[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
U.S. DEPARTMENT OF VETERANS AFFAIRS
BUDGET REQUEST FOR FISCAL YEARS
2025 AND 2026
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
SECOND SESSION
__________
THURSDAY, APRIL 11, 2024
__________
Serial No. 118-61
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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
55-605 WASHINGTON : 2025
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COMMITTEE ON VETERANS' AFFAIRS
MIKE BOST, Illinois, Chairman
AUMUA AMATA COLEMAN RADEWAGEN, MARK TAKANO, California, Ranking
American Samoa, Vice-Chairwoman Member
JACK BERGMAN, Michigan JULIA BROWNLEY, California
NANCY MACE, South Carolina MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina SHEILA CHERFILUS-MCCORMICK,
C. SCOTT FRANKLIN, Florida Florida
DERRICK VAN ORDEN, Wisconsin CHRISTOPHER R. DELUZIO,
MORGAN LUTTRELL, Texas Pennsylvania
JUAN CISCOMANI, Arizona MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia NIKKI BUDZINSKI, Illinois
Jon Clark, Staff Director
Matt Reel, Democratic Staff Director
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
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further refined.
C O N T E N T S
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THURSDAY, APRIL 11, 2024
Page
OPENING STATEMENTS
The Honorable Mike Bost, Chairman................................ 1
The Honorable Mark Takano, Ranking Member........................ 3
WITNESSES
Panel 1
The Honorable Denis McDonough, Secretary, U.S. Department of
Veterans Affairs............................................... 4
Panel 2
Mr. Patrick Murray, National Legislative Service Director,
Veterans of Foreign Wars....................................... 36
Accompanied by:
Mr. Shane Liermann, Deputy National Legislative Director,
Disabled American Veterans
Mr. Roscoe Butler, Senior Health Policy Advisor, Paralyzed
Veterans of America
APPENDIX
Prepared Statements Of Witnesses
The Honorable Denis McDonough Prepared Statement................. 47
Mr. Patrick Murray, Mr. Shane Liermann, and Mr. Roscoe Butler
Prepared Statement............................................. 55
Statements For The Record
Questions for the Record Submitted by Juan Ciscomani, Jennifer
Kiggans and Morgan McGarvey.................................... 61
U.S. Department of Veterans Affairs Response to Questions for the
Record Submitted by Mike Levin and Julia Brownley.............. 64
U.S. DEPARTMENT OF VETERANS AFFAIRS
BUDGET REQUEST FOR FISCAL YEARS
2025 AND 2026
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THURSDAY, APRIL 11, 2024
Committee on Veterans' Affairs,
U.S. House of Representatives,
Washington, DC.
The committee met, pursuant to notice, at 9:03 a.m., in
room 360, Cannon House Office Building, Hon. Mike Bost
(chairman of the committee) presiding.
Present: Representatives Bost, Bergman, Mace, Rosendale,
Miller-Meeks, Murphy, Franklin, Van Orden, Luttrell, Ciscomani,
Crane, Self, Kiggans, Takano, Brownley, Levin, Pappas, Mrvan,
Cherfilus-McCormick, Deluzio, McGarvey, Ramirez, Landsman, and
Budzinski.
OPENING STATEMENT OF MIKE BOST, CHAIRMAN
The Chairman. Good morning. The committee will come to
order. Now I want to welcome Secretary McDonough to review the
U.S. Department of Veterans Affairs (VA) budget request for
2025 and 2026. I want to let everyone know that we are expected
to recess about 10:30 for the Japanese Prime Minister to
address the joint session and then we will resume the hearing
after that. I want to thank all the witnesses for their
patience when we are dealing with this situation so I want to
get right to it.
So you know, the President's request, $369 billion for the
VA Fiscal Year 2025. Now, that is a nearly 10 percent increase
from this year. In March, Congress already appropriated the
vast majority of the 2025 funding or $295 billion. In June of
last year, Congress already appropriated $24.5 billion for
toxic exposure fund for 2025.
We are here today considering the remaining VA account for
2025 and the advance request for 2026. Congress is all always--
I want to say this real clear. Congress has always prioritized
veterans and met VA needs. In fact, for the most part the
Department already has received their funding for Fiscal Year
2025.
I do not want to hear any more baseline rumors and scare
tactics about Congress cutting off support for veterans like we
heard last year. It is disrespectful to the men and women who
have served our great Nation to spread lies in an attempt to
score political points. I will not--we will not go. We cannot.
I want to have a serious conversation about how VA is managing
their taxpayer dollars that Congress provides.
There is a real problem here. Somehow, despite the nearly
$17 billion increase this year and $33 billion requested for
next year, the second largest Federal agency can barely keep
its lights on. Hiring has been cut back or frozen. The
healthcare workforce is shrinking by 10,000 positions.
Construction to modernize the VA facilities has flatlined to
only two major projects. Information Technology (IT)
investments have been cut by 99 percent. Some existing projects
barely have enough funding to continue and new projects are off
the table.
The White House seems to be shortchanging many of the
priorities that President Biden presents in his own budget and
many of our priorities as well. The overall request increase is
large, but a lot of the money seems to be in the wrong places.
The simple explanation is that VA used the enhanced pay
authority that Congress provided in the The Sergeant First
Class Heath Robinson Honoring our Promise to Address
Comprehensive Toxics (PACT) Act and elsewhere to spend
themselves into deficit.
In many VA offices they can no longer afford the employees
they have now, much less recruit talented new ones. It is the
opposite of what Congress intended when we provided these
authorities.
I absolutely support the PACT Act, but VA implementation of
parts of the law is getting very confusing. We are hearing from
some Members' offices that the VA medical centers (VAMC) do not
even understand the new eligibility criteria or veterans.
The whole VA budget is reliant on gimmicks that get more
and more complicated every year. I am talking about transfers,
carryovers, transformation funds, unfunded requirements, doing
away with the second bite for healthcare, and a mandatory
construction account that does not exist.
Yes, despite Congress' intent, VA is using toxic exposure
funds as another budget gimmick. They are shifting regular
expenses out of the baseline budget, dumping them into toxic
exposures fund. Like it or not, 40 percent of the toxic
exposure funds is community care. The VA budget simply does not
have to be this complicated, especially because, unlike the
Federal agencies, Congress always found ways to provide VA--
prioritize VA. We always have and I am confident that we always
will.
I have faith in the Appropriations Committee to sort out
the VA's accounts. We have to do our part, too, as the
authorizing committee. I want effective programs and realistic
estimates. I want the dollars to actually benefit the veterans,
family members, and survivors. We always have to stand guard
against growth in the bureaucracy.
We have in front of us one of the most confusing VA budgets
I have ever seen. Somehow a 10 percent overall increase
contains a lot of cuts in a lot of different areas that,
frankly, do not make sense, but I am committed to protecting
healthcare and benefits. I hope we work together to do that.
With that, I want to thank Secretary McDonough and his
representatives and the representatives of Disabled American
Veterans (DAV), Paralyzed Veterans of America (PVA), and
Veterans of Foreign Wars (VFW), who will also be testifying on
the second panel.
With that, Ranking Member, I now recognize you for your
opening statement.
OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER
Mr. Takano. Well, thank you, Mr. Chairman. Today we welcome
Secretary McDonough and veteran service organization
representatives of the independent budget (IB) to discuss the
Department of Veterans Affairs' budget request for Fiscal Year
2025.
Budgets reflect our priorities. That is true in how we
spend our money and our time. This year's request from the
President of three of $369.3 billion in funding for the
Department of Veterans Affairs is a 10 percent increase over
Fiscal Year 2024. There is no secret that the VA's budget has
grown significantly since the start of the global war on
terror, but this is a feature, not a bug.
President Biden's budget for Fiscal Year 2025 illustrates a
key pillar of his unity agenda to support veterans. This year's
requested increase reflects the President upholding promises
made to those who have served since 9/11 and is a step in the
right direction to care for aging Vietnam veterans.
During the last year, the PACT Act has expanded VA
healthcare and benefits to millions of veterans exposed to
toxins and other hazards. VA has approved more than 862,000
PACT Act-related claims, and more than 400,000 veterans have
newly enrolled in VA healthcare.
Last year, VA also permanently housed over 45,000 homeless
veterans, provided suicide prevention emergency care for over
50,000 veterans thanks to the Veterans' Comprehensive
Prevention, Access to Care and Treatment (COMPACT) Act.
Expanded services for veterans at risk of suicide delivered an
all-time yearly record number of healthcare appointments and so
much more.
Now, this is just the start of what we can accomplish with
a well-funded VA. However, we know that Republicans have a
different vision for VA. Their chosen Presidential candidate's
plan as laid out in his project 2025 proposal will mean the end
of the VA as we know it. It means a spoils system that doles
out contracts to corporate interests and it means the
privatization of VA healthcare. Let me repeat that. It means
the privatization of VA healthcare.
When VA does well it does really well. VA outperforms the
private healthcare sector in terms of quality and patient
satisfaction while my Republican colleagues continually push a
narrative of supposed failure that is not based on reality and
is not based on the reality of many veterans.
Just recently, a Vietnam veteran who receives his care at
VA let me know how much he values it. In response to
congressional efforts to erode that direct care the veteran
told me, ``Don't let them mess it up.'' As such, I am alarmed
to observe the growth in community care budgets since the Trump
administration implemented new access standards in 2019.
VA's healthcare budget is out of balance and rather than
directing billions of dollars to the community, we must provide
VA with the necessary resources and staffing to ensure that
direct care is robust, modern, and meeting veterans where they
are.
We need to continue to do more to house our homeless
veterans and continue to provide VA the ability to hire more
staff to meet the demands of more veterans using VA healthcare
and benefits. Community care is more expensive than direct
care. If we were truly concerned about the cost and fiscal
responsibility we would invest more in direct care as it is
less expensive and most effective for veterans.
Now, this is my 12th year in Congress. In my first year we
dealt with the Phoenix wait time scandal. I was part of the
negotiations on the Veterans Choice Act. As part of that we saw
that Phoenix, like many other places in this country, struggled
with a shortage of healthcare providers both at VA and in the
community.
In the Choice Act I championed a provision that increased
the number of medical residency spots at VA by 1,500 positions.
This is helping to increase the supply of physicians both at VA
and the community and this is why investing in VA is so
important.
I know that ramping up VA's internal capacity is not
simple. It will take time to bring veterans back from the
community and into VA care, but it is something we must do.
I am sure we will hear today Republicans continue to be
mouthpieces for extreme ideologies that amplify messaging that
VA healthcare should be privatized. That is the direction we
are headed if we do not take the time, provide the funding, or
proceed with thoughtfulness to rebalance direct care and
community care.
I look forward to hearing from Secretary McDonough and our
Veterans Service Organizations (VSO) partners today, and I
yield back.
The Chairman. I thank the ranking member for his comments.
Even though some probably are not right, but that is all right.
Secretary McDonough, I am going to swear you in now if you
would. Would you please stand and raise your right hand? You
were way ahead of that.
[Witness sworn.]
The Chairman. Thank you and let the record reflect the
witness has answered in the affirmative.
Now I would like to recognize Hon. Denis McDonough for 10
minutes for his opening remarks. Thank you again for being
here.
STATEMENT OF DENIS MCDONOUGH
Mr. McDonough. Chairman Bost, Ranking Member Takano, and
distinguished members of the committee, thank you very much for
the opportunity to testify today.
Sergeant First Class Constance Cotton served honorably in
the United States Army, including in combat during the Gulf
War. She is a survivor of several incidents of military sexual
trauma, MST. She shared her story of MST with pastors and with
lay leaders.
Eventually she was connected to the VA in Philadelphia and
its chaplain, Reverend Chris Antal, and Vet Center counselor
Renee Smith. For nearly a decade, Chaplain Antal has helped
Constance heal from all her injuries, while Renee has helped
her deal with post-traumatic stress. Constance lives in New
Jersey, but chooses the Philadelphia VA and Vet Center for her
care.
She says, ``I like that they really understand the
challenges that veterans face.'' She goes on, ``I am a walking
miracle. They helped me--helped to give me a sense of community
again.''
We owe vets like Constance, and all vets, including the
many vets on this committee, our very best. We are fighting
like hell to give them exactly that. We are delivering more
care and more benefits to more veterans than at any time in
VA's history.
Over the course of the last year we have enrolled over
400,000 new vets in VA healthcare, 30 percent more than the
previous year and an increase in each of the 50 states of this
awesome Republic. Over 6.5 million vets had 118 million
clinical visits, 47 million in the community, 42 million at VA,
29 million via VA telehealth. The last data point bears
repeating. Millions of vets use VA telehealth.
Now on to benefits. We have decided over 1.9 million claims
shattering the previous year's record by 16 percent. You have
all heard of vets' frustration with Compensation and Pension
(C&P) exams, justifiable, but in the last year we processed 2.4
million C&P exams, a record by nearly 30 percent and took an
average of 31 days to complete them.
In total, we delivered $163 billion in earned benefits to
over 6 million veterans and survivors, another record. The PACT
Act has opened the doors to millions of toxic exposed veterans
and their survivors bringing new generations of vets to VA
healthcare and expanding benefits for many more.
The PACT Act is also delivering additional benefits for
vets, the GI Bill, Veterans Readiness and Employment (VR&E),
homeownership, survivor's pensions, and so much more, benefits
that not only improve veterans' lives, but strengthen the
American economy. We still have a lot of work to do.
The President's proposed budget fully funds VA so we can
continue doing that important work. This budget is also about
preventing veteran suicide, ending veteran homelessness,
supporting healthcare for women vets, modernizing our IT
systems, processing benefits, and honoring vets with eternal
resting places.
No single investment is more critical to veterans that we
serve in VA's future than the people we hire and retain. We
hired at record levels last year, onboarding teammates like
Rose Zundel, one of VA's newest Registered Nurses (RN). Rose
spent 20 years working as a nurse in her community, but she
chose to come to VA to serve vets like her dad and her grandpa.
That is the kind of deep devotion that characterizes VA
clinicians.
Rose said that she is grateful for the critical skills
incentive (CSI) that she received, that it shows VA's
commitment to supporting its employees and that she hopes 1 day
to retire with VA. The work of caring for the brave men and
women who fight our wars and their families, survivors, and
caregivers is in full swing and continues to grow.
The John S. McCain III, Daniel K. Akaka, and Samuel R.
Johnson VA Maintaining Internal Systems an Strengthening
Integrated Outside Networks (MISSION) Act, COVID pandemic, and
the PACT Act, all of these are products of just the last 6
years and any one of them would have been monumentally
challenging. Together they have changed the healthcare
landscape and the statutory basis for the work at VA.
As I said, any one of those on their own would have led to
monumental change. Together they represent a seismic shift in
the way veterans receive care and benefits. The way they
change--they have changed the way we do business creating
enormous opportunities for veterans at VA. Right now we are at
a critical moment for shaping and securing the future of
veteran healthcare in America.
We will work to reliably offer a VA care option to every
veteran, even vets who qualify for community care under the
Mission Act. We want to bring as many vets as possible into our
care because study after study shows that vets do better at VA.
We have made considerable progress, whether in person, via
telehealth, in our community living centers, mobile medical
units, elsewhere, vets can access VA care at almost every turn.
What we do this year and over the next several years,
building on the generosity of Congress in the last many years
and the innovative hard work of VA's workforce, the best in the
Federal Government, will determine what vets can expect from VA
and how we deliver that high standard of care well into the
future. This budget is the next step to continue delivering
more care, more benefits to more vets for generations to come.
We look forward to collaborating even more effectively with
you to build on what is working and to fix what is not. Thank
you. I look forward to your questions.
[The Prepared Statement Of Denis McDonough Appears In The
Appendix]
The Chairman. Thank you, Mr. Secretary. The written
statement of Secretary McDonough will be entered into the
hearing record. Now, we will start on questions and I now
recognize myself for questions.
Secretary McDonough, the Fiscal Responsibility Act exempted
veterans' healthcare from any cuts, yet that is where you have
had a hiring freeze and the biggest budget problems. Can you
explain why, what that is doing?
Mr. McDonough. Yes, thanks so much, Mr. Chairman. VA's
total request represents a 10 percent increase over Fiscal Year
2023 and it is comparable to Fiscal Year 2024, as you said in
your opening remarks, but let me just note a couple of things.
It appears at first blush that it represents a decrease in
community care, but one of the biggest changes in the last
several years, partly because of your generosity over the
course of many years during the pandemic, is additional funding
streams. One of those is unused balances from previous years.
We have been very careful to reinvest those to include in
medical care. Also, under the PACT Act, you overwhelmingly give
us a new authority under the TEF, the toxic exposure fund. When
you consider carryover and TEF, in fact, community care grows.
I think as you have seen in each of your districts, community
care continues to grow at a very rapid rate.
The fact is that when you take the total picture, TEF,
carryover, and the very generous request for discretionary
funding, VA care grows and is sufficient to meet the challenges
that we face as a health system.
It is true that across both non-defense and defense
accounts in the discretionary that the budget agreement forced
difficult choices. We made those difficult choices and we have
put those in black and white. I am here today to defend those
and to be honest with you.
