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

                      A CALL TO ACTION: MEETING THE NEEDS
                         OF THE SPINAL CORD INJURY AND
                      DISORDERS (SCI/D) VETERAN COMMUNITY

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED EIGHTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                            THURSDAY, JUNE 13, 2024

                                   __________

                               Serial No. 118-69

                                   __________

           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
    56-243                  WASHINGTON : 2025

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

                         COMMITTEE ON VETERANS' AFFAIRS

                         MIKE BOST, Illinois, Chairman

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

                           Jon Clark, Staff Director
                      Matt Reel, Democratic Staff Director

    Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
    hearing records of the Committee on Veterans' Affairs are also
    published in electronic form. The printed hearing record remains the
    official version. Because electronic submissions are used to prepare
    both printed and electronic versions of the hearing record, the process
    of converting between various electronic formats may introduce
    unintentional errors or omissions. Such occurrences are inherent in the
    current publication process and should diminish as the process is
    further refined.
                             C  O  N  T  E  N  T  S

                                  ----------

                            THURSDAY, JUNE 13, 2024

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Mike Bost, Chairman................................     1
    The Honorable Mark Takano, Ranking Member........................     3

                                   WITNESSES
                                    Panel I

    Dr. Erica Scavella, Assistant Under Secretary for Health for
      Clinical Services, Veterans Health Administration, U.S.
      Department of Veterans Affairs.................................     4

            Accompanied by:

        Mr. Jeffrey London, Executive Director, Medical Disability
            Examination Office, Veterans Benefits Administration,
            U.S. Department of Veterans Affairs

    Mr. Steve Bracci, Director, Claims and Medical Exams Benefits
      Inspection Division, Office of Inspector General, U.S.
      Department of Veterans Affairs.................................     6

                                    Panel II

    Mr. Robert Thomas, National President and Chairman of the Board,
      Paralyzed Veterans of America..................................    21

    Mr. Carl Blake, Chief Executive Officer, Paralyzed Veterans of
      America........................................................    23

    Ms. Sonya Sotak, Chief Government Affairs Officer, I AM ALS......    24

    Dr. B. Jenny Kiratli, Member, American Federation of Government
      Employees......................................................    26

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Dr. Erica Scavella Prepared Statement............................    37
    Mr. Steve Bracci Prepared Statement..............................    42
    Mr. Robert Thomas Prepared Statement.............................    49
    Mr. Carl Blake Prepared Statement................................    55
    Ms. Sonya Sotak Prepared Statement...............................    68
    Dr. B. Jenny Kiratli Prepared Statement..........................    72

                           Statements For The Record

    MitoSense, Inc. Prepared Statement...............................    75
    Christopher and Dana Reeve Foundation Prepared Statement.........    78
    Neuralink Prepared Statement.....................................    80

                      A CALL TO ACTION: MEETING THE NEEDS
                         OF THE SPINAL CORD INJURY AND
                      DISORDERS (SCI/D) VETERAN COMMUNITY

                                  ----------

                            THURSDAY, JUNE 13, 2024

                        Committee on Veterans' Affairs,
                                 U.S. House of Representatives,
                                                        Washington, DC.
        The committee met, pursuant to notice, at 10:47 a.m., in
    room 360, Cannon House Office Building, Hon. Mike Bost
    (chairman of the committee) presiding.
        Present: Representatives Bost, Bergman, Miller-Meeks, Van
    Orden, Luttrell, Takano, Brownley, Cherfilus-McCormick,
    Ramirez, Landsman, and Budzinski.

                OPENING STATEMENT OF MIKE BOST, CHAIRMAN

        The Chairman. Good morning. The committee will come to
    order, and I want to welcome the witnesses to our hearing
    today. I do want to apologize for the late start, but we are
    going to get started here. Today, we will be discussing the
    care and benefits available to veterans living with spinal cord
    injuries and disorders. You know, we have not had a hearing on
    this issue during my time on this committee, and the oversight
    in this area, it has been long overdue.
        Before we dive into it, though, there is something that I
    want to say, and I think it is important that I do. I am very
    disappointed to see that the U.S. Department of Veterans
    Affairs (VA) did not send a witness from the Spinal Cord Injury
    and Disorder, or the SCI/D, system. That is what this hearing
    is all about. For the VA, should have prioritized having
    someone here from that office that is tasked with helping the
    veterans and their availability to receive those benefits. I
    think it is important that the people in this room, the
    veterans as well as the taxpayers and the veterans who are
    watching this hearing, this is the third time this year where
    we have been declined by the VA to have the witnesses that we
    requested. It does not matter whether we are Republican. It
    does not matter whether we are Democrat. It does not matter
    whether the ranking member, when he was in the majority. It is
    really upsetting whenever the VA makes decisions to overrule
    our decision on who we want and accept your judgment over ours.
        It is the responsibility of this committee to make sure VA
    takes care of all veterans. It is our responsibility for doing
    that to give oversight, and we actually do understand who we
    need to talk to. It is the third time this year that VA has
    tried to make a decision over this committee on who we need to
    talk to. That is not fair to the veterans and it is not fair to
    the taxpayers.
        What you need to understand is we are the Congress of the
    United States. You are an agency, yes, agency controlled by the
    administration, but your budget is ours. Oversight is ours. We
    have to do our job for the American people, whether it is a
    Republican sitting here or a Democrat sitting here. It is not
    the job of the VA to decide who is going to sit before us. It
    is our job to request and your job to deliver. I hope I am
    really clear on what I just said.
        With that, VA has long been recognized for its unique
    ability to provide top-notch SCI/D care. VA has 25 SCI/D
    centers across the country, each specifically designed to meet
    the--just a minute, to meet the veterans issues head on and
    meet those veterans with spinal cord injuries where it is
    convenient for them. Let me put in perspective what I mean.
        One of the centers is in Hines, Illinois, which is about 3
    hours from the top of my district, which means it is 6 hours
    from the bottom of my district. That is a long time to drive
    for an appointment. I want to ensure VA is meeting the veterans
    where they are with the healthcare they have earned. It is that
    simple.
        Now, we have heard stories from veterans about missing
    doctors' appointments due to late or inadequate transportation
    with no coordination from VA. Those missed appointments have
    contributed to about $4 billion cost to the Department from
    what we can calculate.
        We have also heard concerns about staffing shortages that
    have prevented SCI/D centers from operating at full capacity,
    as well as issues with patient safety practices in the VA's
    facilities. Some of the VA's shortfalls in this area are
    addressed in H.R. 8371, the Elizabeth Dole Act, including home
    care, long-term care, and access to SCI/D systems of care. It
    is incredibly important that we pass this important legislation
    to ensure VA can meet the need of all veterans. I hope my
    colleagues on the other side of the aisle, and I am sure they
    will, will put politics aside and support this life-saving
    bill.
        Today, we will also examine VA's failure to ensure all
    disability exams are conducted in properly equipped facilities.
    A recent VA Inspector General (IG) report showed that a large
    number of contract exam facilities did not comply with Federal
    disability law. In this day and age, that is unacceptable.
        Let us be perfectly clear. This is not a mere suggestion
    for the Department. It is what we expect. VA must ensure that
    the veterans they serve have access to accessible and safe exam
    facilities. Without that, veterans are being restricted from
    the benefits they have earned. We know that disability claims
    processing itself is difficult to navigate. Veterans should not
    also face physical barriers to getting an exam.
        Access to benefits, including VA's Specialty Adaptive
    Housing Grant program, are also crucial. Yet we understand that
    the application, the wait times for this program can present
    challenges for veterans and their families that they need help.
    Veterans are required to receive three estimates before they
    can get approval, and it can be difficult to find builders to
    do the work, especially if you are in a rural area. The
    advantage of keeping disabled veterans in their homes not only
    saves money, but it also gives the veterans and their families
    peace of mind. Congress has recently invested in this program.
    VA must make the rubber meet the road so severely disabled
    veterans continue to have access to the benefits that they have
    earned.
        Now, I am eager to hear from the VA today about how they
    plan to fix these years-long problems. We will also learn from
    the expert witnesses who will speak about what more we can do
    to improve access to care and services for catastrophic
    disabled veteran community. I also want to welcome the many
    members of the Paralyzed Veterans of America (PVA) who are
    attending the hearing here today. Thank you all for making the
    trip to DC, and I appreciate that you are spending some time
    here with us this morning.
        Now I would like to recognize Ranking Member Takano for his
    opening comments.

            OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER

        Mr. Takano. Well, thank you, Mr. Chairman. I am pleased to
    be here today to examine how we are meeting the needs of
    veterans with spinal cord injuries and disorders, sometimes
    referred to as SCI/D.
        It is estimated that around a quarter of those with spinal
    cord injuries and disorders are veterans. Many patients live
    with the effects of these injuries for decades. It is crucial
    that VA can provide resources and help meet the needs of
    veterans with spinal cord injuries and disorders at each stage
    in their lifetime of care. Now, this includes access to
    equipment to assist them with mobility, ensuring a high level
    of care coordination to provide appropriate care for both
    preventative and chronic healthcare needs, and access to long-
    term care in settings that make the most sense for the veteran
    and their loved ones.
        As you will hear from many of our witnesses today, VA is
    uniquely positioned among healthcare systems to provide this
    standard of care. Its hub-and-spoke model is intended to help
    ensure that veterans are connected to the same high standard of
    care regardless of where they live. This does not happen by
    accident. VA's position as the best provider of care for
    veterans with spinal cord injuries relies on continual
    investments in VA's infrastructure, workforce, long-term care
    services and supports, and other benefits for veterans with
    spinal cord injuries and their caregivers.
        I share the concerns of some of our second panel witnesses
    about VA's ongoing strategic pause in hiring and the impact it
    is having on staffing and care for veterans with spinal cord
    injuries. The highly specialized training and staffing ratios
    necessary to provide appropriate care to veterans with spinal
    cord injuries means that it can be challenging to fully staff
    VA's SCI/D system of care. However, workforce shortages lead to
    beds going unfilled, decreased access to care, and worse
    outcomes for veterans with spinal cord injuries. We must remain
    vigilant and sure that vacancies at SCI/D centers are
    continuously filled.
        Now, because of the advanced training required of
    healthcare providers that are caring for veterans with spinal
    cord injuries, special attention must be paid to bolstering the
    workforce pipeline. It is vital to ensure VA is training and
    retaining an appropriate workforce for this population, and I
    look forward to discussing ways VA is doing this.
        Now, improving VA's infrastructure has long been a priority
    of mine, but the importance of this goal cannot be overstated
    when it comes to serving veterans with spinal cord injuries. VA
    must focus on infrastructure projects that build more capacity
    for SCI/D beds and ensure additional access within the hub-and-
    spoke model. At the same time, many existing VA facilities are
    in need of repairs or retrofits to ensure that they meet
    evolving standards of care for SCI/D veterans. Now, meeting
    both these needs will take thoughtful investment and planning,
    both from Congress and VA, and I look forward to working with
    VA on these vital projects.
        Finally, veterans need to be able to receive care in the
    venue that best fits their lives and needs, and many veterans
    rely on home-and community-based services for healthcare and
    support. Through the Veteran Directed Care program, veterans
    with spinal cord injuries have the ability to hire their own
    personal care aides and engage in decisions about their care
    that ensures it fits their needs and their lives. Most
    importantly, it is crucial that veterans receive the care that
    they need in the community without being subject to statutory
    spending caps that could drive them to institutionalized
    settings of care.
        Now, my colleague, Congresswoman Julia Brownley's bill, the
    Elizabeth Dole Home Care Act, H.R. 542, meets these needs. It
    passed the House in December, and I urge the Senate to do the
    right thing, to move it forward. I agree with Chairman Bost
    that the politics must be set aside. The last I heard, his
    party is in the majority, and they could bring a bill to the
    floor at any time to address those needs. I would ask that he
    bring such a bill to the floor without the sort of--well, with
    a bipartisan agreement, basically, on what it contains. There
    is bipartisan agreement on H.R. 542.
        I just want to thank all of our witnesses for being here
    today. I look forward to hearing from each of you about how we
    can ensure the well-being of all veterans living with spinal
    cord injuries.
        I thank the chairman again, and I yield back.
        The Chairman. I thank the ranking member for his opening
    statement. We will now turn to our witnesses.
        Testifying before us today we have Dr. Erica Scavella, the
    Assistant Under Secretary for Health for Clinical Services, and
    she is accompanied by Mr. Jeffrey London, the Executive
    Director of the Medical Disability Examinations Office. Also on
    the panel, we have Mr. Steve Bracci, the Director of Claims and
    Medical Exams Benefits Inspection Division of the Office of
    Inspector General (OIG).
        Dr. Scavella, you are recognized for 5 minutes to give your
    opening testimony.

                      STATEMENT OF ERICA SCAVELLA

        Dr. Scavella. Good morning, Chairman Bost, Ranking Member
    Takano, and committee members. My name is Dr. Erica Scavella. I
    am the Assistant Under Secretary for Health for Clinical
    Services, and in that role I directly, through my Deputy
    Assistant Under Secretary, oversee the Spinal Cord Injuries and
    Disorders System Executive Director. I am accompanied by Mr.
    Jeffrey London, the Executive Director for the Medical
    Disability Examination Office with the Veterans Benefits
    Administration. Thank you for this invitation to testify before
    you today.
        Spinal cord injuries and disorders, or SCI/D, present
    unique challenges and complexities, often requiring specialized
    care and support. At VA, we are dedicated to addressing the
    diverse needs of veterans with spinal cord injury and
    disorders, ensuring access to rehabilitative services,
    specialty benefits and services, and assistive technologies.
        VA's SCI/D system of care is a comprehensive network
    designed to deliver exceptional care. This system operates
    under a hub and spokes model wherein 25 regional SCI/D Centers
    serve as hubs providing comprehensive care, while primary care
    services are rendered at VA Medical Centers, acting as spokes,
    by the SCI/D patient-aligned care teams. Mental health services
    are seamlessly integrated into the care plan, ensuring a
    holistic approach. Mobility interventions and walking aids,
    including walkers and canes, manual and motorized wheelchairs,
    and exoskeletons, are tailored to fit the individual needs of
    veterans, enhancing their independence and quality of life. The
    system also offers a range of long-term care options, including
    noninstitutional and home-based care, as well as support
    through the Caregiver Support Program, ensuring a continuum of
    care for those in need.
        While serving as a Marine on his second tour in the Vietnam
    War, Mr. Ron Kovich suffered a spinal cord injury that left him
    paralyzed from the chest down. For the past 53 years, Mr.
    Kovich has received his primary and specialty care through VA.
    This past July, on his 78th birthday, Mr. Kovich penned an open
    letter sharing his thoughts on his VA experiences. In his
    letter, he stated, ``I have been a patient in the Long Beach VA
    spinal cord injury hospital for the past week for a bladder
    infection. The care has been excellent. Aides, nurses, doctors
    have been terrific. Things have vastly improved over the years
    over here. Ever since I was a patient in 1971, I have had to
    come to this hospital many times over the years and I have seen
    many changes. I can honestly say that the care here of our
    veterans is now second to none.''
        VA strives to ensure every veteran's experience echoes that
    of Mr. Kovich. To accomplish this, we provide various
    initiatives and programs to improve the accessibility in
    medical facilities, including providing eligible veterans with
    reimbursement for self-arranged travel, special mode
    transportation, door-to-door appointments, and funding for the
    Highly Rural Transportation Grant service for travel
    coordination in highly rural counties. VA often continuously
    upgrades its facilities, integrates assistive technologies, and
    deploys mobile units for accessibility, prioritizing women
    veterans' unique needs with specialized facilities for their
    privacy, comfort, and tailored care. Outside of the facility,
    VA provides disability compensation, independent living
    training, and housing benefits, including the Special Adaptive
    Housing Grant program you mentioned, providing financial
    assistance for home modifications to address accessibility
    needs.
        Additionally, we oversee contract examinations to ensure
    facility safety, cleanliness, and accessibility, and we work to
    increase the examination of our care through telehealth and
    acceptable clinical evidence exams. The Veteran Readiness and
    Employment Program additionally assists disabled veterans in
    preparing for, obtaining, and maintaining suitable employment.
        Finally, one of our most successful and impactful programs,
    the VA Adaptive Sports Clinics, provides the ability to empower
    veterans with spinal cord injury and disorders and engages them
    in physical activities tailored to their unique needs and
    abilities. These programs, which I have witnessed myself, allow
    veterans the opportunity to participate in a variety of sports
    and recreational activities, promoting physical fitness, social
    interaction, and overall well-being, completing the continuum
    of care.
        Chairman Bost, Ranking Member Takano, this concludes my
    testimony. My colleague and I are ready to answer any questions
    you may have.

        [The Prepared Statement Of Erica Scavella Appears In The
    Appendix]

        The Chairman. Thank you, Dr. Scavella.
        Mr. Bracci, you are recognized for 5 minutes to give the
    OIG's testimony.

                       STATEMENT OF STEVE BRACCI

        Mr. Bracci. Chairman Bost, Ranking Member Takano, and
    committee members, I appreciate the opportunity to discuss our
    review of Veterans Benefits Administration's (VBA) oversight of
    the contract medical exam facilities used for veterans
    disability claims.
        VBA has paid contractors billions of dollars since 2017 for
    these exams, which may be needed to decide claims. The exams
    are typically conducted at the medical examiner's place of
    business, and those facilities must be accessible, safe, and
    clean. The four exam vendors that VBA uses are required to
    inspect these facilities for compliance with American with
    Disabilities Act (ADA) and Occupational Safety and Health
    Administration (OSHA) standards. We focused on veterans'
    feedback and experiences regarding the accessibility, safety,
    and cleanliness of the contract exam facilities. While we are
    not ADA or OSHA compliance officials able to cite specific
    violations, we did identify deficiencies at 113 of the 135
    facilities we visited. These deficiencies created needless
    burdens and safety concerns for veterans with mobility issues
    and those with spinal cord injuries and disorders. We found
    that the deficiencies went largely undetected by Medical
    Disability Examination Office (MDEO) because that office did
    not provide sufficient oversight of the vendors' self-
    certification of ADA and OSHA compliance.
        In 2021, VA modified the vendors' contracts by removing the
    requirement for MDEO to conduct random as well as complaint-
    based site visits. Notably, in Fiscal Year 2022, MDEO did not
    conduct any site visits based on veterans' complaints. Our
    finding was bolstered by four determinations.
        First, MDEO lacked independent access to the current
    inventory of contract facilities. By depending on the vendors
    to provide this information, MDEO could have incomplete lists.
    In fact, two vendors could not provide a definitive number of
    exam locations. Our first recommendation asked MDEO to maintain
    a list of the contracted facilities. While this may be the
    contractor's proprietary information, VA routinely handles this
    critical information like this in other areas and can protect
    this information in the same manner.
        Second, MDEO allowed the vendors to give customer
    satisfaction surveys rating their own performance to veterans
    instead of using an independent survey vendor. This may have
    resulted in VBA lacking a full picture of veterans'
    experiences. Therefore, we recommended that veterans receive
    the comment cards directly from an impartial survey provider.
        Third, MDEO lacked formal guidance for staff conducting
    exam facility site visits. MDEO staff were not trained on the
    standards of review and their checklists were not specific
    enough. For example, MDEO staff did not know specific criteria,
    like the minimum space needed for a wheelchair to turn. Also,
    we found their site visits were based on general observation of
    the facilities. We made three recommendations to develop formal
    site visit procedures, update checklists, and create
    standardized training for staff.
        Fourth, MDEO did not validate the vendors' self-
    certification of ADA and OSHA compliance. The vendors' self-
    certification process was not comprehensive or reliable, likely
    contributing to the deficiencies. Importantly, MDEO was not
    doing reviews based on veterans' complaints. We recommended
    that VBA conduct complaint-based inspections and enforced the
    requirement for vendors to inspect and recertify the
    accessibility, safety, and cleanliness of all facilities.
    Because of accessibility deficiencies, some veterans could not
    complete exams at those facilities. Additionally, some
    facilities had safety deficiencies, including locations with
    blocked exit routes or expired fire extinguishers. Other
    facilities lacked clean common areas or single-use medical
    supplies.
        ADA deficiencies at facilities may make them unable to
    accommodate veterans with mobility issues. Our report has
    numerous examples of facilities where wheelchair users could
    not enter the location, so an exam was not possible.
    Rescheduling exams after veterans have needlessly traveled to a
    facility takes time and could delay their claim. We recommended
    that VBA analyze all veterans' complaints and create action
    plans to remedy them.
        Our last recommendation asked VBA to work with its vendors
    to determine if a veteran requires accessibility arrangements
    before the exam. All recommendations are open and we will
    monitor VBA's progress on implementing the corrective action
    plans to address the hardships and safety issues that veterans
    with mobility challenges have experienced during medical exams.
        Mr. Chairman and members of the committee, I am happy to
    answer any questions that you may have.

