the 
Commission is not required to consider the definition of who is a 
Veteran for purposes of VA health care. As important as eligibility is, 
the definition of who is a Veteran precedes that analysis. This may be 
an important element to consider given the bill's focus. Second, the 
bill does not specifically address eligibility for community care, and 
it is unclear if that is within the intended scope. Given the 
relatively recent enactment of the VA Maintaining Internal Systems and 
Strengthening Integrated Outside Networks Act of 2018 and the creation 
of the Veterans Community Care Program in 2019, that may be 
unnecessary, but the Commission should contemplate the effects that 
eligibility changes might have on modeling for demand and our network 
of community providers. Third, we believe it would be important for the 
Commission to focus on disparities in access to health care and to 
consider whether there is equitable access to VA health care as well. 
These are important issues to VA, as we strive to understand barriers 
to opportunity with the goal of providing everyone, especially those in 
underserved communities, with fair access to health care and benefits.
    The bill would direct the Commission to consider Veterans exposed 
to toxic substances or radiation during military service. We note that 
VA is already working to expand its focus on environmental exposures 
and to implement the Honoring our PACT Act (PL 117-168). Another area 
of focus in the bill is on Veterans eligible for Medicare and TRICARE. 
As VA previously testified before the Oversight and Investigations and 
Technology Modernization Subcommittees on March 30, 2022, we agree that 
the Federal Government should not pay twice for the same medical 
services. The bill would also have the Commission examine eligibility 
for long-term care. Eligibility for institutional extended care was 
established by law more than 20 years ago and has remained stable. The 
elderly population in America, though, is growing. As Veterans age, 
approximately 80 percent will develop the need for long-term care 
services and supports. Some of VA's top efforts focus on helping 
Veterans as they age at home, and VA operates a spectrum of Home-Based 
and Community-Based Services. We want to emphasize that the 
Commission's examination of eligibility for long-term care should 
consider the increasing number of non-institutional alternatives VA has 
developed and offers to ensure an accurate reflection of the 
availability of clinically appropriate care. Additionally, the bill 
would provide the Commission with authority to directly secure 
information it considers necessary, and agencies would be required to 
provide such information. As drafted, this authority resembles the 
authority of the Inspector General or Comptroller General to obtain 
documents. The bill appears to allow parties external to VA to be 
members of the Commission; as a result, this sweeping authority could 
pose issues not generally present when information is shared within an 
agency or between two or more agencies of the executive branch.
    VA has additional concerns about this bill relative to the Federal 
Advisory Committee Act (FACA) and other provisions of law. The bill 
establishes a potential inconsistency with FACA given that the 
Commission's mission may overlap with multiple existing VA Federal 
Advisory Committees (e.g., the Special Medical Advisory Group, the 
Advisory Committee on Women Veterans, the Advisory Committee on 
Minority Veterans, the Advisory Committee on Former Prisoners of War, 
the Veterans Rural Health Advisory Committee, and others). The bill 
also establishes potential inconsistencies with both FACA and the 
Government in the Sunshine Act based on its provisions allowing for a 
quorum of Commissioners to meet and make decisions without a Charter, a 
Federal Register notice of meeting, or a Designated Federal Officer 
present. The bill presents another potential inconsistency with FACA by 
allowing for less than a quorum of Commissioners to meet and make 
decisions without being designated an official subcommittee without a 
Designated Federal Officer present. The bill would override important 
civil service laws for Commission personnel that govern merit systems, 
whistleblower, anti-discrimination, and prohibited personnel 
protections, as well as for suitability and security. The bill could 
also present challenges with the Office of Personnel Management Special 
Government Employee workday limit (less than 130 days per year) given 
the estimated level of effort that would be involved with this 
Commission. The bill does not clarify whether the Commission must abide 
by the National Records Act or the Presidential Records Act. Finally, 
the bill presents issues concerning the Federal employee status of the 
Commissioners.
    We note for the record that, while this bill would not alter 
eligibility for any care or services, the Commission's recommendations 
ultimately could lead to such changes through subsequent action, and 
the financial effects of eligibility changes could be significant. We 
recommend the Committee bear this in mind as it continues to consider 
this bill. We further note that, if VA is responsible for the 
activities of the Commission, there would be increased costs to the 
Department to cover the administrative expenses of the Commission.

    We do not have a cost estimate for this bill.

H.R. 808 Veterans Patient Advocacy Act

    H.R. 808 would amend 38 U.S.C. Sec.  7309A to require, beginning no 
later than 1 year after enactment, VA to ensure that there is no fewer 
than one patient advocate for every 13,500 enrolled Veterans and that 
highly rural Veterans may access the services of patient advocates, 
including, to the extent practicable, with respect to assigning patient 
advocates to rural Community-Based Outpatient Clinics (CBOCs). Within 2 
years of enactment, the Comptroller General would have to submit to 
Congress a report evaluating the implementation by VA of these changes.

    VA Position: VA supports the intent of this bill but does not 
support this bill as written.

    VA supports the goal of the Veterans Patient Advocacy Act to ensure 
Veterans have adequate access to patient advocacy services no matter 
where they live. Over the last few years, the role of the patient 
advocate has expanded since the enactment of the Comprehensive 
Addiction and Recovery Act of 2016 (P.L. 114-198), the VA MISSION Act 
of 2018 (P.L. 115-182), Johnny Isakson and David P. Roe, M.D. Veterans 
Health Care and Benefits Improvement Act of 2020 (P.L. 116-315), the 
Veterans COMPACT Act of 2020 (P.L. 116-214), and the Honoring our PACT 
Act of 2022 (P.L. 117-168).
    VA has been working to identify the best approach to ensuring 
Veterans can access patient advocates and advocacy services as needed 
to support the delivery of their care. VA has explored establishing a 
set ratio, as the bill would do, but believes that a focus on program 
outcomes would be a better model. Focusing on outcomes ensures that the 
things that matter most to Veterans are VA's focus, while preserving 
flexibility in hiring and staffing to ensure that our facilities have 
the personnel and resources needed to deliver timely, high quality, and 
high satisfaction care. VA is concerned that a specific staffing ratio 
for patient advocates could result in facilities having too many 
patient advocates and too few providers or other necessary support 
staff. Advances in technology or different staffing models may yield 
the same or even better outcomes for Veterans than a codified staffing 
ratio would do.
    VA is currently analyzing data from its facilities to determine how 
best to proceed in this area, and we request the Committee refrain from 
further action until this analysis is complete. VA wants to ensure that 
the Patient Advocacy Program is responsive to Veterans' needs based on 
evidence of what those needs are. VA would be happy to brief the 
Committee on its efforts in this regard. Although the data collected 
provided insights to overall staffing levels, it is not clear to what 
extent across VA a patient advocate is designated specifically to rural 
or highly rural CBOCs. VA will analyze the data with this consideration 
in mind to advance and expand access to patient advocacy services 
across VA.
    VA also expresses some concern regarding the timeline for 
implementation that would be required; we are uncertain that one year 
would be enough time to implement the changes the bill would institute.

    VA does not currently have a cost estimate for this bill.

H.R. 1089 VA Medical Center Facility Transparency Act

    Section 2 of the bill would require VA to ensure that each VAMC 
director submits to the Secretary, the Committees on Veterans' Affairs 
of the House of Representatives and the Senate, and the appropriate 
Members of Congress an annual, concise, easy-to-read fact sheet with 
certain statistical information with respect to the year covered by the 
fact sheet. The fact sheets would also need to include a description of 
any successes or achievements experienced by such facilities, a 
description of special areas of emphasis or specialization by such 
facilities (such as efforts aimed at meeting the needs of women 
Veterans, suicide prevention and other mental health initiatives, 
opioid abuse prevention and pain management, or special efforts on 
Veteran homelessness, or other matters as the director determines 
appropriate), and a description of matters that have previously been 
identified as deficient and are still in need of remediation. Directors 
would also have to publish quarterly fact sheets containing the average 
wait times for Veterans to receive treatment at the VAMC. Each fact 
sheet would have to be made publicly available in a physical form at 
the facility in a conspicuous location and in an electronic form on the 
facility's website. Fact sheets would have to be submitted during the 
first fiscal year beginning after the date that is 180 days after the 
date of enactment and would have to be submitted at least annually (for 
the annual fact sheets) and quarterly (for the quarterly fact sheets). 
VA would have to establish a standardized format for the fact sheets to 
ensure that each VAMC director carries out this authority in a 
consistent manner. The term ``appropriate Members of Congress'' would 
mean, with respect to a VA medical facility about which a fact sheet is 
submitted, the Senators representing the State, and the Member, 
Delegate, or Resident Commissioner of the House of Representatives 
representing the district that includes the facility.

    VA Position: VA does not support this bill.