After having the best hiring year in 30 years at VA last
year, we are well-positioned to provide care. Having seen that
this year's cap, like you guys know this better than I do,
those caps it appears to me are not going anywhere, in which
case the prudent thing to do is to begin to make sure that we
are ready to operate in that difficult budget picture. That is
what this budget does. It makes hard choices, but we put them
out there for you all to see.
Last, I am going to just give you one story. I just was
talking to our leadership in Texas yesterday. Our hospital
Chief Executive Officer (CEO) in San Antonio had a difficult
choice to make. Does she hire two Gastroenterologist (GI) docs
that she has been looking for 3 years and she can now hire them
because of the CSIs, because of more competitive hiring, and
because docs want to come work at VA because of the ability to
make decisions based on the veteran's best interests, not
clearing it through Blue Cross/Blue Shield. Okay?
She made the decision to hire those two providers. That is
the right decision. That is not a hiring freeze. That is a
strategic choice to make sure that we have the best providers
available for our vets. This budget allows that to continue and
that will continue.
The Chairman. Okay. Hopefully. The next question I have
got, right now not a problem that you caused, not a problem we
caused, but there is another body across the rotunda that
caused it. They kind of torpedoed what was the infrastructure
review commissions. How are you going to maintain the health
facilities and give veterans care closer to where they live and
fund the community care if you cannot adjust where your
footprint goes?
Mr. McDonough. Yes, thanks. Thanks for the question, Mr.
Chairman. Let me just say right up front because I know that to
you and to Ms. Budzinski and to others, the new facility in St.
Louis, a major priority, it is--remains our major priority. We
had hoped to get some funding in Fiscal Year 2024 and our
budget request for Fiscal Year 2025, which was finalized before
2024 was finalized, as you look at it you get a sense that we
had anticipated there would be some progress on that.
Nevertheless, we anticipate there will be funding for Fiscal
Year 2026 for St. Louis one and two.
We have instituted a strategy here on our infrastructure to
maximize the dollars that we get, and you see that in this
year's request with major investments in West LA and then
across the system, significant investments in minor
construction. You all raised the cap on that to $30 million
which allows us to move with much greater alacrity on new
outpatient clinics to get them closer to veterans. Then we are
also making sure that we are prioritizing working with our
interagency partners, including the U.S. Department of Defense
(DOD), which I think you have all witnessed itself is
reexamining very closely its balance of care between the
community and the direct care system, so we are using the VA
providers in DOD facilities to get that care closer to
veterans.
Three good examples, Shaw Air Force Base outside
Sacramento; Fort Campbell in Kentucky and Tennessee where we
have a Community Based Outpatient Clinic (CBOC) open in the
fort hospital on Fort Campbell; and then third at the Navy
Medical Center in Pensacola, Florida, which reopened as a site
for surgery, ambulatory surgery. We will expand that to a
fuller CBOC for vets' care later this year at no expense, no
additional expense to the taxpayers for that veteran care.
Those are existing facilities that allows us to provide care to
veterans, as I say, at no additional infrastructure cost to the
taxpayers.
The Chairman. I am over on time, but I do need to figure--
and so I am glad you mentioned St. Louis. I hope you are going
to work--that we can get a commitment to work with you----
Mr. McDonough. You got that. You got that.
The Chairman.--on making sure that is brought back on.
Mr. McDonough. Yes.
The Chairman. There is also a quick concern that I have. We
were out in the district this last week. We have seen photos in
my constituents for foreclosed homes that VA manages. They are
invested in--they are infested with mold, stripped of
appliances, occupied by squatters.
Yesterday VA announced the Veterans Affairs Servicing
Purchase (VASP) Program , which will be buying veterans default
mortgages. I am very concerned about this, and I am working on
legislation to give veterans a better solution. The new program
will create huge increases in properties that VA will own
because some will be inevitably defaulted on. How are you going
to manage those right quick and then I am going to----
Mr. McDonough. Yes, Chairman, thanks very much and thanks
for the heads-up about what is happening at home in your
district. We will make sure--I will make sure that we
specifically follow-up on those.
Fact is that our track record at VA on mortgage financing
is best in industry. Foreclosures among VA mortgage holders are
extraordinarily rare. Nevertheless, because of the tumult in
the real estate market as a result of the pandemic, there are
about 40,000 mortgage holders whose, through no fault of their
own, whose mortgages are at risk.
The VASP program, building on existing authority that we
have, you know, which has been over the course of the last
couple of days not uniformly because I know there is critiques
of it here on the committee--we take those very seriously--but
have been warmly received among many veterans groups as well as
the mortgage industry, underscores that this is the most cost-
effective way to keep veterans in their house.
We take that very, very seriously. We think that the risk
that VA takes on in the event of those 40,000 mortgages is
manageable because of the safeguards we have built into the
program because of what I anticipate will be your very
aggressive oversight.
The costs even in extremis of any risk there are far
exceeded by the potential costs and disruption for those
veterans if we do not take this step for those 40,000 cases. I
know that this will be an issue both throughout the rest of
this hearing, Mr. Chairman, and I welcome that, but the one
thing that I want to reassure you of is, you know, we are not
going to be--we are going to be an open book with you on this.
We think that the oversight actually will strengthen our
performance of the VASP program, but we also think it is both
building on existing authority and a reasonable investment for
those 40,000 vets.
The Chairman. Thank you. I am way over on time.
Ranking Member, you were recognized.
Mr. Takano. Well, thank you, Mr. Chairman.
Thank you for being here, Mr. Secretary. Do you agree with
my assertion in my opening statement that overall direct care
is less expensive to deliver than care in the community?
Mr. McDonough. Well, like, I mean, I would say three
things. One, study after study shows that the care that vets
get in the direct care system leads to higher health, more
improved health outcomes so better health outcomes, one.
Two, it is true that the investment that we have made over
the life of VA, and look, let me just underscore again my
appreciation for this committee's support and the entire
Congress' support on a bipartisan basis for historic
investments in VA, including throughout the pandemic, those
investments mean that the unit cost per care over time because
of the investment in the infrastructure to date makes VA a
longer term better outcomes-based investment for the taxpayers.
Then I will say that we are witnessing a great degree of
variability. This is I think a very real policy challenge for
us basically at VA, but also for Congress, which is it is very
difficult to run a system that is both a direct care system and
functionally an insurance company. There are a lot of steps
that you would take under that scenario that lead you to
inefficiencies, rob you of economies of scale.
As we consider the future of VA coming out of these three
monumental changes, the MISSION Act, the pandemic, and PACT
Act, I think we want to get our hands around just how much risk
we can take and not--I call it the cost in community care
variable. That is half right. It is variable in one direction,
namely up.
Then the cost of the fixed care--the fixed cost of the
direct care system that makes for a very difficult challenge
for us in the years ahead. I look forward to working with the
Congress on that.
Mr. Takano. Well, so my question was pretty simple. I mean,
a three-part answer. In your estimation is it----
Mr. McDonough. Yes.
Mr. Takano. It is less expensive to provide care----
Mr. McDonough. I believe that we do, yes.
Mr. Takano. You know, over the last few years VA has
delivered more care and benefits than at any other time in
history. I commend you and the hardworking employees at the VA
for doing that and all the efforts you have gone into
implementation of the PACT Act. When VA delivers it delivers
well, and I think ensuring a balance between direct care and
community care is more important than ever.
That said, I want to make sure I understand your 2025
budget request. First, you are proposing a transfer of $7.3
billion from the medical services or direct care account to the
community care account in order to help cover the estimated
obligations of $40.9 billion for community care in Fiscal Year
2025.
Second, you plan to reduce the overall number of Veterans
Health Administration (VHA) employees by about 10,000 between
now and the start of Fiscal Year 2025.
Third, you are also preparing to transfer $600 million to
the community care account from the medical facilities account
which covers things like VA facility management, renovations,
and leasing, the very things that you said that it is important
to invest in in order to make direct care really feasible.
You have expressed concern throughout your time as
secretary about the unsustainable trajectory of community care
spending and the need for VA to rebalance resources between
direct care and community care. I share this concern.
I want to know how your budget reflects that. How will
redirecting billions of dollars from direct care to community
care and shrinking VA's workforce by 10,000 employees
accomplish our shared goal of ensuring more veterans receive
more of the care at VA facilities rather than in the community?
Mr. McDonough. Yes, that is a fair question. Thank you for
it. Just on that 10,000 Full-time Equivalent (FTE) reduction,
that is not at the beginning of the Fiscal Year 2025. That will
be at the end of Fiscal Year 2025. That is what is envisioned
in the budget.
This reflects the fact that not only did we have an
historically strong hiring year last year, but retention is
highest it is been in a long time. That is a reflection, again,
of the investments that you gave us in the PACT Act and I thank
you all again one more time for that.
CSI's special salary--so critical skills incentives,
special salary rates, retention bonuses are paying very well
because retention is up. Quit rates are down. The fact of the
transfer of 7-plus billion from the direct care into the
community care account is a reflection of what we have seen in
the course of the last 18 months, which is a robust uptake of
care in the community. Prudence dictates that we be ready for
that. That is why we asked for that, that transfer.
Nevertheless, as I have said in my opening remarks, we want
to make sure that partly because of the fundamental
unworkability--for example, if you take Veterans Integrated
Service Network (VISN) 7, which is South Carolina, Georgia,
Alabama, fully 70 percent of vets in care in that system are
drivetime-eligible in the first instance, meaning they qualify
referral to the community by virtue of drivetime alone, even
though there is no private--there are even fewer private
providers available to them. When we refer them into the
community they are going to travel just as far to get the care
in the community.
In light of that, we want to make sure that every time we
have an engagement with a veteran we make clear that the apple
to the apple. If you have a referral option in the community we
have a very clear offering to the veteran for how soon and
where that veteran can get care in the direct care system. We
think that when given that apples-to-apples comparison the
veteran will choose, even when eligible for community care, to
stick with us because veterans understand the positive health
outcomes as well.
Mr. Takano. Well, Mr. Secretary, to your point of the
example about the choices that the--no choices that veterans
have in many rural areas that being referred into the community
is not really a solution because of the lack of providers or
the nonexistence of providers.
You know, this idea that care in the community as a
solution to that veteran's challenge. You know, you have made a
very, kind of, I think, a very clear illustration of where the
solution really is a nonsolution.
I am curious. When can we expect to see a strategy, a plan
on how you are going to rebalance and how you are going to
provide these veterans with true choices?
Mr. McDonough. Yes.
Mr. Takano. I see the response is not more community care
for those rural veterans. I see that we need to stand up
providers in those communities maybe in conjunction with other
Federal payers.
Mr. McDonough. Yes.
Mr. Takano. When can we expect to see a strategy on how we
are going to get our arms around this explosive rise in
community care?
Mr. McDonough. You know, I think it is a fair question. I
think we have pieces of that strategy are being implemented
now. We have talked at length about those, but nevertheless, I
think your request for kind of an all-in strategy that lays out
how we will get this done is a reasonable one and we would look
forward to having that conversation with you guys over the
course of the next several months as you are thinking about the
budget picture for Fiscal Year 2025 and beyond.
Mr. Takano. Well, thank you. I hope we can see that
strategy soon, and I appreciate your being here. I yield back.
Mr. McDonough. Thank you.
The Chairman. Thank you.
Representative--General Bergman, you are recognized.
Mr. Bergman. Good morning, Mr. Secretary.
Mr. McDonough. Sir.
Mr. Bergman. Great to see you.
Mr. McDonough. And you.
Mr. Bergman. We will get right to it because time is
finite. Money seems to not be in some cases but we know in the
end it really is. I am on the Budget Committee this cycle and
in charge of a task force on improper payments across the
government.
You know, as chairman of that oversight task force is
finding out, I hate to say where all the pots of money are, but
how the moneys that have been appropriated out there how they
are being spent. While there has been some progress in recent
years can you tell me how VA, you know, continue to work to
lower the improper payments to the greatest extent possible?
Mr. McDonough. Yes. Thanks very much, General, for the
question. I obviously share your concern about improper
payments. I am proud of the progress that we have made at VA on
this. VA has reported a total reduction of $11.6 billion, which
is a 79 percent reduction in improper payments over the last 5
years, and Fiscal Year 2023 is the lowest reported improper
payments at VA in 9 years.
Our focus going forward is on improving our testing
processes to ensure that we are getting to the root cause of
any remaining improper payments and leveraging every tool
available. Obviously, that is going to be based on automation
and strengthening our processes, working with the committee,
and working with Government Accountability Office (GAO), with
the Inspector General (IG), and with industry to prevent
improper payments on the front end.
I will just give you one example. This is in our education
programming. One of the routines, it is slightly different from
the improper payments basket, but one of the places where we
had been accumulating or veterans had been accumulating
unknowingly debt is education overpayments because they had
stopped going to class.
We have instituted a process of regular text exchange with
student veterans to make sure that they are still where they
had planned to be so that they are not incurring debt
accidentally. That is the kind of testing and automation that
we want to make sure that we are making progress on.
Mr. Bergman. Okay, thank you. Different subject----
Mr. McDonough. Yes.
Mr. Bergman [continuing]. psychedelics, as you--I am the
co-chair of the Psychedelic-Assisted Therapies Caucus----
Mr. McDonough. Yes.
Mr. Bergman [continuing]. along with Lou Correa from
California. I was happy to see the VA issue a request for
applications for studies into 3,4-Methylenedioxymethamphetamine
(MDMA)-assisted therapy to treat Post-Traumatic Stress Disorder
(PTSD) in veterans, and I am glad the budget listed these
treatments as priorities.
However, given the reduced funding for research and reduced
healthcare workforce under the budget, how will VA prioritize
research into psychedelic-assisted therapies and the most
critically probably, the training of the therapists in these
new regimens to administer the treatment so that veterans can
actually, you know, get their results and, you know, as U.S.
Food and Drug Administration (FDA) approval moves forward?
Mr. McDonough. Yes. Well, thanks very much for the question
and thank you for your support of this new tool. Partly by
listing it the way we do in the budget and mindful of what
appears to be fairly rapid progress from FDA, although it is
obviously difficult to see inside FDA, but also because of the
great hope that we hear from many veterans including here in
Congress about these treatments, we feel duty-bound to
prioritize this so that we are ready when FDA gives a green
light so that vets do not rush into this without the support of
VA because there is going to be risk if there is not supportive
of VA. The funding levels that you talked about, the staffing
levels will not impact our prioritization of this.
Last point I will make, Mr. Bergman, is I do, however,
anticipate debate about this up here just judging by the
reaction to our budget proposal. One thing that I think I just
want to dogear is I anticipate that over the course of the next
several months as you all work through and the appropriators
work through our budget I would anticipate seeing some back and
forth, maybe even some effort to limit our ability to invest in
these new tools in the course of this this budget cycle.
I just--I put that out there something that we should make
sure that we are working together on. Yes.
Mr. Bergman. Thank you. I see my time is running short, but
I just wanted to say if you remember a couple of years ago
before the football game we had our picture taken with Brittany
Elliott?
Mr. McDonough. I do. How could I forget?
Mr. Bergman. Yes, with the exoskeleton, and it has been
moving forward. I guess there is more money into it and I would
guess I would implore you and every--the VA has lagged on
getting these devices that are proven to the veterans who need
them. With that I yield back.
Mr. McDonough. I will just say I do not want to drag this
out, Chairman, I just want to say I met last week with an
amazing soldier, a triple amputee from his service in
Afghanistan. I first met him at Walter Reed many years ago. I
used to work in different roles in the U.S. Government.
His experience in both managing his prosthetics but also
the support that he has gotten, for example, adaptive
technologies for driving, left me with the impression that
there is work for us to do across the board on this. We are
instituting a journey map, a review of the veteran experience
on this. We will make sure that we include Brittany in that and
we will make sure that we are doing right by these brave men
and women.
The Chairman. Representative Brownley.
Ms. Brownley. Thank you. Thank you, Mr. Chairman.
Thank you, Mr. Secretary, for being here. Thank you for
highlighting vet centers and the trauma that too many of our
women veterans experience in their service to our country. Vet
centers are such an important footprint within the VA
infrastructure, so I really appreciate you mentioning both of
those.
I have a couple of questions and if you could be as brief
as possible----
Mr. McDonough. Sure.
Ms. Brownley [continuing]. because I would like to get them
all in.
Mr. McDonough. Yes.
Ms. Brownley. The first is on childcare and I noticed that
the budget requests $18.6 million for childcare. Can you give
me some idea of the progress that you are making to ensure that
every VA Medical Center has access to childcare options as was
promised in the Deborah Sampson bill?
Mr. McDonough. Yes. Well, thank you very much. We are
obviously--we are taking this very seriously. Obviously, the
pandemic challenged us in that regard, but we see two paths to
make this happen. One is direct to veteran reimbursement for
the care that that veteran invests to facilitate his or her
appointment. The second is making sure that there is--the
second prong is making sure that there are sites on campus.