        [The Prepared Statement Of Steve Bracci Appears In The
    Appendix]

        The Chairman. Thank you, Mr. Bracci. We are now going to go
    to questions, and I will yield myself 5 minutes for the first
    questions.
        Dr. Scavella, we have heard that VA transportation is often
    inconsistent and not accessible to SCI/D veterans, which result
    in missing medical appointments. Can you tell me how many
    missed appointments are the result of VA transportation issues?
        Dr. Scavella. Thank you for that question. Our goal is to
    make sure we are providing access to our veterans, so we do
    have a number of vehicles to be used by our veterans who may be
    trying to get to appointments. If a veteran who has spinal cord
    injury and disorders self-schedules their appointment, we will
    reimburse them. If they live in a highly rural program or area,
    we have a highly rural transportation program. We also operate
    a Veterans Transportation Program through volunteers, and then
    we do have the beneficiary travel as well as the Veterans
    Transportation Program. I will need to ask for a number. I do
    not have a number of how many veterans may have missed an
    appointment.
        The Chairman. Okay. That is something we need to know from
    the committee. Also, with that, if you can check your records
    and have try to get a calculation, because we try to get our
    calculation, I said in my opening statement, we believe it is
    $4 million that it has cost to miss those appointments. The
    number of appointments and then how much it has actually cost,
    how much it has ran over.
        Mr. Bracci, can you please explain to me the problems with
    the audio booth that is pictured right here behind me?
        Mr. Bracci. Yes, sir. There are a couple of issues with
    that particular audio booth that we saw. The first is
    accessibility. There was not a ramp available where a veteran
    in a wheelchair could get up into the booth. The second issue
    is the actual size of the booth. It was not large enough to
    accommodate a veteran in a wheelchair. The minimum dimensions
    are 60 inches in diameter, and it did not meet that standard.
        This is an important issue because we did identify
    instances where veterans had accidents and they tripped and
    fell trying to get in and out of an audio booth like this, and
    ended up--we saw one case where a veteran fractured their hip
    and required surgery. It is not just a matter of complying with
    standards. It has real impact on veteran safety.
        The Chairman. You answered my second question. That would
    have been, have there been injuries and even severe injuries
    occur because of things like this?
        Mr. Bracci. Yes, based on the work we have done, there
    certainly have been. We identified--I think we have three
    examples in our report that showed issues where veterans have
    had accidents and have been harmed.
        The Chairman. Thank you. Dr. Scavella, what is the average
    time it takes from when a veteran applies for special housing
    adaption to when the contractors begin construction of that
    adaption?
        Dr. Scavella. Thank you for that question. I am going to
    turn that over to Mr. London, who is the executive for the
    Veterans Benefits Administration.
        Mr. London. Thank you very much for the question. Of
    course, it is variable, depending on the types of adaptations
    that a veteran needs to meet his or her or their needs. Also
    the location of the particular residence that is being modified
    and availability of contractors. Generally speaking, it can
    take over 90 days in many cases to accomplish what you asked.
        The Chairman. Then the follow-up question on that is, and I
    know you cannot do anything about location, but what else can
    we do to speed up the process? Every day is a bad day with not
    having access to this.
        Mr. London. I understand the question, and I agree with
    your sentiment. Some of the things that we have done to
    expedite the process to assist the veteran, because one of the
    things that needs to happen is the veteran has to choose the
    contractor, but we do not leave the veteran by his or herself
    to make that decision. We have a list of contractors that have
    successfully completed projects in the area to help expedite
    the process, and they also have familiarity with the details of
    what is required for these special needs.
        The Chairman. Thank you. Dr. Scavella, I am concerned about
    the staffing level at SCI/D centers. Do you believe that VA
    medical facilities are properly staffed for all SCI/D beds?
        Dr. Scavella. Thank you for that question. Our goal is to
    make sure we are providing the care that the veterans need. We
    do have strategic hiring and spinal cord injury disorders is
    one of the areas that we have specifically communicated we
    expect those areas to be fully staffed. We currently have a 9
    percent vacancy rate across the country, which is a decrease in
    the past 5 years. If you look at our statistics between Fiscal
    Year 2019 and Fiscal Year 2024, we have over 232 percent growth
    in that particular area across the country to include all
    staff.
        The Chairman. Well, that is, I guess, how you would respond
    to the VA facilities. There are a lot of claims out there that
    you are short staff nurses in and around the country.
        Dr. Scavella. There is a healthcare shortage generally,
    both within and outside of VA, which we are contending with. We
    are being creative in our salaries, making sure that we are
    being competitive, making sure that we provide the opportunity
    for growth once employed by VA, to make sure that our
    environment of working is something that is desirable by people
    so that they will be willing to come into VA. We are making
    sure that our benefits packages for employees are enticing as
    well.
        We are also collaborating with university affiliates to
    make sure that we bring in the top talent into our
    organization. We realize that people who train within VA, like
    myself, tend to come to VA to work permanently.
        The Chairman. My time has expired by over a minute, but
    thank you very much for the--and I will now recognize the
    ranking member for his questions.
        Mr. Takano. Thank you, Mr. Chairman. Mr. Bracci, thank you
    for the recent OIG report on accessibility and safety at
    contract facilities for disability exams. Veterans may only use
    these facilities for a one-time exam, yet OIG found physical
    barriers that hindered access for veterans who use wheelchairs,
    among other things. Now, I am concerned that there may be
    similar issues with private sector providers that veterans are
    referred to once they start using the VA healthcare system. Has
    OIG looked at VA's community care network providers and whether
    they are meeting ADA and OSHA standards?
        Mr. Bracci. To my knowledge, we have not looked at that
    issue.
        Mr. Takano. Okay. Well, thank you. Would you tell the
    Inspector General Missal that I would like him to look into
    this issue?
        Mr. Bracci. Yes, I will.
        Mr. Takano. Thank you. Dr. Scavella, I understand that as
    of last month, only 153 of the 181 long-term care beds that VA
    is required to have in operation at its SCI/D centers are
    actually available for veterans. Can you explain why?
        Dr. Scavella. Thank you for that question, Congressman
    Takano. We have some challenges in some places, doing staffing,
    and then there are a variety of reasons that may affect our
    ability to have a bed open. If we do have a bed available, but
    it is occupied by a veteran who may have a certain infectious
    disease, we may have to not use the other beds in that room.
        Mr. Takano. Okay. I am hearing staffing, though, is the
    kind of predominant reason, lack of staff. These beds are empty
    because there is no one there to staff the veterans who might
    fill them. Just to be clear, veterans with SCI/D need access to
    long-term care beds at VA. Is there a waiting list?
        Dr. Scavella. We do not have patients who are waiting to
    get in. If we are unable to provide the care within our
    organization because of the acute need of this illness that
    they have, we will make sure that we coordinate with our
    community partners, recognizing or transfer to other facilities
    within our VA.
        Mr. Takano. You are saying there is no waiting list because
    you place them in community partners?
        Dr. Scavella. If we are unable to house them within one of
    our hubs or provide care in our spokes--it is a complicated
    answer.
        Mr. Takano. Okay. Yes, I could go into whether or not those
    community care facilities rise or meet the level that is
    provided at VA. I want to go down another train of thought
    here.
        I am sure you understand that my concern that VA is
    proposing to move up to $10 billion from direct care and
    medical facility infrastructure to community care in Fiscal
    Year 2025 to cover an expected shortfall. Now, this certainly
    will not help fill the vacancies in staffing that we are
    talking about in VA's SCI/D system of care. How can VA make the
    needed investments in the SCI/D workforce to provide the best
    care for veterans if we are diverting so much funding to
    community care?
        Dr. Scavella. As I have said earlier, our goal is to try to
    keep our veterans in our system. We want to make sure that we
    are providing the care for veterans. We have increased our
    staffing in spinal cord injuries and disorder by over 230
    percent in the past 5 years, and we are making sure that we are
    enticing employees to come into our system as a provider of
    choice.
        Mr. Takano. I get that. The administration is making a
    decision to move money out of direct care, which you need you
    need the staffing. Beds are empty, and that is forcing you to
    put people into the community already.
        I share the concerns that PVA expresses in its testimony
    about VA's decision to severely limit hiring in fiscal years
    2024 and 2025. VA issued a May 31 memo directing facilities to
    continue filling vacancies in VA's Spinal Cord Injury System of
    Care. How is VA going to hold the field accountable and ensure
    that there is sufficient workforce to meet the needs of SCI/D
    veterans?
        Dr. Scavella. Thank you for that question. We are coming on
    the heels of a remarkable 61,000--over 61,000 employees who
    have been brought into our system, mostly in direct care
    positions, and we have increased the staffing in our spinal
    cord injury and disorders. We only have a 9 percent vacancy,
    which is lower than it has been. We continue to prioritize that
    through our strategic hiring to make sure that we are providing
    that care.
        Mr. Takano. Excuse me for interrupting, but have you set a
    target date for the field to address staffing challenges that
    led to the closure of long-term care beds specifically? I mean,
    is there a target for that?
        Dr. Scavella. The request is to make sure we are
    strategically hiring, realizing that it takes time to bring in
    nurses and physicians, specifically because of the requirements
    to make sure that their credentials are what they say. We have
    a directive or memo from the Undersecretary for Health
    regarding how we should be moving forward. It is clear to our
    organizations, and the expectation is that those direct care
    appointments and opportunities would be provided first. Our
    plan is to get those employees out there.
        Mr. Takano. I am glad it is prioritized, but has he set a
    target date?
        Dr. Scavella. I would have to look back at the memo to give
    you that date.
        Mr. Takano. Could you get back to me on that? I hope, if
    there is not one, that there will be a concrete target date set
    to fill these beds--to staff these beds.
        I yield back, Mr. Chairman.
        The Chairman. Thank you, Ranking Member.
        Dr. Miller-Meeks.
        Ms. Miller-Meeks. Thank you very much, Chairman Bost. Thank
    the witnesses for being here.
        It is a little bit surreal to me because I started out my
    career as a second lieutenant nurse in the Army, stationed at
    Walter Reed on Ward 10, the neurosurgery floor. Taking care of
    traumatic brain injuries, which we did not call them that at
    the time, spinal cord injuries, I flipped my share of Stryker
    frames and also worked with halos. My husband, interestingly
    enough, got out of the military to get his Bachelor of Science
    in Nursing (BSN). He was an E6 Licensed Practical Nurse (LPN)
    when we met, and took care of a spinal cord injured veteran as
    a private LPN to do that before the VA provided that care. I
    know how challenging this can be.
        Dr. Scavella, according to some of the data obtained by
    committee staff, we know that 18 percent of patients seen in
    the past 3 years for spinal cord injuries and disorders were
    also seen for substance use disorder or had that diagnosis. Do
    you believe that the VA has the capacity provide inpatient
    mental health and substance use disorder care?
        Dr. Scavella. Dr. Miller-Meeks, thank you for that
    question. We do feel as if we have that ability because we are
    an integrated healthcare system. Mental health is embedded in
    the patient-aligned care teams that provide primary care for
    this population of veterans. If they require substance use
    disorder on an inpatient setting, we are able to provide that
    care as well. We do have systems across the--services across
    the system.
        Ms. Miller-Meeks. Are the SC--and this is, again,
    reminiscent of the old, old Walter Reed. Are the SCI/D units
    using four patient bed models in their centers, and do you
    believe that having four patients in a room is appropriate for
    minimizing risk of infection and creating a healing
    environment?
        Dr. Scavella. Yes. Congresswoman Miller-Meeks, thank you
    for that question. We have older facilities, as you just
    reminded us of, that do have four beds in some rooms. We are
    constructing facilities that do not have that configuration.
    Our goal is to try to reduce the size of the rooms to make sure
    that we are giving patients the privacy both from, you know, a
    mental capacity and from a healthcare capacity.
        That is not the standard at this point in construction.
    When and where possible, we will not use all four beds in a
    room to make sure that we are giving patients the privacy that
    they require.
        Ms. Miller-Meeks. Thank you. Just to follow up on
    Representative Takano's question, what are the main barriers,
    and you may have answered this, to staffing SCI/D centers as
    opposed to other VA medical facilities?
        Dr. Scavella. Yes. Thank you for that question. We
    understand that this is a highly skilled area, as you just
    mentioned, during your experience. These veterans require lots
    of care, lots of patience, and so it takes a certain type of
    clinician or professional to be a provider of that care. Making
    sure that we recruit, retain the highest skilled employees in
    those areas is really important. We want to make sure that they
    have the highest quality and so we review that on a regular
    basis through our ongoing professional practice evaluation. We
    also want to make sure that once we bring them in, that we are
    giving them the tools to grow as professionals, to make sure
    that they stay with us and continue to serve veterans.
        Ms. Miller-Meeks. I would say it was some of the most
    rewarding medical care as a nurse or a doctor that I had ever
    administered.
        Mr. Blake, the committee is aware of a few promising
    technologies. I think we cannot have this hearing without
    mentioning the innovation that is occurring in this space,
    mainly brain-machine interfaces, which hold immense promise for
    catastrophically disabled veterans. What research or outreach
    has PVA done in this space and technology and its key players?
        Excuse me, second panel. Thank you very much. I yield back
    my time, but I will submit the questions for the record.
        The Chairman. Representative Brownley.
        Ms. Brownley. Thank you. Dr. Scavella, you testified, I
    think, in response to the chairman's question, that you do not
    know how many missed appointments there are due to
    transportation. Why would you ever turn down a catastrophically
    disabled veteran who had travel issues once they got to the VA?
    Why would you ever turn them down for his or her appointment?
        Dr. Scavella. Thank you for that question. I am not aware
    of us turning anybody away, and that is why I do not think I
    can answer that question. We would make sure that we are
    providing that care, whether they are late, by a day or by a
    minute. It is important that we are providing the care when and
    where they need it.
        If we are, for whatever reason, whatever the condition is
    of that veteran, if they are too ill for the capabilities of
    the facility that they show up in, we will make sure that we
    get them to the appropriate level of care, whether it is in the
    VA system or in the community. Obviously, our goal is to try to
    keep them within our system because of all the things I have
    talked about with continuity, making sure that we can provide
    that care, not just for whatever the issue is, but the whole
    health of the veteran.
        Ms. Brownley. What are your--how would you describe your
    best practices for the LGBTQ community for women who are
    catastrophically disabled?
        Dr. Scavella. Thank you for that question. We appreciate
    legislation that has helped us to ensure that women veterans
    who have spinal cord injury and disorders can receive the care
    in-house or at home that they require, as well as for things
    such as mammography, which is difficult related to positioning
    them. We are very grateful for that.
        Our goal, through the messaging from the Secretary through
    to each employee, is to make sure that we are providing care
    for every veteran who has served. Our mission statement has
    changed to reflect that, and both the Secretary, the Deputy
    Secretary, who is very concerned about us, making sure that we
    are here for women veterans who may not see their place, that
    we are providing that open and welcome care.
        Ms. Brownley. What about the LGBTQ?
        Dr. Scavella. LGBTQ, we have several different projects
    related to making sure that we are being open. Currently, June
    is Pride Month, so we are recognizing our population of both
    employees and veterans during this month to make sure that we
    are providing that care, that people know that they can see
    themselves as their authentic selves here at work. There are a
    lot of things ongoing to make sure that we are being open and
    responsive to the population.
        Ms. Brownley. My understanding is when women with spinal
    cord injuries or disorders show up at a health clinic or a
    medical center, that they are then required to go to an SCI/D
    center first in order to be referred to by an ob-gyn. Is that
    true?
        Dr. Scavella. We are going to try to provide the care to a
    veteran who may show up in whatever care place she may show up.
        Ms. Brownley. I understand that is your goal, but I want to
    know what the reality is happening today.
        Dr. Scavella. When we have a new patient come in, if they
    are coming in for their care, if they are spinal cord injury
    and disorder disorders veteran, we would want to make sure that
    we are tying them in with that population to provide that care.
    If they are coming in for women's health services and we can
    provide that care in the women's health clinic, we will do
    that.
        Ms. Brownley. Basically, you are saying that is not really
    happening. If they show up at a medical center or health
    clinic, they are not getting referred to an SCI/D center?
        Dr. Scavella. Unless you have a specific instance that you
    would like me to look into, I am unaware of that.
        Ms. Brownley. Okay, Okay. Can you speak a little bit to the
    differences between the Elizabeth Dole 21st Century Healthcare
    and Benefits Improvement Act and the standalone bill, that was
    supported in bipartisan way, I will add, the Elizabeth Dole
    Home Care Act. Can you talk a little bit about the differences
    in what the VA really supports in terms of those two bills?
        Dr. Scavella. Thank you for that question, Congresswoman
    Brownley. I will have to take that back. I do not have the
    Department's technical review of those at my fingertips at this
    point, so I cannot speak freely about that.
        Ms. Brownley. Great. Well, the last thing I will just say,
    too, is having had a meeting in my office yesterday, that I
    know that there are PVA members in this room who have
    personally experienced being turned away after traveling to VA
    appointments. I would really encourage you to speak with them
    and hear their stories because I think what you are saying and
    what we are hearing from PVA members do not line up. Obviously
    we need to get to the bottom of that. I would appreciate it.
        With that, I yield back.
        The Chairman. Thank you, Representative Brownley.
        Representative Luttrell, you are recognized.
        Mr. Luttrell. Thank you, Mr. Chairman. Dr. Scavella, if I
    were you, I would take a hard look at the room behind you
    before you get out of here and leave, because they were shaking
    their heads to Ms. Brownley's point. That is something you are
    going to want to have an answer to when you engage with the
    committee. Okay? How long have you been in this position?
        Dr. Scavella. I have been in this position since January
    2022. I have been at the VA for 25 years.
        Mr. Luttrell. Twenty-five years. Mr. Barachi, that IG
    report, are there any bullet points on that report that have
    been replicated over previous years?
        Mr. Bracci. Some common themes. You know, as far as the
    contract exam program, we have been focusing on that for
    several years now because of the millions of veterans that
    impact----
        Mr. Luttrell. What discrepancies that we are seeing in the
    VA system that are ongoing?
        Mr. Bracci. I would say that just the oversight by MDEO, we
    see that continuously. I will say that they address issues as
    we identify them and as we make recommendations, but it is the
    proactive oversight up front.
        Mr. Luttrell. Well, the oversight report that you submitted
    and the previous oversights report that we have engaged with
    are stating the same thing over and over again. Dr. Scavella,
    can you tell me why the VA system is, I guess in my opinion, I
    am going to say, taking this kind of haphazardly and not
    engaging with--I mean, when you have spinal cord injuries--
    again, I am saying because I am looking behind you and I am
    seeing everybody. Right?
        I really want to know why this--and the Secretary's number
    one priority is suicide, and I appreciate that wholeheartedly.
    When our veterans have lost the ability to be mobile, amongst
    other things, everyone is neck and neck. If we continue to have
    an IG report that is pretty much beating the hell out of the
    VA, I want to know why the leadership is not taking advantage
    of the situation and fixing the problem.
        You have not given us any dates. I have listened to the
    committee members, including the ranking member, ask questions.
    What are the dates? The dates. In the military, we ask for
    dates. Those are hard lines because we function that way. That
    is how we operate. I want to know when the VA is going to throw
    us a hard time and say, hey, this is when we are going to fix
    this. Can you answer that question for me?
        Dr. Scavella. Thank you for that question, Congressman
    Luttrell. We are making sure that we are answering the mail
    when it comes to these findings. I am in the Veterans Health
    Administration (VHA).
        Mr. Luttrell. Well, what does that mean?
        Dr. Scavella. I am going to turn this question over to the
    Veterans Benefit Administration, who runs this program. I do
    not oversee it.
        Mr. Luttrell. Mr. London.
        Mr. London. Congressman Luttrell, thank you very much for
    the question. To answer your question specifically, the
    recommendations that OIG identified in the report, will all be
    satisfied by the end of this fiscal year, so by September 30.
    Three of the recommendations we have already implemented, and
    we will provide all of the evidence to OIG after they are
    completed on September 30.
        Mr. Luttrell. September 30, that is a hard time. That OIG
    report is going to be completely resolved?
        Mr. London. Yes, sir, and, yes, sir. Last year, when I
    testified before your subcommittee, you challenged me to make
    sure that you were going to hold me accountable. You can hold
    me accountable for those dates as well.
        Mr. Luttrell. Absolutely. Thank you, sir. I respect your
    leadership and honesty. Thank you for doing that.
        My second question is, I ran into a lovely young lady. She
    was over here in the Longworth Building. She had--and for life
    of me, I cannot remember the exact mechanism that she--she has
    a robotic mechanism that allows exoskeleton. Thank you, Mr. Van
    Orden. Hearing her story of what she had to go through to get
    that, she ended up having to pay for it on her own, her and her
    family. She was telling me the story. She was a Marine, by the
    way, so you can only imagine how engaging that story was. My
    curiosity is, why has not the VA stepped up in that space?
        Dr. Scavella. Sure. Thank you for that question, Mr.
    Luttrell. When it comes to exoskeletons, because of the level
    of independence that is required, there are certain
    requirements that need to be in place in order to determine
    which veterans are best suited to actually have an exoskeleton.
    We have to weigh the benefits and the risks. The benefits are
    increased mobility and increased autonomy. However, the
    manufacturers of exoskeletons require the assistance of another
    person. Even though a veteran may be moving around, in order to
    get into and out of that equipment, they do require another
    person to be around. That is stated by our veterans as the
    largest barrier to them, actually.
        Mr. Luttrell. Sure. Yes, her father was with her. I think
    there may be a communication breakdown because the VA did not
    come through with her, and she benefits greatly because of her
    exoskeleton. I do not know by, with, and through the
    organization how we need to move the pieces on the chessboard
    to fix this. I think there is a way to do that to fix this
    problem set. I just would ask the VA to take a harder look at
    the advancements in technology for our members in need.
        Dr. Scavella. Thank you for that statement. We are
    continuing to look at innovative projects and programs to
    support our veterans. In 2016, I am not sure when she received
    her exoskeleton, we did devise a specific type of evaluation
    for those veterans who are interested in exoskeleton. There are
    a number of other types of innovative technologies to include
    neurostimulation and other types of equipment that can help our
    veterans who have spinal cord injury and disorder. Again,
    everything is evaluated on a case-by-case basis to make sure
    that it is the safest for veterans.
        The downside, unfortunately, of some of these is because of
    the mobility issues, is that they can have skin breakdown,
    which can lead to infections and other problems, as well as
    some other neuromotor issues that can happen with spinal cord
    injury disorders veterans. We need to make sure that we are
    providing care that is not only what they want, but what we
    think is safe.
        Mr. Luttrell. Thank you, Doctor.
        I yield back, sir.
        The Chairman. Representative Landsman., you are recognized.
        Mr. Landsman. Thank you, Mr. Chair, and thank you for the
    hearing, and thank you all for being here.
        The U.S. Government Accountability Office (GAO) report that
    my colleagues have been talking about, we are talking about
    here the number of deficiencies. You know, something like 85
    percent of the facilities had one or more deficiencies. I do
    not want to get into that. I mean, I appreciate the comment
    about the report and the fact that the recommendations will be
    dealt with in some period of time.
        I have a larger question which I typically ask around
    continuous improvement and hospitals in general. We think of
    them as places where, you know, good things happen and bad
    things do not, though we know and you all know, the folks here
    know, that bad things happen all the time. The bad things are
    really bad in some instances. I mean, these are adverse events
    or serious safety events, medical errors, these kinds of
    things.
        I bring those up because in Cincinnati, we have a
    Children's Hospital which is now ranked, I believe, number one,
    but it is one, two, three every year. They got that way based
    on a commitment to being the best at getting better. That is
    what the board decided. That is what the leadership decided.
    That is what surgeons and nurses and everyone affiliated with
    the Children's Hospital in Cincinnati decided. It took them
    years, but they started with the serious safety events, and
    they wanted to get that to zero, because the only number that
    was acceptable is zero. They have not had a serious safety
    event in over 2 years, and it led them to get very serious
    about everything, from post-surgical infection rates, to the
    customer experience and things like this, this GAO report and
    deficiencies.
        They, you know, so, for example, they had a million--they
    got a 96 percent satisfaction rate. One of the board members 1
    year said that that is good, but we see a million people every
    year, so that means 40,000 people were unsatisfied. Let us do
    better. It was that attitude. Now they are--you know, they have
    much higher satisfaction rates.
        I am curious about, you know, because you all deal with
    some of the most significant and complicated medical issues,
    and I am curious, what approach do you all have now as it
    relates to getting better, the measures that you use? What does
    it look like in terms of the culture? How would you describe
    where you are at now versus where you would like to be?
        Dr. Scavella. Yes, thank you for that question, Mr.
    Landsman. We are constantly striving to improve the care we
    provide within our organization, and we also have the same type
    of stretch goal, to have no complications, no falls, no
    infections, things like that. We have a continuous improvement
    process that takes place at the medical centers individually.
        I do want to make a distinction that the concerns raised in
    the report were related to the oversight of external
    organizations that we are sending veterans to as opposed to our
    medical centers themselves as--.
        Mr. Landsman. Yes, to that. This was just one data point,
    and it had to do with care unrelated to yours. The adverse
    events or medical errors associated with community providers
    was 2X in one particular area. We have contracts with those
    organizations and presumably they could, you know, ascribe to
    or be required to ascribe to the same continuous improvement
    and performance measures as us. What does that look like?
        Dr. Scavella. Right. One of the things I will talk, and I
    will let Mr. London add to this answer, is that we are
    increasing the number of visits that we are conducting to the
    those facilities. You know, this is coming off the tail of the
    pandemic where first we did not travel because it was unsafe
    and then there was still a restriction on travel.
        Mr. London, would you like to add to that?
        Mr. London. Yes. Very similarly, we started traveling in
    April 2022 to do site visits. Since that time, we have done
    over 700, including an additional 300 virtual visits. We plan
    to continue to do those and increase the number of visits that
    we are going to have going forward to make sure that we are
    continuously improving.
        Mr. Landsman. I appreciate it. My time is up. Thank you. I
    yield back.
        The Chairman. Mr. Van Orden.
        Mr. Van Orden. Thank you, Mr. Chairman.
        Dr. Scavella, we keep hearing the same words and phrases
    all the time: continuously improving, doing our best, we are
    shooting this. We keep hearing the same stuff over and over and
    over again. We are trying to get better. We are trying. We are
    trying.
        Will you turn around, please? I would like you to get the
    view that--I am serious. Will you please turn around? This is
    the view that Congressman Luttrell had of these people that are
    permanently assigned to having to have artificial apparatuses
    to function and live. As your Department continuously strives
    to improve and get better and do all this stuff, and the IG
    report just says you are not, they are still stuck in those
    chairs, ma'am, while you get to go home, and while your staff
    that is continuously improving gets to go run in a field with
    their family, and they do not get to do that.
        I am thoroughly unimpressed with your Department's
    performance. I think that the IG report says that you guys are
    failing. When is someone at the Veterans Affairs, when is
    someone at the VA going to be held accountable to the point
    where they are not working there anymore?
        Dr. Scavella. Thank you for that question. When we do see
    performance issues, we have to document those and go through a
    process to separate someone from employment. In those
    instances, whether it is related to poor care or poor
    coordination of care, we take those actions.
        Mr. Van Orden. When is the last time you have fired someone
    from the VA for poor performance?
        Dr. Scavella. I am not overseeing direct patient care, so
    my answer to that question would not really be illustrative of
    what is happening in the field.
        Mr. Van Orden. Okay. For what period of time did you not do
    performance oversight visits during the COVID-19 public health
    emergency? Was it the entire time?
        Dr. Scavella. I will have to turn that over to Mr. London
    because these were for the Benefits Administration.
        Mr. London. Thank you very much for the question. Up until
    from March 2020 to April 2022, we were precluded from in-person
    travel.
        Mr. Van Orden. Okay, so what happened during that period of
    time? The vendors have been doing stuff the whole time, right?
        Mr. London. Yes, sir. The vendors were responsible
    contractually to ensure that each facility that they are used
    to send our veterans for examinations were safe, sound, and met
    the requirements of the contract to include OSHA and ADA.
        Mr. Van Orden. Did you sign an employment contract, sir?
        Mr. London. Did I sign an employment contract?
        Mr. Van Orden. Yes. Like it says, Department of Veterans
    Affairs.
        Mr. London. I am employed by the Department of Veterans
    Affairs, yes, sir.
        Mr. Van Orden. Okay. You signed an employment contract to
    be held accountable to the people that are sitting behind you,
    essentially in wheelchairs. Correct? Yet you failed to do your
    job during the entire COVID-19 thing, but you expected other
    people to do theirs, is that right?
        Mr. London. Mr. Van Orden, I appreciate your question. I
    want to make clear that I joined this office in December 2021.
    As soon as we were required or allowed to travel, I actually
    went with the team and did site visits personally to make sure
    that these sites met requirements. As soon as I was able----
        Mr. Van Orden. Who is your predecessor?
        Mr. London [continuing]. under my accountability, sir, that
    is what I am here to do.
        Mr. Van Orden. Mr. London, who is your predecessor?
        Mr. London. My predecessor is now retired.
        Mr. Van Orden. Okay. Did they retire with full benefits?
        Mr. London. I am unaware of his situation.
        Mr. Van Orden. Okay. I think you are seeing where I am
    going here.
        Mr. London. I do, sir.
        Mr. Van Orden. Consistently, the theme that I get from the
    Veterans Affairs Administration is that the Veterans Affairs
    Administration is putting the Veterans Affairs Administration
    above the veterans. That is not why you are here. It is not why
    we are here. You guys have to understand, your bureaucracy is
    not more important than the people sitting behind you in
    wheelchairs who are trapped in that reality, and they cannot
    escape that reality.
        They are clapping for the hope that there will be
    accountability in the Veterans Affairs Administration. I join
    them.
        With that, I yield back, Mr. Chairman.
        The Chairman. Representative Budzinski.
        Ms. Budzinski. Thank you, Mr. Chairman, and good afternoon,
    everyone. I am glad we are having this important conversation
    today about the unique issues that are affecting our veterans
    with spinal cord injuries and disorders, SCI/D.
        As my colleagues have spoken to and the OIG report
    outlined, there is a lot of work to be done for this vulnerable
    community. I want to focus on an area that I am particularly
    interested in seeing improvements, which is with the veterans--
    the women veterans living with SCI/D. I have attended several
    congressional women veterans roundtables with VSOs who are
    leading in the women's space, including Paralyzed Veterans of
    America.
        I just recently hosted my second women veterans roundtable
    at home in my district and have heard specific concerns related
    to today's topic. Women veterans already face very unique
    barriers when seeking care, and those barriers are only
    exacerbated among women veterans living with SCI/D. Many of our
    health clinics or specialty areas within VA continue to lack
    basic accessibility measures for those with of SCI/D, and the
    cooperation among the SCI/D system and women's health
    facilities continues to be severely lacking.
        As you know, one of the main SCI/D centers in the midwest
    is located in the St. Louis VA system, which serves many
    veterans, including many in the southern part of my district in
    Illinois, and I want to ensure we are equipping it with the
    resources needed to provide adequate care for women vets living
    with SCI/D.
        Dr. Scavella, I believe that the VA continues to be the
    best system for our vets with SCI/D to get care, but we have to
    improve what I believe to be communication between systems. My
    first question for you is, you know, what steps is the VA going
    to take to ensure better cooperation and continuum of care
    between SCI/D systems and women health clinics in particular?
        Dr. Scavella. Thank you for that question. We continue to
    partner with our women's health clinics to make sure that they
    are able to meet the unique needs of the spinal cord injury and
    disorder community. We are making sure that facilities have the
    appropriate equipment as well as space to make sure that our
    veterans who are women coming in for gender-specific care or
    other care are afforded the privacy, the comfort that they are
    entitled to. Those are things that are undergoing.
        The Women's Health Innovation and Staff Enhancement (WHISE)
    funding has been particularly useful in making sure that we
    have the ability to provide that care, as well as other pieces
    of legislation that specifically address mammography and access
    for women who are spinal cord injury and disorders.
        Ms. Budzinski. Is there anything specifically that you
    could speak to just in observations on what women's health
    clinics are equipped with today that would be something
    immediately helpful to help those women veterans with SCI/D
    kind of better integrate into a women's health clinic?
        Dr. Scavella. Yes, thank you for that question. When we are
    constructing newer facilities, we are ensuring that doorways
    are wide enough, that rooms are able to be modified and
    transitioned so that we can accommodate veterans who may be
    coming in using motorized wheelchairs, which tend to be larger.
    Then we can do appropriate gender-specific care in those spaces
    with our employees who are skilled and trained in those areas.
        That is what we are doing with our newer facilities. We do
    recognize that some of our older facilities have some more
    challenging navigation, especially for some of the newer
    motorized wheelchairs that may not be able to get through those
    spaces.
        Ms. Budzinski. Okay. I wanted to highlight, there have been
    instances of women with SCI/D getting a late diagnosis because
    they had to put off appointments due to these accessibility
    issues at their nearest women's VA clinics. This is especially
    true, as you have just highlighted, for women with SCI/D who
    are using wheelchairs.
        Dr. Scavella, how is the VA going to improve access? You
    talked about the needs, but what are kind of immediate next
    steps that we can do regarding access to gender-specific care
    for women living with SCI/D and how can we ensure facilities?
    Again, you pointed out the things that need to happen, but what
    can we do to take immediate action to make sure that is
    guaranteed so our women veterans get the care they need?
        Dr. Scavella. Yes, so we will make sure that we talk to
    each of our veterans to understand exactly what they need. One
    thing that we are making sure is happening is for veterans who
    are coming in with spinal cord injury and disorders, we want to
    make sure that all routine annual screening is completed,
    whether we are talking about our women or our men, and that
    those things are not afterthoughts. As part of their patient-
    aligned care teams, they are specialized in spinal cord injury
    and disorders. At those spokes or those centers, those hubs, we
    are making sure that that is part of the care.
        It may look different. We may not bring you physically to a
    place to get that care. We can provide that care to you either
    in the facility, in the hospital, or in your home. Then there
    is telehealth as well as other modalities to make sure that we
    are doing what we need to do.
        Ms. Budzinski. Okay, thank you. Last, PVA leaders testified
    at a recent Senate hearing that when providers are made
    available to SCI/D clinics to provide ob-gyn services, they are
    often general practitioners that are unable to answer questions
    specific to women vets living with SCI/D.
        Dr. Scavella, again, what can the VA do to better prepare
    practitioners to provide culturally competent care for women
    veterans living with SCI/D that need these services?
        Dr. Scavella. Thank you for that question. We do have a
    number of gynecologists, obstetrician/gynecologists who are
    employed by VA. Then we do have a number that are in partner
    with our university affiliates providing that care. Those are
    two of the ways we can make sure they are receiving the highly
    skilled gender-specific care that they require.
        Then if we do have an internist or another specialty that
    has the skills and the training to provide gender-specific
    care, we just make sure that they are educated on this
    particular population. We have ongoing engagement with the
    Spinal Cord Injuries and Disorders National Program Office to
    provide training specific to our veterans as well as other
    types of engagements face-to-face, virtual, on an ongoing basis
    as well as a community of practice. We are really making sure
    that we are giving our employees the skills that they need, as
    well as bringing in the skilled providers, physicians to
    provide that care.
        Ms. Budzinski. Thank you very much. I yield back my time.
        The Chairman. Thank you. Thank you, Dr. Scavella and Mr.
    London and Mr. Bracci for testifying today. You are excused.
        We need to--we would like the second panel of witnesses to
    approach the witness table and get ready. Thank you.
        I would like to welcome Mr. Robert Thomas, the national
    president and chairman of the board of the Paralyzed Veterans
    of America. Accompanying him is Mr. Carl Blake, the executive
    officer for Paralyzed Veterans of America.
        Mr. Thomas, if you would, I would recognize you for 5
    minutes to give your PVA's testimony.