    VA has several concerns with this bill as written because of its 
specificity. We understand the fundamental interest or concern of the 
bill, but VA already provides significant information online about 
patient experience, wait times, and quality for each VAMC. Wait time 
data is further broken down into primary care and specialty care areas, 
while the bill would require VA to report a single wait time standard. 
Repackaging or revising this information to meet the specific 
requirements in this bill would further increase costs without an 
expected benefit, and in some ways could result in misleading or 
inaccurate information being provided to Veterans and the public.
    The requirement for each VAMC director to submit to Congress 
directly on an annual basis these fact sheets would be very involved 
and would require each facility to establish redundant processes and 
systems; allowing the Secretary to distribute this information instead 
would allow for economies of scale and better standardization. Further, 
fact sheets of the Department are required by (the Veterans and Family 
Information Act (P.L. 117-62) to be published in more than 10 different 
languages. Again, requiring 140 different VAMCs to produce this content 
separately would result in significant additional costs than a 
centrally managed process.
    We also believe some of the specific requirements that must be 
included in the fact sheets are unclear or would be difficult to gather 
or likely of little use. For example, the bill would require the fact 
sheets to provide statistics regarding the number of Veterans who were 
treated at ``a medical facility of the Department under the 
jurisdiction of the director''. In some areas, VA operates contracted 
CBOCs that are not legally under the jurisdiction of the VAMC director; 
excluding these locations could create an inaccurate representation of 
the care VA furnishes. Further, Veterans who are eligible to and elect 
to receive their care upon VA authorization from community providers 
may not be ``treated at a medical facility of the Department'' but 
still reflect VA workload. The bill also requires providing statistics 
regarding ``the most common illnesses or conditions for which treatment 
was furnished'' would likely result in concerns common among primary 
care appointments (such as the common cold or the flu). Finally, the 
required congressional audience is likely too narrow. Many facilities 
serve Veterans from more than one State and more than one congressional 
district. Limiting the distribution to only those Senators who 
represent the State and the Representative, Delegate, or Resident 
Commissioner of the district where the facility is located would likely 
result in some Members with legitimate interest in the facility not 
being included in the distribution.

    We do not currently have a cost estimate for this bill.

H.R. 1256 VHA Leadership Transformation Act

    Section 2(a) of the draft bill would amend 38 U.S.C. Sec.  
305(a)(1) to establish a 5-year term for the Under Secretary for 
Health.

    VA Position: VA has no objection to this subsection. Setting a 5-
year term could provide VA with continuity of operations when there is 
a change in Presidential administrations and could allow VA to continue 
providing support and care to our Nation's Veterans without 
interruption.

    Section 2(b) of the draft bill would amend 38 U.S.C. Sec.  
7306(a)(3) to allow VA to appoint as many Assistant Under Secretaries 
for Health as it determines appropriate.

    VA Position: VA fully supports this subsection, which is consistent 
with a VA legislative proposal in the FY 2024 budget request.

    This change would give VA the flexibility to recruit and retain 
highly qualified executives with various experience to fill these 
critical leadership positions.
    Section 2(c) of the draft bill would further amend section 7306 by 
striking subsection (b), which provides certain qualifications and 
limitations regarding Assistant Under Secretaries for Health. It would 
also make other conforming changes.

    VA Position: VA supports this subsection, which is also consistent 
with VA's legislative proposal in the FY 2024 budget request.

    This subsection would allow VA to recruit the best qualified 
candidates, regardless of their health care professional background. 
This is critical to achieving VA's goals for quality, timely, and safe 
patient care. While VA recognizes the need for a clinical background 
for some Assistant Under Secretary for Health positions, the 
requirements of those positions should be identified in the position 
description or policy establishing that position, rather than statute.
    VA estimates this bill would result in no additional costs as there 
are no new resources required to implement these flexibilities.

Conclusion

    This concludes my statement. We would be happy to answer any 
questions you or other Members of the Subcommittee may have.
                                 ______
                                 

                    Prepared Statement of Jon Retzer

    Chairwoman Miller-Meeks, Ranking Member Brownley and Members of the 
Subcommittee:
    Thank you for inviting DAV (Disabled American Veterans) to testify 
at today's legislative hearing of the Subcommittee on Health. DAV is a 
congressionally chartered non-profit veterans service organization 
(VSO) comprised of more than one million wartime service-disabled 
veterans that is dedicated to a single purpose: empowering veterans to 
lead high-quality lives with respect and dignity. DAV is pleased to 
offer our views on the bills under consideration today by the 
Subcommittee.

                H.R. 41, the VA Same-Day Scheduling Act

    H.R. 41, the VA Same-Day Scheduling Act of 2023, would direct the 
Secretary of Veterans Affairs to ensure the timely scheduling of 
appointments for health care at medical facilities of the Department of 
Veterans Affairs (VA).
    The Veterans Health Administration (VHA) operates the largest 
integrated health care delivery system in the United States, providing 
health care to approximately 6.4 million veterans annually. In the last 
decade, Congress has taken steps to expand access for eligible veterans 
to receive care from community providers when they face challenges 
accessing care at VHA medical facilities; these steps include 
establishing the Veterans Community Care Program in 2019. While most 
veterans still receive the majority of their care at VHA facilities, 
including 170 VA medical centers (VAMC) and over 1,000 outpatient 
facilities, approximately 2 million veterans received care from non-VHA 
providers in the community in Fiscal Year 2021, according to VA.
    In recent years, the Government Accountability Office (GAO) and 
others have reviewed VA's scheduling process and identified specific 
challenges that VHA has in ensuring that both VHA and community care 
appointments are scheduled in a timely manner. For example, GAO 
reported (GAO 23-105617) that VHA's appointment scheduling process for 
care from community providers was structured in a way that made it 
difficult to meet the statutorily required timeframes for veterans to 
receive care. This required timeframe specified the number of days it 
should take for a veteran to receive care under the Veterans Choice 
Program--the precursor to the current community care program. GAO 
recommended that VHA establish an achievable wait-time goal for the new 
community care program to monitor whether wait times for veterans to 
receive care in the community are comparable with those at VHA 
facilities. Due to this concern with wait times and other issues, VHA 
health care continues to be on GAOs' High Risk List.
    This legislation would require the Secretary to ensure that 
whenever a veteran contacts the Department by telephone to request the 
scheduling of an appointment for care or services at any VA facility, 
the scheduling for the appointment occurs during that telephone call 
(regardless of the prospective date of the appointment being 
scheduled).
    DAV strongly supports H.R. 41, in accordance with DAV Resolution 
No. 435, as it would improve current scheduling procedures and require 
real-time scheduling practices that ensure more timely access to 
quality health care services.

                H.R. 366, the Korean American VALOR Act

    H.R. 366, the Korean American Vietnam Allies Long Overdue for 
Relief Act, or the Korean American VALOR Act, would recognize and treat 
certain individuals who served in Vietnam as a member of the armed 
forces of the Republic of Korea as a veteran of the Armed Forces of the 
United States for purposes of the provision of health care by the VA.
    Currently, section 109 of title 38, United States Code, provides 
benefits for discharged members of allied armed forces of governments 
associated with the United States in World War I and II, except any 
nation which was an enemy of the United States during World War II. The 
Secretary may prescribe medical, surgical, and dental treatment, 
hospital care, transportation and travel expenses, prosthetic 
appliances, education and training. Hospitalization in a Department 
facility shall not be afforded under this section, except in 
emergencies, unless there are available beds surplus to the needs of 
veterans of this country.
    This legislation would add a new subsection to section 109 of title 
38, United States Code, to allow a person whom the Secretary determines 
served in Vietnam as a member of the armed forces of the Republic of 
Korea at any time during the period beginning on January 9, 1962, and 
ending on May 7, 1975, or such other period as determined appropriate 
by the Secretary to be eligible for health care treatment by the VA.
    DAV does not have a specific resolution to provide VA health care 
treatment for individuals who served in Vietnam as a member of the 
armed forces of the Republic of Korea alongside the Armed Forces of the 
United States as outlined in H.R. 366 and takes no formal position on 
this bill.

               H.R. 542, the Elizabeth Dole Home Care Act

    H.R. 542, the Elizabeth Dole Home-and Community-Based Services for 
Veterans and Caregivers Act would improve VA home-and community-based 
services for veterans by expanding options for long-term care (LTC) 
services and supports.
    Title 38, United States Code, subsection 1720 C(a)(1), (2) notes 
that ``the Secretary may furnish medical, rehabilitative, and health-
related services in noninstitutional settings for veterans who are 
eligible under this chapter for, and are in need of, nursing home care 
for veterans who are in receipt of, or are in need of, nursing home 
care primarily for the treatment of a service-connected disability; or 
have a service-connected disability rated at 50 percent or more.''

    This bill adds new subsections to subsection 1720 that would direct 
the Secretary to expand options for LTC through:

      The Program of All-inclusive Care for the Elderly (PACE);

      Veteran-Directed Care;

      Homemaker and Home Health Aide;

      Home-Based Primary Care; and

      Purchased Skilled Home Care.

    Additionally, the Purchased Skilled Home Care Program would provide 
caregiver support services, which includes covered respite services and 
annual wellness contact.
    Subsection 1720 C(d), states that the total cost of providing 
services or in-kind assistance may not exceed 65 percent of the cost 
during that fiscal year. This bill would amend this section by 
increasing the expenditure cap from 65 percent to 100 percent for 
provided services or in-kind assistance--not to exceed 100 percent of 
the cost per year.
    Over the next two decades, an aging veteran population, including a 
growing number of service-disabled veterans with specialized care 
needs, will require LTC. While the overall veteran population is 
decreasing, the number of veterans in the oldest age cohorts with the 
highest use of LTC services is increasing significantly. For example, 
the number of veterans with disability ratings of 70 percent or higher, 
which guarantees mandatory LTC eligibility, and who are at least 85 
years old is expected to grow by almost 600 percent--therefore, costs 
for LTC services and supports will need to double by 2037 just to 
maintain current services.
    In order to meet the exploding demand for LTC for veterans in the 
years ahead, Congress must provide the VA resources to significantly 
expand home-and community-based programs, while also modernizing and 
expanding facilities that provide institutional care. The VA must focus 
on addressing staffing and infrastructure gaps in order to maintain 
excellence in skilled nursing care. The VA also needs to expand access 
nationwide to innovative and cost-effective home-and community-based 
programs, such as veteran-directed care and medical foster home care. 
Unfortunately, funding for home-and community-based services in recent 
years has not kept pace with population growth, demand for services or 
inflation. For noninstitutional care to work effectively, these 
programs must focus on prevention and engage veterans before they have 
a devastating health crisis that requires more intensive institutional 
care.
    DAV supports H.R. 542, the Elizabeth Dole Home-and Community-Based 
Services for Veterans and Caregivers Act, in accordance with DAV 
Resolution No. 016, which calls for legislation to improve the VA's 
program of long-term services and supports and increase timely access 
to both institutional and noninstitutional long-term services and 
supports.