We think the two sites closest ready to go are Fresno and
Shreveport. There are two questions here is how quickly can we
get the regulatory process done? The appropriators have warned
us about that being slow to an order places on campus to open
up, so we are looking now at whether there is some regulatory
guidance meaning something more quick we can do to get those
sites stood up to partner along with places like Seattle where
we have deployed other pilots.
Our promise in the Deborah Sampson Act I think is by Fiscal
Year 2026. We will keep pushing on this very aggressively. I
cannot make a definitive promise that we will make Fiscal Year
2026 at every VA facility, but there will be good progress on
this one.
Ms. Brownley. Thank you. We should also try, you know, try
to put at least one to test it in a big, urban, I think in a
big, urban center in a medical center.
Mr. McDonough. Fair enough.
Ms. Brownley. Yes. In terms of VA spending on our women
veterans, it seems to me that it is difficult really to
determine whether the budget allocated for gender-specific care
is proportional to the growing rate of utilization of women and
other gender-specific care. Do you have the data to compare
these metrics over a 5-year period, over a 10-year period?
Mr. McDonough. You know, what I can tell you is that we
have doubled the funding in the last 10 years, but I cannot--
let me take that and then give you that and maybe lay that
against the demographic or actuarial data to show you how we
are making the investments.
We do use the model, what we call the middleman model, to
inform our decisions on gender-specific care and to inform our
decisions on the office of woman's health which oversees the
WISE grants, which is also the basis by which we hire gender-
specific providers and deploy gender-specific technology like
mammography.
I think that is a fair question. Let us get that to you in
writing.
Ms. Brownley. That would be great because it is really hard
without the data to really understand if we are, you know, the
budgets that are being proposed are adequate enough based--you
know, we need that proportionality.
Mr. McDonough. I think that is a fair question.
Ms. Brownley. Great. Great, great, great.
Mr. McDonough. That is a good question.
Ms. Brownley. I also notice that, you know, in the budget
that you are seeking a 20 percent increase in the caregiver
support program and also I think for long-term support services
you are asking for $17.9 million, which I think is about an
$800 million increase. I guess my question is if we were to
pass and put into law the Elizabeth Dole bill would you
eventually see the cost of those two programs diminish over
time?
Mr. McDonough. That is a good question. In the interest of
time let me just say two things. One, let me take that and get
that back to you in writing because I had not considered that,
but two, the investments that are in there are a reflection of
what we anticipate of turning back on the expanded caregiver
program, which we will do over the course of this fiscal year--
sorry, next Fiscal Year into 2025.
Let me make sure that I understand specifically the impact
of your bill on the long-term cost of that program and I will
get that back to you.
Ms. Brownley. Thank you very much, and I yield back.
The Chairman. Representative Rosendale.
Mr. Rosendale. Thank you, Mr. Chair.
Good morning, Secretary.
Mr. McDonough. Good morning.
Mr. Rosendale. Always good to see you again.
Mr. McDonough. And you. And you.
Mr. Rosendale. Let us start off, thank you very much for
your help in Montana. We are making a lot of progress to
improving the healthcare delivery for the veterans there, and I
am looking forward to having a permanent director, which I
understand is very soon----
Mr. McDonough. Yes, in the works.
Mr. Rosendale [continuing]. to make sure that we get Fort
Harrison straight.
Secretary, in January an opinion article in The Hill was
written by three VA psychologists with over 40 years of
clinical experience and it was titled, ``The VA is abandoning
women veterans' rights for gender identity'.'' The article
pointed out that, ``Single sex spaces within the VA, those
ensuring bodily privacy such as bathrooms, exam rooms, and
medical exam areas can now be accessed by males who self-
identify as women.''
Now, we have just made an incredible investment in the VA
facilities across the Nation because of the growing population
of females within the veterans' community and so I really do
not understand so that we were making all this investment to
try and make them feel comfortable, to make them feel more
welcomed into the veterans' facilities why we would now be
opening these exact same facilities to males who are
identifying as women?
Are you aware of a letter that I wrote about this topic
with Representative Crane back on February the 12th?
Mr. McDonough. I am aware of your letter. I would have to
refresh my memory if I have responded to you yet, but I know
that we are working that. I also know that when I saw the
report in the newspaper I also reached out to VHA to make sure
that they were talking to our clinicians across the system.
You know, our commitment to all of our vets is that they
get care in a safe environment, that they feel safe, and I have
every expectation. In fact, it is my conviction that we ensure
that for veterans.
Mr. Rosendale. We are not just talking now about the
veterans and their level of comfort to make sure that our
female veterans can come into these facilities and feel
inviting, okay, and feel safe about it, but the article was
published. One of the psychologists' direct reports delivered a
memorandum removing her from her role as a psychologist. A
psychologist was pulled away from her patients for
approximately 1 week after being reinstated. There is no
question that this resulted in disruption of care for her
patients.
One of the other psychologists who wrote the article was
kicked out of the VA chat and was previously prevented from
supervising students for his opposition to Diversity, Equity,
and Inclusion (DEI) initiatives.
You said at a press conference when asked about the
article, ``We do not require our employees to choose between
their conscience and their career.''
Mr. McDonough. We do not.
Mr. Rosendale. That is the case 365-24-7. That is a noble
goal. However, these employees did speak their conscience and
they were punished. There seems to be a little bit of a
disconnect between the words and what has happened to these
employees. Are you aware of the retribution that these
employees have faced?
Mr. McDonough. What I understand is that it is standard VA
practice that when, you know, there is a dust-up around a
provider that the local leadership would take a look at what
the dust-up is about and then they would make some decisions
about. That is, as I understand of what happened in this case,
as your question suggested, the veteran--sorry--the provider
went back to patient care within a week. You said there is no
question that had an impact on the veterans' care. I actually
have not seen any sense that there is a question whether it
impacted veterans' care, meaning I have seen no evidence that
it did impact veterans' care.
Those kinds of procedures which are laid out in VHA
practice guidebooks across the system are the kinds of steps
that I would think a responsive, high reliability organization
would take.
Mr. Rosendale. The employees should not, in your words,
``be subject to retribution for speaking their conscience.''
Mr. McDonough. I do not think this is retribution,
Congressman. Like, again, this is all derivative. I am learning
this partly to make sure that I can respond to you and Mr.
Crane. These are decisions--these are potential processes laid
out in VHA guidebooks about how to make sure that we are
managing the provision of care effectively across the system. I
do not think this is retribution.
There was questions about the dust-up. It sounds to me like
the local leadership looked into it and within a week the
person was back on the job.
As to the employee-controlled chat group, you know, I mean,
I am not going to--I do not think it is appropriate for me to
start managing who is members and who is not members of a chat
group. You know, I think those are collegial decisions that our
professionals can----
Mr. Rosendale. Well, I will take you at your word because--
--
Mr. McDonough. Yes.
Mr. Rosendale [continuing]. we always have been able to
rely on each other and it has always been also my experience
that when you are made aware of these things----
Mr. McDonough. Yes.
Mr. Rosendale [continuing]. that you have looked into them
and made sure that they were made straight.
The last comment that I would just like to make is that
while Ranking Member Takano embraces the expansion of the VA,
what our job here is to make sure that the veterans get the
care that they have earned, that they deserve, when they want
it where they want it, not to protect the VA. It is not to
protect the VA. It is to make sure that the veterans get the
care that they have earned and that they deserve when they want
it where they want it.
I assure you when you are dealing in urban areas it is a
lot easier for the veterans to slip into a VA facility than it
is in Montana where we have 100,000 veterans that are dispersed
across 145,000 square miles and they are heavily dependent on
the community care in order to make sure that they are being
taken care of.
Thank you very much. I appreciate----
Mr. McDonough. Thank you.
Mr. Rosendale [continuing]. I appreciate all your work.
Mr. McDonough. Thank you and I appreciate your always being
available to me and, you know, look, I think Montana is
emblematic of the challenge that we face in this country, which
is access in rural settings. I have spent time in many of your
districts asking these same questions.
I suggest that among organizations making investments in
rural settings few rival the amount of dollars that VA itself
is investing in rural settings, and I think that is important.
Part of that is based on our belief that rural veterans deserve
access to the highest quality care, too, right?
This is also why we are working with DOD and even now with
U.S. Department of Agriculture to make sure that we have high
quality care sites available to veterans across 140,000 miles--
--
Mr. Rosendale. 145,000 square miles.
Mr. McDonough [continuing]. 145,000, yes. It is a little
bigger than Minnesota but not that much.
Mr. Rosendale. Yes. Thank you. I yield back, Mr. Chair,
thank you.
The Chairman. Representative Levin.
Mr. Levin. Thank you, Mr. Chairman.
Mr. Secretary, great to see you. Thank you for your
continued hard work----
Mr. McDonough. Thank you.
Mr. Levin [continuing]. on behalf of our veterans and your
team as well. We appreciate you and thanks for visiting so many
of our districts.
Mr. McDonough. You are right to thank them. They do all the
work, not me.
Mr. Levin. Absolutely. Absolutely. Thank you for always
being available visiting so many of our districts. You are
always welcome----
Mr. McDonough. Thank you.
Mr. Levin [continuing]. in our district. I wanted to get
through a few questions. First, I want to bring something up
that I have discussed in our budget hearings for the past 2
years and that is the veteran and spouse transitional
assistance grant program. I was proud to authorize the program
as part of Isakson and Roe to support local organizations that
provide coordinated transition assistance services, such as
resume assistance, interview training, and job recruitment
training to veterans and their spouses.
VA issued a proposed rule for implementation of this
program in July 2023 and last month Congress appropriated $5
million to begin awarding grants. Now that VA has the funding
in hand when do you expect to open the grant application?
Mr. McDonough. Well, we are working through the comments
that we have received now, and so I have to be careful about
that, but we are working through those comments and we will
publish a final rule when we are done there. Then we will be in
a position to begin administering the grants, you know,
pursuant to well-established, publicly commented on rules so
that everybody gets a fair shot at it.
Mr. Levin. Thank you for that. VA estimated that full
program implementation would cost $26.3 million per year, but
the Fiscal Year 2025 budget request maintains level funding for
$5 million and with the program only authorized for 5 years VA
has limited time to scale it up, make the case for long-term
authorization.
I have the same question for you that I did last year,
hoping for a clear answer. When does VA plan to fully fund the
program?
Mr. McDonough. When we can prove that we have the right
programmatic setup to ensure that it is successful. I think we
want to, you know, build to that through experience and through
proven performance rather than--which is something that we do
all too often, buy the dream and then find out that we cannot
execute the full dream. We end up complicating outcomes for
veterans and not being the best stewards of taxpayers' dollars
along the way. We will build to it. I cannot give you a firm
number on that but this is why it is so important that we get--
--
Mr. Levin. Along those lines, Mr. Secretary, will you
commit to moving as expeditiously as you can----
Mr. McDonough. You have that. You have that----
Mr. Levin [continuing]. so that I do not have to ask the
same question next year?
Mr. McDonough. Yes.
Mr. Levin. Excellent, thank you. Wanted to move on to a
local issue for me, the Jennifer Moreno VA Medical Center in
San Diego, who has been trying to purchase land from the
University of California, San Diego since Fiscal Year 2020. VA
has not included this request and its short-term budget year
requests.
When VA facilities have to wait years for Congress and VA
to allocate funding for a land acquisition project and the cost
of land continues to increase, we end up unnecessarily wasting
taxpayer money. In both last year and this year's budget
request you asked for Congress to pass legislation allowing VA
to allocate funding for land acquisition projects without
specific congressional authorization.
The final Fiscal Year 2024 appropriations bill included
language that removed the requirement for VA to get specific
authorization from Congress on VHA land acquisition projects,
but it did not amend the underlying statute or allocate any
funding for VHA land acquisition projects.
Do you still need authorizing language in a separate
appropriations line item to make the VHA land acquisition line
item a reality?
Mr. McDonough. We do.
Mr. Levin. I look forward to working with my colleagues on
this committee to get the authorization enacted into law so we
can get the resources to VA facilities as quickly as we can.
Last, Mr. Secretary, I want to thank you for your steadfast
commitment to ending veteran homelessness. Your budget includes
$3.21 billion for this purpose with increases for most
programs, except supportive services for veteran families,
SSVF, which would receive a decrease. SSVF, I believe, is the
heart of VA's homelessness prevention efforts and has grown in
recent years to fill critical needs, but can you discuss the
rationale behind the funding decrease for SSVF?
Yes. You know, this year's funding level really draws on
what we learned last year which is that we have an increase in
unsheltered homelessness. This is why grant per diem is really
so important, but also why we are investing as much as we are
investing in prevention this year.
We are trying to get ahead of the challenge by keeping more
veterans in their homes, hence the things like the VASP
program, but also trying to make sure that because we saw last
year for the first time in a number of years, I think 3 years,
an increase in 7 percent of veteran homelessness, which
included unsheltered veteran homelessness.
That is what is reflected in the budget.
Mr. Levin. I am out of time. Again, I want to say thank you
for the hard work that you and your team----
Mr. McDonough. Thank you.
Mr. Levin [continuing]. are doing and I look forward to
further discussions soon. I yield back.
The Chairman. Representative Van Orden.
Mr. Van Orden. Thank you, Mr. Chairman.
Mr. Secretary, April 21, 2023, the Veterans Administration
put something on their website and I want to ask you if these
things became true. With our budget we are discussing that
Veterans Administration said that there would be 30 million
fewer veteran outpatient visits that take place?
Mr. McDonough. No. We had a net increase.
Mr. Van Orden. That we undermined access to telehealth. Did
that take place?
Mr. McDonough. No.
Mr. Van Orden. Or wait times worsen for benefits because
you are going to be forced to eliminate 6,000 staff members?
Mr. McDonough. Again, we gained----
Mr. Van Orden. An estimated 134,000 claims?
Mr. McDonough. We are resolving claims 17 days faster this
year than last year.
Mr. Van Orden. Were you prevented from construction of VA
healthcare facilities that veterans needed?
Mr. McDonough. No.
Mr. Van Orden. No. Did you fail to honor the memories of
all our veterans by eliminating approximately 500 staff that
take care of our cemeteries?
Mr. McDonough. I did not. We did not.
Mr. Van Orden. It did not happen? Okay. Did you cut housing
for veterans? I do not think you did because we just talked
about that. Did food security increase for veterans--
insecurity?
Mr. McDonough. No, it did not.
Mr. Van Orden. It did not. Okay. Deprive veterans of mental
health substance use healthcare services, did that happen? That
did not happen either, did it? Okay. Did you eliminate job
training? Did not do that either.
When the ranking member of this committee says that the VA
will end as we know it if Donald Trump is elected, do you think
that that is true?
Mr. McDonough. You know, I am not going to get----
Mr. Van Orden. I do not like politicizing this either, sir,
but I am telling you I am not standing for this stuff. There
are article after article after article about how Donald Trump
increased the ability for veterans to get care. This stuff that
you put on your website and that these people echoed on the
other side of this chamber, you just said on the record did not
take place.
We are not going to fearmonger here with our veterans. I
know you do not do it. You did it here. We talked about this.
You came to our office. There is absolutely no place for this
in this committee at all.
I believe that Mr. Takano should publicly apologize for
this. Donald Trump will not be destroying the Veterans
Administration as we know it when he is elected as President.
Okay. I did not plan on doing that, but I am not going to stand
by and listen to this political garbage in this committee at
all.
Okay. VASP, sir, you said in your letter you sent it over
here last night about 8 that you think that the VASP thing is
going to turn out well for veterans. Can you envision a world
where the Veterans Administration is going to force veterans to
leave their homes? Will the Veterans Administration foreclose
on a veteran and make them homeless?
Mr. McDonough. No.
Mr. Van Orden. Okay. Here is the problem, sir. If the
Veterans Administration assumes these loans, puts them on their
books, first of all, the amount of work that has been done on
this is wholly inadequate even from the staffing amount of
folks that you think you are going to have to hire to
administer about $15 billion worth of loans. Veterans may or
may not be able to pay these loans back and they are going to
be on the VA books.
You just told me that you are not going to evict a veteran
from a home which means that the Veterans Administration is
going to be paying the mortgage of a home for a veteran which
means the government of the United States of America is going
to essentially make these public buildings because we are
paying for it. You are going to have a private citizen living
in a public building. They tried that before in the Soviet
Union and it did not work.
The issue that we have here--no one on this committee, Mr.
Levin is my ranking member who I respect tremendously, cares
about veterans homelessness as do I. This is not the way to do
this.
The Veterans Administration has the potential to destroy
the second best thing the Veterans Administration has ever
done. The first thing is the GI Bill that fundamentally created
the middle class. The second one is the veterans home loan
guarantee. By you guys doing this in a very unthoughtful manner
I am afraid that you are going to wreck that program and we
cannot have that.
That is how I bought my home. I want our young veterans to
be able to buy homes with that program and because there has
been a nearly complete lack of thought put into this and there
has been, go through it in a different form, I do not want to
extend this conversation. I believe that you are going to do
much more harm than good and it is unintentional.