                       STATEMENT OF ROBERT THOMAS

        Mr. Thomas. Thank you. Chairman Bost, Ranking Member
    Takano, and members of the committee, I appreciate the
    opportunity to testify on behalf of the tens of thousands of
    veterans with spinal cord injuries and disorders who rely on
    the benefits and healthcare available through the Department of
    Veteran Affairs.
        For nearly 35 years, I have navigated the VA health care
    and benefits system following the spinal cord injury I
    sustained while on active duty. The care and benefits available
    through the VA not only saved my life, but have given me the
    ability to have a family, work, and serve my fellow veterans,
    most recently, as you stated, as Paralyzed Veterans of America,
    national president and chairman of the board.
        I received my medical care through VA's direct care system.
    However, about 10 years ago, I was in a motor vehicle accident.
    I was taken to the nearest community hospital for immediate
    care. I recall the emergency room doctor asking me if I was in
    pain from the accident. I told the doctor that I was paralyzed
    and unable to feel such pain. Without further examination, I
    was given pain medication and just released. I knew that I
    needed to get to the VA, where I later received the proper
    examination. I know firsthand why people with spinal cord
    injuries who did not serve tell me that they wish they could
    access the care and support available through the VA.
        Without the VA's SCI/D system of care, I do not know where
    I would have been, and many of the men and women sitting here
    behind me would say exactly the same thing if they were
    speaking today. That is why we become so concerned when the
    SCI/D centers have to close beds because they do not have
    enough nurses to properly staff them.
        Veterans Health Administration Directive 1176 provides the
    staffing guidelines to allow healthcare professionals to
    properly care for veterans with SCID. Depending on the function
    level of an acute SCI patient, a nurse may spend an hour or
    more each time with the veteran's room. That is why it is
    important for SCI/D centers to have higher staffing levels than
    other wards. We need every level of VHA, including Central
    Office, Veterans Integrated Service Networks (VISN), and the
    individual medical facilities, to take seriously the
    requirements of VHA's Directive 1176. We need the VA to
    properly deploy its resources and request the funding needed to
    provide the level of care outlined in the directive. If the VA
    system of care is not properly funded to ensure the staffing
    levels meet the needs of the veterans with SCI/D, then our
    government is defaulting on a promise made to care for us who
    become catastrophically injured or ill in our service to this
    great Nation.
        It is not just acute post injury or diagnosis that we
    depend on. It is also the lifelong care that allows us to
    remain independent.
        Caregivers are tremendously important for veterans with
    catastrophic disabilities. My wife, LaShon, is not only my
    spouse, she is also my caregiver. I mentioned Andrew, a veteran
    with Amyotrophic Lateral Sclerosis (ALS), when I testified in
    March. It is only because of the tremendous advocacy of
    Andrew's wife, Lisa, that he is still receiving care at home.
    Recently, she took the exceptional steps of petitioning
    directly to the undersecretary of health, which compelled his
    local facility to recalculate the cost of his care in an
    attempt to delay his reaching the statutory cap. No family
    should be forced to take such aggressive measures.
        The Elizabeth Dole Home Care Act would fix this problem. We
    need Congress to pass the Senator Elizabeth Dole's 21st Century
    Veterans Healthcare and Benefits Improvement Act, which
    includes this important legislation. I and my fellow paralyzed
    veterans believe that the backing of every major veterans
    organization should be enough to get H.R. 8371 through Congress
    without further delay. Andrew cannot wait anymore. Lisa cannot
    wait anymore. We cannot wait anymore for Congress to do the
    right thing and pass this bill.
        I am grateful for the support I received through the VA,
    but my fellow veterans and I are concerned about the future of
    the VA SCI/D system of care. Without a robust system, we are in
    danger of living diminished, shortened lives. This is not what
    we fought for and it is not what we will settle for. Thank you
    for the opportunity to provide you with my perspective on VA's
    SCI/D system of care and I will be happy to answer any
    questions.