 H.R. 562, the Improving Veterans Access to congressional Services Act 
                                of 2023

    H.R. 562, the Improving Veterans Access to congressional Services 
Act of 2023, would direct the Secretary of Veterans Affairs to permit 
Members of Congress to use VA facilities for the purposes of meeting 
with constituents.
    The VA Secretary and the Administrator of General Services would 
jointly identify available spaces in facilities of the Department for 
such purposes.

    The space within a facility of the Department provided to a member 
would be:

      Available during normal business hours;

      Located in an area that is visible and accessible to 
constituents of the member;

      Subject to a rate of rent (payable from the member's 
Representational Allowance or the Senator's Official Personnel and 
Office Expense Account) that is similar to the rate charged by the 
Administrator of General Services for office space in the area of the 
facility; and

      May not prohibit a member from advertising the use by the 
member of a space within a facility of the Department.

    Prohibited activities include:

      Campaigning in support of or opposition to any political 
office;

      Statements or actions that solicit, support, or oppose 
any change to Federal law or policy;

      Any activity that interferes with security or normal 
operation of the facility;

      Photographing or recording a veteran patient at such 
facility;

      Photographing or recording a patient, visitor to the 
facility, or employee of the Department without the consent of such 
individual;

      Photography or recording for the purpose of political 
campaign materials;

      Using a facility during the 60-day period preceding an 
election for Federal office in the jurisdiction in which such facility 
is located; and

      Unreasonably restricting use of a facility of the 
Department by a member if:

          there is space in such facility not in regular use by 
        personnel of the Department; and

          use of such space shall not impede operations of the 
        Department in such facility.

    DAV does not have a specific resolution that directs the Secretary 
of Veterans Affairs to permit Members of Congress to use VA facilities 
as proposed in H.R. 562 and takes no formal position on this bill.

                        H.R. 693, the VACANT Act

    H.R. 693, the VA Medical Center Absence and Notification Timeline 
Act or the VACANT Act, would limit the detailing of VA medical center 
directors to different positions within the Department.
    Over the past several years, the GAO added VA health care and 
acquisition management to its High-Risk List. This list identifies 
areas that are most vulnerable to fraud, waste, abuse, mismanagement, 
or the need for transformation. VA has made marked progress recently in 
addressing these high-risk issues by identifying root causes of the 
deficiencies and establishing action plans to address them. However, 
these are only the initial steps of the long-term commitment required 
to achieve transformational change.
    The total number of veterans enrolled in VA's health care system 
increased from 7.9 million to about 9.2 million from FY 2006 through FY 
2022. GAO has identified challenges related to VA's management and 
oversight of its health care system, including:

      Ensuring veterans' health care appointments are scheduled 
in a timely manner;

      Having complete information to determine if it has an 
adequate number of health care providers to meet veterans' needs;

      Effectively identifying and meeting the demand for mental 
health and other behavioral health services among veterans; and

      Ensuring timely implementation while addressing data 
quality issues as it works to modernize its electronic health record 
system.

    Addressing each of these longstanding challenges requires sustained 
leadership and strong management and would help ensure veterans receive 
the care and benefits they deserve. Given the scope of VA's 
responsibility to serve veterans, effectively addressing its management 
challenges will require sustained commitment from VA leadership.
    This legislation would require the VA Secretary to appoint a VA 
Medical Center director as acting director after detailing that 
director to a different position within the Department. The individual 
appointed as acting director would be afforded all of the authority and 
responsibilities of the detailed director. The VA Secretary would also 
be required to notify the House and Senate Veterans' Affairs Committees 
of such detail, including the location at which the director is 
detailed; the position title of the detail; the estimated time the 
director is expected to be absent from their duties at the medical 
center; and any other information as the Secretary may determine 
appropriate.
    Last, this bill requires, not later than 180 days after such detail 
with limited exception, that the Secretary return the individual as 
director of the medical center or reassign the individual from the 
position as director of the medical center and begin the process of 
hiring a new director for such position.
    This legislation would help improve accountability to sustain 
needed leadership to ensure the VA health care system runs seamlessly 
during a period of transition and that veterans' continuity of care and 
benefits are not disrupted.
    DAV supports this legislation in accordance with DAV Resolution No. 
056, which recognizes that staffing shortages and vacancies at every 
level of the VA health care system, especially for critical management 
positions, can impede the delivery of care for service-disabled 
veterans who rely on the VA to receive timely, high-quality, veteran-
centric medical care.

     H.R. 754, the Modernizing Veterans Health Care Eligibility Act

    This legislation would establish a Commission on Eligibility to 
examine policies guiding veterans' health care eligibility and make 
recommendations, if feasible and advisable, to change them. The 
Commission would be composed of 15 members appointed by the President; 
Senate Majority Leader; Senate Minority Leader; House Speaker and House 
Minority Leader (three each, at least one of whom would be a veteran). 
The President would designate the chair of the Commission and at least 
one member must be appointed from a veterans service organization; one 
member that has worked for a large private health care system; one 
representative with experience in a government health care system; and 
one individual familiar with the VHA, but not currently employed there.
    The Commission would be required to hold its first meeting no later 
than 15 days after a majority of its members are appointed and issue a 
preliminary report with findings and recommendations no later than 90 
days after its first meeting and a final report and recommendations no 
later than one year from its initial meeting. The President would then 
be required to submit a report to Congress on the advisability and 
feasibility of each recommendation, along with the executive actions 
and legislation necessary to implement them. DAV believes these 
proposed timelines would not allow individuals selected for the 
Commission, who may have little familiarity with the VA, its mission, 
and the specialized programs it has created for the veterans it serves, 
enough time to undertake a comprehensive evaluation and assessment of 
the eligibility system and to understand the nuanced policy decisions 
Congress has legislated since the establishment of the VA health care 
system.
    Additionally, we do have concern about previous efforts proposing 
to diminish the size and scope of the veterans' health care system, 
whether by proposing changes in eligibility to limit the number of 
veterans who may receive care or by pressing for privatization of VA 
medical services. Congress has made thoughtful decisions about assigned 
priority for care and eligibility for various groups of veterans 
outlined in this bill--including service-disabled veterans and most 
recently expanding eligibility for veterans exposed to combat and or 
toxic exposures or radiation, under the PACT Act and veterans in mental 
health crisis, under the Compact Act. These two pieces of bipartisan 
legislation that became law, are good examples of Congress maintaining 
an eligibility system that meets the needs of our Nation's veterans 
including our newest generation of wartime veterans. We appreciate 
Congress' oversight in providing VA the authority to exercise and 
implement new requirements of eligibility to veterans who have rightly 
earned access to VA health care.
    Veterans' health care eligibility and VA's medical benefits package 
for enrolled veterans are clearly defined in title 38, United States 
Code, and accompanying Federal regulation and continue to be modified 
in accordance with the needs of veterans at Congress' and the 
Administration's discretion. Because Congress has full authority to 
modify eligibility requirements or VA's medical care benefits package 
through the legislative process, it is unclear why a special outside 
commission is necessary.
    We prefer that Congress continue to make decisions in the best 
interests of veterans by conducting oversight of VA health care 
eligibility and legislating the changes it deems necessary.

              H.R. 808, the Veterans Patient Advocacy Act

    H.R. 808, the Veterans Patient Advocacy Act, would improve the 
assignment of patient advocates at VA medical facilities.
    The Veterans Health Administration (VHA) has designated patient 
advocates at each VA medical center (VAMC) to receive and document 
feedback from veterans or their representatives, including requests for 
information, compliments, complaints and assist with clinical appeals. 
In recent years, the importance of a strong patient advocacy program 
has taken on new significance given concerns with VHA's ability to 
provide veterans timely access to health care, among other issues.
    VHA provided limited guidance to VAMCs on the governance of patient 
advocacy programs and its guidance, a program handbook, has been 
outdated since 2010. VAMCs are still expected to follow the outdated 
handbook, which does not provide needed details on governance, such as 
specifying the VAMC department to which patient advocates should 
report. Officials from most of the VA facilities that the Government 
Accounting Office (GAO Report 18-356) reviewed noted that the 
department to which patient advocates report can have a direct effect 
on the ability of staff to resolve veterans' complaints. The lack of 
updated and complete guidance may impede the patient advocacy program 
from meeting its expectations, to receive and address complaints from 
veterans in a convenient and timely manner.
    VHA also has provided limited guidance to VAMCs on staffing levels 
for the patient advocacy program. VHA's handbook states that every VAMC 
should have at least one patient advocate and appropriate support 
staff; however, it did not provide guidance on how to determine the 
number and type of staff needed. Officials at all but one of the eight 
VAMCs in GAO's review stated that their patient advocacy program staff 
had more work to do than they could realistically accomplish. This 
limited guidance on staffing does not support good practices to ensure 
there are an appropriate number of patient advocates and support staff 
to address veterans' complaints in a timely manner.
    This legislation would direct VAMC directors to ensure there is no 
fewer than one patient advocate for every 13,500 veterans enrolled in 
the system. Additionally, it would also address the need for highly 
rural veterans to have access to the services of patient advocates 
assigned to rural community-based outpatient clinics.
    DAV supports this legislation in accordance with DAV Resolution No. 
056, which recognizes that staffing shortages and vacancies in the VA 
health care system including critical positions like patient advocates 
can hamper the ability of veterans, who rely on the VA, to overcome 
barriers to accessing the care they need and deserve.
    We recommend that additional research be conducted to ensure that 
the ratio of patient advocate to veterans is adequate and balanced. 
Veterans want and need a proactive patient advocacy program. Patient 
advocacy offices should be staffed appropriately to provide timely 
assistance to veteran patients in accessing health care and clinical 
appeals. A consistent system-wide organizational structure for patient 
advocates will help to facilitate best practices and improve patient 
satisfaction.