I would like, again, to follow-up. We had a meeting with
the chairman and your undersecretary on this but we have got to
get down to brass tacks on this because I am unwilling to be
the chairman of the subcommittee that is responsible for
destroying the veteran home loan guarantee.
Thank you for your time, sir.
Mr. McDonough. Thank you.
Mr. Van Orden. Yes. It is good to see you.
Mr. McDonough. And you.
Mr. Van Orden. With that, I yield back, Mr. Chairman.
The Chairman. Representative Pappas.
Mr. Pappas. Thank you, Mr. Chairman.
Mr. Secretary, good morning----
Mr. McDonough. Good morning.
Mr. Pappas [continuing]. and I appreciate your thoughts
here today, particularly as they pertain to community care and
that is what I intended to ask about. I do not want to be
repetitive here, but this is an issue that we think a lot about
in New Hampshire.
We know that we have got a lot of rural communities that
are underserved. Community care clearly has helped close
important gaps but we also want to make sure that it does not
supplant VA healthcare, which is a concern that I hear directly
from our medical center leadership.
They have made great strides at improving services at the
Manchester VA, recently opening a wellness center. They have
got a women's health clinic that is under construction, but
they are expressing concerns that they could be unable to
further expand services at the facility and make it an
attractive option for veterans if we are going to continue to
see the community care budget increase. This is in a State
where everyone is automatically eligible for community care.
Can you talk about that balance as it pertains to the
Manchester VA and how we can work with leadership there to make
sure they can continue to bolster services and show veterans
the advantage that they provide in terms of seeking care within
that facility?
Mr. McDonough. Yes. Well, I thank you very much for that
question and I appreciate the conversations we have had about
this. I think a challenge for us as a country is to ensure that
there is greater access in rural communities to healthcare, and
this is a major challenge in every one of your states, a
particular challenge in yours. It is a particular challenge for
VA because veterans are more likely than non-veterans to come
from rural communities and to return to rural communities.
The challenge for us is making sure that we can get that
care closer to veterans and that we do not think that making a
referral into the community is the end of our relationship with
a veteran because, (a), we have to coordinate that care, make
sure that it is fit into all the other care that the veteran is
getting, but we also have to make sure that we are not just
referring the vet into the community and then he ends up
driving 3 hours to see somebody in the private sector anyway
when they might be able to go a much shorter distance to come
to a VA facility, even if that VA facility is outside the 30-or
60-minute drivetime window.
That is what we are trying to do. We are also trying to
make and take advantage of things like VA Health Connect. All
of us have access. Well, I will just say myself, I have access
to Blue Cross/Blue Shield. I can get a nurse practitioner on
the phone to triage concern about my kids or my family or
myself. We now through VA Health Connect have concluded 45
million calls last year. These would not be included in
clinical encounters we had talked about earlier. That gets a
vet in touch with a nurse practitioner to resolve that
veteran's question obviating the need to travel.
That is the kind of use of telehealth, the kind of use of
triage available options that we are trying to test to ensure
that we do not boil this down to just say, hey, you have
qualified for travel time. Here is your referral over. You go
take care of this.
Mr. Pappas. Sure, and I am wondering if you can address
concerns that some of the VSOs have in their testimony about
the infrastructure spend in Fiscal Year 2025? The request is 33
percent lower than last year.
Some concerns also around State home construction grant
programs funding, VA requested $30 million less than Fiscal
Year 2024 levels, which we know is woefully short of where we
need to be to fund priority projects, especially as we think
about the number of veterans that are in long-term care in
these facilities.
Can you talk about specifically the State home construction
grant program and----
Mr. McDonough. Right.
Mr. Pappas [continuing]. that that level that you
requested?
Yes. Look, as I said in my opening, in the opening set of
questions, the caps did force difficult decisions on the
Federal Government. I think that is, well, it is as it is.
This is one of those cases where we made that decision. We
are examining different funding streams, as I said, cooperation
with other Federal agencies. Last year we attempted to try to
get mandatory funding for this to make sure that we can invest
at the levels and rates we need to.
When your average facility in terms of hospitals, I do not
have to remind you of this, is 62 years old, the major
construction account is not going to be made whole each year
at, you know, $2 billion. We have to figure out a different way
to do that.
We are testing options. I really appreciate the VSOs
pushing on this because we have to figure out how we get around
a difficult set of caps, especially when we have the dynamic on
costs that we have been talking about throughout the course of
the year.
Mr. Pappas. Yes. Thank you for your comments there. It is a
huge issue. We have got a significant backlog. We have got to
address it.
Mr. McDonough. Thank you.
Mr. Pappas. I yield back.
The Chairman. Representative Luttrell.
Mr. Luttrell. Thank you, Mr. Chairman.
Mr. McDonough. Sir.
Mr. Luttrell. Good to see you as always, sir.
Mr. McDonough. And you.
Mr. Luttrell. Thank you for all the hard work and please
pass the word to all the undersecretaries and everybody that
comes in front of the Disability Assistance Subcommittee. I am
not always easy on them, but they are doing an amazing job.
I heard you state the previous year's numbers and the
growth rate in employees and the successes that we have or are
having in the VA, which I am over the moon about, but there is
one number that grew last year that you and I spoke about that
should not be growing. That is your number one issue from what
I understand at the VA and that is suicide.
Mr. McDonough. Yes.
Mr. Luttrell. That is something we have yet to corral. As a
neuroscientist studying the brain and emotional behaviors for
the past 15 years now, I think, I want to solve this problem.
This should not be a conversation that we are having. You and I
every time we have a meeting together this is the number one
topic that we talked about.
I heard the general speak about the progression of
alternative medications in space in alternative to the opioid
problems that we have, the Selective Serotonin Reuptake
Inhibitors (SSRI)----
Mr. McDonough. Yes, sir.
Mr. Luttrell [continuing]. and the existing modalities that
we are utilizing for these problem sets. That, you know, if you
roll the clock back a decade the numbers are--they are
sustained. We are not doing what we need to be doing.
Mr. McDonough. Right.
Mr. Luttrell. We need to fix that problem. It saddens, it
sickens me to sit here in the House of Representatives and say
that, hey, we have this problem. We have to fix it, but we say
this every year.
Mr. McDonough. Every year.
Mr. Luttrell. I want the VA to be the leading edge of the
sword. You have that capability. If there is legislation that
is not in place that allows the VA to be where all the other
institutes of higher learning and research come running to the
VA to say you are leading the way how can we help you or can we
learn from you, that is what I want to see.
That transcends the research space down into our veteran
community where we do not have this problem set. With the
budget line, I mean, I can throw numbers at this all day long.
What are we going to do? How are we going to fix this problem?
I know you cannot answer that question because it exists.
It is such a wide net that we have to cast, but no more. I
mean, what was it, over 6,000 deaths last year? What are we
doing? How are we going to fix this problem, sir? I mean, with
this budget line are we moving money in the proper direction to
centrally focus on this issue?
Mr. McDonough. Yes. Well, I think that we have got to, as
you are suggesting, I think we have got to get the solutions
closer to the veterans' communities and closer to the veteran.
I think what you see in this budget is enhanced efforts at
outreach to try to get veterans into our care, enhanced
investments in the people and organizations who know their vets
best.
You know----
Mr. Luttrell. If it is community care or primary direct
primary care at the VA that is----
Mr. McDonough. That but also investing in local
organizations who know vets.
Mr. Luttrell. Yes, absolutely.
Mr. McDonough. So----
Mr. Luttrell. We have to be, and I hate to say this, sir,
because I would never put myself in your position, but we have
to be hyperaggressive on this. I mean in an uncomfortable
momentum----
Mr. McDonough. Yes. No, look I mean, we have got to be,
like, hyperaggressive about it because we have to act like a
life depends on it because it turns out more than 6,000 do
depend on it.
This is the whole idea is to get the care, the awareness,
the investments closer to the veteran, closer to the people who
know the veterans most to ensure that when a veteran stops
showing up, when a veteran is isolated there is support, (a),
people know that there is support for people who know that to
do something about it.
Then there is availability of mental health treatment so
that when the veteran reaches a moment when he will come out of
isolation and get the care that he does not have to wait to get
the care, that he gets the care. You know, we are trying to
push that as close to the veteran as we can.
Mr. Luttrell. I would like to see the expansiveness of
this, of not only this dollar amount but the research mechanism
inside the VA----
Mr. McDonough. Yes.
Mr. Luttrell [continuing]. go out into deeper waters, deep
brain stimulations. We are seeing research that says, hey, that
addresses addiction and emotional instability.
Mr. McDonough. Yes.
Mr. Luttrell. You know? I am going to close with my last 20
seconds. I do not know if I heard you correctly but did you say
there is going to be problems on this side as far as moving
appropriations to research with the psychedelic medications?
Mr. McDonough. I am just reading back to you the mem cons
that I got out of our briefing about our budget. I think we
were surprised that we got a little pushback. I cannot remember
from whom we got that pressure----
Mr. Luttrell. I can assure you I will be digging into that
because not only just the veterans in this community that you
see now, but there is a high majority of the congressional
Members that they do not want this problem to exist any longer.
I think with the research and the experiences that the veterans
have had to share with the body I think we can put that----
Mr. McDonough. You have had----
Mr. Luttrell [continuing]. hopefully put that to bed.
Mr. McDonough. You have made the sale. You have underscored
to me the impact of this, and the more I scratch at it, as I
told you, I am skeptical.
Mr. Luttrell. Yes, sir. I understand.
Mr. McDonough. The more I scratch at it the more--and the
more I hear from our providers the more determined we are to
make sure that we do the right thing.
Mr. Luttrell. Thank you, Mr. Secretary. I appreciate it.
Mr. Chairman, I yield back.
The Chairman. Representative Cherfilus-McCormick.
Ms. Cherfilus-McCormick. Thank you, Mr. Chair.
Mr. Secretary, the Fiscal Year 2025 request indicates a 44
percent cut to the IT modernization account. The budget seems
to be focused on maintaining legacy systems over modernizing
them. There are several modernization efforts already in
progress. How do you intend to fund those programs under this
budget?
Mr. McDonough. Yes. This is, you know, among the challenges
in the budget. This is one. As I said, the caps and the fact
that we are no longer operating in the pandemic era of very,
very generous appropriations which, again, I thank everyone on
the committee, Republicans and Democrats for those investments.
This is a maintenance budget. I will just be very candid
with you. As we briefed it out we have made that clear to your
teams as well. That is true in IT.
We have got to make sure that we are maintaining the
progress we have made. We do have incremental funding so that
we can maintain momentum on modernization projects like
Financial Management Business Transformation (FMBT), for
example. Obviously, we will stay on top of those but, you know,
the budget does force some tough choices and IT is one of those
places.
Ms. Cherfilus-McCormick. You said it is a maintenance
budget but right now when we look at the Electronic Health
Record Modernization (EHRM) budget, which was cut in half, I
understand that it is related to the program's current status
under reset. However, the dramatic budget cut in this program
leaves me concern that there are no real plans to move from
reset to implementation.
Mr. McDonough. Yes.
Ms. Cherfilus-McCormick. Do you expect EHRM to resume any
go-lives in Fiscal Year 2025?
Mr. McDonough. Yes. Well, here is what I would say. We are
not staying in reset forever. We are going to get into
deployment one, two. Why? This is really, really, really
important and we are committed to making it happen. We need a
single health record across the VA system, and we need one that
talks more effectively to DOD.
The fact is that when we get to the, well, during the
course of this year as we approach the end of the year I
anticipate us being in discussions to get out of reset. When we
get there remember that we have, and this is one of the things
that the chairman talked about, we have carryover. We have
prior year funding. It is 3-year funding available to us to
deploy in the first instance beyond the reset.
We have existing money that would not that be accounted
for, prior year appropriated money not accounted for in this
year's request that is slated and available for us when we exit
reset.
Ms. Cherfilus-McCormick. Just for clarification purposes--
--
Mr. McDonough. Yes.
Ms. Cherfilus-McCormick [continuing]. do you plan on being
in reset for the entirety of Fiscal Year 2025 or not?
Mr. McDonough. We do not.
Ms. Cherfilus-McCormick. How do you plan on specifically
funding the go-lives if we are having this----
Mr. McDonough. With the 3-year funding that is existing
already. We have that at VA already so we have prior
authorized--prior appropriated money available to us to deploy
when we get out of reset.
Ms. Cherfilus-McCormick. Okay. The budget request also
indicates a 65 percent cut in the infrastructure readiness
program that is focused on addressing VA's massive technical
debt. Given that most of VA's work relies on the department's
aging IT infrastructure, this is a huge disservice to VA
employees and veterans. How can we expect to expand access to
care and benefits for veterans on IT systems and equipment that
are growing older and more obsolete every day?
Mr. McDonough. Well, this is why, for example, TEF is so
important. TEF allows us, and look, we have been very, very
careful with the TEF. The law that you all passed said any
incremental funding for the treatment of toxic exposure over
the Fiscal Year 2021 baseline can be TEF.
We have been very careful about this. We have briefed your
teams at length about it. We have methodologies for each of our
components, including IT, Office of Information and Technology
(OI&T), and we are going to be in a position to make sure that
because of that TEF money we can continue to make progress,
including on important infrastructure improvements like benefit
delivery.
Moreover, some of our infrastructure was bought ahead
during, for example, EHRM deployment. We are getting sites
deployment ready so we are in a position to continue, as I
said, maintain momentum, continue momentum, maybe not at the
level we would have anticipated in a place where I forget who
said that, I guess General Bergman said that sometimes money
seems infinite. We get that it is not.
We think it is prudent to make the decisions that we are
making, and we think that we have a plan to make that happen.
Ms. Cherfilus-McCormick. Well, one more thing I wanted to
ask you because it seems like with all the cuts you are really
relying on the excess of the supplemental funds that you had
from TEF and other sources. Now, do you have any concerns that
you might run short because it seems like in all these cut
areas that you are planning on supplementing it there? Is there
enough to supplement the entire budget because we see so much
extensive cuts?
Mr. McDonough. Yes. You know, I think I would disagree with
the characterization of extensive cuts. I think we have been
trying, you know, as I said, you were very generous to us
throughout the pandemic. You know, we have been planning
carefully, carefully planning the use of those funds so those
carryovers those are incorporated into the budget laid out in
front of you. We are in a position to use those.
Am I worried that, you know, we are going to have to, you
know, for example, the chairman mentioned that there is no
second bite in the budget. We do not anticipate one but if we
need one we will come back and talk to you guys about it then.
Ms. Cherfilus-McCormick. Thank you. I yield back.
The Chairman. Thank you. It is the chair's intent to
recognize Representatives Self for his 5 minutes and then we
will go break and go into recess for the Ambassador's speech.
Return please as quickly as possible after the speech.
Representative Self.
Mr. Self. Thank you, Mr. Chairman.
Mr. Secretary, good to see you.
Mr. McDonough. Sir.
Mr. Self. I have heard several comments in this hearing
that community care is more expensive. According to your
budget, and this was quickly done, you are asking for 52
million outpatient visits at community care for $37 billion.
You are also expecting 89 million outpatient visits with
VHA for $83 billion.
Now, this indicates that community care is not more
expensive so we probably ought to refine our figures and our
comments along those lines. Do you have a sense of the ratio of
your 10,000 personnel cuts through attrition? What will be the
ratio of bureaucracy versus frontline providers? Do you have a
sense?
Mr. McDonough. I think I could probably get you a more
detailed sense of that. I think we just did a deep dive with
your staffs last week, but we have, obviously, prioritized
hiring frontline providers, frontline workers. I think,
throughout the course of the pandemic we did, for example,
because we did make a decision to protect the most vulnerable
veterans in our care.
We did make a decision in individual facilities to move
more care into the community so that requires a different kind
of hire in those pandemic years 2020, 2021, for example, than
we would normally be making.
I would anticipate that in this year of strategic hiring we
are focusing overwhelmingly in the hires on providers.
Mr. Self. I would ask you that through your attrition what
is the ratio of your loss, however you want to structure that,
because I want to focus----
Mr. McDonough. We will get you----
Mr. Self [continuing]. exactly as you just said. We need to
be focused on our providers.
Mr. McDonough. Yes.
Mr. Self. If we take the attrition cuts it needs to be in
the bureaucracy.
Now, in the latest the budget that was passed, the one we
are in now----
Mr. McDonough. Yes.
Mr. Self [continuing]. I understand that now it is very
clear that you are not to report veterans who have a fiduciary
to the National Instant Criminal Background Check System (NICS)
data base. Is that correct and have you changed your policies
to make sure that does not happen? That we are giving the
constitutional protections to our veterans simply because they
have a fiduciary?
Mr. McDonough. Let me answer that question by what we did
because I am not sure I understand about changing the policies.
Mr. Self. Well, in the past you have, because you read the
law differently than most people, other Federal agencies, that
if you have a fiduciary for a veteran you would then put them
in the NICS data base. That was your policy in the past, and I
think that is forbidden under the latest budget and I want to
make sure that your policies follow the law.