        [The Prepared Statement Of Robert Thomas Appears In The
    Appendix]

        The Chairman. Thank you Mr. Thomas.
        Mr. Blake. Mr. Blake, you are now recognized for 5 minutes.

                        STATEMENT OF CARL BLAKE

        Mr. Blake. Thank you Mr. Chairman. You know, I have been
    here a long time and you mentioned earlier how long you have
    been here and do not recall a hearing on SCI/D. I have been
    here a lot longer than you have and I cannot recall an
    oversight hearing on this. I certainly thank the committee for
    its willingness to address this issue today.
        I sat there last night and I was trying to think what could
    I tell you that would get your attention. That we get people to
    listen and understand what Robert was just saying. I have never
    told my story ever. It is just a personal thing I do not do
    because it is personal, but I am going to share a little bit of
    my story.
        I am a PVA member. I have a combat-related spinal cord
    injury. I was told by the Army once, if I do not die, I will
    never walk again. I was told by a private medical facility
    there is no chance this person will ever walk again. I rolled
    into the VA SCI center in Richmond, Virginia, on a gurney and I
    walked out of there after 12 months of rehab. VA did that.
    While the VA gets a bad rap and gets beat up, it is a valuable
    system to our members.
        I do want to say I appreciate Dr. Scavella's testimony.
    Clearly, she spent a lifetime committed to veterans and the VA,
    and she is to be commended for that. I think it is important
    that we step back now and realize what is really going on in
    the SCI system of care.
        The fact is, the SCI system is at a breaking point. We
    survey all of the SCI centers on an annual basis. Every month
    we do bedding/staffing survey of the SCI system of care. This
    is what we know to be true. There are staffing shortages all
    over the system. It is not 9 percent, it is more like 30
    percent. There is a severe lack of resources dedicated to this
    system of care.
        The VA has a larger financial problem that, for whatever
    reason, no one is willing to admit and accept. The VA has been
    given a lot of money over the years. We recognize that fact,
    especially in recent years. What the hell they have done with
    it, we do not know. Where it has been directed is not toward
    the SCI system of care.
        We met with the SCI leadership from all over the country a
    couple of months ago, and here is what they told us: they
    cannot hire anyone, not just because there are not providers
    available. There are no incentives to bring people on. There
    are people who are interested in working in the system, and
    those are the most dedicated people. The system is not set up
    to bring those people on board in an efficient manner, and most
    of the time they are lost. The HR process is broken. It does
    not serve the needs of the system to bring people in in an
    expeditious manner.
        We have heard a lot about net zero growth in VA because of
    the fiscal challenges it has. It is not net zero, it is net
    negative. This is what is happening in the SCI system of care.
    When a position comes open, it is not only not being filled, in
    some cases it is being abolished, taken off the books. The VA's
    handbook 1176 expressly says, this is what the staffing
    methodology and model should be for VA, and these are the
    policies and processes that should be followed for providing
    direct care. Those leaders across the system told us that they
    have been told at the local level and even up to the VISN level
    we do not care what 1176 says. We are not beholden to that. It
    is not the law. That is bulls--.
        If you are going to craft a policy and a process to deliver
    care, then you should follow it. If you are unwilling to do so,
    admit why. As it is, our members are struggling to get the care
    that they need, and the system is at a breaking point. We do
    not want to ask Congress for more money. We recognize the
    challenges that is faced across the entire spectrum. Resources
    are going to have to be put in the system somehow to ensure
    that they are able to staff, provide the equipment, and build
    the capacity that they need.
        There are centers that are actively being degraded today.
    They are actively closing beds today. The system is shrinking.
    The population that needs this service is not. Yes, it is
    getting older. That does not mean the population is shrinking.
    Some real effort needs to be put into rejuvenating this system
    or it is going to collapse on itself and everyone in this room
    and everyone listening and all of our members are going to
    suffer because of it.
        There were questions about women's healthcare. They will be
    irrelevant if we do not fix this system before it is too late.
    That is close to where we are now. It is important that we all
    understand the VA has a vital role to our members, to all
    veterans. If veterans want to go out into the community, PVA
    does not have an express opposition to veterans getting care in
    the community. It is a necessary tool for the VA.
        That option is not available to our members. It is only the
    SCI system of care that makes their care possible and we have
    to invest in it. If we do not, there are much worse horror
    stories that could come from it. We are here pleading with you
    to actually put the emphasis behind it. All the memos in the
    world, all the policy directives in the world do not do any
    good if it is not being enforced. It is all well and good to
    say we support the system of care. Well, show it to us, because
    we do not feel like that is what is happening today. Thank you,
    Mr. Chairman.

        [The Prepared Statement Of Carl Blake Appears In The
    Appendix]

        The Chairman. Thank you, Mr. Blake.
        I now recognize Ms. Sonya Sotak, the chief government
    affairs officer of I AM ALS, for 5 minutes to deliver your
    testimony.

                        STATEMENT OF SONYA SOTAK

        Ms. Sotak. Good afternoon. Chairman Bost, Ranking Member
    Takano, and members of the committee, it is my honor to be
    invited to testify today on behalf of I AM ALS and the ALS
    community, including the approximately 6,000 veterans living
    with ALS in the United States.
        ALS, commonly known as Lou Gehrig's disease, is a 100
    percent fatal neurodegenerative condition. Upon diagnosis,
    individuals are told, get your affairs in order, go home and
    prepare to die, with the current survival rate being 2 to 5
    years. ALS strips away a person's independence, gradually
    robbing them of the ability to walk, speak, and eventually the
    inability to breathe. Tragically, every veteran diagnosed with
    ALS will succumb to this disease. Regardless of how hard they
    fight or how hard their valor is, every veteran will lose their
    battle against ALS.
        As this committee is aware, ALS in veterans has been
    determined to be 100 percent service-connected, with veterans
    being twice as likely as civilians to develop the disease, and
    post 9-11 Air Force veterans showing a tenfold increase in
    incidents. It is estimated that 5,000 to 6,000 of the 30,000
    individuals living with ALS in the United States are veterans,
    roughly 16 percent of cases. However, these figures are
    approximate due to challenges in accurately diagnosing ALS.
        After being diagnosed, many of our veterans and their
    families must take significant time to advocate for themselves
    while managing the disease. Frequently, it is to explain to the
    VA what their VA benefits are as a veteran with ALS. To help
    veterans navigate this complex system, I AM ALS's veterans team
    developed a comprehensive toolkit that outlines the available
    the available benefits for veterans, including how to access
    them. While our community of veterans with ALS are incredibly
    grateful for the VA benefits available to them, this toolkit
    underscores the complex nature of the benefit structure, which
    often leads to veterans and their families diverting valuable
    time and energy to navigate and navigating instead of being
    able to focus on their health.
        Lack of knowledge of the VA system can result in
    frustration and delays in service. Because ALS can progress
    rapidly, delays need to be avoided at all costs. Congress
    recognized this when you all work together in a bipartisan
    manner and pass the ALS waiver, eliminating the Social Security
    Disability Insurance (SSDI) waiting period in 2020. Our
    veterans with ALS and their families deserve the same
    recognition when accessing benefits, including home health
    care. While the VA spinal cord injuries and disorder centers
    are equipped to address the needs of veterans with static
    spinal cord injuries, they often struggle to meet the complex
    requirements of ALS care. ALS demands a multidisciplinary
    approach and specialized equipment that many SCI/D centers
    lack. Geographical barriers of the centers compound the
    challenges faced by veterans with ALS, especially those not
    living in certain urban areas.
        Based on the needs of our ALS veteran community, I AM ALS
    is asking for an increase in this expenditure cap for
    noninstitutional care from 65 percent to 100 percent of the
    cost of the closest VA community living center through the
    Elizabeth Dole Home Care Act, which is included in the Senator
    Elizabeth Dole 21st Century Veterans Healthcare and Benefits
    Improvement Act. By raising the cap to 100 percent, veterans
    with ALS and their caregivers will be able to access healthcare
    in the comfort of their homes. This will enhance the quality of
    life for veterans with ALS and alleviate the burden on their
    families and caregivers.
        I AM ALS and our veteran community also appreciate that the
    Elizabeth Dole Home Care Act acknowledges the crucial role of
    caregivers, often family, in managing the daily needs of
    veterans with ALS. The act offers resources, training, and
    financial assistance to caregivers, easing their emotional and
    financial burdens and enabling them to provide improved care
    and support to our veterans.
        I am going to take a moment to share with you the impact of
    this legislation could have had on our Navy veteran Garrett.
    Garrett served as part of the Seabees, a Navy construction
    battalion, with tours in Iraq and Afghanistan. Garrett's battle
    with ALS epitomizes the challenges many veterans face,
    especially when trying to remain in their homes as the disease
    progresses. When Garrett was first diagnosed, he and his wife
    attempted to manage his care at home with most of his care
    falling on his spouse to avoid reaching the 65 percent cap.
    However, despite their efforts to navigate the system, Garrett
    was trapped in a cycle of bureaucratic red tape. Garrett
    eventually required more assistance, surpassed the home cap,
    and was put in an institution. Garrett elected to remove his
    trach, ending his life early rather than being isolated in an
    institution. Garrett simply wanted to be at home. At the end of
    his life, Garrett felt hopeless and out of options. His
    heartbreaking decision to end his life because of the complex
    system not providing the best support for his final battle
    shows the urgency of passing this legislation, and Garrett is
    not an outlier. Unfortunately, I can tell you about other
    veterans who have had the same circumstance. Through the
    Elizabeth Dole Home Care Act, you can improve the quality of
    life for veterans living with ALS and their caregivers as it
    provides them with flexibility and how they receive care.
        I will end, I know I hit my time. I do not want to go over.

        [The Prepared Statement Of Sonya Sotak Appears In The
    Appendix]

        The Chairman. Thank you, Ms. Sotak.
        Now we recognize Dr. Jenny Kiratli, representing the
    American Federation of Government Employees. Dr. Kiratli is
    also the director of spinal cord injury clinical research for
    the VA Palo Alto healthcare system.
        Doctor, you are recognized for 5 minutes to deliver your
    testimony.

                       STATEMENT OF JENNY KIRATLI

        Dr. Kiratli. Chairman Bost and Ranking Member Takano and
    members of the House Committee of Veterans' Affairs, thank you
    for inviting the American Federation of Government Employees,
    AFGE, to participate in today's committee hearing on meeting
    the needs of spinal cord injury and disorders veteran
    community.
        You have just introduced me, so I will skip that. Well,
    actually, I am a member of the AFGE since 2009. AFGE's National
    Veterans Affairs Council represents more than 302,000 AFGE VA
    employees. My role at VA as a research health scientist in the
    SCI/D center at VA Palo Alto since 1991 with more than 30 years
    of experience conducting research on clinical issues affecting
    people with spinal cord injury. In addition, I am on the
    faculty of the SCI Medicine Clinical Fellowship program and a
    member of our SCI/D Center Leadership Council.
        As you have been hearing about re-ed rate, the VA Palo Alto
    SCI/D center is one of the 25 VA SCI/D centers that offer
    lifelong, comprehensive, integrated, coordinated care,
    including primary care, rehab, emergency care, acute medical
    and surgical care, mental health care, and home care aimed at
    supporting the veteran as a whole person with services that
    reintegrate veterans in the community. Care is also delivered
    via telehealth, which VA Palo Alto pioneered in 2000 and has
    expanded tremendously to enhance access to VA services
    remotely. SCI/D providers include physicians, nurses,
    psychologists, social workers, physical therapists,
    occupational therapists, recreation therapists who coordinate
    care with many disciplines such as pharmacy, radiology,
    urology, orthopedics, plastic surgery, and many other clinical
    services. The expertise of the interdisciplinary care team and
    breadth of services available makes the VA SCI/D network based
    on a hub and spokes model, the most comprehensive healthcare
    system for people living with SCI/D in the U.S.
        Primary care physicians need special training to serve the
    specific needs of this patient population, as they must be able
    to diagnose and treat an array of problems that may present
    differently, such as bone fractures and infections. They also
    must be trained to recommend appropriate preventive care at
    screenings and manage comorbidities such as metabolic and
    muscular disorders in collaboration with other specialists.
    Most physicians in the VA SCI/D centers pursue an additional
    year of specialty training through SCI medicine fellowship
    programs, and VA plays an important role in these training
    programs in collaboration with academic affiliates. However,
    more needs to be done to encourage young clinicians to enter
    the field of SCI medicine. Of the approximately 31, 32
    positions in SCI clinical fellowships, usually fewer than 20
    positions are filled in any given year.
        Another unique aspect of the VA system is the large and
    very active research enterprise which I am part of. Clinical
    research conducted at the VA Palo Alto SCI/D center and other
    VA centers can drive improvements in care delivery that also
    may benefit nonveterans living with spinal cord injury and
    disorders and contribute to best practices. One of my current
    projects is a collaboration with the Minneapolis VA to evaluate
    a novel wheelchair that provides mobility while staying. This
    adaptation will allow greater time in an upright position and
    thus reduce the risk for pressure injuries, improve blood flow
    and bladder and bowel function, reduce spasticity and pain, as
    well as enhance functional capabilities of the user.
        VA Palo Alto also was involved in the multisite VA research
    to explore the effect on quality of life with exoskeleton-
    assisted ambulation, as well as a project a few years ago to
    implement and evaluate a model of vocational rehab to return
    individuals with SCI/D to employment. Other recent projects
    that I have been involved with include exploration of video
    gaming as a mode to elicit upper extremity muscle activation
    and a current study to improve evaluation of fracture risk by
    determining a reliable method to measure bone loss at the knee,
    a common fracture site.
        Through its research in clinical care initiatives, VA is at
    the forefront of improving clinical outcomes and quality of
    life for veterans and all people living with spinal cord
    injuries and disorders. However, more can be done to strengthen
    the VA SCI/D system. There is a great need, as we have been
    hearing, for increased staffing for SCI/D services. Staffing
    requirements for SCI/D centers should reflect the high acuity
    and complexity of care needed, which often require specialized
    certification and advanced training. The high acuity of care
    creates burnout, and younger clinical staff often leave just as
    they have gained sufficient skills to perform all their duties.
    Additional retention incentives are needed to address vacancies
    and turnover, with specialty pay as a high priority.
        In summary, the VA's SCI/D model provides uniquely
    comprehensive and integrated services delivered by highly
    knowledgeable teams of specialists that do not exist in the
    private sector. While the mission act increased access to non-
    VA facilities, use of VA and none non-VA care has the potential
    to increase unintended duplication of services, costs, and
    fragmentation of care. The risk of inadequate care is a great
    concern for veterans with SCI/D because of the need for
    specialized expertise.
        In addition, non-VA providers lack access to VA resources
    such as medical equipment and a wide array of adaptive products
    often created for each individual for his or her specific
    needs. Care should be taken to ensure that increasing
    privatization of VA services does not upend the VA's
    specialized SCI care model that provides an array of integrated
    services and supports research used to develop best practices
    for all people living with spinal cord injuries and disorders.
    Thank you very much for this opportunity to talk about it.

        [The Prepared Statement Of Jenny Kiratli Appears In The
    Appendix]