       H.R. 1089, the VA Medical Center Facility Transparency Act

    H.R. 1089, the VA Medical Center Transparency Act, would require 
the Secretary to ensure VA medical center directors submit an annual 
easy-to-read fact sheet to the Secretary, the House and Senate 
Veterans' Affairs Committees, and certain Members of Congress.

    The fact sheet would be required to be made publicly available and 
provide statistics regarding:

      Number of veterans treated;

      Average wait time for veterans to receive treatment;

      Number of appointments conducted;

      Most common illness or conditions treated;

      Veterans' satisfaction rates;

      How veterans' satisfaction compares with other 
facilities; and

      Other matters the director determines appropriately.

    The bill would also require that the fact sheet provide data and 
highlight special areas of emphasis or specialized care programs at 
each VA facility that are aimed at meeting the needs of women veterans, 
homeless veterans, suicide prevention and other mental health 
initiatives to include opioid abuse prevention and pain management 
services, or actions taken to improve the facility or quality of care.
    Accurate and effective data collection is at the heart of assuring 
quality care. Without it, veterans, stakeholders and VA officials can 
be blindsided by crises that are otherwise difficult to identify, such 
as the access crisis in 2014, that led to major VA reforms under the 
Veterans Choice Act, and subsequently, the VA MISSION Act.
    The Government Accounting Office (GAO Reports; 21-169, 22-103718, 
22-105522, and 23-106665) has made a number of recommendations to 
improve this type of information to allow for greater program 
accountability and transparency in areas from assessing the quality of 
care provided to LGBTQ veterans, to understanding staffing needs for 
suicide prevention efforts and Vet Centers, to improving its electronic 
health record management system. Similarly, the Office of Inspector 
General (OIG Reports; 19-08658-153, 20-02186-78, 21-03020-168, and 21-
00175-19) has made recommendations for improving data to ensure 
visibility into quality. Providing accurate, easily accessible, and up-
to-date information to veterans will help to improve their care 
experience, as well as better inform policymakers overseeing the VA 
health care system. We suggest the Subcommittee consider adding a 
provision to the bill requiring VA to also provide comparable access 
and quality metrics for VHA providers and providers in VA's community 
care network.
    DAV supports H.R. 1089, the VA Medical Center Facility Transparency 
Act, in accordance with DAV Resolution No. 121, which calls for greater 
attention and effort to be focused on developing and publicly sharing 
common access and quality metrics for both VA and non-VA providers 
participating in the VA's community care network. This information is 
essential for veterans to make fully informed decisions about their 
care.

H.R. 1256, the Veterans Health Administration Leadership Transformation 
                                  Act

    H.R. 1256, the Veterans Health Administration Leadership 
Transformation Act, would make certain changes to the laws pertaining 
to the appointment of the VA Under Secretary of Health (USH) and 
Assistant Under Secretaries of Health (AUSH).
    Currently, Section 305 of title 38, United States Code (USC), 
states that in the VA, an Under Secretary for Health is appointed by 
the President, by and with the advice and consent of the Senate. 
Whenever a vacancy in the position of Under Secretary for Health occurs 
or is anticipated, the VA Secretary is required to establish a 
commission to recommend individuals to the President for appointment to 
the position.
    This legislation would extend the term of appointment for the Under 
Secretary for Health to 5 years and remove restrictions for the number 
of Assistant Under Secretaries for Health that can be appointed 
(currently not to exceed eight). Last, the bill would eliminate the 
requirement that all but two AUSHs be physicians or dentists.
    We understand the intent of this bill is to provide greater 
leadership stability at VHA and believe the proposed changes would help 
address identified governance challenges that have at times impeded 
oversight and accountability within the health care system. It would 
also empower the USH to more effectively manage and carry out their 
responsibilities to ensure veterans' health care needs are met. While 
DAV does not have a specific resolution that calls for changes to the 
laws relating to the appointment of these positions, we have no 
objection to the Subcommittee moving this bill forward.
    This concludes my testimony on behalf of the DAV. I am pleased to 
answer any questions you or members of the Subcommittee may have.
                                 ______
                                 

                  Prepared Statement of Tiffany Ellett

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                   Prepared Statement of Morgan Brown

    Chairwoman Miller-Meeks, Ranking Member Brownley, and members of 
the Subcommittee, Paralyzed Veterans of America (PVA) would like to 
thank you for this opportunity to present our views on pending 
legislation impacting the Department of Veterans Affairs (VA) that is 
before the Subcommittee. No group of veterans understand the full scope 
of benefits and care provided by the VA better than PVA members--
veterans who have incurred a spinal cord injury or disorder (SCI/D). 
PVA provides comment on the following bills included in today's 
hearing.

H.R. 41, VA Same-Day Scheduling Act of 2023

    PVA supports the intent of the VA Same-Day Scheduling Act. This 
legislation would require the VA to ensure that when a veteran enrolled 
in the VA health care system contacts the VA by telephone to schedule 
an appointment for care or services at a VA facility, the appointment 
would be scheduled during that telephone call. Scheduling all 
appointments when requested by the veteran should be a key goal for the 
department and we believe most appointments are already being scheduled 
in this manner. However, it is unclear if the VA has the resources to 
fully comply with this mandate within the 120 days specified by this 
legislation. When an appointment slot at the VA is not available based 
on a physician's request, the department might be limited in providing 
veterans with an appointment each time they contact the VA. It may also 
be difficult for some specialty clinics to comply if they control their 
own scheduling verses using the medical center's patient service 
center. We recommend the language of this bill be adjusted to provide 
for circumstances like this, while ensuring compliance occurs whenever 
possible.

H.R. 562, Improving Veterans Access to congressional Services Act of 
    2023

    The Improving Veterans Access to congressional Services Act directs 
the VA Secretary to permit Members of Congress to use VA facilities for 
the purposes of meeting with constituents. PVA does not have an 
official position on this bill but recognizes it may allow greater 
numbers of veterans to have better access to their elected officials. 
Therefore, we have no objection to the Subcommittee moving this bill 
forward.

H.R. 808, Veterans Patient Advocacy Act

    The Veterans Patient Advocacy Act seeks to ensure there are an 
adequate number of patient advocates at VA medical facilities. Patient 
advocates are highly trained professionals who can help resolve 
veterans' concerns about any aspect of their health care experience, 
particularly those concerns that cannot be resolved at the point of 
care. These advocates listen to any questions, problems, or special 
needs that a veteran has and works to resolve them. PVA supports H.R. 
808, which directs VA medical center directors to ensure there is no 
fewer than one patient advocate for every 13,500 veterans enrolled 
annually in the system. Another provision ensures patient advocates are 
assigned to rural community-based outpatient clinics to ensure timely 
access to health care, and time to address requests for information, 
compliments, complaints, reimbursements, and assistance with clinical 
appeals. Although we support this legislation, we are concerned that 
the ratio of one advocate per 13,500 veterans seems rather high and 
believe it should be examined further to ensure that this number of 
advocates is adequate.

S. 3304, the Patient Advocate Tracker Act

    PVA supports the Patient Advocate Tracker Act, which directs the VA 
to establish an information technology system that allows a veteran or 
their designated representative to electronically file a health care-
related complaint and view its status. The system would include interim 
and final actions that the VA has taken to resolve the issue. This 
would be a tremendous improvement over the current system which 
oftentimes leaves veterans feeling like their concerns are being 
ignored.

H.R. 754, Modernizing Veterans' Health Care Eligibility Act

    This legislation would establish a 15-member, bipartisan commission 
to assess veterans' eligibility for VA health care, and recommend ways 
to revise and simplify eligibility for consideration by the VA and 
Congress. These types of commissions are normally convened when outside 
subject matter expertise is needed and have a clearly defined purpose. 
As written, H.R. 754 lacks clarity on why an outside commission is 
needed to assess the current eligibility system. While it is true that 
considerable time has elapsed since overall eligibility for VA health 
care was last examined, we are unaware of any compelling reason that 
would make appointment of a commission to examine eligibility 
necessary. We also believe there is sufficient knowledge and expertise 
between veterans' stakeholders, Congress, and veterans' health 
providers; thus, an expert commission is unnecessary. Recent efforts by 
some Members of Congress and outside organizations to reduce the number 
of veterans who are eligible to receive VA health care, limit the types 
of medical services provided, cut costs, and privatize VA health care 
have been repeatedly dismissed by Congress and outside experts alike. 
We believe Congress, particularly this Committee, should continue to 
exercise its exclusive authority to conduct oversight of VA health care 
programs to include eligibility, while ensuring that veterans receive 
timely access to the quality care they have earned and deserve.