Mr. McDonough. Yes. We turned off, or I think it is a
monthly or bimonthly reporting mechanism, to the Department of
Justice. We turned that off when Congress enacted the rider on
the appropriations bill. We are not reporting any fiduciaries,
any new fiduciaries to the Department of Justice at the moment
nor, incidentally, since that reporting is now turned off can
we take any veterans no longer on the fiduciaries who had been
reported to Justice off.
The reporting is turned off.
Mr. Self. Does that apply to your advance budget for 2025,
I guess, as well?
Mr. McDonough. It is an appropriations bill rider, so as
with all appropriations bill riders it will expire at the end
of the fiscal year.
Mr. Self. That was my question. I am afraid that is the
case.
I also, and I am almost out of time, I would like for you
to look at the training videos that you are using in VA today.
They are produced by someone that is associated with Planned
Parenthood, and I am very concerned that they promote abortion
as the safest option for pregnant veterans.
I find that a little oxymoron in aspect, but I would ask--
--
Mr. McDonough. I would think that that would--I would have
a hard time believing that is true.
Mr. Self. Well, absolutely.
Mr. McDonough. I will find out.
Mr. Self. I would ask for a report on that because if this
is true, and apparently it is, I would like to know about it.
Mr. McDonough. Fair enough.
Mr. Self. With that, I yield back, Mr. Chairman.
The Chairman. The gentleman yields back.
The committee will stand in recess until the end of the
Ambassador's speech. Hopefully, like I said, everybody can get
back.
Mr. Secretary, thank you for staying.
Mr. McDonough. Yes, of course, of course. Thank you very
much.
[Recess.]
The Chairman. The committee will come back to order. At
this time we are going to continue with questions.
Representative Deluzio, you would have 5 minutes to ask your
questions.
Mr. Deluzio. Mr. Chairman, thank you.
Secretary, good to see you. Thanks for your patience as we
welcomed the Japanese Prime Minister today. I will be blunt. I
am a little worried about this budget. I think it is driving a
trend toward privatization that I am alarmed by.
Since the VA MISSION Act was implemented we have seen fee-
for-service, excuse me, community care go from accounting for a
relatively limited portion of the VHA's budget intended to help
improve veterans' access to care when direct care from VA was
not convenient, was not nearby, did not make sense to now what
I think is a ballooning program that now accounts for more than
a third of all spending on veterans' health care with worse
outcomes in many respects.
That community care has been siphoning funds from what I
think is already an underfunded Veterans Health Administration.
The trends show that that sign or those signs are not going to
be changing anytime soon.
Since 2020, the financial obligations for medical community
care has grown about twice the rate of VA direct care, and yet
we already know that community care is more expensive, its
quality on many measures has been worse, patient outcomes in
many places have been worse, care coordination is worse,
oversight is more limited. Let us talk as an example about
emergency room care.
A study found veterans treated in private Emergency Rooms
(ER) twice as likely to die in the first 28 days after
admission that they have been admitted to a VA facility. If
veterans had an ambulance transport them to the VA emergency
department their prospect of dying in the subsequent months was
46 percent lower than if they had gone to a non-VA facility.
Now, let us talk about opioids. Last September the Office
of Inspector General (OIG) released a report about the stunning
lack of oversight of private non-VA providers who prescribe
opioids to veterans outside the VA. Found that about 80 percent
of those non-VA providers who prescribed opioids in veterans in
Fiscal Year 2021 did not complete VA's training module nor
certify they received and reviewed the guidelines put in place
under the MISSION Act.
Their sample of those community providers show that about
two-thirds did not check the State data bases that are meant to
monitor against over prescriptions and abuse.
Stock wait times, we do not have, frankly, wait time data.
Veterans cannot look up what a wait time will be in community
care, but based on most of the studies wait times are shorter
in VA care and getting better. The same is not happening in the
community.
Training, VHA does not require the same training it does of
VA providers or folks in the community and only a small share
of those private providers complete the training.
I think we are at a tipping point. I think this
privatization trend is not fiscally responsible. I do not think
it is good for veterans.
Just this week I received notice that the Pittsburgh VA in
my district effective immediately is implementing a hiring
freeze and why? The explanation given so they can deal with
rising costs of fee-for-service community care. I see the
direct connection and it worries me. I know Pittsburgh VA is
probably not alone in this.
I think, Mr. Secretary, this budget is doing much of the
same to encourage these trends that I worry about. More than
$20 billion has already been appropriated to fee-for-service
community care for 2025. Community care has already received
$9.8 billion from the cost of war toxic exposure fund, as I
understand it.
This budget proposes siphoning around $7.3 billion from VA
direct care to fee-for-service community care. Do I have the
basic numbers right, Mr. Secretary?
Mr. McDonough. You do.
Mr. Deluzio. Okay.
Mr. McDonough. Yes, you do.
Mr. Deluzio. I know you agree we need to curb the spending
issue here. One way I think VA could easily do that would be to
update access standards so that telehealth counts. In other
words, VA today I cannot point to the availability of a
telehealth appointment when thinking about whether someone you
refer to the community and yet that same veteran might find
themselves receiving a telehealth appointment.
My question, Mr. Secretary, do you plan to change those
access standards, and if so, what is that timeline looking
like? I know we have talked before about this.
Mr. McDonough. Yes. Mr. Deluzio, thank you very much. We
are looking at the access standards. We are looking expressly
at the telehealth access standard. We have talked to your teams
about this, House and Senate.
We do think that it is not helpful to veterans to give them
a referral and then they just end up seeing a doctor in
telehealth outside the VA system, so we think that does not
make a lot of sense. We are looking at that. I cannot give you
a specific timeline on that regulation but we are working it.
Then we have two other parts of our--two other additions to
our strategy over and above what I talked about before, which
is the apple-to-apple offer of in-house care every time a
veteran is referred out. We have dramatically increased access
through our access sprints. We saw 25,000 new patients, more
new patients in VA clinics October to February. That is an 11
percent increase.
We saw that increase in 81 percent of our facilities,
including Pittsburgh. That means 14 percent fewer veterans had
to wait to get into the community. They got directly into VA.
We did that through offering evening clinics, weekend clinics,
additional access to telehealth. We are going to continue to do
that.
All of that requires us to maintain strategic hiring. That
is why we had the good hiring year we had last year and that is
why the strategic hiring will continue.
Last, in your visit, I think Pittsburgh and the rest of
that system does a very good job at using telehealth
authorities across the State to get access to things like tele-
oncology. Let me just say one thing about tele-emergency care.
We have now rolled this out in 25,000 individual instances
across VA have. Far this year 15,000, 10,000 cases last year.
The median case has us meet the veteran's medical needs
within 30 minutes never leaving his home, meaning he does not
have to drive, he does not have to risk infection, he does not
have risk hassles of going to an emergency department, a VA
emergency department or a private sector emergency department.
Things like that, VA Health Connect, tele-emergency care,
and enhanced access, as we have just demonstrated in the last 5
months of the access sprints, means that we will make sure that
a veteran has timely access to the best available care, namely
the VA system, whenever and with clear understanding of what
those parameters for each offering will be.
Mr. Deluzio. Mr. Secretary, thank you.
Mr. Chairman, I thank you for indulging on the time. I
appreciate the apples-to-apples work. I think it is very
important, Mr. Secretary.
Mr. McDonough. Thank you.
The Chairman. Dr. Miller-Meeks.
Ms. Miller-Meeks. Well, thank you very much. It is
wonderful to see you again, Secretary McDonough. Thank you,
Chairman Bost, for holding this hearing.
Let me just say that I am a veteran. I am a doctor. I
delivered community care and I had excellent outcomes, thank
you very much, despite having tremendous hurdles getting the VA
to approve of community care.
Secretary McDonough, have no difficulties with tele-
emergency care. We actually had that discussion yesterday in
Energy and Commerce, or access standards. I want to know,
number one, of care that is delivered in the community how much
of it is specialty care and how much of it is primary care?
Mr. McDonough. It is overwhelmingly specialty care.
Ms. Miller-Meeks. Thank you. That would make a difference
in the cost regardless of whether that care was provided at the
VA specialty care is higher than it is generalized primary
care, is it not?
Mr. McDonough. Yes. Well, cost is a function both of the
care provided but then also what we call the standard episodes
of care provided.
Ms. Miller-Meeks. And----
Mr. McDonough. What we find is that the access standards or
the standards as prescribed now for many years include a suite
of standard episodes of care that lead to what appears to be
redundant care, what appears to be maybe prescribing
techniques, like Mr. Deluzio said. This is not uniformly the
case. I am just saying these are some of the things that we see
that contribute in the IG's findings, anyway, contribute to----
Ms. Miller-Meeks. Do you have severity data on patients
that are either admitted to the hospital or come to the ER,
i.e., to your point, are we comparing apples-to-apples?
Mr. McDonough. Severity data in what sense? I am sorry.
Ms. Miller-Meeks. In individuals who go to the emergency
room or are admitted to the hospital what severity, medical
severity are they? If you do not have that data if you could
get that data to us? That is----
Mr. McDonough. Sure. I do not have it at my fingertips, but
yes.
Ms. Miller-Meeks. Thank you. I understand the VA is setting
up a red team to write a report on reducing community care
spending, but the report has not been shared with this
committee. Who are the members of this red team, who appointed
them, and what are they recommending?
Mr. McDonough. Thanks for your question. The red team is,
and this is, kind of, standard analytic tool designed to answer
questions about what has happened with community care over the
course of the last 6 years since the new law was signed into
statute. I gather they have finished their report. I have not
seen it. They have submitted it to VHA.
The members of the committee include former
undersecretaries of health in Republican and then Democratic
administrations, as well as public health and medical experts.
I do not have the names in front of me because I am, frankly,
not intimately familiar with the report yet, although I will
get there.
Ms. Miller-Meeks. Is any veteran forced to go into
community care?
Mr. McDonough. Is what?
Ms. Miller-Meeks. Is any veteran forced to go into
community care?
Mr. McDonough. You know, it is an interesting question. You
talk to veterans and some of them feel that they have been and
so----
Ms. Miller-Meeks. Why would that be? Specifically the
MISSION Act is within 30 days or so many miles, so if a veteran
can get into an appointment within 30 days at the VA----
Mr. McDonough. Within 20 for special--for primary care
visits.
Ms. Miller-Meeks. Then they have no need to seek community
care----
Mr. McDonough. Right.
Ms. Miller-Meeks [continuing]. is my point. A veteran is
not forced to go into community care. I, however, know veterans
who would prefer to go into community care.
Mr. McDonough. Yes, ma'am.
Ms. Miller-Meeks. Building new clinics to get access when
you have hospitals or other facilities that are in deplorable
condition, I would say, would question one's priorities.
A question on homelessness that was asked, Department of
Housing and Urban Development Veterans Affairs Supportive
Housing (HUD VASH) is an important program to permanently house
veterans' homelessness, and I applaud the VA's work to house
over 48,000 vets last year. However, I think there are still
some challenges that we have. Do you know how many vouchers are
made available on an annual basis?
Mr. McDonough. I do not have the voucher number on my
fingertips.
Ms. Miller-Meeks. Okay. Do you know how many vouchers are
unused on an annual basis?
Mr. McDonough. We have that. We can get you that data by
VISN, but we have that data. We set execution standards every
year and we report those to you guys as well.
Ms. Miller-Meeks. Okay. My understanding is that many of
the HUD VASH vouchers go unused year after year, so why are we
still increasing the overall budget for this program?
Mr. McDonough. That is true that some HUD VASH vouchers go
unused. We have identified a range of reasons why that is.
Sometimes that the value of the voucher is insufficient given
the price in a particular market. Some of it has to do with our
slowness in appointing or hiring case managers, which are
really important to organize----
Ms. Miller-Meeks. Well, maybe instead of letting 10,000
healthcare providers go and increasing the number of
bureaucrats, as was alluded to earlier, maybe that is a part of
our budget we could rethink.
With that, I yield back.
Mr. McDonough. Just for the record, our proposal is not to
reduce clinical providers and then increase bureaucrat. Though
I just want to go back to one thing about how veterans feel.
You know, the Veteran Signal is something that we have
instituted now for 10 years. It is a really important tool.
You know, what we do find is that, I hear it anecdotally,
we see it in some of the data that veterans feel that they have
been forced into the community. I am not saying that they have.
I am saying that they feel that.
This is why it is so important to us to communicate to
every veteran very clearly apple-to-apple what their
opportunities are. We feel like when they are in our care they
do better. That is what study after study says.
The Chairman. Dr. Miller-Meeks, do you want to reclaim
time?
Ms. Miller-Meeks. I am going to reclaim my time. Thank you
for that. When I met with veterans, and I am in the veteran
community a lot as a fellow veteran, they love the care they
receive at the VA hospital. They do not like waiting periods.
They also appreciate the care they receive in the community
and they want choice and they want flexibility. Thank you.
Mr. McDonough. Yes.
The Chairman. Representative Budzinski.
Ms. Budzinski. Thank you, Chairman Bost and Ranking Member
Deluzio.
Secretary, it is great to see you.
Mr. McDonough. It is good to see you.
Ms. Budzinski. Thank you for all the work you and your team
do at the VA every day for our veterans.
Mr. McDonough. Thank you.
Ms. Budzinski. It is very appreciated. I wanted to talk a
little bit about research that the VA is doing. I very much
believe that that worked at the VA is doing in the research
fields is critically important to understanding illnesses and
mental health. Its research breakthroughs have huge impacts on
not only our veteran populations but on the general population
as well.
I am glad to see that the VA's research priorities largely
reflect the needs of the veteran population, but I am concerned
that the actual funding request does not meet the urgency for
research on these topics.
Additionally, the latest VA veteran suicide prevention
report noted an increase in veteran suicide and specifically
that that rate has increased dramatically for women veterans in
particular. I am wondering how the VA is ensuring the budget
request is taking into account the specific needs of our women
veterans.
My question is, Secretary McDonough, in that vein is can
you speak to why the Fiscal Year 2025 budget request includes
flat funding for suicide prevention efforts and decreases
funding for our VA priority areas like the million veterans
program, precision oncology, or VA Office of Research and
Development (ORD) infrastructure and Traumatic Brain Injury
(TBI) and brain health research in particular?
Mr. McDonough. Yes. Well, thanks very much. You know, as I
said earlier that obviously we make tough choices in the budget
and that is a function of the caps. That is also a function of
being now in this period post-pandemic where we just do not
have the very, very generous budgets that we had gotten from
you all over the previous several years.
Nevertheless, the research budget does allow us to continue
funding for priority research efforts. The million veteran
program is, obviously, a very big priority for us. It is also a
very significant security priority for us by the way. Ability
to access that data base is not solely dependent on VA funding.
Important innovations that will come out of that data base
are not uniquely connected to our funding. We have researchers
who can bid to use that data and that means that prior year
robust investments in tools like that mean that very innovative
research can continue in the out years notwithstanding, for
example, when we reduce investments in that.
As it relates to women's health and woman's health research
in particular, all of our research decisions are made by the
veteran experience and by what veterans therefore are
experiencing. Our budget does allow both based on existing
funding it does allow us to continue advancements and
particular focuses for women veterans.
It is true that if we could do more we would obviously
welcome that opportunity, but we think that these are important
investments.
Ms. Budzinski. Is the VA able to, you know, assuming that
these funding levels stay where you have requested, is there,
kind of, preparation that the VA can be doing to take into
account just to make sure that these programs continue to
optimally operate and coordinate with VSOs in particular for
their feedback on how to, kind of, work with the VA on these
types of funding levels?
Mr. McDonough. Absolutely, definitely.
Ms. Budzinski. Yes.
Mr. McDonough. Definitely.
Ms. Budzinski. Great. I wanted to ask about another
question as well, another important note. Chairman Bost and I
share some VA facilities, and I want to ensure that our rural
veterans are getting the care that they need, something that I
have taken a specific interest in on this committee.
One of those facilities I wanted to ask you about is the VA
Hospital in St. Louis. What are some of the ways the VA is
exploring optimizing rural healthcare initiatives and
infrastructure projects, given the budget constraints for VA
facilities like the St. Louis VA, which serve large numbers of
rural and women veterans?
Mr. McDonough. Yes. Well, thanks so much. You know, for the
last couple of years that I have been here the Office of Rural
Health has been flat funded, but it is been flat funded for a
really important reason which is, first and foremost, it is one
of the principal funders for the clinical resource hubs and for
the rural health centers of excellence or the rural health
resource centers.
There is five of those and that funding allows us to then
make sure that we can expand the capability of VAMCs like St.
Louis to reach farther into rural communities through
telehealth and through innovations.
The second thing that the Office of Rural Health allows us
to do is invest in new modalities of the provision of care in
rural settings. Home-based primary care is a good example of
this. Tele-healthcare over the course of the last 10 years or
so was underwritten by the Office of Rural Health.
Those things get incubated by the Office of Rural Health
but then get deployed into the field and therefore funded by
the medical care account itself.
Last, as it relates to rural facilities we are more and
more deploying through programs like Closer to Me, which is a
oncology treatment and infusion care program, allows us to
deploy providers from somewhere like St. Louis into a CBOC in a
more rural setting in southern Illinois or central Illinois and
have a veteran get their oncology treatment at the CBOC rather
than driving all the way to St. Louis.