        The Chairman. Doctor, thank you very much for your
    testimony.
        We will now go to questioning and I recognize myself for 5
    minutes.
        Mr. Blake, in PVA's opinion, what is it--why is it
    necessary for Congress to pass H.R. 8371, the Senator Elizabeth
    Dole 21st Century Veterans Healthcare and Benefits Improvement
    Act, to continue improving services for your membership?
        Mr. Blake. Thank you Mr. Chairman, for the question. A lot
    of our members rely on home care services, home-based services.
    The Veteran-Directed Care program is a very popular program for
    our members where it is available. The Elizabeth Dole Act would
    make those opportunities much more available. It would
    eliminate the 65 percent cap. It would allow our members to be
    at home where they want to be and receive the care that they
    need and not end up in simply a facility and would just improve
    their independence and opportunity.
        I think if the bill does not get passed, then our members
    will continue to struggle along or we are going to end up in a
    situation like the lady from I AM ALS mentioned. Those are
    totally unacceptable circumstances. That should never happen
    simply because of some arbitrary cap or some limitation on home
    care services that are available.
        The Chairman. Thank you. Ms. Sotak, can you explain why VA
    must ensure that accessibility and safe contracted exam
    facilities are available right away for veterans with ALS?
        Ms. Sotak. Sure. Thank you for the question. ALS progresses
    quickly, not for everybody, but for many. Some veterans have
    limited mobility at the time of their diagnosis. For that, we
    believe that contracted exam facilities must be accessible. I
    think we heard earlier testimony saying that is sometimes very
    often a challenge. We need to make sure that they get in
    quickly before their disease progresses more and we are able to
    hopefully mitigate the rapid progression of that disease.
        The Chairman. Thank you. Mr. Blake, VA told the committee
    staff that they were operating at a 9 percent vacancy rate for
    the clinic staff. I think in your testimony you said that you
    probably do not believe that. What do you believe it actually
    is?
        Mr. Blake. Well, let me correct that. I do not believe that
    that is not true. We simply think it is not true. We survey the
    system of care every month for its bed and staffing. According
    to our own medical services records and our team that surveys
    that system, we believe that vacancy rate is closer to 30
    percent, not 9 percent.
        The Chairman. Do you think that the VA has the staff needed
    to safely care for the groups, for this group of veterans?
        Mr. Blake. Well, I could just simply say no. That would be
    too easy. The answer is no.
        The Chairman. Yes.
        Mr. Blake. Clearly it is not, because the system is
    actually being drawn down, it is not being expanded at all.
        The Chairman. Mr. Thomas, can you tell me why it is
    important to have competent, properly trained clinical staff
    when you are being treated as SCI/D veterans?
        Mr. Thomas. Thank you for that question, Mr. Chairman. I
    can simply say that, you know, our lives, my life, the life of
    our members are in their hand. We really need them to be able
    to diagnose us when we come in because the only thing that we
    know something is going on. We cannot feel, we cannot tell
    exactly what it is. We need to rely on these doctors and nurses
    to tell us what is going on and not just simply provide us with
    some medication to say, I will see you next time. Check back
    with me in a week.
        The Chairman. I think you said in your opening statement
    that, you know, we know VA wants to provide this. We have just
    got to make sure that we do the oversight to make sure that it
    is doing it at the top level that you all deserve. We want to
    continue to work to do that.
        With that, I am going to turn it over to Mr. Takano for his
    questions. Recognized for 5 minutes.
        Mr. Takano. Thank you, Mr. Chairman. I want to start with
    Dr. Kiratli. Dr. Kiratli, can you expand on the training and
    continuing professional education that clinicians have to
    undergo to be able to provide appropriate care to SCI/D
    veterans? We just have been talking about the importance of
    highly trained people to take care of this SCI/D population.
    Can you expand on the training that is necessary?
        Dr. Kiratli. Thank you for that question. Yes, I am glad
    to. We have one of the clinical fellowship training programs at
    our facility in Palo Alto, and it is a year-long intensive
    program for physicians who want to have a subspecialty in
    spinal cord injury medicine. They become board-certified. It
    includes exposure to inpatient, outpatient, all sorts of
    additional specialty trainings that can be provided. We partner
    with--our program at Palo Alto is actually under Stanford
    University, and we partner with the community SCI/D center
    nearby. Most of the programs, many of the programs involve VA,
    but not all. When residents choose programs, often they value
    being able to be at a VA to gain that training, the training
    opportunities to work with veterans in the system for the high
    level of specialty training that they can get.
        Mr. Takano. Well, thank you. Does VA cover all the costs of
    the ongoing training?
        Dr. Kiratli. No, not that I know of.
        Mr. Takano. They do not. They do not cover the ongoing
    costs of continuing education they need to do?
        Dr. Kiratli. No, the various professionals have
    requirements for ongoing training. For instance, physicians
    have to recertify board training. We have a variety of other
    specialty certifications, such as wound training, high level
    seating training. I think there is some funds available, but
    not--it certainly does not cover all of it. There is a limited
    amount available for conference attendance.
        Mr. Takano. It is fair to say that it takes thoughtful
    investment in VA's workforce in order to provide the high level
    of care that SCI/D veterans require and deserve. Would you say
    that is right?
        Dr. Kiratli. Absolutely. Well said.
        Mr. Takano. My colleague Julia Brownley has an important
    bill, the Department of Veterans Affairs Continuing
    Professional Education (VA CPE) Modernization Act, H.R. 543. We
    have been stymied in advancing this bill because of its cost,
    estimated by the Congressional Budget Office (CBO) to be about
    $3.3 billion in combined discretionary and mandatory spending
    over 10 years. This is addressing the cost of training SCI/D
    employees. However, I think this would be a very worthwhile
    investment. This legislation would provide stipends of up to
    $2,000 per year for VA clinicians continuing professional
    education expenses. What would this mean for employees for VA's
    SCI/D system of care; It would mean a lot, would it not?
        Dr. Kiratli. That would be wonderful.
        Mr. Takano. Well, I would like to change to Mr. Thomas. Mr.
    Thomas, in your testimony, you highlighted how VA's SCI/D
    system of care is uniquely positioned to meet VA's PVA members,
    your members. Why do you think it is so important to ensure
    that VA is able to continue to meet the needs of SCI/D
    veterans?
        Mr. Thomas. Thank you for that question. I believe that
    being able to meet the needs of all of my members, myself to be
    included, is that it is very important because, you know,
    outside in the community, as I stated in my oral statement,
    that, you know, the doctors do not know. They are unsure of
    what goes on. The specialized training that is provided for VA
    clinicians and everything, it is important to us to make sure,
    again, that we can be diagnosed correctly. They know what is
    going on.
        A prime example is if an individual comes up with autonomic
    dysreflexia and the individual doctor does not know how to
    treat that, it can become very severe to our members and to
    myself as well. Having those specialized care, having a
    specialized care system available to us means a lot.
        Mr. Takano. Our current investments in VA infrastructure
    and direct care--direct care, not Community Care--direct care
    for veterans with SCI/D, are they sufficient?
        Mr. Thomas. I would turn that over to our Chief Executive
    Officer (CEO) Blake to answer that question.
        Mr. Blake. I will answer it like the other question. No.
        Mr. Takano. Thank you. Well, I agree with both of you.
    Congress needs to make more considered effort to balance the
    amount of funding going out of VA to private sector providers
    rather than into VA in the form of investments in the direct
    care workforce and improvements in medical care facilities.
    Would you agree with what I just said?
        Mr. Blake. Yes.
        Mr. Thomas. Yes.
        Mr. Takano. Well, I am glad we agree on that premise. That
    is why we must continue to prioritize efforts that invest in
    VA. I believe investments in VA are investments in veterans,
    especially veterans who truly depend on the specialized care
    that VA can offer. We need to build on that offering and expand
    it, as well as other benefits.
        In your testimony, you mentioned the importance of enacting
    legislation like the Autonomy for All Disabled Veterans Act,
    which would increase grants for veterans to make structural
    improvements to their homes and the Rural Veterans
    Transportation to Care Act, which would provide innovative
    transportation options for veterans traveling to medical
    appointments. I agree that these should be priorities for
    Congress and that we should ensure that we advance these kind
    of bills.
        Now, I would like to go back for a moment to Dr. Kiratli.
    What kind of feedback do you hear from physician fellows and
    other providers about training they have received at VA? What
    do they like about practicing at VA versus in the private
    sector?
        Dr. Kiratli. Thank you for that question. It is an
    excellent question. The constant feedback we get is how the
    clinicians are able to practice medicine as they have been
    taught. They have access to the specialty services, they have
    access to resources, and they do not have to curtail or
    prioritize care based on what might be available to support it.
    It really allows them to practice to the fullest extent and the
    best interests in the health and well-being of the patient.
        Mr. Takano. Well, thank you. I yield back. I am sorry, I
    went over my time.
        The Chairman. Not a problem. General Bergman, you are
    recognized for 5 minutes.
        Mr. Bergman. Thank you, Chairman Bost, for holding this
    hearing and giving us the opportunity to focus on the needs of
    our paralyzed veterans. As has been made clear through the
    testimony today, there are a wide range of reforms and
    improvements needed at VA to ensure the best possible care for
    these veterans. I appreciate being able to hear our witnesses'
    support for bills like the Elizabeth Dole Home Care Act.
        My focus today will be on VA's annual health assessments
    for spinal cord injured and disabled, or SCI/D, veterans, as
    well as access to assistive devices to promote mobility and
    independence. As a note, when you were talking, Doctor, you
    talked about inactive versus active care, and I would suggest
    to you that things like an assistive wheelchair to stand and
    all that is outstanding, it enables that patient. I also
    believe that on the active side, things like the exoskeleton
    probably promotes more active care. I will leave it to the
    scientists to decide that.
        Mr. Thomas, great to see you again, as always. Last time I
    think we talked was over on the Senate side. Could you please
    describe the benefit of these annual preventative health
    assessments for SCI/D veterans?
        Mr. Thomas. The benefit to having an annual exam would be
    that you could stay ahead of any issue that may be coming up,
    and the doctors are aware of the smallest thing that the
    individual has not came to that realization that is going on
    and happening with them. For me, I did not know that I was
    coming down with type 2 diabetes without going to this annual
    exam. Having doing that, it gets me to be on top of that and
    find a way to try and not be too diabetic, if I could say that,
    if that is a real way. It prevents everything. To me, medicine
    is preventive care anyway.
        Mr. Bergman. Basically, what I am interpreting you to say
    that VA should, wherever possible, be doing more to ensure more
    paralyzed veterans nationwide are made aware of and then,
    therefore, are able to receive these assessments. I assume a
    simple yes would probably be----
        Mr. Thomas. You are absolutely correct, yes.
        Mr. Bergman. Roger that. Okay. Regarding assistive devices,
    do you feel there are improvements that can be made to ensure
    paralyzed veterans are able to be assessed for and provided
    with devices that they are clinically eligible to receive based
    upon the assessment of the individual veteran?
        Mr. Thomas. I would also say yes to that. If there is any
    new and innovative technology that comes out, I feel that they
    should always be on top of that so that they can increase our
    mobility access.
        Mr. Bergman. Perfect. You know, as veterans, we know what
    we have been subject to some interesting new technologies over
    the course of our careers, and let us keep it to the good ones
    and advance capabilities and a better life for others.
        While the VA has procedures in place on paper to provide
    annual assessments for SCI/D veterans and provide them with
    assistive devices, the reality for many paralyzed veterans has
    shown that there is more that needs to be done. I am grateful
    for PVA's support of my bill, H.R. 6373, the Veterans Spinal
    Trauma Access to New Devices, or Veterans STAND Act, which I
    introduced along with Chairman Bost, Health Subcommittee
    Ranking Member Brownley, and Congresswoman Debbie Dingle. This
    bill will codify the VA's obligation to offer annual
    examinations for SCI/D veterans, take steps to improve outreach
    for those who are eligible, and ensure paralyzed veterans are
    able to be assessed for and provided with assistive devices.
        As I said, there is still a lot of work to be done on
    behalf of our paralyzed veterans. I hope this committee will
    advance the Veterans STAND Act so we can make the progress
    necessary in those efforts.
        With that, I yield back.
        Mr. Luttrell. [Presiding.] Thank you, General.
        Ranking Member you are recognized for closing remarks.
        Mr. Takano. Thank you, Mr. Chairman. Well, Chairman Bost
    raised concerns at our budget hearing in April about
    significant year-to-year increases in VA's overall budget. I
    would love to work with the chairman to address this
    unsustainable trajectory, as it is pretty clear that community
    care is placing the biggest strain on VA's budget. The chairman
    and I seem to have fundamental philosophical differences about
    whether community care should be funded at the expense of other
    veterans policy priorities. H.R. 8371, the veterans package,
    would throw another $1 billion at community care in the short
    term and at least $3 billion if we extend temporary authorities
    beyond the sunset dates included in the bill. I am sorry, I
    just cannot in good conscience throw more good money after bad
    and further expand community care eligibility, especially not
    when VA is already proposing to transfer as much as $10 billion
    from direct care and VA facility infrastructure to community
    care in Fiscal Year 2025.
        PVA members are among the most medically vulnerable
    veterans VA serves, and they will suffer the most if Congress
    does not properly fund the VA direct care system by investing
    in VA's workforce and medical facility infrastructure. Now, it
    is up to the chairman to put the bill on the floor that can
    pass, and I have been very clear about my concerns. We are in
    agreement on about 95 percent of the provisions in H.R. 8371,
    including those taken from H.R. 542, the original Elizabeth
    Dole Home Care Act, which passed the House more than 6 months
    ago. However, if we want to act quickly, the Senate should pass
    Congresswoman Brownley's bill right now. Then we can actually
    spend time on the provisions that need more work and that have
    received very little progress, including getting updated
    stakeholder input and more information on the true cost of
    provisions that are going to have lasting impacts on VA's
    ability to do deliver care.
        Thank you Mr. Chairman, and I yield back.
        The Chairman. Thank you Mr. Takano. I would like to thank
    the witnesses for coming today. I would like to thank the
    veterans and the veterans' families that are in the audience
    for your service and everything that you provided for the great
    country that we live in. We would not be able to do our work in
    this committee without each and every one of you. I want to say
    again that many of the issues raised today will be addressed
    with the passage of H.R. 8371, the Dole Act.
        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 objections, so
    ordered. The hearing is now adjourned.
        [Whereupon, at 12:39 p.m., the committee was adjourned.]

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

                             A  P  P  E  N  D  I  X

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

                        Prepared Statement of Witnesses

                                  ----------

                      Prepared Statement of Erica Scavella

        Good afternoon, Chairman Bost, Ranking Member Takano, and Committee
    Members. Thank you for the opportunity to testify before you today to
    discuss SCI/D, which present unique challenges and complexities
    requiring specialized care and support. At VA, we are dedicated to
    addressing the diverse needs of Veterans with SCI/D, ensuring access to
    rehabilitation services; specialty benefits; and services, and
    assistive technologies. Joining me today is Jeffrey London, Executive
    Director for the Medical Disability Examination Office, with the
    Veterans Benefits Administration (VBA).

    Overview of Care

        VA's SCI/D System of Care is the largest and most comprehensive
    network in the U.S. dedicated to providing exceptional care for
    individuals with SCI/D, and it is the preferred choice for most
    Veterans. Its objective is to enhance the health, well-being,
    functionality, and quality of life for Veterans through a coordinated
    system of care. The system operates on a ``Hub-and-Spoke'' model, with
    25 regional SCI/D Centers (Hubs) offering comprehensive care, while
    primary care services are delivered at VA medical centers (VAMC)
    without SCI/D Centers (Spokes) by SCI/D Patient Aligned Care Teams
    (PACT).
        The SCI/D Centers cater to Veterans with SCI/D, as well as those
    with motor neuron diseases and multiple sclerosis with spinal cord
    involvement, offering acute/sustaining and long-term care beds.
    Interdisciplinary teams of highly trained SCI/D clinicians provide a
    full continuum of services through the SCI/D System of Care, including
    acute rehabilitation, medical and surgical treatment, primary and
    preventative care, prescribed durable medical equipment, prosthetics/
    rehabilitative devices, respite care, and end-of-life care.
        Mental health services are provided or coordinated throughout the
    SCI/D System of Care as part of the overall integrated care team plan.
    Annual evaluations ensure ongoing assessments of Veterans' needs,
    including psychological, social, and vocational assessments. SCI/D-
    trained psychologists and social workers are embedded into the care
    teams and serve as excellent resources and mental health providers for
    enrolled Veterans. When needed, these SCI/D-trained psychologists and
    social workers make additional mental health referrals, which are
    facilitated by the SCI/D Center or PACT. Peer counseling services and
    programs are also offered directly at the SCI/D Center, and through
    Veterans Service Organizations (VSO) and community-based programs.
    These help Veterans adjust to new impairments, understand the
    rehabilitation process, develop social skills, and transition to
    community living. Additionally, VHA offers comprehensive pain treatment
    options tailored to the unique needs of SCI/D Veterans, ensuring they
    receive the highest quality of care and support.

    Mobility Interventions and Walking Aids

        The prescriptive use of mobility interventions and walking aids is
    individualized to the Veteran and often specific to the setting where
    the Veteran is seen. Evaluations typically include reviews of
    pathology, impairments, functional limitations, and risk factors. If
    deemed medically appropriate, the inclusion of mobility devices and
    technologies is matched based on the individual Veteran's functional
    goals, focusing on enhancing mobility, independence, and overall
    quality of life. These can include walking assistive devices, bracing
    supports, prostheses, orthotics, shoe modifications, functional
    electrical stimulation devices, powered exoskeletons, body-weight
    support treadmills, and virtual reality gait training.
        VA has implemented rigorous quality control measures and continues
    to advance prosthetic technology to deliver the highest standard of
    care to Veterans. This approach aims to empower Veterans to live their
    lives to the fullest, despite the challenges their SCI/D presents. In
    line with this goal, the Office of Advanced Manufacturing is developing
    technologies to improve the efficiency and effectiveness of prosthetic,
    orthopedic, and assistive devices. The resulting 3D-printed devices can
    increase a Veteran's quality of life, maintain the Veteran's
    independence, and reduce caregiver burnout.

    Long-Term Care Options

        VHA recognizes that SCI/Ds are not limited to the geriatric
    population and that Veterans with SCI/D have complex and personalized
    needs. To address these needs, VA offers a comprehensive SCI/D System
    of Care that focuses on providing Veteran-centric care and support in
    the least restrictive environment possible. VA offers a range of non-
    institutional and home-based primary care options to eligible Veterans
    based on their clinical needs, regardless of age, including medical
    foster homes, Veteran-directed care, bowel and bladder care, SCI/D home
    care, home health aide care, skilled home health care, community or VA-
    provided adult day health care, respite care, and telehealth.
    Additionally, many Veterans in the SCI/D System of Care receive support
    through the Caregiver Support Program, which includes the General
    Caregiver Support Services and the Program of Comprehensive Assistance
    for Family Caregivers. For Veterans who require institutional care,
    available options include assisted living facilities, VA Community
    Living Centers, community nursing homes, State Veterans Homes, and VA
    SCI/D Long Term Care Centers.

    Patient Safety Practices in Emergency Departments

        VA emergency departments are required to offer a medical screening
    evaluation to all Veterans, including those with SCI/D, to determine if
    an emergency medical condition exists. This is the general expectation
    of emergency medical care, and our policies require a posture of
    continuous readiness to initially stabilize almost any medical
    emergency. We can then call upon community providers if there are
    ongoing clinical needs beyond what would typically be expected in a VA
    emergency care setting, ensuring integrated care for the Veteran. While
    there are emergent disease processes more prevalent in the SCI/D
    population, including sepsis and autonomic dysreflexia, the role of the
    emergency department in providing emergency stabilizing treatment would
    apply equally.
        If deemed stable for discharge after an episode of emergent care,
    there would typically be coordination or follow up with the Veteran's
    primary or specialty care team to ensure appropriate care. Veterans
    receive specific information and education when discharged from the
    emergency department. This communication often involves caregivers--
    with the Veteran's permission--to provide them an opportunity to ask
    questions and gain an understanding of the necessary next steps and
    safety precautions in the Veteran's care journey.
        All clinically active emergency department providers undergo
    ongoing professional practice evaluation to ensure an appropriate
    standard of care. This is in addition to existing quality controls
    within VHA to ensure high-quality care, including formal peer review
    and patient safety reporting. Additional specialized education is
    available through VA's Talent Management System and VA Library
    resources. Specialized training specific to SCI/D is not mandated for
    VHA emergency care clinical staff, as recognition and treatment of
    unstable emergency conditions would be a pre-existing standard across
    all clinical presentations.

    Staff and Provider Training

        Clinician training for providers, nurses, and interdisciplinary
    teams involved in caring for individuals with SCI/D is facilitated
    through various channels.\1\ SCI/D Centers offer local and regional
    training, while the SCI/D National Program Office provides national-
    level training opportunities. These programs include monthly expert
    learning series, continuing education credits, and VA-professional
    community networking sessions. Additionally, annual training is
    provided for SCI/D PACTs located throughout the country and PACTs are
    also invited to annual leadership summits with SCI/D Centers. The
    primary objective of these training channels is to stay updated on best
    practices and ensure we deliver optimal care.
    ---------------------------------------------------------------------------
        \1\ Training requirements for the SCI/D System of Care are
    described in VHA Directive 1176(2 ), Spinal Cord Injuries and Disorders
    System of Care (Sept. 30, 2019; amended Feb 7, 2020).

    ---------------------------------------------------------------------------
    Addressing Transportation Concerns

        VA recognizes that transportation can pose a significant barrier
    for Veterans with SCI/D and, as a result, VA provides various
    assistance options. Eligible Veterans can receive beneficiary travel
    (BT) benefits for regular and special mode transportation, such as
    ambulances and wheelchair-accessible vehicles. In 2016, Congress
    expanded BT eligibility to include Veterans with SCI/D, among other
    populations, when their travel is connected to care provided through a
    VA special disabilities rehabilitation program if that care is provided
    on an inpatient basis or during a period in which VA provides the
    Veteran temporary lodging at a VA facility to make the care more
    accessible. Additionally, VA operates the Veterans Transportation
    Program, offering door-to-door transportation to appointments,
    including wheelchair service, regardless of BT eligibility. To support
    Veterans in rural areas, VA oversees the Highly Rural Transportation
    Grant Program in 13 states, where VA provides funding to State Veterans
    Service Agencies or VSOs coordinating transportation in highly rural
    counties.

    Construction and Facilities Management

        VA is committed to ensuring accessibility across all aspects of its
    medical facilities, particularly in older facilities. This includes
    targeted upgrades, renovations, and integrating advanced assistive
    technologies to create modern, inclusive spaces that cater to the
    diverse needs of Veterans. VA has also pioneered the deployment of
    dedicated mobile units equipped with state-of-the-art equipment and
    resources, which serve as vital extensions of the health care network,
    reaching Veterans in remote or underserved areas and providing
    essential services and support. While not specific to SCI/D care, the
    Mobile Prosthetic and Orthotic Care program, supported by the VHA
    Innovators Network, aims to increase access to care for Veterans in
    rural areas. The program, already adopted in 10 VAMCs and set to roll
    out in 5 new areas in 2024, has improved the experience for Veterans
    who previously had to travel long distances for VA appointments.
        VA's commitment to enhancing accessibility extends beyond physical
    infrastructure to a holistic approach to care. The organization has
    taken proactive steps to address the unique needs of women Veterans,
    implementing specialized facilities that ensure privacy, comfort, and
    tailored care. These spaces serve as safe havens for women Veterans to
    access the services and support they need in a compassionate and
    supportive environment that prioritizes their well-being and dignity.
        As part of ongoing efforts to prioritize the health and safety of
    all Veterans, VA is also dedicated to reducing infection transmission
    rates within its facilities. Through rigorous infection control
    protocols, regular monitoring, and continuous staff training, VA is
    working tirelessly to create a safe and sterile environment that
    minimizes the risk of infections for patients, including those with
    SCI/D.

    Overview of Benefits and Services

        Spinal cord injuries are a significant cause of disability, with
    profound and, in many cases, devastating consequences. VBA's foremost
    concern is ensuring that the most catastrophically disabled Veterans
    receive the benefits they deserve and have earned through their
    military service. This includes disability compensation, employment and
    independent living training, and support through VA's Veteran Readiness
    and Employment (VR&E) program, housing benefits, and the Specially
    Adapted Housing Program.

    Contract Examinations

        As part of the disability compensation process, VBA oversees
    medical disability exam (MDE) contracts and related ancillary support
    and oversight contracts. VBA provides oversight of the exam contracts
    by setting metrics expectations for the Veteran experience, quality,
    timeliness, and production; overseeing ancillary contracts to verify
    examiners' credentials; and providing financial and data audits, to
    include invoice validation and beneficiary travel.
        VBA conducts frequent in-person site visits and administrative site
    visits (virtual desk reviews) to ensure facilities are safe, clean, and
    accessible. In-person site visits allow VBA to visually inspect vendor
    examination locations for compliance with VA standards. In addition to
    in-person site visits, VBA conducts administrative site reviews
    (virtual desk reviews) to supplement onsite facility inspections and
    increase overall oversight of all locations where Veterans obtain
    examinations. Post-site visit reports note best practices and items
    that require vendor actions. All action items are tracked until
    completed.
        In Fiscal Year (FY) 2023, VBA conducted 288 site visits and has
    already conducted 288 site visits in Fiscal Year 2024, with plans to
    complete at least another 112 site visits by the end of the fiscal
    year. To improve oversight, VBA also conducted a series of joint site
    visits with all MDE contract vendors to ensure consistency in site
    inspections and MDE vendor compliance.
        In May 2024, the Office of Inspector General (OIG) issued a report
    titled ``Better Oversight Needed of Accessibility, Safety, and
    Cleanliness at Contract Facilities Offering VA Disability Exams.''
    Contract facilities are required to comply with the Americans with
    Disabilities Act and Occupational Safety and Health Administration
    standards to ensure every facility where exams are performed is
    accessible, safe, and clean. VBA takes Veterans' safety as its utmost
    priority and continues to work diligently to enhance Veteran safety and
    the overall Veteran experience. OIG made nine recommendations, which
    VBA is acting on, including updating contract requirements and standard
    operating procedures, and implementing improved customer feedback
    mechanisms. VBA is targeting to complete these actions by the end of
    Fiscal Year 2024.