H.R. 693, Veterans Affairs Medical Center Absence and Notification 
Timeline (VACANT) Act

    The VACANT Act limits the detailing of medical centers directors to 
different positions within the VA and requires the department to notify 
Congress whenever these transfers take place. There is overwhelming 
evidence that an effective leader should be visible and available so 
they can work closely with their employees. PVA doesn't have a formal 
position on this legislation, but we have no objection to the 
Subcommittee moving this bill forward.

H.R. 366, the Korean American VALOR Act

    PVA supports this bill which would give roughly 3,000 Korean 
veterans who are naturalized citizens of the United States access to VA 
health care. While they served under a different flag during the 
Vietnam War, they served with the same duty, honor, and valor as our 
United States service members. The Korean American VALOR Act bill 
simply extends to them the same recognition and benefits the country 
has given our U.S. European allies of World War I and World War II.

H.R. 1089, VA Medical Center Transparency Act

    The VA Medical Center Transparency Act requires every director of a 
VA medical facility to publish an annual fact sheet that includes 
statistical information on the facility including average patient wait 
times and prevalent health concerns. The factsheet would also include 
what, if any, improvements have been made to patient care and service, 
and plans for future improvements. These fact sheets will be 
distributed to the VA Secretary, members of the House and Senate 
Veterans' Affairs Committees, and the Members of Congress who represent 
the facility. They would also be published on the facility's website 
and displayed in the facility. PVA supports efforts like this that make 
it easier for veterans to obtain the timely and accurate information 
they need.

H.R. 542, Elizabeth Dole Home-and Community-Based Services for Veterans 
and Caregivers Act of 2023

    PVA gives its strongest support to this critically important 
legislation which would make urgently needed improvements to VA's Home 
and Community-Based Services (HCBS), including several that target our 
concerns about current program shortfalls.
    In February 2020, the U.S. Government Accountability Office (GAO) 
released a report entitled, ``Veterans' Use of Long-Term Care Is 
Increasing, and VA Faces Challenges in Meeting the Demand.'' \1\ The 
report describes the use of and spending for VA long-term care, 
discusses the challenges the VA faces in meeting veterans' demand for 
long-term care, and examines the department's plans to address those 
challenges. From fiscal years 2014 through 2018, VA data shows that the 
number of veterans receiving long-term care in these programs increased 
14 percent (from 464,071 to 530,327 veterans), and obligations for the 
programs increased 33 percent (from $6.8 to $9.1 billion). The VA 
projects the demand for long-term care will continue to increase, 
driven in part by growing numbers of aging veterans and veterans with 
service-connected disabilities. Expenditures for long-term care will 
increase as well and are projected to double by 2037. According to VA 
officials, the department plans to expand veterans' access to 
noninstitutional programs, when appropriate, to prevent or delay 
nursing home care and to reduce costs.
---------------------------------------------------------------------------
    \1\ GAO-20-284, Veterans' Use of Long-Term Care Is Increasing, and 
VA Faces Challenges in Meeting the Demand
---------------------------------------------------------------------------
    The VA has identified the need to provide additional SCI/D long-
term care facilities and some of these requirements have been 
incorporated in a pair of ongoing construction projects but most of 
their plans have been languishing for years. Long-term care services 
are expensive, with institutional care costs exceeding costs for HCBS. 
Studies have shown that expanding HCBS entails a short-term increase in 
spending followed by a slower rate of institutional spending and 
overall long-term care cost containment.\2\
---------------------------------------------------------------------------
    \2\ Do noninstitutional long-term care services reduce Medicaid 
spending?
---------------------------------------------------------------------------
    Reductions in cost can be achieved by transitioning and diverting 
veterans from nursing home care to HCBS, if they prefer it, and the 
care provided meets their needs. VA spending for institutional care 
doubled between 2016 and 2021; however, the number of veterans being 
cared for in this setting has remained relatively stable--partially 
attributed to expanding HCBS--indicating the cost of institutional care 
is rising. Despite doubling HCBS spending between 2016 and 2021, VA 
currently spends just over 30 percent of its long-term care budget on 
HCBS, which remains far less than Medicaid's HCBS national spending 
average for these services among the states. The VA must continue its 
efforts to ensure veterans are able to live in their communities and 
remain with their families for as long as possible.

Caps on Care

    Section two of this bill raises the cap on how much the VA can pay 
for the cost of home care. Currently, the VA is prohibited from 
spending more than 65 percent of what it would cost to care for a 
veteran in a nursing home. When the VA reaches this cap, the department 
can either place the veteran into a VA or community care facility at a 
significantly higher cost or rely on the veteran's caregivers who are 
often family members to bear the extra burden. Depending on the 
services available in their area, some veterans must turn to their 
state's Medicaid program to receive the care they need, even for 
service-connected disabilities.
    Amyotrophic lateral sclerosis (ALS) is presumptively related to 
military service and is rated by the VA at the 100 percent level. And 
yet, we are aware of many ALS veterans who are not receiving proper 
home care. One veteran with ALS who uses a gastrostomy tube, has a 
tracheostomy, and is ventilator dependent was only able to get a nurse 
to come to his home for 2-hour visits, two times per week to check his 
vitals. Unfortunately, these hours were not enough to care for his 
medical complexities and the VA was unable to provide additional 
services due to cost. Instead, the VA told him he could receive 24/7 
skilled nursing at a facility. Another ALS veteran needs 120 hours of 
skilled care per week for him to be at home with his wife and family. 
Medicaid authorized 70 hours per week, but the VA was unable to approve 
the additional coverage due to the cost and instead the veteran is in a 
much costlier facility. And another ALS veteran lives with his wife who 
is responsible for around 130 hours of care a week on her own. She can 
no longer afford to pay out of pocket for additional care. The VA's 
only option was to place the veteran in a facility due to cost.
    It isn't just ALS veterans who are impacted by this cap. A 39-year-
old SCI veteran who is tracheostomy dependent has been in a facility 
since 2019 due to the cost of his care. He has a 10-year-old daughter 
that he has not been able to see since before COVID. Another veteran 
with a form of multiple sclerosis who has a gastrostomy tube, a 
tracheostomy, and is ventilator dependent is on the verge of ending up 
in a facility. His family needs 8 hours of care per day on the 
weekdays, but the VA is only able to approve 16 hours per week due to 
costs. Congress needs to allow the VA to cover the full cost of home-
based care services for these veterans and others like them without 
exhausting their caregivers and leaving them struggling to cobble 
together the services and supports they need to stay home with their 
families.
    On February 16, 2023, the Senate Veterans' Affairs Committee 
advanced a similar version of this bill (S. 141) without the language 
raising VA's cap on care primarily due to its cost. The Congressional 
Budget Office's (CBO) score for this section is perplexing, because we 
believe that only a few hundred veterans are currently exceeding the 65 
percent threshold. Some may need rates to be raised to the full cost of 
nursing home care, but the majority would not. The VA has committed to 
enhancing and maintaining the quality of life for all veterans but the 
current limitations due to the cap on services is contrary to this 
vision. Nothing in this legislation expands the number of veterans in 
this category and the number of them in this situation is relatively 
stable from year-to-year. We suggest this Subcommittee work with CBO 
and your Senate counterparts to review the current calculations to 
determine if they are accurate.

Veteran-Directed Care Program

    PVA strongly believes that the VA and Congress must make HCBS more 
accessible to veterans and section four of this bill would require the 
VA to administer programs like Veteran-Directed Care (VDC) at all VA 
medical centers. The VDC program allows veterans to receive HCBS in a 
consumer-directed way and is designed for veterans who need personal 
care services and help with their activities of daily living. Examples 
of the types of assistance they can receive include help with bathing, 
dressing, or fixing meals. VDC also offers support for veterans who are 
isolated, or whose caregiver is overburdened. Veterans are given a 
budget for services that is managed by the veteran or the veteran's 
representative.
    Unfortunately, the VDC program is not available at all VA medical 
centers, and it currently has an enrollment of only about 6,000 
veterans. Our members and other veterans are constantly asking for help 
in getting this program implemented at their VA health care facility. 
Milton, a PVA member in Ohio, is one of many veterans who have been 
waiting more than four years for the Cleveland VA to implement the 
program. Even if the program is available at a particular facility, 
veterans may not be aware of it or given the opportunity to enroll. The 
VDC program was available at our National President's VA medical 
center, but he was not made aware of it until last year. After several 
attempts to learn about accessing the program, he was told he had not 
been considered for it. Veterans should be given the choice to access 
this program where it is available.
    Also, the need for a caregiver does not go away whenever veterans 
with catastrophic disabilities are hospitalized. Neither community 
hospitals nor VA medical centers are adequately staffed or trained to 
perform the tasks veterans with SCI/D need. Currently, veterans with 
high-level quadriplegia and other disabilities must pay out of pocket 
for their caregivers or caregivers donate their time, as veterans 
cannot receive caregiving assistance through VA programs while in an 
inpatient status. The bill addresses this need by allowing these 
veterans to retain their VDC payments to ensure that they can be 
properly cared for while hospitalized and timely discharged home.
    Last year, the VA announced plans to expand the VDC program to 75 
additional sites over a five-year period. We are pleased that VA's 
Under Secretary for Health recently directed the Veterans Health 
Administration (VHA) to accelerate the timeline and we urge Congress to 
provide the necessary funding so every VA medical center can offer a 
robust VDC program as quickly as possible.