It reduces the demand or the challenge of travel for that
veteran, allows the veteran maybe then to have family with them
as they are getting that infusion, and it means that the
veteran does not also have to go into the private sector which
may not have treatment options any closer than that CBOC. These
kinds of efforts to promote access and to promote ease of
access are a big part of our strategy going forward.
Ms. Budzinski. That is great. Thank you, Secretary.
I yield back. Thank you.
Mr. McDonough. Thanks.
The Chairman. Mr. Secretary, thank you for your time----
Mr. McDonough. Thank you.
The Chairman.--and waiting around with this situation that
we had today. I do need to address one more important matter
before you leave.
Mr. McDonough. Please.
The Chairman. Over the past year VA has been more than a
month late in responding to over a dozen letters. Currently, VA
owes this committee responses to numerous letters, including on
important issues like improper benefit payments, abortion, and
employee misconduct at VA medical centers.
Further, when VA finally responded to committee letters the
response is often inadequate. Your repeated failure to provide
sufficient answers to my Office Of Resolution Management,
Diversity, and Inclusion (ORMDI) letter last fall led to the
committee's first subpoena in 8 years. Most recently, in your
2-month--you are 2 months late on a response to a letter
seeking documents related to VA's attorney's anti-Semitic
comments, and we have not been given any of the documents that
we were asking for.
I do want to ask if we can get your commitment for those
documents that I asked for and the letter that was in January
20, that we had sent on January 25th? If we could try to get
those by next Friday if at all possible?
Mr. McDonough. Okay. I will turn to this as soon as they
get back to the office.
The Chairman. Thank you so much for being here and thank
you for, as I said, waiting around when we do not--you know we
do not normally do this.
Mr. McDonough. No, no, thanks very much for the opportunity
to testify.
The Chairman. Thank you. We would like to welcome the next
panel up.
All right. I would like to welcome our second panel. Thank
you for hanging around for the length of time you did, and we
appreciate it.
Representing the independent budget service organizations
from the Veterans of Foreign Wars we have Mr. Patrick Murray,
the director of national legislative services.
We also have Mr. Shane Liermann, the deputy national
legislative director of Disabled American Veterans.
Finally, we have Mr. Butler, the senior health policy
advisor at Paralyzed Veterans of America.
I ask the witnesses to please stand and raise your right
hand.
[Witnesses sworn.]
The Chairman. Thank you, and let the record reflect that
all witnesses answered in the affirmative.
Mr. Murray I now recognize you recognize you for 5 minutes
for any opening remarks.
STATEMENT OF PATRICK MURRAY
Mr. Murray. Thank you, Chairman Bost, Ranking Member
Deluzio and members of the committee. On behalf of the
independent budget VSOs, DAV, PVA and VFW, thank you for the
opportunity to present our recommendations to properly fund the
Department of Veterans Affairs.
For more than 30 years, the IB VSOs have provided
independent recommendations to ensure that VA remains fully
funded and capable of carrying out all of its missions. I would
ask for the record our complete independent budget document
will provide an overview of our most significant
recommendations.
First, it is important to note that VA's full-year
appropriations was not enacted until half the year had passed.
This routine use of continuing resolutions limits VA's ability
to expand access to critical benefits and services for
veterans. We believe Congress must do better.
Mr. Chairman, with veterans continuing to roll and receive
higher priority eligibility due to PACT Act, the IB VSOs
recommend that VHA be provided a total of $152.8 billion for
Fiscal Year 2025, which would be a 6.6 percent increase from
the previous year.
Underlying all of VA's healthcare delivery is its
infrastructure, the buildings in which it provides care and
services. We are concerned that VA's request for major and
minor construction is one-third lower than what VA requested
last year and that is far below what is necessary.
We recognize the critical importance of having modern up-
to-date facilities which is why the IB VSOs recommend $5.2
billion alone for major construction which is four times more
than the current funding level and almost $1 billion for minor
construction, which would be a 30 percent increase.
Infrastructure funding has remained stagnant for far too
long. In the past 10 years it has only increased 5 percent.
During that same time, the construction backlog known as the
strategic capital infrastructure, sorry, strategic capital
investment plan, known as a SCIP, has grown exponentially. In
2014, the SCIP was approximately $16 billion worth of work.
Right now it is estimated to be $130 billion. That is an
increase of 116 percent. Funding cannot remain stagnant.
Private healthcare invests considerably more into the
infrastructure of their networks. Last Congress, Kaiser
Permanente testified before the Senate Veterans Committee that
they invest approximately 3 percent of their overall budget
into its infrastructure. VA invests considerably less, only
close to 1 percent. Unless there is drastic increase in
resources for VA infrastructure we will continue to see
additional gaps in the backlog versus work that is able to be
performed each year.
Infrastructure costs have gone up year-over-year and it
will not get any less expensive over time. This will also force
more care into the community and exacerbate hiring challenges
for VA.
Mr. Chairman, generally the administration's budget request
takes a positive step toward fulfilling our Nation's
obligations to America's veterans. In fact, with the exception
of a few items, like the aforementioned infrastructure issue,
VA budget meets or comes close to many of our recommendations.
However, we do have concerns about funding trends in the VA's
budget.
Over the past decade VA's reliance on community care has
risen drastically. While we agree that veterans must have non-
VA options to fill gaps in care, we believe VA must remain the
primary provider and coordinator of veterans' care. While VA is
requesting an overall increase for medical care, the community
care program would grow at a faster rate than VA-provided care.
In addition, VA's request would cut 10,000 healthcare FTE
including 600 physicians, 2,400 nurses, 500 nonphysician
providers, and over 2,000 healthcare technicians despite VA
reporting more than 66,000 healthcare vacancies at the start of
this year. We should not be cutting positions when we cannot
even fill the ones we currently have.
We are also concerned that VA proposes using $12.7 billion
in carryover funding rather than requesting new discretionary
appropriations. If VA's unobligated balance at the end of
Fiscal Year 2024 is less than projected we are concerned about
a potential funding shortfall next year.
Last, we believe that the greatest roadblock to properly
funding veterans' benefits and services comes from budgetary
enforcement mechanisms designed to limit Federal funding. To
ensure our Nation meets its sacred obligations to America's
veterans, the IB VSOs call on Congress to exempt veterans'
programs, services, and benefits from congressional Pay As You
Go (PAYGO), as well as work to eliminate the use of CRs for VA
care.
Mr. Chairman, this concludes our testimony. My DAV and PVA
colleagues and I will be pleased to answer any questions you or
members of the committee may have.
[The Prepared Statement Of Patrick Murray, Shane Liermann
And Roscoe Butler Appears In The Appendix]
The Chairman. Thank you, Mr. Murray. The written statements
of all three witnesses will be entered into the record. We will
now proceed to questions.
Mr. Murray, I spoke earlier about the VA attorney who made
the terrible anti-Semitic comments. VA Office of General
Counsel is requesting a significant budget increase. What is
your view of how VA has handled the situation with this
attorney and what do you think the office's priorities should
be in dealing with this?
Mr. Murray. You know, obviously anything anti-Semitic is
terrible. That needs to be flatly stated. Office of General
Counsel needs a lot of resources. They are under resourced
right now. They are still working in paper-based systems. They
are understaffed.
In fact, there is a lot of discussion about the claim
agents and nonaccredited folks, but they are not even, we
believe, enforcing the laws for the actual accredited people
right now, the rules and laws that they have already have. For
example, there are accredited attorneys who are violating the
law and all they are doing is receiving demand letters telling
them to stop.
They can do a better job. We do not believe they are
prioritizing that. We hope more people and more resources will
take care of that so that accredited attorneys and agents who
are already breaking existing laws are held to account.
The Chairman. Okay. My next question is going to be real
difficult for each one of you to answer, but I know in your job
you are going to say nothing, probably, but let me ask you
anyway. Mr. Murray, and all three of you, the VA budget is
approaching $400 billion. What wasteful and ineffective
programs would you cut? How and why would you do that?
I know that is not really, like I said, within your, you
know, but we are trying to know that everything that we are
doing is efficient and truly helping the veterans. When an
agency is the second largest bureaucracy in the world it is in
there somewhere.
Mr. Murray. Sure. There are ways to be more efficient with
your spending. I do not know necessarily about cutting, but if
we spend more money appropriately we will save money in the
long term, for example, paper-based systems. That takes a lot
of manhours. That takes a lot of resources. We need to
modernize it. It has an upfront cost to some of those things,
much like the Electronic Health Record (EHR) does, but also
infrastructure.
If we spend appropriately now it is going to save us less--
more money in the future. Having to eliminate wasteful repairs,
maintenance, things like that on old systems just to keep them
limping along instead of spending the proper money to build
efficient, modern systems.
It is not necessarily a cut but it is a better way to spend
the money we do have.
Mr. Liermann. Thank you so much for the question. Along
with what Mr. Murray just said, I do not have a recommendation
on a program that cut but an idea for us to be more efficient,
specifically when we are talking about toxic exposures and
presumptive diseases.
We all know the PACT Act was monumental and will continue
to be, but we also know it came with a very large cost. That is
because we decided to wait 20, 30, 40 years before we take
action on establishing presumptive diseases.
There is a way we can do it faster, do it quicker. If we
can establish things up front we are not going to wait 20 or 30
years with such a larger cost to do something. DAV and Military
Officers Association of America (MOAA) we are going to be
putting out a report and a study coming out in July to talk
about all of these conditions and our recommendations on how to
make this presumptive disease process work more efficient for
veterans, the VA, and when it comes to spending.
Mr. Butler. I do not have a recommendation either, but I
believe the OIG has identified numerous opportunities for cost
savings with regard to waste, fraud, and abuse, and VA has not
lived up to those recommendations. I would recommend that
Congress hold VA accountable in regard to the OIG report as it
regards to waste, fraud, and abuse, and ensure that they take
corrective actions to eliminate those that are wasting money
due to fraud and abuse.
The Chairman. Thank you. You know, I am going to continue
down this path because I have to believe, and we are monitoring
this, and matter of fact, Mr. Self is himself has jumped into
it as well, that when we are looking at many of the programs we
are wanting to do after the PACT Act, many of our bills were
wanting to move.
Somewhere, sometime there has to have been some program
that was passed that has either been ineffective or wore out
its effectiveness of possible treatments, programs, or
whatever. I know, like I said, you want to see the expansion
but we want to see that to make sure that the things that we
are investing in are those that do what they were promised to
do when we passed the legislation, whether it was while we have
been here or those that came before us to try to straighten it
out. Any suggestions you might have at a later time I might----
Mr. Murray. Mr. Chairman, if you look at some programs that
were obviously well-intentioned at the time with the VRRAP
program, the Veteran Rapid Retraining Assistance program,
right, that was built up for COVID putting people back to work
post or during COVID, things like that were well-intentioned.
Did not exactly pan out.
If we look at things like the GI Bill restoration that was
part of the Forever GI Bill there was a lot of money that was
set aside for that. It did not live up to the numbers that we
thought it might have.
There are ways to look at things we have done over the
years where we might have overestimated or gone, you know,
worked off of Congressional Budget Office (CBO) scores that may
not have been----
The Chairman. Right.
Mr. Murray [continuing]. totally accurate over time. Blue
Water Navy is another example. There were massive estimations
about who that is going to help, how many people. It was not
nearly as much.
There are places to look at that. We would more than happy
to chat with you and----
The Chairman. All right. I would appreciate that help.
Representative Deluzio.
Mr. Deluzio. Thank you, Mr. Chairman, and echo your good
concern about public expects us to give the best bang for the
buck of taking care of our fellow veterans. Never be shy please
with ways that VA can do better.
Gentleman, the independent budget recommended $36.8 billion
in overall funding for fee-for-service community care for
Fiscal Year 2025. It turns out to be about $4 billion less than
what VA itself is expecting to obligate for that care next
fiscal year.
What are your thoughts about VA's proposal to transfer 7-
plus billion from direct care medical services account to the
fee-for-service community care account in Fiscal Year 2025?
Relatedly, do you have concerns about the effect this will have
or may have on VA medical facilities and VA's ability to
provide direct care to veterans?
Mr. Murray. Mr. Deluzio, we do have concerns about that. As
you mentioned some of the statistics in your statement, it is
some of the trends that we are looking at. That is why making
VA care as the primary provider of care the first thing we
think is important because of all the success metrics we have
seen, but we cannot do that without the people to provide the
care and the up-to-date, safe buildings to do that in.
That is why to the chairman's point about fraud, waste and
abuse we think we want to focus more on efficiency. I we get
those things done in place, that there is a place to do that,
we think that is going to save money in the long run.
Mr. Deluzio. Very good. Anyone else on the panel if you
feel free?
Mr. Butler. I will just say the staffing reductions that VA
is talking about reducing staffing, they would not have to
reduce staffing if they can find ways to lessen community care
out in the community. They should not be reducing staffing.
They should be building its staffing levels to ensure that
institutional care or VA care they have the resources to
provide that care to our Nation's veterans.
Mr. Deluzio. Thank you. Just real quick, we are always
concerned about VA is not the primary care provider. Is there
going to be a good coordination of that care, especially when
we started talking about medications and what they refer to as
polypharmacy?
A lot of veterans can get multiple medications from
multiple sources within VA or in the community care and nobody
is watching what that negative synergistic effect is going to
have on their care.
That is why we really believe VA being the primary care
provider and coordinating it is the best interest for veterans.
Mr. Deluzio. Well, I appreciate that point on care
coordination in particular. We have had some oversight about
that and I have asked questions of it is very inconsistent and
very sporadic what providers outside of VA are doing in terms
of getting records back into VA, what veterans can see about
their care.
Certainly VA can do better and we are going to push VA to
better on care coordination, but it seems like the Wild West.
Some providers I am sure do well. Seems like others do not, and
so I appreciate that point.
With what little time I have left, transitional housing, so
those providers are routinely contacting this committee to
discuss resources they need to serve aging veterans or those
with disabilities and their care. Would H.R. 491, the Return
Home to Housing Act, provide more resources for Grants and Per
Diem (GPD) providers? What kind of resources do those providers
need to better be able to serve the aging and disabled homeless
population?
Mr. Murray. Mr. Deluzio, passing the Home Act would go a
great way in accomplishing that mission. GPD payments we
believe they need to be upheld to the rate that they are in
that bill. It does cost a lot to accomplish that mission so
putting that bill forward, getting that done in the veterans'
package I know that is being threatened to be dropped for
months, but we want that to come to fruition.
Mr. Deluzio. Very good. Gentlemen, thank you.
Mr. Chairman, I yield back.
The Chairman. Representative Ciscomani. Easy for me to say
this late in the day.
Mr. Ciscomani. Thank you, Mr. Chair. I appreciate the
opportunity and thank you so much for being here with us today.
My first question here is for Mr. Liermann. Thank you. The
VA budget proposes to cut VR&E staff, and as I have been
talking about and hearing a bit, I introduced legislation this
week, the Vets Opportunity Act, which would expand the
educational opportunities available to veterans and skilled
trade programs. Do you perceive there to be an issue with the
VR&E cuts and then the staff cuts and the VA's ability to
connect our most-deserving veterans with career and education
opportunities?
Mr. Liermann. Absolutely. Over the last year, and thank you
for the question, there was a 40 percent increase in
applications for VR&E and a lot of that is because of the PACT
Act more veterans are eligible. Any change to that is going to
have a negative impact on veterans trying to complete their
programs.
Any way that we can find that will assist them in
transitioning and, most importantly, overcoming their own
service-connected disabilities to find gainful employment is
where we should always be focused.
Mr. Ciscomani. Thank you. Thank you. Maybe you know this, I
represent the southeastern part of Arizona. This is over 70,000
veterans are in my district and one military base and one
military installation, Davis-Monthan (D-M) Air Force Base and
Fort Huachuca. Especially in the Cochise County area where Fort
Huachuca is, the veteran population is a strong and big
percentage of the population there. This is very important to
my constituents so I want to make sure that those services are
there and available.
Now, Mr. Murray, it is a goal of mine to ensure that
veterans have the option to receive care conveniently as close
to home if they have the ability. We have heard from veterans
in my district, as well as some VA staff, that there is
confusion among veterans when it comes to their community care
appointments. Specifically, they are sometimes unsure who their
points of contact are scheduling appointments and follow-ups,
especially in light of the VA's proposal to cut community care
by, quite frankly, an astounding $10 billion.
Do you have suggestions on how the VA can better be
allocating resources to go toward outreach and education to
veterans regarding the utilization of community care?
I gave Cochise County as an example. This is one of the
main areas where I hear this from, more on the outside of rural
areas where there is confusion when they have to travel to get
care. This is, again, very important to my district. Would you
mind commenting on that?
Mr. Murray. Absolutely, sir. I have experienced it myself
personally. Some members of my family have experienced some of
the confusion about coordinating community care. I think that,
you know, picking up the phone and having to call around and
speak to the right person, get transferred, wait on hold, speak
to the right person----
Mr. Ciscomani. Yes, exactly.