    Increasing Examination Access

        VBA continues to work with MDE vendors to ensure all Veterans,
    including those with SCI/D, have access to VA exams by using modalities
    such as acceptable clinical evidence (ACE) exams and telehealth
    appointments that limit travel for in-person exams. MDE vendors use
    traveling providers, claims clinics, and per-diem or rented locations
    to assist Veteran populations that require additional support. Vendors
    have mobile units deployed throughout the country and are equipped to
    complete most exam types, as well as diagnostic testing. The units are
    accessible, with wheelchair lifts and ramps, and are fully self-
    contained with power supply and internet connectivity. Vendors continue
    to expand their mobile unit fleets and collectively have 28 operational
    individual units. For Veterans with SCI/D who are homebound or have
    transportation barriers, traveling providers, mobile units, and non-in-
    person examinations allow greater access. They reduce wait times
    without degrading the quality of the exam. In Fiscal Year 2024, through
    April 2024, vendors have completed over 1.9 million appointments
    consisting of over 200,000 (11.9 percent) ACE exams and over 160,000
    (8.2 percent) telehealth appointments.
        In addition to increasing exam modality options, during the
    examination scheduling process, MDE vendors are required to include
    specific language in appointment notification letters regarding
    accessibility needs. VBA is also partnering with VA's Veterans
    Experience Office (VEO) to improve the scheduling process and increase
    Veterans' understanding of the examination process to build clarity,
    predictability, and flexibility to meet Veteran needs.

    Customer Satisfaction and Feedback

        In April 2024, VBA implemented improvements to the Customer
    Satisfaction survey process. A new customer service contract vendor
    mails survey cards to Veterans to improve process integrity. Before
    April 2024, MDE vendors were responsible for releasing survey cards
    directly to Veterans. VBA also enhanced the actual customer
    satisfaction survey by incorporating a VA trust question, allowing VA
    to gain better insights into Veterans' confidence in the contract
    examination process, like other Veteran Experience surveys across the
    VA enterprise. VA also incorporated a quick-response code onto the
    survey, reducing the Veterans' burden of responding by allowing them
    immediate access to their survey by using a smartphone or computer.
        VBA takes feedback from Veterans and stakeholders seriously. As an
    example, based on a suggestion from Paralyzed Veterans of America, VBA
    made interim updates and clarified existing guidance regarding the
    Remaining Effective Function of the Extremities sections on the
    Amyotrophic Lateral Sclerosis (ALS), Multiple Sclerosis, Central
    Nervous System and Neuromuscular Diseases, and Peripheral Nerves
    Conditions Disability Benefits Questionnaires (DBQ). Additionally, in
    May 2024, VBA attended an ALS workshop in Seattle, Washington, which
    VHA hosted. VEO led this workshop and received a list of 29 suggested
    revisions to the ALS DBQ. VBA is evaluating these requests through its
    joint VBA-VHA DBQ Change Control Group.

    VR&E

        The mission of VA's VR&E program is to assist qualified Service
    members and Veterans with service-connected disabilities prepare for,
    obtain, and maintain suitable employment or maintain a life of
    independence. VR&E achieves this mission by providing comprehensive
    vocational counseling services to transitioning Service members and
    Veterans to ensure goals are suitable and attained.
        During Fiscal Year 2023, VA provided VR&E services to 131,179
    Veterans and Service members, and 17,135 Veterans successfully
    completed their VR&E program. During Fiscal Year 2023, VBA paid over
    $1.6 billion in VR&E benefits. As of May 1, 2024, VR&E has 151,769
    Veteran participants, with 90,380 enrolled in Long-Term Services, which
    helps program participants obtain the education and training they need
    to find work in a different field that better suits their current
    abilities and interests.
        VR&E assists Veterans with SCI/D, and any other Veteran who meets
    the eligibility and entitlement criteria. A Vocational Rehabilitation
    Counselor (VRC) works with the individual to develop a plan of action
    that includes structured, individualized services ranging from
    education or necessary training to find work in a suitable field to
    services that assist with living as independently as possible if
    returning to work is not an option at the time the plan is developed.

    VR&E Independent Living Services

        The VRC conducts an assessment to determine if achieving a
    vocational goal is currently reasonably feasible. To qualify for
    independent living (IL) services, the following requirements must be
    met:

          Service-connected disability of 20 percent or more,

          Serious employment handicap resulting in substantial part
    from the service-connected disability(ies),

          Inability to achieve a vocational goal,

          Limitations in activities of daily life impacting the
    individual's level of independence, and

          Reasonable likelihood that the gains in independence will
    continue after completing the program of IL services.

        The VRC works with the individual to conduct a preliminary IL
    assessment to determine if there are any impairments in activities of
    daily living. Areas such as housing, emotional, spiritual, leisure, and
    avocational needs are discussed to ensure all aspects of the
    individual's needs are considered.
        If the preliminary IL assessment confirms impairments in activities
    of daily living, the VRC must coordinate a comprehensive evaluation. A
    comprehensive in-home evaluation delves deeper into the preliminary
    assessment findings and any other areas of need, particularly potential
    barriers to living independently.
        The VRC works with the Veteran to develop an individualized
    independent living plan, enabling the individual to live independently
    and participate in family and community life to the maximum extent
    possible. IL services may increase the Veteran's potential to return to
    work by providing services designed to lessen or accommodate the
    effects of the disabilities. Veterans may receive:

          Assistive technology/modifications,

          Referrals for IL skills training,

          Referrals to community-based support services,

          Case management services,

          Coordination assistance with VA and non-VA service
    providers, and

          Support of an avocational activity.

    VA Specially Adapted Housing (SAH) Program

        This year marks the 76th anniversary of the VA SAH grant program,
    which provides essential financial support for home adaptations, and
    addresses the unique accessibility needs of eligible Service members
    and Veterans with specific severe, service-connected disabilities,
    including SCI/D. The SAH program assists Service members and Veterans
    in constructing an adapted home, purchasing a home with adapted
    features, or adapting their own home. These projects, funded through
    this critical benefit, make Veterans' homes more accessible by removing
    barriers for those with qualifying disabilities. Since the program's
    inception in 1948, VA has administered over 52,000 SAH grants to
    eligible Service members and Veterans, totaling over $2.1 billion. For
    Fiscal Year 2024, through May 2024, VA has approved 1,507 SAH grants
    totaling $94.3 million.
        With the enactment of P.L. 115-177 in June 2018, the funding and
    construction activities for home adaptations made necessary by VR&E
    rehabilitation program transitioned to VA's Loan Guaranty Service (LGY)
    SAH program. The VR&E and LGY SAH programs have worked together to
    develop the qualifying factors for the grant process, including the use
    of licensed contractors, permits, technical drawings, and compliance
    inspections. Generally, VA may provide home adaptations up to $107,357
    as part of an approved VR&E rehabilitation program for individuals who
    are unable to work due to service-connected disabilities or who require
    home adaptations to achieve a vocational goal. The amount can change,
    based on inflationary adjustments.
        Other types of grants administered under the SAH program include
    the section 2101(a) grant (sometimes referred to as Specially Adapted
    Housing) and the section 2101(b) grant (sometimes called Special Home
    Adaptation). Also, the Temporary Residence Adaptation allows eligible
    individuals to adapt a family member's home where the Veteran or
    Service member is temporarily residing. The physical criteria for
    eligibility are defined by statute and, depending on the type of grant,
    include loss of use of extremities or blindness. Based on the type and
    level of a Veteran's service-connected disability, Veterans may be
    eligible for up to $117,014 in assistance under a section 2101(a) grant
    or $23,444 under a section 2101(b) grant. These amounts represent the
    maximum grant amounts in Fiscal Year 2024, which change annually based
    on an industry cost-of-construction index.

    Conclusion

        Chairman Bost, Ranking Member Takano, this concludes my testimony.
    Thank you once again for the opportunity to update you on VA's holistic
    approach, encompassing innovative technologies, specialized care, and
    unwavering support, to ensure Veterans with SCI/D receive the highest
    quality of care and services possible. Our commitment to ensuring that
    all Veterans receive the care, support, and respect they deserve
    remains unwavering. My colleagues and I are prepared to answer any
    questions.

                       Prepared Statement of Steve Bracci

        Chairman Bost, Ranking Member Takano, and members of the Committee,
    thank you for the opportunity to testify on the independent oversight
    conducted by the Office of Inspector General (OIG). The OIG is
    committed to conducting work that results in clear findings and
    practical recommendations to help the Veterans Benefits Administration
    (VBA) promptly and accurately provide veterans, their families,
    survivors, and caregivers with the benefits and services they have
    earned.
        As of March 31, 2024, more than 5.8 million veterans were receiving
    disability compensation benefits.\1\ Given the significant hardships
    veterans may face when the disability compensation benefit program does
    not work as intended, the OIG remains vigilant in its oversight of
    various aspects of the program. This written statement focuses on
    improvements that VBA can make in its oversight of the vendors
    providing medical exams for veterans' disability benefits claims.
    ---------------------------------------------------------------------------
        \1\ VA, ``VA Benefits & Health Care Utilization,'' https://
    www.va.gov/vetdata/docs/pocketcards/pocketcard.pdf, accessed June 3,
    2024.
    ---------------------------------------------------------------------------
        When a veteran files a claim, VBA staff may request medical exams
    to assess the disability before deciding and rating the claim. These
    exams, most of which are provided by contracted medical professionals,
    represent a multibillion-dollar investment of taxpayer dollars by VBA
    since 2017. Exams are typically conducted at the medical examiner's
    place of business, and those facilities must be accessible, safe, and
    clean according to contract requirements.\2\ The contracts also mandate
    that the vendors inspect all facilities where exams are conducted to
    ensure compliance with the Americans with Disabilities Act (ADA) and
    Occupational Safety and Health Administration (OSHA) standards.\3\
    ---------------------------------------------------------------------------
        \2\ Medical Disability Examination Contracts, Section 5.1 Place of
    Performance.
        \3\ Americans with Disabilities Act of 1990, 42 U.S.C. Sec.  12101
    et seq.; Occupational Safety and Health Act of 1970, 29 U.S.C. Sec.
    651 et seq.; Medical Exam Contract, Section 8.5 Deliverable Tasks Nov
    28, 2018.
    ---------------------------------------------------------------------------
        Starting in 2022, the OIG assessed concerns raised by veterans
    through customer satisfaction surveys that VA requires be provided to
    veterans after a disability exam. The OIG review focused on veterans'
    feedback regarding the accessibility, safety, and cleanliness of the
    contract exam facilities. The team inspected 135 facilities for
    compliance with contractual and legal requirements and reviewed key
    aspects of VBA's oversight of exam vendors. During the review, the OIG
    team identified one or more ADA and OSHA deficiencies at 114 (about 84
    percent) of the exam facilities. This testimony highlights the finding
    and recommendations detailed in the resulting May 2024 report.\4\ The
    report focused on three issues related to (1) the lack of oversight
    over the contract exam facilities, (2) the prevalence of noncompliance
    with ADA and OSHA standards, and (3) the impact on veterans with
    mobility issues.
    ---------------------------------------------------------------------------
        \4\ VA OIG, Better Oversight Needed of Accessibility, Safety, and
    Cleanliness at Contract Facilities Offering VA Disability Exams, May 8,
    2024.
    ---------------------------------------------------------------------------
        The numerous deficiencies at these locations created needless
    burdens for veterans, especially those with spinal cord injuries and
    disorders and those using wheelchairs. Proactive monitoring of
    contractors' facilities is essential to ensure compliance with laws and
    regulations for accommodating individuals with disabilities and
    maintaining an accessible, safe, and clean environment for all veterans
    seeking exams. VBA has made some progress on remediating these issues.
    However, additional monitoring is needed to ensure full compliance.

    BACKGROUND

        Regardless of whether a veteran is seen at a VA medical center or
    contract exam facility in the community, all exam facilities must
    comply with ADA and OSHA standards.\5\ The ADA ensures people with
    disabilities have the same access, opportunities, and rights as
    everyone else.\6\ In particular, the act mandates that publicly
    accessible buildings have features to help people using wheelchairs,
    walkers, or crutches to maneuver safely. OSHA sets and enforces
    standards and guidance requiring businesses to maintain clean and
    sanitary workplaces. It also conducts inspections to maintain safe
    working conditions. Notably, exit routes must be free, unobstructed,
    and properly labeled.\7\ They also must be reasonably straight and have
    smooth, solid, and substantially level walkways.
    ---------------------------------------------------------------------------
        \5\ MDE contracts sec. 8.5, ``Deliverable Tasks,'' November 28,
    2018; Americans with Disabilities Act of 1990, 42 U.S.C. Sec.  12101 et
    seq. (1990); Occupational Safety and Health Act of 1970, 29 U.S.C.
    Sec.  651 et seq. (1970).
        \6\ The OIG's review focused on the ADA's Title III, which applies
    to businesses serving the public. ``Introduction to the Americans with
    Disabilities Act'' (web page), accessed November 8, 2023, https://
    www.ada.gov/topics/intro-to-ada/#businesses-that-are-open-to-the-
    public; Title III regulations.
        \7\ ``United States Department of Labor, Occupational Safety and
    Health Administration: Maintenance, safeguards, and operational
    features for exit routes. standard 1910.37(a)(3)'' (web page), accessed
    October 23, 2023, https://www.osha.gov/laws-regs/regulations/
    standardnumber/1910/1910.37.
    ---------------------------------------------------------------------------
        VBA created the Medical Disability Examination Office (MDEO) to
    oversee contract exams. VBA staff request disability exams from one of
    the contract exam vendors when the veteran's nearest VA medical center
    has reached or exceeded its maximum capacity for conducting these
    exams.\8\ According to MDEO, during the OIG's review period from
    January 1 through December 31, 2022, three contract vendors performed
    about 88 percent of all exams and a fourth vendor was added.\9\
    ---------------------------------------------------------------------------
        \8\ VA Manual 21-1, ``Mandatory Use of the ERRA Tool,'' updated May
    31, 2022, sec. IV.i.2.A in Adjudication Procedures Manual, topic 1c.
        \9\ The OIG team conducted inspections at facilities from each of
    the four vendors. The fourth vendor was added in June 2022; however,
    that vendor did not complete exams until December 2022.

    THE MDEO MUST IMPROVE ITS OVERSIGHT OF CONTRACTORS' DISABILITY EXAM
    ---------------------------------------------------------------------------
    FACILITIES TO ENSURE ACCESSIBILITY AND SAFETY MANDATES ARE MET

        The vendors' contracts require them to inspect all their facilities
    or subcontracted facilities for compliance with ADA and OSHA
    standards.\10\ Yet when the OIG team conducted a complete inspection of
    99 facilities, and partial inspections for an additional 36, more than
    80 percent of them had one or more ADA and OSHA deficiencies.\11\ These
    deficiencies reflect problems related to accessibility, cleanliness, or
    safety, which, in a number of cases, made it difficult to accommodate
    some veterans who needed exams.
    ---------------------------------------------------------------------------
        \10\ The applicable 1991 and 2010 building standards (whichever is
    applicable to the site); Americans with Disabilities Act of 1990 (web
    page); https://www.ada.gov/law-and-regs/design-standards/1991-design-
    standards/ and ``2010 ADA Standards for Accessible Design'' (web page);
    29 C.F.R. Part 1910, https://www.ada.gov/law-and-regs/design-standards/
    2010-stds/, accessed April 19, 2024.
        \11\ Partial inspections generally consisted of examining only
    facilities' exteriors. This was due to reasons such as the team finding
    facilities closed that had unclear operating hours or operational
    status, or the interior being inaccessible because exam rooms were
    continuously occupied, and the review team did not want to prolong
    veteran exam wait times.
    ---------------------------------------------------------------------------
        The deficiencies went largely undetected by VBA because MDEO did
    not provide sufficient oversight to assess the accuracy of vendors'
    self-certification of ADA and OSHA compliance. The original vendor
    contracts required MDEO to conduct site visits both randomly and in
    response to complaints at exam facilities to assess compliance.
    However, MDEO modified the contracts in September 2021 to state MDEO
    ``may'' conduct both random and complaint-based site visits at contract
    facilities at VBA's discretion. In Fiscal Year 2022 (October 1, 2022-
    September 30, 2023), MDEO conducted visits at 76 randomly selected
    sites but did not visit any sites in response to complaints. An MDEO
    assistant director said sites are selected based on their proximity to
    exam vendors' headquarters.
        The OIG team's finding was supported by the following four
    determinations:

            MDEO Depended on Vendors for Contract Facility Information

        As of the report's publication, MDEO did not have independent
    access to a current inventory of all contract facilities used to
    perform disability exams, instead relying on vendors to provide this
    information. This reliance has limited its ability to conduct site
    visits. Depending on vendor-provided lists that can be incomplete or
    weighted toward more compliant facilities affects MDEO's capability to
    oversee its vendors. If facilities are overlooked, compliance issues
    may not be found and addressed.
        MDEO reported that the ``vendor is responsible for developing and
    recruiting a provider network and therefore, a complete list of all
    providers they are contracted with would be considered proprietary
    information that they do not wish us to disclose to their
    competitors.'' The OIG contends that VA routinely receives proprietary
    information from contractors and that necessary controls can be
    instituted to limit access to those VA personnel who need the
    information. Particularly where oversight of veteran safety and
    contract exams are at issue, VA must have accurate information.
        Concerningly, two of the four vendors could not provide a
    definitive number of facilities where their subcontractors conduct
    exams. One vendor reasoned that facility numbers are fluid and contract
    facilities are added and removed continually. Another vendor stated
    that when MDEO requests a list of exam facilities, the vendor provides
    10 locations in the geographic area of the facilities where most
    veterans are likely to be seen. Another vendor reported that it would
    provide addresses and hours of operation for the facilities in an area
    upon request from MDEO.
        An MDEO chief said site visits are generally within commuting
    distance of each vendor's headquarters. An assistant director claimed
    that staff plan to expand site visits throughout the country. Another
    assistant director also noted it was difficult to provide an exact
    number of contract facilities, as some examiners practice at more than
    one location, multiple examiners practice at the same locations, and
    some examiners have short-term leases. MDEO's executive director said
    it is working on maintaining its own list and information on contract
    exam facilities, so staff can conduct site visits and desk audits.\12\
    ---------------------------------------------------------------------------
        \12\ Per MDEO, desk audits would include virtual inspections of
    contract exam facilities through photographs, internet images, and any
    available information to validate facility compliance.

    ---------------------------------------------------------------------------
            Recommendation

        MDEO was asked to submit a plan and documentation of progress to
    the OIG on implementing VBA's maintenance of an independent, updated
    list of contract facilities. VBA concurred with maintaining a list of
    facilities but stated it was unable to independently verify all of a
    vendor's active subcontracts.
        This recommendation, and the other eight discussed below, remain
    open (not fully implemented) at this time. In accordance with the OIG's
    routine follow-up process, the first request for an update on all the
    recommendations is on August 9, 2024.\13\ The OIG will monitor VBA's
    progress on its implementation of all recommendations.
    ---------------------------------------------------------------------------
        \13\  At quarterly intervals commencing 90 calendar days from the
    report issue date, the OIG sends a follow-up status request to the
    action office asking for an implementation status report. The follow-up
    staff provides VBA 30 calendar days to respond. Nothing precludes VA
    from submitting information before target dates or scheduled follow up.