Improve Coordination with VA Caregiver Program

    Section five requires the VA to provide a personalized and 
coordinated handoff of veterans and caregivers denied or discharged 
from the Program of Comprehensive Assistance for Family Caregivers 
(PCAFC) into any other home care program for which they may be 
eligible. Veterans are routinely denied entry into the PCAFC, and the 
provisions in section five would ensure veterans are assessed for 
participation in other HCBS programs.
    Additionally, veterans and their caregivers often express 
frustration trying to find information on HCBS. Information about HCBS 
is available through several websites and other sources which tends to 
lead to a lack of awareness about all the services that might be 
available. Section six would address this problem by establishing a 
``one-stop shop'' webpage to centralize information about available 
programs for families and veterans.

Direct Care Workforce Shortages

    Section seven would make it easier for veterans to find direct care 
workers or home health aides. Even when veterans have access to 
programs like VDC or Homemaker Home Health, it can be challenging to 
find home care workers. That is the experience of Ron, a PVA member 
from Minnesota who sustained a traumatic spinal cord injury in a 
vehicle accident in the spring of 2020. After spending four months in 
rehabilitation, he was released to an assisted living facility that did 
not meet his needs; so, he briefly lived with his mother while he and 
his family built an accessible home. In the fall of 2020, the VA 
authorized 24-hour care for him in his home and Ron was thrilled to 
have this option. His wife is very supportive but often feels sad and 
helpless because she is physically unable to care for him. He depends 
entirely on the home health staff for his daily care, health, and 
welfare. Unfortunately, because the VA did not have home care staff, he 
had to go through a community agency. Despite having many hours 
authorized, he has never found enough qualified people to fill them. He 
is fortunate when he has someone to get him out of bed and help him 
through the day. Oftentimes, he goes to bed at 7 p.m. because help 
isn't available at his usual bedtime of 9 or 10 p.m. He regularly 
spends weekends in bed because no staff is available to assist him and 
he is depressed and frustrated because he can't find the direct care 
workers he needs to assist him with daily activities.
    The shortage of caregivers or direct care workers is not unique to 
the VA. Across the country, there is an increasing shortage of direct 
care workers, and a national effort is needed to expand and strengthen 
this workforce. We believe the pilot program established in section 
seven would lessen the difficulty in finding direct care workers at the 
10 sites the VA selects and may reveal additional ways the VA could 
alleviate this problem for veterans nationwide.
    Again, this important bill addresses many pressing concerns for 
catastrophically disabled veterans, and we urge Congress to pass it 
this year.

H.R. 1256, Veterans Health Administration Leadership Transformation Act

    The intent of the Veterans Health Administration Leadership 
Transformation Act is to ensure greater leadership stability at VHA, an 
issue that has become a concern in recent years. We appreciate the 
sentiment of this legislation but fear changes like fixing the term of 
appointment for the Under Secretary for Health at 5 years could present 
a new host of challenges to continuity. Therefore, we take no position 
on this bill at this time.
    PVA would once again like to thank the Subcommittee for the 
opportunity to present our views on the legislation being considered 
today. We look forward to working with the Subcommittee on this 
legislation and would be happy to answer any questions.

  Information Required by Rule XI 2(g) of the House of Representatives

    Pursuant to Rule XI 2(g) of the House of Representatives, the 
following information is provided regarding Federal grants and 
contracts.

                            Fiscal Year 2023

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events--Grant to support rehabilitation sports 
activities--$479,000.

                            Fiscal Year 2022

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events--Grant to support rehabilitation sports 
activities--$ 437,745.

                            Fiscal Year 2021

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events--Grant to support rehabilitation sports 
activities--$455,700.

                     Disclosure of Foreign Payments

    Paralyzed Veterans of America is largely supported by donations 
from the general public. However, in some very rare cases we receive 
direct donations from foreign nationals. In addition, we receive 
funding from corporations and foundations which in some cases are U.S. 
subsidiaries of non-U.S. companies.

                       Statements for the Record

                              ----------                              


             Prepared Statement of Veterans of Foreign Wars

    Chairwoman Miller-Meeks, Ranking Member Brownley, and members of 
the subcommittee, on behalf of the men and women of the Veterans of 
Foreign Wars of the United States (VFW) and its Auxiliary, thank you 
for the opportunity to provide our remarks on legislation pending 
before this subcommittee.

H.R. 41, VA Same-Day Scheduling Act of 2023

    The VFW supports this legislation that would mandate the Secretary 
of Veterans Affairs (VA) to ensure veterans are able to schedule 
appointments for health care at VA medical facilities in a timely 
manner. The VFW understands that it is essential for veterans who need 
care to be able to schedule appointments via telephone, rather than 
have to wait for return calls from VA staff members. In practicality, 
appointments outside of referrals should be set up that same day to 
ensure high quality care is being delivered to veterans.

H.R. 366, Korean American Vietnam Allies Long Overdue for Relief 
(VALOR) Act

    The VFW does not currently have a resolution supporting care and 
benefits for allied forces, therefore, we have no position on this 
legislation.

H.R. 542, Elizabeth Dole Home Care Act of 2023

    As life expectancy continues to increase, so must life quality, and 
for many veterans that means having home health care as a choice. The 
VFW continues to advocate for long-term care options as stated in our 
legislative priority goals and resolution, which is why we support this 
proposal.
    Home health care benefits the veteran, caregiver, and VA in many 
ways. Caregivers relieve VA of the necessity to place veterans in 
institutional long-term care. Even though veterans may require 
assistance with daily activities, being at home offers independence and 
familiarity, which is essential for veterans in the beginning stages of 
dementia. This freedom to remain in their homes needs to be supported 
by VA services and funding, while not financially stressing veterans 
and their families.
    A Kaiser Family Foundation report released in February 2022 states 
that almost twenty-five percent of individuals who died from COVID-19 
lived in long-term care settings. People living in nursing homes most 
often cohabitate with two beds per room separated by a curtain, and 
share a bathroom, increasing the likelihood of becoming ill or dying. 
By residing at home, a veteran's risk of exposure to infectious 
diseases decreases.
    This bill contains many ways VA would expand home and community 
services for veterans and their caregivers. VA would be required to 
partner with a state's Program of All-Inclusive Care for the Elderly to 
ensure veteran care is coordinated. All medical centers would have the 
programs of Veteran Directed Care, Home Maker and Home Health Aide, 
Home-Based Primary Care, and Purchased Skilled Home Care to support and 
provide veterans a non-institutional care setting. Caregivers would 
receive a warm handoff to home and community service programs if they 
are denied or discharged from the Program of Comprehensive Assistance 
for Family Caregivers. By closing the gap, caregivers would be more 
aware of other VA programs that provide caregiver support. VA would 
pilot a program to address locations with home health aide shortages. 
Offering both medical and financial support would make the decision to 
keep veterans at home easier.

H.R. 562, Improving Veterans Access to congressional Services Act of 
    2023

    The VFW supports this legislation that would require VA to provide 
space at VA facilities for congressional offices to provide constituent 
assistance. As a Veterans Service Organization that for more than one 
hundred years has been assisting veterans with filing claims to obtain 
their earned benefits, the VFW understands the value and need for 
constituent services at VA facilities. We have heard positive feedback 
and believe VA should continue to provide space where available, as 
long as it does not conflict with patient care.

H.R. 693, Veterans Affairs Medical Center Absence and Notification 
Timeline (VACANT) Act

    The VFW supports this proposal to provide transparency regarding VA 
officials being detailed for other positions. We understand there are 
times when VA calls on its best staff, which includes directors of VA 
Medical Centers (VAMCs) for essential detail coverage. However, in-
house leadership at those facilities is crucial for staff morale, the 
mission of caring for America's veterans, and ensuring that the VAMC 
meets production deadlines. When a director is utilized for detail, it 
must be clearly communicated in appropriate time so a qualified 
replacement can fill in if needed.

H.R. 754, Modernizing Veterans' Health Care Eligibility Act

    The VFW cannot support this proposal at this time. While we agree 
VA's eligibility standards may not be perfect and could be improved or 
streamlined, we do not think a complete overhaul of the system is 
called for at this point. We also do not think a proposed commission is 
the way to accomplish that goal. Commissions like the one described in 
this proposal are needed when subject matter experts are required for 
an issue and an outside commission is established. The VFW feels if 
changes are needed for eligibility, there is more than enough knowledge 
and expertise between veterans' stakeholders, Congress, and veteran 
health care providers that an expert commission is unnecessary.
    Additionally, a major issue we have with the proposed goal is it is 
too vague. Typically, we would like to see a proposal have a specific 
directive, examples such as diminished or expanded eligibility, or to 
consolidate priority groups. We think the mission of the proposed 
commission is not narrowly defined, which could lead to creating 
solutions for problems that do not exist. The VFW welcomes the 
discussion to improve care and access to care by modifying existing 
eligibility requirements, especially for emergency situations, but does 
not think the entire system needs an overhaul.

H.R. 808, Veterans Patient Advocacy Act

    For the past nine years, the VFW has partnered with Student 
Veterans of America (SVA) to select student veterans from across the 
country to research and advocate for improving an issue that is 
important to veterans. VFW-SVA Fellow and Grand Valley State University 
graduate Cameron Zbikowski focused his semester-long research proposal 
on enhancing VA's patient advocate program. Cameron called for the 
improvement of the program by making sure there is an adequate amount 
of patient advocates at each facility.
    The VFW supports this bill that would ensure there is no less than 
one patient advocate for every 13 thousand five hundred veterans 
enrolled in the local VA system. It would also provide highly rural 
veterans with better access to the services of patient advocates.