Mr. Murray [continuing]. it is very difficult. We can do
better with technology. I know that apps might not be the most
preferred thing for a lot of folks, but it will help streamline
things if we get things online, appointments, the ability to
track and schedule, things like that so you can see that in
real time right from your phone.
We can get better at informing our veterans about their
care and their appointments, what is available, and then also
places for them to follow-up so there is not spending the
better part of a morning on the phone waiting on hold.
Mr. Ciscomani. Yes, and I do agree that, obviously,
technology is always going to be more cost effective and we
want our Federal agencies and departments to be conscious of
those expenses to be put in the right place. At the same time I
do not think any effort is too big to be able to reach our
veterans as well. Some would prefer the app or technology. Some
will prefer, depending on their comfort level, to speak to a
person.
I understand the staffing challenges on that, but I also
appreciate the priority placed on making sure that every
veteran is met where they are, both in their comfort level on
communication, but many times physically as well in making sure
that we have these resources and services where they live
without having to go to great extent to travel and get there.
Even more so when they already do not have the services
locally but it is hard to get a hold of someone that makes it
even more difficult. I have had cases where just a simple
question--this was not for care to go visit someone but the
preface of a question they had to travel to feeling that they
had a better shot at someone hearing them if they were there in
person.
I do not like to hear that. I do not think any of us like
to hear that. I just challenge you to address this issue as
well and make sure that we meet veterans where they are both
physically but also in their comfort level to communicate.
Mr. Murray. Completely agree.
Mr. Ciscomani. Thank you, sir.
I yield back, Mr. Chairman.
The Chairman. Thank you. I want to say a thank you again
for staying around and had the day drawn out like it did, but I
am dealing with these issues. We are and I am very concerned
that the VA seems to be struggling to manage its budget.
Congress has also provided the resources VA requested and I
am committed to prioritizing our veterans. That is from our
Republican side of the aisle regardless of what might have been
said in opening comments and you all know that. I believe both
Republicans and Democrats are trying to do the best that we can
to make this budget work for those people who have served us so
well.
The budget gimmicks that the VA is using are becoming more
and more complicated, and I think they are seeing some of it
backfire on them. VA is the only organization I know of where a
10 percent budget increase can result in a shortfall. Does not
happen in your house. I just do not see it, but it does not add
up.
I want to assure you and the veterans and VA employees
watching this hearing that we will continue to work with the
department to straighten this mess out. We are going to
preserve the health care and benefits that veterans depend on
and the other services that VA provides. We are going to make
sure that employees are treated fairly.
I think we can best accomplish that by simplifying the
budget. With that, I ask unanimous consent that all members
shall have 5 legislative days in which to revise and extend
their remarks and include any extraneous material. Hearing no
objection, so ordered.
This hearing is now adjourned.
[Whereupon, at 12:50 p.m., the committee was adjourned.]
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A P P E N D I X
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Prepared Statement of Witnesses
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Prepared Statement of Denis McDonough
Chairman Bost, Ranking Member Takano, and distinguished Members of
the Committee, thank you for the opportunity to testify today in
support of the President's Fiscal Year 2025 Budget and Fiscal Year 2026
Advance Appropriations (AA) Request for VA.
VA is honored to serve the Nation's heroes--our Veterans. Over the
last 3 years, we have delivered more care and more benefits to more
Veterans than at any other time in our Nation's history. VA is working
to provide Veterans, their families, caregivers, and survivors the best
care in the world, the benefits they have earned, and a dignified last
resting place that honors their service and sacrifice. Last year,
Veterans submitted over 2.4 million claims--a record, and 39 percent
more than in 2022. Veterans also submitted nearly 2.3 million intents-
to-file--another record, and 65 percent more than in 2022. In Fiscal
Year 2023 alone, the Veterans Benefits Administration (VBA) completed
more than 1.9 million disability compensation and pension claims,
breaking the previous year's record by nearly 16 percent. VA delivered
a record $163 billion in earned benefits to over 6 million Veterans and
survivors--and provided more in-person, tele-health, and telephone
appointments than ever before. The Board of Veterans' Appeals processed
over 103,000 appeals, more than in any previous year. Additionally,
more than 46,000 Veterans were permanently housed, far surpassing the
Department's goal of 38,000. And more than 4.1 million Veterans of
every war and conflict, now rest in VA national cemeteries.
The Sergeant First Class Heath Robinson Honoring our Promise to
Address Comprehensive Toxics (PACT) Act of 2022 (P.L. 117-168)
represents the largest expansion of Veterans' benefits in a generation,
and I am immensely proud that our broad efforts have yielded
outstanding results as we continue to see steady increases in the
number of toxic exposure-related disability compensation claims
processed. VA just recently fully implemented section 103 of the PACT
Act, ahead of schedule, which expanded health care eligibility to all
Veterans who were exposed to toxins and other hazards while serving our
country at home or abroad and all Veterans who served in the Vietnam
War, the Gulf War, Iraq, Afghanistan, or any combat zone after
September 11, 2001, or were deployed in support of the Global War on
Terror. Nonetheless, we can do more to ensure that every eligible
Veteran receives the benefits and health care they have earned. Our
focus remains on increasing Veteran outreach, timely and accurately
processing of claims, providing more and better-quality health care,
modernizing our information technology (IT) systems, and ensuring that
we have the necessary staffing with the right skills to deliver on our
promise to Veterans.
FY 2025 Budget and Fiscal Year 2026 AA Request
VA's total 2025 request is $369.3 billion (mandatory and
discretionary, including collections and the Recurring Expenses
Transformational Fund (RETF)), which is a $32.9 billion or 9.8 percent
increase above the 2024 level. This includes a discretionary budget
request of $134.0 billion (with $4.4 billion from medical care
collections and $307 million from RETF), an $8.9 billion, or 6.2
percent, decrease from 2024. The 2025 mandatory funding request is
$235.3 billion, with $24.5 billion from the Toxic Exposures Fund (TEF),
an increase of $41.8 billion, or 21.6 percent, above 2024.
The decrease in discretionary funding of $8.9 billion from 2024
reflects the Fiscal Responsibility Act of 2023 (P.L. 118-5), which set
overall non-Defense discretionary budgetary ceilings. Nevertheless, we
project that the 2025 request will provide the necessary resources to
meet VA's commitment to deliver timely access to world-class health
care and earned benefits to Veterans. The request fully funds over 9.1
million enrolled Veterans, including the continued operation of the
largest integrated health care system in the United States and support
for care delivered through community providers consistent with the
MISSION Act. In 2025 it will also provide disability compensation
benefits to nearly 6.9 million Veterans and their survivors and
administers pension benefits for over 224,000 Veterans and their
survivors. The 2026 Medical Care AA request includes a discretionary AA
of $131.4 billion, plus a mandatory advance appropriation request of
$22.8 billion for the TEF. The 2026 mandatory AA request is $222.2
billion for Veterans benefits programs (Compensation and Pensions,
Readjustment Benefits, and Veterans Insurance, and Indemnities).
PACT Act
As of March 23, 2024, VA has received more than 1.3 million PACT
Act-related claims and completed over 1,149,000 claims. Using the new
PACT Act authorities, VA has granted service connection for over 10,000
terminally ill Veterans. VA will continue to award disability
compensation to those Veterans who were subject to a presumption of
service connection from the PACT Act. At the same time, in accordance
with Title II of the PACT Act, VA is exercising the new presumptive
decision process by studying acute and chronic leukemias and multiple
myeloma as potential presumptions due to exposure to particulate matter
in Southwest Asia. VA is also evaluating other conditions and exposures
that may require formal reviews in the future.
In calendar year 2023, more than 361,000 Veterans were newly
enrolled into VA health care, an increase of more than 73,000 from
Fiscal Year 2022. Our 2023 health care enrollment efforts focused
primarily on bringing in Post-9/11 combat Veterans during a 1-year
special enrollment period created by Section 111 of the PACT Act. This
targeted effort contributed to one of the largest health care
enrollment growth periods in VA history. The special enrollment period
for combat Veterans ended in September 2023 and, in that month alone,
we enrolled 48,763 Veterans in VA health care. In comparison, the prior
year's monthly enrollment total around that same time was about 26,000
Veterans.
VA expects our enrollment to continue to grow with the expedited
implementation of Section 103 of the PACT Act. Originally planned to be
phased in over several years, VA made this new health care eligibility
effective in its entirety as of March 5, 2024. That means that toxic-
exposed Veterans and those who supported certain overseas contingency
operations will be eligible for care earlier than expected, affording
our heroes with the world-class health care they have earned sooner.
Investing in Our People
Providing world-class service is only possible with employees who
are the best and brightest in their respective fields. We are focusing
on improving the employee experience so that they, in turn, deliver
exceptional care and benefits to Veterans and their families,
caregivers, and survivors. We are increasing the use of incentives for
recruitment and retention, maximizing the use of existing pay and
scheduling authorities as well as the new authorities recently enacted
by Congress in the PACT Act, expanding scholarship opportunities, and
providing more education loan repayment awards than ever before. From
October 1, 2021 through March 23, 2024, we have hired 14,447 new VBA
claims processors - growing our claims processing workforce by
approximately 58 percent - and increased the total size of VBA to more
than 33,900 employees, resulting in a record level of claims
processing. As a result, VBA has completed 1,030,089 rating benefit
claims in Fiscal Year 2024, as of March 5, 2024, 35 percent greater
than this point in Fiscal Year 2023. Also, the disability compensation
and pension claims backlog (comprised of claims pending for longer than
125 days) as a percentage of all claims received is at 38 percent as of
March 5, 2024, compared to 70 percent in 2013, which is the last time
the rating claims inventory was nearly this high. Forecast modeling
continues to show VA remains on track to bringing the claims backlog to
100,000 claims or fewer by the end of 2025. Likewise, the Veterans
Health Administration (VHA) hired nearly 62,000 new staff in Fiscal
Year 2023 and, together with substantially improved retention rates,
grew the health care workforce by 7 percent.
During 2023, VHA administered 4,845 scholarships for clinical
education to employees and increased the number of new Education Debt
Reduction Program (EDRP) awards to 3,398, which brought the total
active EDRP participants to over 9,000. Additionally, the percentage of
staff receiving recruitment, retention, and relocation incentives (3R)
increased from 12 percent to 18 percent. At rural facilities, the use
of 3Rs continued to climb in Fiscal Year 2023, increasing from 19
percent to 20 percent. In addition, for some critical shortage
occupations, such as medical technicians (18 percent to 33 percent) and
police (13 percent to 29 percent), the use of 3Rs increased even more
dramatically. These incentives reduced losses for critical shortage
occupations and helped VA successfully compete for health care and
entry level staff. Additionally, VHA adjusted over 1,700 special salary
rates, resulting in a 10 percent average increase in salaries impacting
nearly 41,000 health care workers in support of PACT Act
implementation. VHA also authorized critical skills incentives for over
28,000 employees in 37 different occupations as of the beginning of
Fiscal Year 2024. The average critical skills incentive amount received
by these employees was approximately $7,900.
Thanks to the robust hiring efforts in 2023, VBA and VHA are well-
positioned to serve Veterans and need not continue the staff growth of
2022 and 2023 in 2024. Consistent with the 2025 budget, VA will
strategically focus its hiring in key areas, to include mental health
providers and front-line health care workers in regions with shortages.
Focusing on Wellbeing of Veterans
The Fiscal Year 2025 budget provides the resources that support
Veterans' overall health and economic well-being. The Fiscal Year 2025
request includes $4 billion in discretionary funding for the VBA
General Operating Expenses account, $136 million more than the 2024
President's Budget. This includes funds for increased overtime funding
for the timely processing of claims and investments in artificial
intelligence to improve key processes.
The President's Budget provides disability compensation and
survivor benefits to over 7 million Veterans and their families,
delivers education and job training benefits to1.1 million Veterans and
qualified dependents, guarantees 433,000 home loans, and funds 5.6
million total lives insured for Veterans, Service members, and
qualified dependents.
VA remains steadfast in our commitment to assist Veterans, active-
duty Service members, and eligible surviving spouses in retaining their
homes and avoiding foreclosure, having assisted over 145,000 borrowers
to retain their homes in Fiscal Year 2023. VA has leveraged a suite of
traditional and COVID-19 related loss mitigation options to aid
borrowers who have trouble making mortgage payments. To address the
needs of Veteran borrowers still experiencing the effects of the COVID-
19 pandemic in a rising interest rate environment, or other economic
shocks, VA plans to launch the Veterans Affairs Servicing Purchase
program on May 31, 2024. This program will provide Veterans an
affordable, scheduled monthly mortgage payment that reduces the debt
owed over time at a rate much lower than the current market interest
rate while eliminating the uncertainty resultant from balloon payments
and payoffs.
Preventing Veteran Suicide
Suicide prevention requires a comprehensive public health approach.
With a focus on evidence-based clinical interventions and community-
based, evidence-informed prevention strategies, we aim to reach all
Veterans--both those inside and outside of our system with life-saving
interventions.
Suicide is a complex public health and national security issue. In
addition to mental health risk factors for suicide, the evidence
indicates that we assess a broader array of socio-economic and socio-
cultural risk factors. With no single cause, there is no single
solution, and we must be comprehensive in our approach as we know some
Veterans may not receive any services from VA. To support this
nationwide effort, the budget specifies $583 million for suicide
prevention outreach programs, in addition to $2.7 billion in suicide
prevention-specific treatment. Additionally, the budget plans to spend
$17.1 billion in Fiscal Year 2025 for mental health care, a critical
component of suicide prevention.
Our 10 year National Strategy on Preventing Veteran Suicide (2018)
has been codified through VA's Suicide Prevention 2.0 Initiative,
Suicide Prevention Now initiative, new laws including the 2020
Commander John Scott Hannon Veterans Mental Health Care Improvement
Act, the Veterans Comprehensive Prevention, Access to Care, and
Treatment Act of 2020, the National Suicide Hotline Designation Act of
2020, and emerging innovations like Mission Daybreak, combined with
research and program evaluation. These efforts together help VA to
reach all Veterans, not only those engaged in VA services. For example,
in September 2023, the Staff Sergeant Parker Gordon Fox Suicide
Prevention Grant Program (SSG Fox SPGP) awarded $53 million to 80
community-based organizations across 43 States, the District of
Columbia, Guam, and American Samoa. These organizations provide or
coordinate the provision of suicide prevention services for eligible
individuals, including Veterans and their families. VA prioritized
grants to rural communities, Tribal lands, Territories of the United
States, areas with medically underserved groups, areas with a high
number or percentage of minority Veterans or women Veterans, and areas
with a high number or percentage of calls to the Veterans Crisis Line.
Twenty-one grantees serve Tribal lands including the Navajo Nation,
Cherokee Nation, Choctaw Nation, Alaskan Native Tribes, and others. VA
published the Notice of Funding Opportunity for the SSG Fox SPGP on
January 26, 2024, for a third year of services.
Increasing Access to Mental Health Care
Telehealth, especially video mental health care including substance
use disorder treatment, has played a crucial role in improving access
to mental health services. Video mental health care now constitutes 33
percent of total mental health care visits, showcasing the significant
role of telehealth during and beyond the pandemic. In Fiscal Year 2023,
over 1 million Veterans benefited from nearly 6 million video
telemental health (TMH) care visits, marking a 5 percent increase in
Veterans and a 1 percent increase in visits compared to Fiscal Year
2022; 96 percent of these TMH visits occurred in a Veteran's home or
offsite location, emphasizing the convenience and accessibility of the
service. Because most mental health visits can be conducted using TMH,
it increases the available options for providing mental health care to
all Veterans, no matter where they or their providers are in the U.S.
This helps increase health care equity and access. Telehealth offers
Veterans greater choice and removes their individual barriers to care--
barriers such as stigma, transportation, distance to facility,
childcare, financial constraints, logistical issues, and lack of access
to in-person specialists who can deliver evidence-based interventions.
Telehealth has become a primary consideration for Veterans seeking
mental health care, with those in rural areas using video services at
rates comparable to others. With plans to increase telehealth support
staff and specialized providers, VA is to enhance its nationwide TMH
network so even more Veterans can access mental health care virtually.
Among the risk factors for suicide, substance use disorder (SUD) is
strongly implicated. In addition, drug overdose fatalities have
escalated. The President's Budget includes $254 million to improve VA's
opioid safety initiative and to continue our joint work with the
Department of Defense (DoD) in the field of pain management, consistent
with the requirements of the Comprehensive Addiction and Recovery Act
of 2016 (P.L. 114-198, Title IX, Subtitle A, Sec. Sec. 911-912, the
Jason Simcakoski Memorial and Promise Act). VA is also expanding
evidence-based SUD treatment and harm reduction initiatives consistent
with the Biden-Harris Administration's National Drug Control Strategy.
The President's Budget includes $264 million to support VA initiatives
that address Veteran specific needs, including employment, case
management for Veterans experiencing housing instability, peer support,
as well as in-patient, residential, and out-patient SUD care, delivered
in-person and via telehealth, inside and outside specialty care
settings.