            MDEO Assigned Exam Vendors the Task of Distributing
    ---------------------------------------------------------------------------
            Satisfaction Surveys Rating Their Own Performance

        VBA contracts with a separate survey vendor to work with the four
    exam vendors to obtain veteran contact and appointment information to
    provide all veterans with a paper survey card regarding their exam
    experience, as well as access to other methods such as email or text.
        However, the survey vendor reported it distributed the blank
    customer satisfaction survey forms to the exam vendors, which then
    mailed them to individual veterans. MDEO confirmed the practice was
    consistent with its guidance. Consequently, the survey vendor could not
    monitor how, or if, the customer satisfaction surveys were properly
    distributed and whether every veteran examined received one. As a
    result, MDEO lacks assurance it is receiving the full picture of
    veterans' experiences. MDEO needs the survey vendor or other
    distributor with no vested interest in the results to be responsible
    for mailing the surveys to veterans. Additionally, because the survey
    vendor's performance was tied to the survey response rate, MDEO cannot
    fairly evaluate its performance.
        Per its contract, the survey vendor is expected to meet a minimum
    response rate of 15-20 percent. In 2022, MDEO reported that the overall
    response rate to the customer satisfaction survey was about 11 percent.
    VBA's response to this report noted that in October 2023, a new
    customer satisfaction survey vendor was onboarded.\14\
    ---------------------------------------------------------------------------
        \14\ The rate equals the number of unique responses divided by the
    number of appointments completed.

    ---------------------------------------------------------------------------
            Recommendation

        VBA concurred with the report's second recommendation to comply
    with the requirements of the customer satisfaction survey contract by
    routing exam comment cards directly between the survey vendor and the
    veteran examined.

            MDEO Lacked Formal Standard Operating Procedures and Training
            for Site Visits to Assess Safety and Accessibility Compliance

        MDEO lacked formal, written, standard operating procedures
    outlining the responsibilities, tasks, and processes for staff
    conducting exam facility site visits. According to VBA's contracts with
    exam vendors, the standard of review for a site visit is based on ADA,
    the Joint Commission on Accreditation of Healthcare Organizations,
    OSHA, and any applicable State or local standards.\15\ VBA does not
    provide its staff with training on ADA or OSHA compliance. Staff use a
    checklist with a series of yes/no questions and a space for related
    comments. These questions are not specific enough to effectively
    address whether the contractual standards have been met. This was
    particularly true for questions regarding building and exam room
    accessibility for veterans using wheelchairs.
    ---------------------------------------------------------------------------
        \15\ The OIG did not evaluate whether exam vendors met the Joint
    Commission's standards for clinical operations.
    ---------------------------------------------------------------------------
        Some MDEO employees said they based their site visit checklist
    responses on simple visual observation, rather than addressing
    established criteria. When MDEO staff and managers were asked about
    specific ADA and OSHA requirements, several reported not knowing the
    specific criteria. For example, parking lots require a minimum
    percentage of disabled parking spaces, and there are minimum dimensions
    for wheelchair turning radius, wheelchair ramp slope, and doorframe
    widths.
        Formal training plays an important role in helping staff acquire
    knowledge, develop skills, and improve performance, especially when
    employees have different roles and tasks. An MDEO assistant director
    stated that most training is done on the job for the practical purpose
    of inspecting facilities; however, MDEO is not opposed to formal
    training. The MDEO executive director said staff are working on a
    formal training program and standard operating procedures, and a
    dedicated team was created to be responsible for providing external
    training to exam vendors and MDEO staff.

            Recommendations

        VBA concurred with the report's third recommendation to develop and
    implement formal standard operating procedures for the contract exam
    facility site visits detailing roles, responsibilities, objectives, and
    monitoring. It concurred in principle with the fourth recommendation
    for MDEO to update the site visit checklist to include a focus on
    specific ADA and OSHA criteria required by exam vendor contracts. VBA
    also concurred in principle with recommendation 5 to complete a
    standardized training plan for site visit staff to include ADA and OSHA
    compliance.

            MDEO Did Not Verify Vendor Compliance with ADA and OSHA
            Requirements

        Exam vendors are required to self-certify annually that they meet
    all ADA and OSHA requirements for accessibility, safety, and
    cleanliness, and certify all new facilities in the quarter after they
    are added. The contracts allow VBA to suspend any facilities for which
    MDEO has identified concerns regarding health and safety. However, exam
    vendors generally relied on subcontractors to self-certify, and MDEO
    did not validate the self-certifications. One MDEO leader said exam
    vendors should be able to inspect every facility to ensure compliance,
    while another reported being unaware of any instance in which action
    was taken for noncompliance. Further, one of its employees confirmed
    that tracking individual facilities would not be possible because staff
    do not receive a list of each facility being self-certified; they
    received regional certification from the vendor. The vendor's self-
    certification process was not comprehensive or reliable because there
    was no validation, likely contributing to the unresolved ADA and OSHA
    facility deficiencies.
        Veterans can submit complaints about contract exams through avenues
    such as the OIG hotline, VA regional offices, the White House hotline,
    veterans service officers, and MDEO. Exam vendors also submit incident
    reports to MDEO.\16\ However, MDEO was not conducting complaint-based
    reviews even when survey responses identified deficiencies. The OIG
    found that MDEO should review all sources to determine if a complaint-
    based site visit is warranted.
    ---------------------------------------------------------------------------
        \16\ An incident report is required in instances of physical
    distress, violent or threatening behavior from the veteran, or natural
    disaster.
    ---------------------------------------------------------------------------
        The OIG's report describes two incidents in which veterans were
    unable to be examined because a contract facility could not accommodate
    a wheelchair. In one incident, the veteran was injured being
    transferred from a wheelchair into an audio booth with inadequate space
    to maneuver a wheelchair.

            Recommendations

        VBA concurred with the sixth recommendation to conduct complaint-
    based contract facility inspections, and with recommendation 7 to
    enforce contractual requirements for vendors to conduct inspections and
    recertify all facilities for ADA and OSHA compliance. Although VBA
    requested the latter recommendation's closure, the OIG will only do so
    after monitoring MDEO's contract enforcement.

    THE OIG FOUND ADA AND OSHA DEFICIENCIES THAT MAKE EXAM FACILITIES
    DIFFICULT TO ACCESS AND UNABLE TO ACCOMMODATE SOME VETERANS

        Some veterans said their exams were canceled as contract facilities
    did not comply with ADA or OSHA requirements and could not accommodate
    their mobility or sensory issues. For example, accessible medical
    equipment should include adjustable-height exam tables and chairs,
    wheelchair-accessible scales, adjustable-height radiologic equipment,
    portable floor and overhead track lifts, and gurneys and
    stretchers.\17\ The OIG review team also found numerous facilities
    lacking adjustable exam tables.
    ---------------------------------------------------------------------------
        \17\ ``Access to Medical Care for Individuals with Mobility
    Disabilities'' (web page), accessed November 13, 2023, https://
    www.ada.gov/resources/medical-care-mobility/.
    ---------------------------------------------------------------------------
        Examples of survey responses from veterans highlight accessibility,
    safety, and cleanliness concerns at contract exam facilities:

          ``Wheelchair access is too sleep [sic] for handicap with
    wheelchair.''

          ``Not handicap accessible very hard getting a wheelchair
    in and out of the main entrance door.''

          ``No ramp for wheelchair.''

          ``The doorway entering the building has a 2-3 inch
    threshold that a wheelchair or scooter has to be lifted over.''

          ``Handicap ramp not wheelchair friendly.''

          ``Wasn't able to complete exam due to not being able to
    get into the exam booth.''

          ``Getting in and out of the sound booth was difficult
    because the wheelchair is too large for the booth. Very unsafe.''

          ``Office was dirty with bugs crawling on the floor.''

        The OIG team developed a site visit protocol that enhanced the MDEO
    approach by including ADA and OSHA compliance criteria to be used for
    135 sites. This protocol consisted of questions related to seven areas
    of concern: (1) the facility location, (2) safety and protective
    equipment, (3) exam rooms, (4) general medical clinical equipment and
    supplies, (5) audiology clinical equipment and supplies, (6)
    ophthalmology or dental clinical equipment and supplies, and (7)
    protections for vulnerable veterans.
        Using this protocol, the team first inspected 87 randomly selected
    facilities (62 complete and 25 partial inspections) that performed
    disability exams nationwide from January 1 through December 31, 2022.

        The OIG found that

          45 facilities had at least one accessibility
    deficiency,\18\
    ---------------------------------------------------------------------------
        \18\ Accessibility deficiencies included a steep ramp or curb, lack
    of ramps, narrow doorways, an elevated audio booth with no ramp, no
    adjustable exam tables, and improper door hardware.

          36 facilities had at least one safety deficiency,\19\
    ---------------------------------------------------------------------------
        \19\ Safety deficiencies included expired fire extinguishers,
    partially blocked exits, and tripping hazards.

          eight facilities had at least one cleanliness deficiency,
    ---------------------------------------------------------------------------
    and \20\

        \20\ Cleanliness deficiencies included bugs in fire alarms, stained
    carpets, inappropriate waste disposal, and no available hand sanitation
    equipment in designated areas.

          15 facilities had no deficiencies.\21\
    ---------------------------------------------------------------------------
        \21\  Facilities with no deficiencies were based on results from
    the 62 complete inspections only. Some facilities had more than one
    type of deficiency; therefore, numbers may not sum to the total number
    of sites.

        The team then inspected 48 newly added facilities (37 complete and
    11 partial inspections) from the four vendors chosen both randomly and
    based on veteran complaints. The facilities were added between January
    1 and March 31, 2023, allowing the OIG review team to ascertain whether
    ---------------------------------------------------------------------------
    newly added facilities complied with ADA and OSHA standards.

        The team identified

          28 facilities with at least one accessibility deficiency,

          23 facilities with at least one safety deficiency,

          one facility with at least one cleanliness deficiency,
    and

          six facilities with no deficiencies.\22\
    ---------------------------------------------------------------------------
        \22\ Facilities with no deficiencies were based on results from the
    37 complete inspections only.

    ---------------------------------------------------------------------------
            Examples of ADA and OSHA Deficiencies

        ADA accessibility deficiencies included issues with handicap
    parking, wheelchair ramps, accessible entrances, bathrooms, exam rooms,
    medical equipment, and audio booths. For example, the team found the
    entrance threshold at a facility in California was too high. Facilities
    in Texas, Wisconsin, and Missouri all had audio booth accessibility
    deficiencies, ranging from insufficient wheelchair turning radius to
    higher-than-allowed door thresholds or no permanent or temporary
    wheelchair ramp access.
        Examples of safety deficiencies included blocked stairways,
    noncompliant handrails, expired or inaccessible fire extinguishers, and
    blocked exit routes. No materials or equipment may be placed, either
    permanently or temporarily, in the exit route. Additionally, the exit
    route must have a smooth, solid, and substantially level walkway. At a
    facility in Texas, the OIG found a fire extinguisher that was stored in
    a cabinet under a sink, also with the last evidence of inspection being
    June 2017. The review team also identified eight facilities from the
    initial inspection of 12 states with at least one cleanliness
    deficiency. Some deficiencies included common area cleanliness, lack of
    personal protective equipment and single-use medical supplies, and lack
    of available hand sanitation equipment in designated areas.

    EXAMS SCHEDULED AT FACILITIES WITH ADA AND OSHA DEFICIENCIES MAY CREATE
    DIFFICULTIES FOR VETERANS WITH MOBILITY ISSUES

        MDEO told the OIG that vendors are not allowed to cancel an exam
    specifically because a facility was not ADA-compliant, noting that
    vendors would need to reschedule appointments if a room, booth, or exam
    table was not accessible at the time of the scheduled exam for someone
    who uses a wheelchair. Concerningly, one vendor could not confirm if
    its scheduling unit asked veterans if they needed accommodations at the
    time the appointment was set up.
        The OIG's inspection confirmed ADA deficiencies may make it unable
    to accommodate veterans with mobility issues. Rescheduling these exams
    after veterans have needlessly gone to a facility takes time and may
    entail traveling long distances. Rescheduling may also delay their
    disability benefit claims from being processed. The OIG determined MDEO
    had not been holding vendors accountable to ensure exam facilities are
    accessible, safe, and clean for veterans attending exams.

            Recommendations

        VBA concurred in principle with the report's eighth recommendation
    to analyze all veteran complaints related to facilities received
    through all entities and perform complaint-based site visits or create
    action plans, as necessary. It also concurred with the final
    recommendation for MDEO to develop a plan with its vendors to determine
    if each veteran requires accessibility arrangements before scheduling
    an exam.

    CONCLUSION

        A critical foundation of accountability for any program is
    effective oversight to detect and resolve issues. This is crucial for
    medical exams given how critical they are to ensuring veterans receive
    accurate and timely disability benefits claims decisions. Additionally,
    the need for VBA to conduct thorough oversight is essential given the
    billions of taxpayer dollars paid to contractors. The OIG recognizes
    the challenges with doing so when most of these exams are conducted
    outside of VA facilities by nongovernmental personnel. As a VBA leader
    noted, however, while VA does not own contractor exam facilities, they
    represent the face of VA for veterans applying for benefits.
        The deficiencies identified by the OIG persisted because MDEO's
    oversight was ineffective at detecting and correcting them,
    particularly in failing to consistently conduct site visits in response
    to veterans' complaints. VBA and its vendors must continue to take
    swift corrective action to ensure veterans with spinal cord injuries
    and disabilities, as well as others requiring accommodations, have
    prompt access to suitable exams that will help determine their
    disability benefits. Mr. Chairman, this concludes my statement. I would
    be happy to answer any questions you or members of the subcommittee may
    have.

                      Prepared Statement of Robert Thomas
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                       Prepared Statement of Sonya Sotak

        Chairman Bost, Ranking member Takano and members of the committee,
    it is my honor to be invited to testify today on behalf of I AM ALS and
    representing approximately 6,000 veterans living with ALS in the United
    States. My name is Sonya Sotak and I am the Chief Government Affairs
    Officer for I AM ALS. I AM ALS is a small but mighty non-profit
    organization for people living with ALS. Our organization is a patient-
    centric driven organization, and many of our activities and policy
    efforts are driven by and collaborated with the actual community. We
    were established in 2017 by Brian Wallach and his wife, Sandra, after
    Brian was diagnosed with ALS at the age of 37 on the same day they
    brought their second daughter home from the hospital. Since then, I AM
    ALS has been privileged to partner with many of you here today to help
    move significant pieces of legislation through Congress to support
    people with ALS. First, the ALS Disability Insurance Access Act, which
    passed with unanimous support in the House of Representatives in 2020;
    next, we worked with many of you to get the ACT for ALS passed in 2021,
    again, with overwhelming bipartisan support. Also, many of you on both
    sides of the aisle have helped the community increase funding for the
    ALS research program at the Department of Defense. For the last 2
    years, I AM ALS and the entire community of ALS organizations have
    urged Congress to double this funding since the incidence of ALS among
    veterans is at least two times that of the general population.
        We also know that the Department of Defense ALS research program is
    receiving more than double the amount of quality research proposals
    that need grant support--proposals that they cannot approve at the
    current funding amount--and represent strong science that otherwise
    might be able to address the needs of veterans with ALS. We know that
    the proposed Fiscal Year 2025 funding measure remains at $40 million
    but we continue to urge Congress to find a way to increase resources
    for this program for Fiscal Year 2025 and invest in research that can
    address this horrible disease and help the 1 in 6 people with ALS who
    are veterans.
        We thank each of you and all of Congress for these important
    accomplishments and truly appreciate the bipartisanship effort that it
    took to achieve each of these advancements and the willingness for
    everyone to work together to pass legislation improving the lives of
    people, including thousands of veterans living with ALS.
        As I mentioned, our organization is driven by community members
    affected by ALS themselves, thousands of volunteers taking action. Our
    veterans team created by incredible veterans and caregivers for
    veterans living with ALS is one of our most powerful and impactful
    committees. These veterans with ALS and their loved ones identify
    barriers, create tools and toolkits, and advocate to ensure that the VA
    benefit and health care system is easier to navigate and provides
    better and more accessible services. Sadly, we know all too well that
    this advocacy is needed to ensure basic, supportive care for veterans
    with ALS. As an example, our toolkit helps veterans identify and
    receive existing veteran benefits once they are diagnosed with ALS.
    This basic guide is over 45 pages long--that is how complex the system
    is for our veterans at a time when they are already overwhelmed and
    should be focusing on maximizing life with family rather than
    navigating a complex, bureaucratic healthcare system. Lack of knowledge
    of the VA system can result in frustration and delays in service.
    Because ALS can progress rapidly, delays need to be avoided at all
    costs. Congress recognized this when you passed the ALS waiver
    eliminating the SSDI waiting period. Our veterans with ALS and their
    families deserve the same recognition when accessing benefits. We urge
    you to work to ensure that all the veterans not yet diagnosed will be
    taken care of and hopefully enter a VA system that provides stronger
    and better access to health care and support services than they have
    had while enduring ALS.
        As the Chairman and committee members know, ALS is recognized as a
    one hundred percent service related disease. Statistics vary but we
    know at a minimum members of our military are two times more likely
    than civilians to develop ALS. This stat skyrockets to ten-times when
    examining post-9/11 Airforce veterans. We also have seen data that
    estimates approximately 5000-6000 of the 30,000 people with ALS in the
    United States are veterans or again, about 16 percent. I say
    approximately because the world of ALS lacks solid data for many
    reasons but one key reason is the significant delay and complexity in
    diagnosing ALS. The prevalence of misdiagnosis is incredibly high and
    many people may never receive the right diagnosis or receive their
    diagnosis too late for being factored into national data. We also have
    a national system that does not compel data collection and is based on
    self reporting. This is such a complex topic it's worthy of its own
    hearing another day up here.
        Before I dive into access to home health care that is critical for
    our veterans with ALS I want to set the table with some critical facts.
        First, I want to be sure that the committee and everyone here today
    knows that ALS, or Lou Gehrig's disease as it is often known, is 100
    percent fatal.
        Nobody survives ALS and most die within 2-5 years after being
    diagnosed. When people finally receive a diagnosis they are told to go
    home--get their affairs in order and prepare to die. So every one of
    our veterans that develop ALS will die from it no matter how hard they
    fight or how strong their valor. Every single veteran will lose their
    battle with ALS.
        ALS is a neurodegenerative disease that affects nerve cells in the
    brain and spinal cord. ALS is a wicked, cruel disease that slowly
    paralyzes a person, taking away their capacity to be self sufficient
    and eventually losing their ability to breath.
        ALS was determined to be a one hundred percent service connected
    disease by the Department of Veteran Affairs on September 23, 2008.
    Following that decision it has been a tough and multifaceted journey
    for a multitude of reasons within the VA to provide the necessary,
    appropriate and equitable support for Veterans with ALS. The VA issued
    the VHA directive 1101.07 the ALS system of care in August 2021. The
    intent of this directive is to ensure that all care, services and
    access to equipment is known to veterans and their families including
    the responsible parties for ensuring access. Too often while managing
    ALS, many of our veterans and their families have to take significant
    time to advocate for themselves and often it is to explain to the VA
    what their VA benefits actually are as a veteran with ALS.
        The VA's Spinal cord injuries and disorders (SCI/D) centers are
    designed to provide comprehensive care for veterans with spinal cord
    injuries and related injuries. However, these centers often face
    challenges fully meeting the needs of veterans with ALS due to the
    multifaceted nature of ALS. Part of the challenge is the SCI/D's are
    set up for your typical spinal cord injury which are often a static
    disease while ALS is a progressive & increasingly complicated
    debilitating disease.

        Specialized care: ALS requires specialized neurological and
    respiratory care that is often not fully available at SCI/D centers.
    For instance, expertise in managing progressive muscle weakness and
    continued respiratory failure is something lacking at these centers.
    ALS requires multidisciplinary care with a coordinated approach by a
    team of health care professionals from a variety of disciplines to
    manage the complex needs of a Veteran with ALS. The goals are to
    improve the quality of life, slow the disease progression and provide
    much needed psychological and social support. This is too often not
    possible and simply not how the SCI/d's are set up and they often lack
    the staffing capacity and training for meeting the needs of our
    veterans with ALS. Expertise is often lacking for managing progressive
    muscle weakness and repository failure at the centers.