H.R. 1089, VA Medical Center Facility Transparency Act

    The VFW supports this bill to require VAMC directors to submit to 
VA and Congress an annual fact sheet containing specified information 
about their facilities. This would allow for standardized reporting to 
identify specific health care needs and services provided at each 
location. This data would be informative when discussing the health 
conditions that are prevalent in the veterans' community. Improvement 
to VAMCs is vital for access and quality of care. Giving executive 
teams the opportunity to review and understand areas of progress and 
areas still in need of improvement would help develop better 
approaches, and quarterly reports would allow VA, Congress, and the 
VAMCs to determine what is and is not working. The VFW believes an 
improvement for this proposal would be to include data on efforts 
focused on the needs of underserved veterans, suicide prevention and 
other mental health initiatives, pain management and opioid abuse 
prevention, and combating veteran homelessness.

H.R. 1256, Veterans Health Administration Leadership Transformation Act

    The VFW cannot support this bill at this time. We understand that 
this proposal seeks to provide stability within the Veterans Health 
Administration by ensuring the Under Secretary of Health and Assistant 
Under Secretaries of Health positions will not be vacant. This could be 
helpful in maintaining consistency. On the other hand, we respect every 
administration's position to choose appointees who align with their 
command message. Since Presidential terms are for four years at a time, 
appointing certain positions for five-year terms could cause some of 
these appointments to bridge different administrations and impact the 
delivery of care if VA leadership is not fully aligned. For these 
reasons, we cannot offer support at this time.
    Chairwoman Miller-Meeks, this concludes my testimony. Again, the 
VFW thanks you and Ranking Member Brownley for the opportunity to 
provide remarks on these important issues pending before this 
subcommittee.

 Information Required by Rule XI2(g)(4) of the House of Representatives

    Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW 
has not received any Federal grants in Fiscal Year 2023, nor has it 
received any Federal grants in the two previous Fiscal Years.

    The VFW has not received payments or contracts from any foreign 
governments in the current year or preceding two calendar years.
                                 ______
                                 

           Prepared Statement of Student Veterans of America

    Chair Miller-Meeks, Ranking Member Brownley, and Esteemed Members 
of the Subcommittee, thank you for inviting Student Veterans of America 
(SVA) to submit a Statement for the Record on legislation before you 
today.
    With a mission focused on empowering student veterans, SVA is 
committed to providing an educational experience that goes beyond the 
classroom. Through a dedicated and expansive network of on-campus 
chapters across the country, SVA aims to inspire yesterday's warriors 
by connecting student veterans with a community of like-minded chapter 
leaders.
    Every day these passionate leaders work to provide the necessary 
resources, network support, and advocacy to ensure student veterans can 
effectively connect, expand their skills, and ultimately achieve their 
greatest potential.

H.R. 808 - The Veterans Patient Advocacy Act

    SVA fully supports the Veterans Patient Advocacy Act (H.R. 808), 
which represents a crucial step toward improving the quality of 
customer service and care for our Nation's veterans., This bill would 
require the Department of Veterans Affairs (VA) to ensure that no fewer 
than one Patient Advocate is available for every 13,500 veterans 
enrolled in the system of annual patient enrollment. This increase in 
staffing would allow VA to better assist veterans with their 
complaints, resulting in reduced frustration, improved accountability, 
and a higher quality experience.
    Patient Advocates play a vital role in helping veterans, including 
student veterans, express concerns about their treatment and resolve 
any problems with their care providers. However, well-documented 
issues, including staffing and workload challenges, have limited the 
effectiveness and ability of Patient Advocates to adequately serve 
veterans in need. According to the VA, there are currently only 550 
Patient Advocates nationwide, with at least one full-time position per 
VA Medical Center in accordance with the current VHA Directive 
1003.04.\1\ The national average caseload for a Patient Advocate is 
around 1,025 inquiries annually.
---------------------------------------------------------------------------
    \1\ E-mail from congressional staff to author concerning current 
program staffing levels provided by VA in response congressional 
inquiry on file with author (March 24, 2023) (on file with author).
---------------------------------------------------------------------------
    The Government Accountability Office (GAO) documented many concerns 
with the Patient Advocate program, including staffing and workload 
issues, in an April 2018 report.\2\ According to the report, there was 
near universal concern among the VA Medical Center officials 
interviewed by GAO about program staff workload.\3\ The report details 
how backlogs have resulted in basic administrative tasks, among other 
things, going unaddressed. Consider this particularly concerning 
excerpt from the report.
---------------------------------------------------------------------------
    \2\ See generally U.S. GOV'T ACCOUNTABILITY OFFICE, GAO-18-356, VA 
HEALTH CARE: IMPROVED GUIDANCE AND OVERSIGHT NEEDED FOR THE PATIENT 
ADVOCACY PROGRAM (2018).
    \3\ Id. at 13.

        Officials from one VAMC [GAO] spoke with in July 2017 stated 
        that due to workload demands and not enough patient advocacy 
        program staff at their VAMC, they had roughly 300 unanswered 
        phone calls at that time from veterans who wanted to provide 
        feedback to a patient advocate. Officials from several VSOs we 
        spoke with stated that there is not enough patient advocate 
        staff, adding that veterans reported that their calls to 
        patient advocates were not answered, they were unable to reach 
        an advocate, or their calls were not responded to in a timely 
        manner.\4\
---------------------------------------------------------------------------
    \4\ Id.

    This bill would help solve the staffing issues in the Patient 
Advocate program by requiring VA to hire an additional 78 Patient 
Advocates, with the expectation that 35 of them placed at Community-
Based Outpatient Clinics where there was no physical presence of a 
Patient Advocate previously. SVA urges the Subcommittee to support and 
pass the Veterans Patient Advocacy Act, which is an excellent next step 
toward addressing the challenges faced by veterans using the Patient 
Advocate program.
    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 Chair, Ranking Member, and the Subcommittee Members 
for your time, attention, and devotion to the cause of veterans in 
higher education.
                                 ______
                                 

            Prepared Statement of Elizabeth Dole Foundation

    Chairman Bost, Ranking Member Takano, and Members of the Committee, 
thank you for the opportunity to provide a written statement for 
today's hearing. Today's docket consists of a series of legislation for 
your consideration, and we would like to focus our attention on one: 
The Elizabeth Dole Home Care Act.
    As you may know, the Elizabeth Dole Foundation is the preeminent 
organization empowering, supporting, and honoring our Nation's military 
caregivers; the spouses, parents, family members and friends who care 
for America's wounded, ill or injured veterans. The Foundation was born 
out of Senator Elizabeth Dole's conversations with caregivers while 
Senator Bob Dole was receiving care at Walter Reed Medical Center, and 
she realized that not enough was being done for military and veteran 
caregivers. Senator Elizabeth has since made the transition from 
caregiver to survivor after the passing of Senator Bob in 2021, but she 
remains steadfast and fervent in her advocacy on behalf of caregivers.
    The Elizabeth Dole Home Care Act is critically important to 
military and veteran caregivers across the Nation. This legislation was 
first introduced in both the House and Senate during the 117th 
Congress. It received bipartisan support and endorsed by a diverse 
coalition of organizations, including Paralyzed Veterans of America, 
The American Legion, AARP, Disabled American Veterans, Wounded Warrior 
Project, Veterans of Foreign Wars, National PACE Association, National 
Council on Urban Indian Health, and the National Association of 
Counties.
    This bill is an investment in resources that help veterans age in 
place and could not come at a more appropriate time. In 2014, research 
conducted by RAND and commissioned by the Elizabeth Dole Foundation 
found that there are approximately 5.5 million military and veteran 
caregivers in the United States that provide $14 billion annually in 
unpaid labor, caring at home for their veteran loved ones. With 
inflation, this equates to approximately $20 billion today. Experts 
predict that by 2050, there will be an estimated 1.5 billion people 
aged 65+ worldwide, which is a sharp increase from 703 million in 2019. 
Not only are people living longer, but they are more likely to have 
chronic health conditions that require regular care. A study conducted 
by AARP found that 76 percent of people aged 50 or older would prefer 
to remain in their current home for as long as possible. These trends 
all point to the ever-growing need to invest in home and community-
based services and the caregivers who step into this role.
    The version of The Elizabeth Dole Home Care Act as introduced 
during the 117th Congress included the following provisions:

      Increase the non-institutional expenditure cap from 65 
percent to 100 percent.

      Expedite and expand access to the Department of Veterans 
Affairs (VA) Home and Community-Based Services (HCBS) to all Medical 
Centers, including those in the U.S. territories, in 2 years. Services 
include:

          The Veteran Directed Care Program - Provides veterans 
        a flexible budget to hire friends, family, and neighbors to 
        help with activities of daily living.

          The Home Maker Home Health Aide Program - Allows VA 
        to contract with a community partner that employs home health 
        aides to care for veterans in their homes.

          The Home-Based Primary Care Program - For a veteran 
        who has difficultly traveling, is isolated, or whose caregiver 
        is burdened, a VA physician will supervise healthcare in the 
        veteran's home.

          The Purchased Skilled Home Care Program - For 
        veterans who have higher levels of need the VA will contract 
        with a community agency to provide skilled nursing care in a 
        veteran's home.

      Require VA to continue working with caregivers if they 
are denied from a program to find an alternative. VA must inform 
caregivers of other services they can access and ensure they are 
connected to appropriate resources.

      Expand access to respite care for family caregivers of 
veterans enrolled in home care programs.

      Establish a ``one stop shop'' webpage to centralize 
information for families and veterans on all programs and includes an 
informational eligibility assessment tool.