Furthermore, VA's budget continues to support expansion of its
Psychotropic Drug Safety Initiative to address the growing number of
Veterans with stimulant use disorder and crisis of overdose fatalities
associated with illicit stimulant use. This initiative increases
Veterans' access to evidence-based treatments for stimulant use
disorder and overdose prevention, while also ensuring the safe and
appropriate prescribing of stimulant medications. Evidence-based
treatments for stimulant use disorder include cognitive-behavioral
therapy and contingency management, both of which are recommended by
the 2021 VA-DoD Clinical Practice Guidelines (CPG) for the Management
of SUDs.
Health Care Budget Request
Providing Veterans access to the soonest and best care is at the
core of our mission. At a time when VA is expanding access to health
care for millions of Veterans and delivering record numbers of
appointments, VA is laser-focused on making sure that Veterans have
access to world-class health care whenever and wherever they need it.
In 2025, planned obligations for VA health care, including TEF, are
projected to be $149.5 billion, an increase of 5.4 percent above the
2024 budget.
VA offers affordable, timely, and high-quality health care for the
Nation's Veterans. In 2023, nearly 70 percent of VA hospitals receiving
4 or 5 stars in the annual Centers for Medicare & Medicaid Services
Hospital ratings, compared to just 41 percent of non-VA hospitals. VA
hospitals outperformed non-VA hospitals in all 10 core patient
experience metrics in Medicare's latest survey of patients and, most
importantly, more than 91 percent of the Veterans we serve trust VA
with their care, a level unmatched anywhere in the private sector.
VA will ensure that every eligible Veteran has a chance to access
VA care, including community care. We can now offer Veterans VA care at
almost every turn, whether that is through an in-person appointment,
telehealth appointment, placement in our community living centers, or
another option. And that is exactly what we want to do.
Women Veterans' Health Care
In 2023, VA celebrated 100 years of providing health care to women
Veterans. The budget requests $264 million for women's health and
childcare programs. This funding level supports $210 million for the
Women's Health Innovation and Staffing Enhancement Initiative (WHISE).
VA is strategically enhancing services and access for women Veterans by
hiring women's health personnel nationally to fill any gaps in capacity
across all Veterans Integrated Service Networks. Through WHISE, VA is
funding over 1,000 women's health personnel including: primary care
providers, gynecologists, mental health providers and women's health
care coordinators, including maternity care coordinators. VA is also
using WHISE funding to purchase needed clinical equipment such as new
or replacement mammography equipment, exam tables designed for women
with low mobility, and breastfeeding privacy pods.
Among eligible women Veterans receiving VHA care, more than half
have at least one mental health condition and many struggle with
multiple mental health concerns, medical comorbidities, and
psychosocial challenges. These include gender-specific conditions, such
as premenstrual dysphoric disorder, postpartum depression, and
perimenopausal depression, all of which are associated with heightened
suicide risk. VA has implemented numerous initiatives to ensure that
women Veterans seen at any VA medical facility have access to mental
health clinicians with the knowledge and skills to treat gender-
specific mental health conditions, including reproductive mental health
concerns. Examples include the National Reproductive Mental Health
Consultation Program, comprehensive training in reproductive mental
health across the lifespan, evidenced-based treatments tailored for
women Veterans (as recommended by 2023 VA-DoD CPG for the Management of
Pregnancy), and at least one designated Women's Mental Health Champion
at each VA medical center (VAMC).
Women Veterans often feel a sense of connection and trust with peer
specialists who can relate to their experiences in the military.
Evidence shows that peer support is effective for alleviating some
conditions unique to a woman's experience, such as postpartum
depression. The President's Budget includes $2 million to support
expanding peer support services for women Veterans. VHA is committed to
honoring women Veterans' specific needs and treatment preferences by
implementing national peer support training initiatives and
disseminating novel, gender-tailored peer support interventions. These
interventions are developed to be delivered both in person and via TMH
to ensure greater access for women Veterans who often report barriers
due to caregiving responsibilities.
Homelessness Programs
The 2025 budget provides $3.2 billion for Veterans' homelessness
programs, with the goal of ensuring every Veteran has permanent, safe,
sustainable housing with access to high-quality health care and other
supportive services to end and prevent future Veteran homelessness. The
budget includes funds to assist with designing and developing expanded
services for aging and disabled Veterans, a growing need and area of
focus for the Department of Housing and Urban Development (HUD) - VA
Supportive Housing (VASH) program. In addition, funds will be used to
provide a medical home model and population tailored approach to
provide in-home primary care and wrap around services to Veterans
actively enrolled in the HUD-VASH program, provide additional resources
to increase outreach and community engagement efforts, as well as the
expansion of Veteran justice services, such as treatment courts and
Veteran-focused criminal justice initiatives. Funding will also support
the VA Grant and Per Diem program to increase per diem rates to
community partners actively supporting VA's effort to end Veteran
homelessness.
On December 15, 2023, HUD, released the 2023 Point-in-Time Count,
the annual effort to estimate the number of Americans, including
Veterans, without permanent housing. Data show that on a single night
in January 2023, 35,574 Veterans experienced homelessness in the U.S.
Although this reflects a 7 percent increase in the number of Veterans
experiencing homelessness from 2022, VA and our Federal partners have
reduced Veteran homelessness by more than 52 percent since 2010. During
calendar year 2023, VA permanently housed 46,552 homeless Veterans,
surpassing the goal to house 38,000 Veterans by more than 22 percent.
Research
The 2025 budget requests a total of $927 million for research,
which includes $59 in mandatory through the TEF funding. These
resources will improve Veterans' health and well-being through basic,
translational, clinical, health services, rehabilitative, genomic and
data science research; apply scientific knowledge to develop effective
individualized care solutions for Veterans; attract, train, and retain
the highest-caliber investigators and nurture their development as
leaders in their fields; and ensure a culture of professionalism,
collaboration, accountability, and the highest regard for research
volunteers' safety and privacy.
In 2025, the Office of Research and Development will coordinate
with environmental exposure focused programs as part of the
implementation of the PACT Act by building capacity (including the
number of researchers funded to conduct military exposures research)
and strengthening inter-governmental partnerships. This includes to
implement an interagency workgroup on toxic exposure research, called
for in section 501 of the PACT Act, to identify evidence gaps and craft
a strategic plan to address gaps. The budget invests $59 million in
2025 for military environmental exposures research, an increase of $13
million from the current estimate for 2024.
Caregivers
The budget recognizes the important role of caregivers in
supporting the health and wellness of Veterans and offers support and
services through the Program of General Caregiver Support Services to
family members and friends caring for a Veteran as well as through the
Program of Comprehensive Assistance for Family Caregivers (PCAFC) to
family caregivers caring for Veterans who meet specific eligibility
requirements. The $2.9 billion included in the budget supports
staffing, stipend payments, training, education, and other services to
empower caregivers of Veterans. VA is currently undertaking a broad
programmatic review of PCAFC to ensure it meets the needs of Veterans
and their family caregivers. While this review is underway, VA has
suspended annual reassessments for PCAFC participants. While the
current eligibility criteria are examined, VA will not discharge or
decrease stipends or support to PCAFC participants and their family
caregivers, based on an annual reassessment. VA is also expanding
services to family caregivers, to include specific suicide prevention
training, mental health services, and respite services.
Connected Care
The 2025 budget includes $440 million for the Connected Care
program and supports the ongoing expansion and enhancement of
telehealth services directly to Veteran homes (e.g., video-to-home
services); goals to standardize the availability of digital services
for all Veterans; expansion of regional telehealth hubs, novel access
and experience innovations; and the need to sustain previous expansion
efforts funded with the support of the Coronavirus Aid, Relief, and
Economic Security Act and the American Rescue Plan funding. VA
delivered over 11.6 million telehealth episodes of care to Veterans in
the last fiscal year. This includes over 9.4 million episodes of care
to Veterans in their home or other locations and more than 2.9 million
telehealth episodes of care to rural Veterans. Overall, VA provided
telehealth services to over 2.4 million unique Veterans, representing
about 40 percent of Veterans served in VA.
Aging Veterans
Because they make up a significant portion of the Veterans we
serve, aging and older Veterans must be a significant priority now and
in the future. Veterans over the age of 65 represent about 50 percent
of all VHA enrollees. Currently, VA is expanding home-and community-
based services. This expansion includes programs such as Veteran
Directed Care, Medical Foster Home, and Home-Based Primary Care
programs. All are aimed at enabling Veterans to age in place with the
necessary support and services. VA is focused on implementing the VHA
Institute for Healthcare Improvement's Age Friendly Health Systems
initiative and VA's Geriatric Emergency Department Accreditation from
the American College of Emergency Physicians initiative to prepare VA
facilities and staff with the leading evidence-based care practices. VA
is on a strong path to become the largest integrated age-friendly
health system in the world. As of January 8, 2024, 132 VAMCs have
earned formal Age-Friendly recognition in 305 care settings. The new
2024 VA Age-Friendly Health System initiative action community has
projects registered for another 410 teams from 126 facilities. As of
December 2023, 68 of the VA's 111 Emergency Departments earned
Geriatric Emergency Room accreditation and others are actively in the
process for 2024.
Infrastructure
The President's 2025 Budget includes $2.8 billion for construction
requirements, including $2.5 billion in Major and Minor Construction
appropriations and an estimated $307 million from the Recurring
Expenses Transformational Fund (RETF) for VHA Minor Construction
requirements. This request is $593 million greater than VA's
discretionary 2024 request.
Funding for two major medical facility projects includes the West
Los Angeles New Critical Care Center, Central Utility Plant,
Demolition, and Renovations to Building 500 and Dallas Clinical
Expansion for Mental Health, Expansion of Parking Facilities, and Land
Acquisition, together supporting over 400,000 Veteran enrollees. The
2025 budget also includes $45 million in Major Construction funds for a
gravesite development project at Fort Logan National Cemetery in
Denver, Colorado. The budget requests $687 million for Minor
Construction, inclusive of RETF. This amount includes $174.1 million in
Minor Construction funds to address gravesite expansion and columbaria
requirements to keep existing national cemeteries open as well as
address infrastructure deficiencies and other requirements necessary to
support national cemetery operations. In addition, VHA's Medical
Facilities account includes $2 billion for non-recuring maintenance.
Also included in the 2025 budget are nine major medical facility
leases totaling over 1.9 million square feet of space supporting a
workload of over 2.3 million outpatient visits and bed days of care per
year. These leases are key to modernizing VA's clinical points of care
and increasing access for the increasing number of Veterans anticipated
to access VA care because of benefit expansion offered by the PACT Act.
Further, VA is aggressively working to pursue implementation of the
goals of Executive Order 14057, which creates a broad set of
challenging goals and requirements for Federal agencies to eliminate
their carbon footprint and make their operations more sustainable and
resilient. In support of this, VA's 2025 budget request includes Minor
Construction funding totaling $7 million for the National Cemetery
Administration (NCA) and VBA electric vehicle charging requirements.
Information Technology Serving Veterans
The 2025 budget provides $7.6 billion for VA IT systems and
telecommunications support, including $6.2 billion in base
discretionary funding and $1.4 billion in TEF, reflects the Office of
Information and Technology's efforts to deliver modern, innovative,
secure, and efficient solutions for the Nation's Veterans. To increase
Veterans' access to VA information and services, strategic IT
investments through the limited, controlled expansion of modernization,
cybersecurity, and IT workforce, will allow VA to make key investments
in Federal initiatives, including Zero Trust Architecture, Artificial
Intelligence, and improved access for Veterans with certain
disabilities through Section 508 Compliance.
To create a 21st Century VA focused on meeting the demands of
Veterans in the digital age, IT modernization is critical in achieving
digital transformation goals. The 2025 budget sustains the increased
investments made in the 2024 budget and supports the continued
operations and maintenance of VA's existing aging and legacy systems.
VA continues to expand critical modernization initiatives bolstering
the Department's ability to serve the Veteran including: the
Infrastructure Readiness Program to reduce technical debt, Financial
Management Business Transformation (FMBT) to enable compliance with
financial management legislation and improve stewardship of resources,
and Supply Chain Management to provide cost-effective logistics and
ensure the delivery of world-class health care and benefits to
Veterans.
When Veterans leverage technology to access VA services, they trust
that the underlying digital ecosystem is safe, reliable, and secure.
The 2025 budget invests $670 million in cybersecurity and VA's Zero
Trust Architecture acceleration effort will deliver a robust and
resilient security posture for the nine million Veterans that use VA
for care and benefits and the hundreds of thousands of VA employees and
contractors spanning over 600,000 connections to the network.
Investing in the IT workforce makes VA an attractive employer for
top talent that can better deliver services to Veterans. The 2025
budget supports the Special Salary Rate authorized in 2023 for IT
technical positions under PACT Act authorities. VA will maximize these
incentives for targeted expansion of IT services - including Artificial
Intelligence - to VA employees and Veterans during a period by record
growth in health and benefits delivery. This investment is critical for
VA to continue delivering world-class IT products and services to
millions of Veterans, their families, and caregivers.
Electronic Health Record Modernization
As part of an Electronic Health Record Modernization Program Reset
(Reset) announced in April 2023, VA deferred work on future deployments
of the Federal electronic health record (EHR), the sole exception being
the successful joint VA and DoD deployment at the Captain James A.
Lovell Federal Health Care Center (North Chicago, Illinois) in March
2024, while the Department prioritizes improvements at the 6 sites and
22 clinics that currently use the Federal EHR. The purposes of the
Reset are to: optimize the current state of the Federal EHR, closely
examine and address the issues that clinicians and other end users are
experiencing, and position VA for future deployment success. VA is
seeing incremental, but accelerating progress as it addresses the
issues that clinicians and other end users are experiencing and as it
optimizes the current state of the EHR system to ensure the enterprise-
wide foundation is in place for success when deployments resume. The
Fiscal Year 2025 budget of $894 million supports the Reset and
sustainment/maintenance of the six sites. VA acknowledges that an
updated deployment schedule is critical to demonstrating commitment to
providing the Federal EHR to end users across the enterprise and will
provide that schedule to the Committee once it has been determined.
Financial Management Business Transformation (FMBT)
The 2025 budget includes $313 million for FMBT, a program that is
improving VA's fiscal accountability and enhancing analytic and
resource management capabilities for our employees who serve Veterans.
Deployment of the Integrated Financial and Acquisition Management
System (iFAMS) is taking place in phased implementations across VA
Administrations and Staff Offices. Looking ahead, iFAMS will be
implemented for VBA's Loan Guaranty Service, and the program recently
initiated the first VHA implementation.
Honoring Veterans' Legacies
The President's 2025 Budget includes $495 million for NCA's
operations and maintenance account, an increase of $15 million (3
percent) over the 2024 budget. These funds will ensure Veterans and
their families have access to exceptional burial and memorial benefits
including expansion of existing cemeteries as well as new and
replacement cemeteries. With these funds, NCA will provide for an
estimated 137,440 interments, the perpetual care of over 4 million
gravesites, and the operations and maintenance of 158 national
cemeteries and 35 other cemeterial installations in a manner befitting
national shrines.
While every eligible Veteran may be interred at any one of VA's
open national cemeteries and a significant majority of the 122 VA
grant-funded Veterans cemeteries, VA realizes that proximity to a
cemetery is an important consideration in whether Veterans and family
members choose a VA-funded cemetery for their final resting place. For
this reason, NCA is committed to providing 95 percent of the Veteran
population with access to first interment burial options (for casketed
or cremated remains, either in-ground or in columbaria) in a national
or State Veterans cemetery within 75 miles of the Veteran's place of
residence. VA has made continuous, significant progress toward meeting
that target. In 2025, an estimated 94 percent of the Veteran population
will be served with such access. The 2025 budget also includes $60
million for the Veterans Cemetery Grants Program to continue important
partnerships with states and tribal organizations. The grants program
plays a crucial role in NCA achieving its strategic target of providing
95 percent of Veterans with reasonable access to a burial option.
Additionally, the 2025 budget continues NCA's implementation of the
Veterans Legacy Memorial (VLM), the Nation's first digital platform
dedicated to the memory of nearly 10 million Veterans interred in VA's
national cemeteries and VA grant-funded State, territorial, and tribal
Veterans cemeteries. VLM allows family, friends, and others to preserve
their Veteran's legacy by posting tributes. In November 2023, VLM 's
website had its largest expansion yet with the creation of nearly 5
million pages for Veterans in private and other cemeteries who have
received a headstone, marker, or medallion from NCA since 1996.
Conclusion
Chairman Bost, Ranking Member Takano, thank you for the opportunity
to appear before you today to discuss our progress at the Department
and how the President's Fiscal Year 2025 Budget and Fiscal Year 2026
Advance Appropriations Request will serve the Nation's Veterans.
Prepared Statement of Patrick Murray, Shane Liermann And Roscoe Butler
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Statements for the Record
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Questions for the Record Submitted by Juan Ciscomani, Jennifer Kiggans
and Morgan McGarvey
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U.S. Department of Veterans Affairs Response to Questions for the
Record Submitted by Mike Levin and Julia Brownley
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