        Advanced respiratory Support : Veterans with ALS often need
    advanced respiratory support, including non-invasive ventilation or
    mechanical ventilation which is often not the focus of SCI/D centers.

        Comprehensive team : As I outlined earlier, the SCI/D centers do
    not have all the specialists available for ALS veterans or do not have
    the same level of coordination and collaboration as some ALS clinics or
    even what is available through accessing care in a veterans home
    setting.

        SCI/Ds often have Insufficient focus on ALS specific interventions
    including:

    Assistive technology:

        Veterans with ALS often need specific assistive technologies such
    as augmentative and alternative communication devices which may not be
    readily available or supported in the centers.

    Adaptive equipment

        Too often the centers focus on spinal cord injury specific
    equipment and not the evolving and very demanding and intricate needs
    of ALS veterans.

    Psychological and social support gaps

        The specialties counseling and training needs for managing the
    extensive emotional and psychological support needed by ALS veterans
    and their families as a result of the rapid progression and terminal
    nature of the disease is often found to be lacking at the centers.

    Palliative and end of life care

        Many of the SCI centers do not have integrated palliative care
    services tailored to the specific needs of ALS veterans. ALS support
    requires significant palliative care and end of life planning which has
    a unique perspective and approach for managing ALS symptoms and quality
    of life.
        Another key challenge is the location of the 25 centers. Many of
    them are simply not near many of our veterans living with ALS and not
    easily accessible for the veterans scattered around the country
    managing the very debilitating disease of ALS.
        I AM ALS and our veterans community believe an important component
    of their ALS care is being able to remain in their home. For this
    reason, I AM ALS fully supports the Senator Elizabeth Dole 21st Century
    Veterans Healthcare and Benefits Improvement Act. While this
    comprehensive bill contains many important measures, I would like to
    focus on the pieces that are most important for veterans with ALS--The
    Elizabeth Dole Home Care Act contained in this comprehensive package is
    significant for veterans with ALS for several reasons:

        Most significant for our community of veterans with ALS is that the
    legislation increases the expenditure cap for non-institutional care
    from 65 percent to 100 percent of the cost of the closest VA Community
    Living Center (CLC). This would allow the most vulnerable veterans and
    caregivers the support they need to stay in their homes, often leading
    to better outcomes for veteran families, especially veteran families
    grappling with ASL.
        The removal of the cap would help families care for their 100
    percent service-disabled veterans with ALS. Because of the mandated
    cap, families constantly have to fight with the VA to get the
    appropriate support in their home so their veteran can continue to
    enjoy being near family rather than being sent away to a facility which
    is often hours away from the much needed support system of family and
    friends. For many veterans remaining in their home with friends and
    family during their hardest battle managing ALS is paramount. Staying
    in their home with loved ones improves their quality of life but it can
    also help reduce medical complications.
        Let me share the story of Navy veteran Garrett who served as part
    of the Seabees, a construction battalion with tours in Iraq and
    Afghanistan. Garrett's journey with ALS was challenging and started
    with him being forced to make the longer journey to Milwaukee because
    they had the VA ALS clinic even though the Iron Mountain VA was much
    closer to his home. As the disease progressed, and these road trips
    were no longer feasible Garret had to start a Go Fund Me campaign to
    try and offset the additional home health care he needed that wasn't
    provided by the VA. Eventually, he did hit the cap. It was far more
    complicated--his wife was overwhelmed with managing his care alone for
    so many hours to prevent hitting the 65 percent cap, while also being a
    single parent for their three young children. Then, Garret had to get a
    trach. After all this chaos, Garrett hit the cap and had to go to an
    institution. Garret tried his best to maneuver the system so he could
    get back home with medical support from home care. Unfortunately, the
    current structure would not afford him that final return home and
    Garrett made the decision to remove his trachea and end his own life
    rather than spend his days alone in the center far from his family and
    without the daily support from friends, family and his kids. Garrett is
    not the only veteran that we know that chose to end their life early
    rather than endure being in a VA institution that failed to meet their
    medical needs and lacked an appreciation for the care they needed as a
    veteran with ALS. Even one veteran is one veteran too many to be
    isolated from friends and family because of the distance from their
    communities and family when forced to leave their homes for care
    because of a cap limiting their access to support in their home .

        Comprehensive care for veterans with ALS. As I shared earlier--ALS
    is a neurodegenerative condition and as the disease progresses,
    veterans with ALS require extensive and specialized care. The Elizabeth
    Dole Home Care Act ensures that our Nation's veterans receive
    comprehensive home-based care tailored to their complex needs, improves
    their quality of life and allows them to remain in a familiar and
    comfortable environment with their families, friends or loved ones.
        Also included in the Elizabeth Dole Home Care Act is the Veteran
    Directed, Home-Based Primary Care and the Homemaker Home Health Aide
    programs that support the care and quality of life of veterans and
    caregivers, especially at home and can serve as a lifeline for veterans
    and caregivers in need. This program, a joint offering from the VA and
    U.S. Department of Health and Human Services (HHS), offers veterans and
    caregivers greater choice and control over their care and services by
    allowing participants to utilize friends and family members to provide
    unskilled care including transportation support and other services to
    support the veteran in their home. Veterans and caregivers can
    supervise their own employees and hire additional support during the
    hours that are needed rather than being subject to agency hours and
    restrictions. In addition, this program has been especially helpful to
    those who struggle to find appropriate care in their homes either due
    to contracted agency employee absences or the general dearth of HHA
    providers around the country.

    Support for Caregivers.

        The Elizabeth Dole Act recognizes the important role of caregivers,
    often family members, in managing the daily needs of veterans with ALS.
    By providing resources, training and financial support to caregivers,
    the Act helps reduce the emotional and financial burdens and allows
    them to provide better care and support for our veterans. Being a
    caregiver is hard work; being a caregiver for a person with ALS is
    beyond daunting and incredibly exhausting.

    Access to Medical Services.

        The medical needs for veterans with ALS are complex and frequent
    including physical therapy, respiratory care and many other specialized
    treatments. The Elizabeth Dole Act facilitates access to these
    necessary treatments at home, reducing the need for hospital visits or
    visits to SCI/D centers that often lack the personnel and speciality
    training needed for minimizing the risks for people with ALS, including
    infections, complications and sadly, but very frequently medical
    professionals who simply are not familiar with ALS and unintentionally
    create more complications when they treat our veterans with ALS.

    Quality of Life

        Helps maintain a sense of independence and dignity for veterans
    while ensuring they receive the medical attention and daily assistance
    they need while remaining in a safe and comfortable home environment
    with advocates around them to ensure their needs are being met.

    Economic benefits

        Home based care is more cost effective than institutional care. By
    raising the cap to 100 percent and supporting veterans with ALS
    receiving home care the EDHCA helps manage health care costs more
    efficiently while allowing veterans to receive high quality
    personalized care.
        I AM ALS is so pleased that the Elizabeth Dole Home care Act is
    bringing greater awareness of the challenges and needs of veterans
    living with ALS especially those that need more support than the
    current SCI centers can provide. This bipartisan legislation advocates
    for and demands higher quality care including respect and dignity of
    care in their homes with loving friends and family. This legislation
    will ensure that our Nation's veterans with ALS receive the respect and
    care they certainly deserve after their service to our country.
        I would be remiss if I didn't take the honor and privilege of
    engaging with Chairman Bost, Ranking Member Takano and the entire
    committee without mentioning other key priorities for veterans with ALS
    that we hope you will support and guide through Congress quickly for
    our veterans with ALS.
        As I mentioned earlier, I AM ALS supports doubling the funding for
    CDMRP ALS Research at the Department of Defense. Multiple studies have
    reported that Veterans are significantly more likely to be diagnosed
    with ALS than those who did not serve in the U.S. military. While the
    specific cause of this increased risk is unknown, the correlation
    between military service and ALS is well-established so we encourage a
    significant investment in researching this disease and finding a way to
    treat ALS for the thousands of veterans that will develop this horrific
    disease. We know that the additional research projects exist and are
    simply not being funded because of the lack of resources being
    allocated. We urge you to increase the funding to $80 million for
    Fiscal Year 2025.
        I AM ALS also urges Congress to pass the Justice for ALS Veterans.
    This bipartisan legislation would fix the unfair policy that denies
    benefits to the surviving spouses of veterans who died from ALS by
    providing the surviving spouse with the DIC kicker without meeting the
    8 years of disability requirement. Unfortunately, because most people
    with ALS, a recognized service-connected disease, live fewer than 8
    years from diagnosis, the surviving spouses of veterans with ALS have
    been unfairly denied this benefit. The same spouses who may have quit
    their jobs to take care of their loved ones who progressively lost
    muscle control, became paralyzed and relied heavily on their caregiver
    to stay alive.

    Closing

        I AM ALS is incredibly appreciative for all that Congress has done
    for the ALS community in a bipartisan, collegial manner, but the ALS
    community needs Congress to do even more for this 100 percent fatal
    disease with no real treatment options. And we need you to do more with
    a specific focus on our veterans with ALS. We should not allow a system
    of care to continue that sees more veterans like Garrett decide that
    ending their lives is preferred to enduring a VA institution that fails
    them that doesn't provide the support and medical care they need, and
    certainly doesn't have the staff available or trained to meet their
    complex medical needs despite their sacrifices and commitment to our
    Nation through their military service. I AM ALS encourages the
    Committee and Congress to continue working together without politics
    and to help move important measures forward including the Elizabeth
    Dole Home Care Act as part of the Elizabeth Dole 21st Century Veterans
    healthcare and Benefits Improvement Act. Our veterans with ALS who have
    sacrificed for our country and selflessly served our Nation deserve to
    have access to home based care. They need all of you to keep working
    together to support them and support their families as they are in
    their final battle against a wicked, cruel disease.
        Thank you for your time and know that the ALS community appreciates
    your efforts and continued work together in Congress for people with
    ALS, especially our veterans. For this reason we urge you to work
    together to get the Elizabeth Dole 21st Century Veterans Healthcare and
    Benefits Improvement Act passed this year on suspension so critical
    services are made available for veterans with ALS.

                      Prepared Statement of Jenny Kiratli

        Chairman Bost and Ranking Member Takano, and Members of the House
    Committee on Veterans' Affairs:

        Thank you for inviting the American Federation of Government
    Employees (AFGE) to participate in today's Committee hearing, ``A Call
    to Action: Meeting the Needs of the Spinal Cord Injury and Disorders
    (SCI/D) Veteran Community.''
        I am Dr. Jenny Kiratli, and I have been a member of AFGE since 2009
    and a research health scientist in the Spinal Cord Injury and Disorders
    (SCI/D) Center, VA Palo Alto Health Care System (VAPAHCS) since 1991.
    AFGE's National Veterans Affairs Council represents more than 302,000
    AFGE VA employees across the Veterans' Health Administration (VHA),
    Veterans Benefits Administration (VBA), and the National Cemetery
    Administration (NCA). I have more than 30 years of experience
    conducting research on clinical issues affecting people with SCI
    including musculoskeletal conditions, bone and body composition; and
    nutrition, activity, and exercise interventions--with a focus on
    extending therapies into the home to facilitate wellness. I am Director
    of the VA Advanced Fellowship Program in SCI Research and Associate
    Research Director for the SCI Medicine Clinical Fellowship Program. I
    am dedicated to mentoring junior investigators and fostering
    partnerships with veterans and other stakeholders and colleagues to
    conduct research that can be implemented into best practice.
        The Spinal Cord Injury and Disorders (SCI/D) Center, VA Palo Alto
    Health Care System (VAPAHCS) is one of 25 Spinal Cord Injury and
    Disorders Centers located around the country. These centers offer
    lifelong, comprehensive, integrated, coordinated care that includes
    primary care, rehabilitation, emergency care, acute medical and
    surgical care, mental health care, and home care. The Palo Alto VA also
    has dietitians, respiratory therapists and orthotists & prosthetists on
    staff. Our services are aimed at supporting the veteran as a whole
    person including services that reintegrate veterans into the community
    and provide respite care and family education. Our facility has also
    pioneered telehealth services, which we launched in 2000. The expertise
    of the interdisciplinary care team and breadth of the services makes
    the VA SCI/D network the most comprehensive SCI/D care delivery system
    in the U.S.
        The VA's system of care for SCI/D uses a hub and spokes model. The
    25 SCID centers are the hub facilities staffed with clinicians
    including therapists and psychologists trained to provide specialized
    care to people with a spinal cord injury or disorders. These hub
    facilities coordinate with approximately 120 designated medical
    ``spokes'' facilities that do not have their own SCI/D center. The hub
    and spokes model expands the reach of the SCI/D program ensuring that
    veterans not located near an SCI/D center have access to comprehensive
    primary and specialized care tailored to the unique needs of
    individuals with spinal cord injuries and disorders. Primary care
    physicians need special training to serve SCI/D patients' specific
    needs. For example, primary care physicians treating the SCI/D
    population must be able to diagnose and treat an array of problems that
    may present differently in patients with spinal cord injuries such as
    bone breaks and infections. They must also be trained to recommend
    appropriate preventive care screenings and manage comorbidities common
    to SCI/D patients such as metabolic disease, endocrine disease, and
    musculoskeletal disorders. Most physicians in the SCI/D Centers pursue
    an additional year of focused training in SCI Medicine through
    fellowship programs.
        Veterans comprise more than a quarter of the SCI/D population in
    the U.S.\1\ The Palo Alto SCI/D system serves approximately 1,000 of
    the 18,000 veterans that receive SCI/D services across the VA system.
    Our center serves veterans and active-duty military personnel. While
    those with service-connected injuries are eligible for enhanced
    services, VA SCI/D centers serve veterans and active-duty military
    personnel with nonservice related spinal cord injuries and disorders.
    ---------------------------------------------------------------------------
        \1\ Cai S, Bakerjian D, Bang H, Mahajan SM, Ota D, Kiratli J. Data
    acquisition process for VA and non-VA emergency department and hospital
    utilization by veterans with spinal cord injury and disorders in
    California using VA and State data. J Spinal Cord Med. 2022
    Mar;45(2):254-261. doi: 10.1080/10790268.2020.1773028. Epub 2020 Jun
    16. PMID: 32543354; PMCID: PMC8986188.
    ---------------------------------------------------------------------------
        Clinical research conducted at Palto Alto SCI/D center can drive
    improvements in care delivery that can also benefit non-veterans living
    with spinal cord injuries and disorders. VA Palo Alto's Spinal Cord
    (SCI/D) Center conducts significant clinical research aimed at
    developing best practices for care for veterans with SCI/D. In my role
    as director of clinical research, one of my current studies aims to
    improve the assessment of bone health of veterans living with SCI/D.
    Prior to this work, there has been no standardized method for measuring
    bone health at the knee, a common fracture site for those with SCI/D.
    This study will help inform evaluation of bone health for all veterans.
        Adaptive gaming is another area where VA is plugging a research gap
    that existed for the SCI/D population. Adaptive gaming as a therapeutic
    tool had been studied within the stroke population, but specific
    research was needed on muscle activation of upper limb muscles in
    people with spinal cord injuries to determine whether video gaming
    improved upper limb motor performance, balance, coordination, and
    cardiovascular status. The project I led found that selected Wii games
    were able to elicit upper extremity muscle activation and elevated
    heart rates for individuals with SCI that may be used to target
    therapeutic outcomes.
        VA further serves the general SCI/D population by pioneering
    modifications to existing technologies to adapt them for the SCI/D
    population. For example, a modification to standing wheelchairs
    pioneered by a team from the Minneapolis VA Health Care System allows
    people to move while in standing positions. Early models of standing
    wheelchairs allowed people to stand but not to move in the standing
    position. VA physicians worked with biomedical engineers to add a chain
    drive system to the chair that allows users to push their chairs from a
    standing position. The Palo Alto VA collaborates with the Minneapolis
    VA to research the use of this adaptation to maximize the use of the
    technology for the SCI/D population. All VA research is ultimately
    shared with non-VA SCI facilities through published research and
    conferences, contributing to the overall benefit of the larger, non-VA
    SCI/D population.
        VA also plays an important role in training SCI/D professionals
    collaborating with academic programs to provide clinical training. VA
    has an advanced fellowship training in SCI medicine. More needs to be
    done to encourage young clinicians to enter the field. Of the 31
    positions for the SCI clinical training program only usually fewer than
    20 positions are filled.
        We also participated in a multi-site VA study to establish,
    implement and test a model for vocational rehabilitation that greatly
    enhances opportunities for veterans with SCI/D to return to work and
    contribute to the workforce in meaningful ways by partnering with
    potential employers to understand the needs of each individual and
    develop jobs that meet their needs.
        The VA is at the forefront of improving clinical outcomes and
    quality of life for veterans and all people living with spinal cord
    injuries and disorders. However, more can be done to strengthen the
    VA's SCI/D system. While the hub and spokes model greatly expands
    access to VA's SCI/D services, there are gaps in care, particularly for
    veterans in rural areas where more spoke facilities are needed.
        There is a great need for increased staffing for SCI/D services.
    Individuals with SCI have challenging and complex health care needs
    requiring significant support. They live with many secondary
    complications that require vigilance to prevent functional decline and
    premature death. Individuals with SCI are two to five times more likely
    to die a prematurely.\2\ SCI is also associated with higher rates of
    mental illness, with one in five suffering from depression,
    significantly higher rates of anxiety, posttraumatic stress disorder,
    and death by suicide. \3\ Staffing requirements for SCI/D centers
    should be updated to reflect the higher acuity of the SCI/D population.
    Because of the complexity of SCI/D care, it requires specialized
    certification and training. The high acuity of care creates burnout and
    younger clinical staff often leave just when they have gained
    sufficient skills to perform all their duties. It is difficult to use
    temporary staff, such as floating nurses, to deal with short staffing
    in SCI/D centers because specialized training is required. As a result,
    SCI nurses can be moved elsewhere to deal with staffing shortages, but
    non-SCI nurses cannot easily fill in on SCI unit. Additional retention
    incentives are needed to address vacancies and turnover.
    ---------------------------------------------------------------------------
        \2\ Touchett, H., Apodaca, C., Siddiqui, S. et al. Current
    Approaches in Telehealth and Telerehabilitation for Spinal Cord Injury
    (TeleSCI). Curr Phys Med Rehabil Rep 10, 77-88 (2022). https://doi.org/
    10.1007/s40141-022-00348-5
        \3\ Touchett, H., Apodaca, C., Siddiqui, S. et al. Current
    Approaches in Telehealth and Telerehabilitation for Spinal Cord Injury
    (TeleSCI). Curr Phys Med Rehabil Rep 10, 77-88 (2022). https://doi.org/
    10.1007/s40141-022-00348-5
    ---------------------------------------------------------------------------
        The Mission Act increased access to non-VA facilities. Research
    suggests that use of VA and non-VA care has the potential to cause
    unintended duplication of services, costs and fragmentation of care.\4\
    But the potential for inadequate care is a greater concern for veterans
    with SCI/D. The VA's SCI/D model provides uniquely comprehensive and
    integrated services delivered by highly knowledgeable teams of
    specialists that do not exist in the private sector. In addition, non-
    VA providers lack access to VA resources such as medical equipment and
    a wide array of adaptive products, often created for each individual
    veteran to meet his or her specific needs. Further, non-specialists
    often do not recognize serious disorders (e.g., a bone fracture)
    because of an absence of the normal symptoms. Care should be taken to
    ensure that increasing privatization of VA services does not upend the
    VA's specialized SCI/D care model that provides veterans living with
    spinal cord injury and disorders an array of integrated services and
    provides research used to develop best practices for all people living
    with spinal cord injuries and disorders.
    ---------------------------------------------------------------------------
        \4\ Hatch MN, Etingen B, Raad J, Siddiqui S, Stroupe KT, Smith BM.
    Dual utilization of Medicare and VA outpatient care among Veterans with
    spinal cord injuries and disorders. J Spinal Cord Med. 2023
    Sep;46(5):716-724. doi: 10.1080/10790268.2022.2027321. Epub 2022 Feb 2.
    PMID: 35108176; PMCID: PMC10446768.

                           Statements for the Record

                                  ----------

                     Prepared Statement of MitoSense, Inc.
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

          Prepared Statement of Christopher and Dana Reeve Foundation
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
                        Prepared Statement of Neuralink
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     [all]