      Mandate stronger coordination between the Program of 
Comprehensive Assistance for Family Caregivers (PCAFC) and VA's other 
services. If a veteran is denied or discharged from PCAFC, the veteran 
must be assessed for participation in all other HCBS programs.

      Establish a three-year pilot program to address shortages 
of home health aides. VA will directly hire or repurpose current 
nursing assistants to be home health aides for veterans.

    Last winter, the Congressional Budget Office (CBO) published their 
cost estimate for The Elizabeth Dole Home Care Act. They projected that 
the bill would cost $16.1 billion in discretionary spending and $8.5 
billion in mandatory spending, totaling $24.6 billion over 10 years. 
CBO estimated that the section raising the non-institutional 
expenditure cap would cost $24.5 billion over this timeframe. Due to 
this provision contributing to the vast majority of the cost, it has 
become the subject of debate and has been consequently removed from the 
Senate version of the bill.

Addressing the Cost:

    The non-institutional care expenditure cap is VA's ability to pay 
providers of in-home health care services up to 65 percent of the total 
cost to the VA if it had provided care within a VA facility (38 U.S.C. 
Sec.  1720C(d) (1997)). When veterans-those of whom usually have 
complex care needs-reach this limit, their families and caregivers are 
required to bear the other 35 percent of the costs or must place their 
veteran in institutional care.
    Not only is in-home care essential to our community's well-being, 
but we are concerned that the CBO score does not properly reflect the 
true costs of implementing this provision, especially when considering 
more complex care facilities. It is the opinion of our experts, as well 
as a coalition of military and veteran-serving organizations, that the 
projected cost estimate is unintentionally inflated. At the high end, 
approximately 500 veterans have reached the 65 percent cap and not all 
of them need it increased to 100 percent. Because the share of veterans 
reaching the cap is so low, it is improbable that adding funding for 
this small group will cost $24.5 billion over 10 years. We strongly 
encourage the respective House and Senate Committees on Veterans 
Affairs to challenge the CBO score and ensure that this was calculated 
properly.
    In addition to reevaluating the cost, it is important to 
acknowledge the money that is saved on a continued basis by veteran 
caregivers across the country. In order to put the value of family 
caregiving into perspective, CBO should also calculate how much it 
would cost if every veteran who qualified for institutional care at the 
VA elected to utilize it. We are confident that cost over 10 years 
would be far greater than the projected cost of raising the non-
institutional expenditure cap, especially as AARP recently reported 
that civilian family caregivers nationwide contribute over $600 billion 
in unpaid labor each year.

The Non-Institutional Expenditure Cap's Impact:

    In addressing this issue, it is crucial to go beyond the numbers 
and consider how it operates in practice. For caregivers, raising the 
non-institutional expenditure cap would be a much-needed relief for 
their families. Caregivers like Karee, Jim, Mary, and Lara know this 
struggle all too well.
    In North Carolina, Karee and Jim are impacted every day by this 
cap. Karee and Jim are both Army veterans and they have nine children, 
many of whom have followed in their parents' footsteps and become Army 
officers too. One of those children was Kimmy, who at 25-years-old 
following a deployment to Afghanistan, suffered a Traumatic Brain 
Injury (TBI) while stationed in Italy. Karee and Jim now care for a 34-
year-old Kimmy. Kimmy requires 24-hour care as well as tube feeding, 
frequent pulmonary care, support with all activities of daily living 
(ADLs,) and additional therapies.
    Despite living just outside of Raleigh, a city home to exceptional 
healthcare facilities and North Carolina's State capital, no facility 
would accept Kimmy within 40 minutes of her parents' house. Kimmy 
receives her care at home and is enrolled in Veteran-Directed Care 
(VDC), which pays for a small portion of her healthcare costs. Kimmy's 
pension from the Army funds the rest, including income for professional 
caregivers to assist with her 24/7 care. Together this costs upwards of 
$200,000 annually and leaves little for additional expenses.
    Theoretically, Kimmy could receive care in an institution for the 
rest of her life. Despite the potential benefits, her parents are 
willing to take on these responsibilities in order to ensure that their 
daughter has the best quality of life possible. If placed in 
institutional care, Kimmy would suffer immeasurably and miss the 
interactions with her eight brothers and sisters, going to family 
events, and her vast community of friends who regularly have her over 
in their homes. Karee and Jim would be unable to see Kimmy regularly 
and would be an hour away should anything happen. Despite all of the 
current challenges that come with caring for Kimmy at home, Karee and 
Jim do it anyway because it is the best option for their daughter.
    Two hours south of Raleigh, another family is experiencing similar 
struggles. Mary cares for her husband, Tom, who is 68 years old. He 
served in the Marine Corps from 1972 to 1975. In 2010, he was diagnosed 
with service-connected Amyotrophic Lateral Sclerosis (ALS). He has been 
living with ALS for nearly 13 years. Mary is 63 years old and retired 
several years ago to become his full-time caregiver. He has 
specifically requested that he remain in the home through the end of 
his life, rather than be cared for in a facility. Mary is fully 
supportive of this decision and can see no other way for him to live 
out his days than at home surrounded by family, pets, music, and his 
paintings. Mary currently does not have outside help to care for Tom, 
but likely will require it in the near future. Because of the 
expenditure cap, she will care for Tom at home without the appropriate 
amount of care and it will come at a great expense, both financially 
and physically. When asked what keeps her up at night, she replied, 
``that the disease will consume me from exhaustion, and I will die 
before him.''
    This experience is not isolated to the East Coast. In Texas, 
caregivers are facing similar challenges caused by the non-
institutional expenditure cap. Lara was the wife and caregiver to her 
husband Tom, a US Air Force veteran. Tom was diagnosed with service-
connected ALS in 2016, received a tracheostomy and became ventilator 
dependent in 2019, and passed away from the disease on July 15, 2022.
    For the last three years of his life, he was paralyzed, received 
nutrition and medication through a feeding tube, required a 
tracheostomy and ventilator to breathe, and communicated using eye gaze 
technology. Tom's care was considered high acuity, meaning not only did 
he need help with all aspects of Activities of Daily Living, but he 
also required the support of his ventilator and circuits, feeding tube, 
and constant evaluation for skin breakdown. His care was like the care 
received in a hospital-level ICU. Lara was able to keep Tom in their 
home, where he wanted to be in the last years of his life, surrounded 
by family, friends, and his loyal service dog, Lou. Lara was not a 
trained medical professional, but she cared for Tom to the best of her 
ability, despite her fear and uncertainty.
    Tom's care was 24 hours, 7 days a week. Tom's ventilator had to be 
monitored at all times and provide the required suctioning, as well as 
ensure that he was regularly adjusted to avoid skin deterioration. Tom 
required the use of a Hoyer lift to be moved out of the bed for 
toileting, showering, or to be placed in his wheelchair. It took Lara 
over a year of advocating to the Central Texas VA to have skilled 
nursing approved to provide much-needed skilled help in the home. Her 
VA found a path forward to getting the care she needed in the home, but 
her experience is very much an exception and not the rule.
    Solitary caregiving, like what Lara provided to Tom prior to 
receiving skilled care, led to extreme physical and mental exhaustion. 
The cumulative exhaustion felt by Lara was not only unhealthy for her 
as the caregiver, but also for the care recipient-the husband she 
adored. On several occasions, Lara's exhaustion did lead to her making 
errors in Tom's care; from minor ones like forgetting to restart the 
feeding pump after toileting to more serious ones of inadvertently 
turning the ventilator off. The lack of in-home nursing support, sleep 
deprivation, and grief took a toll on Lara's mental and physical 
health, and Lara began experiencing suicidal ideations.
    For high acuity veterans and their caregivers, having skilled care 
in the home is so much more than just a break in care responsibilities 
or respite for the caregiver. It is essential for the health of the 
caregiver. In Lara's case, having skilled care in the home enabled her 
to get more than 2-3 hours of sleep most nights. Skilled care also 
allowed for moments that would allow her to give her attention to their 
teenage son, Trey, and gave her space to step away to allow herself to 
grieve her husband and the life they shared before ALS entered it.
    Keeping the 65 percent cap on care services the VA offers, 
especially for high-acuity veterans, is detrimental to the caregiver's 
physical and mental well-being, which ultimately reduces the quality of 
care for the veteran. Caring for high-acuity veterans in the home is 
possible with services offered by the Veterans Health Administration, 
especially when the veteran is adamant about living their life in their 
home.
    Providing a path forward for these high-acuity veterans and their 
families and removing the 65 percent cap is vital for the well-being of 
military families.
    The unfortunate reality is that there are so many other families 
who are just like Karee, Jim, Mary, and Lara. They are parents who will 
never stop caring for their children and spouses who are taking on more 
than they ever expected. Not only are veterans lucky to have them by 
their side, but our Nation should feel lucky too.

Conclusion:

    Senator Elizabeth Dole was honored to lend her name to legislation 
that is uniquely focused on improving caregiver resources and 
supporting care within the home. Congress has an opportunity to invest 
in this population and an obligation to ensure that veterans receive 
the treatment that they want and deserve. It is critical to include 
provisions that address the non-institutional expenditure gap and 
continue to provide solutions for those wanting to receive care at 
home.
    Passing this legislation helps veterans and their caregivers get 
the services they need now while also building the infrastructure 
needed to serve veterans into the future. Caregivers cannot afford to 
wait any longer. Thank you for considering this critical issue, and we 
look forward to the Elizabeth Dole Home Care Act becoming law.
                                 ______
                                 

   Prepared Statement of The American Association of Retired Persons

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