[Senate Hearing 118-]
[From the U.S. Government Publishing Office]




 
     MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2024

                              ----------                              


                       WEDNESDAY, APRIL 26, 2023

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:30 a.m. in room SD-124, Dirksen 
Senate Office Building, Hon. Patty Murray (chairwoman) 
presiding.
    Present: Senators Murray, Tester, Schatz, Baldwin, 
Heinrich, Peters, Boozman, Murkowski, Hoeven, Collins, and 

Fischer.

                     DEPARTMENT OF VETERANS AFFAIRS

STATEMENT OF HON. DENIS R. MCDONOUGH, SECRETARY

               OPENING STATEMENT OF SENATOR PATTY MURRAY

    Senator Murray. The hearing of the Senate Appropriations 
Subcommittee on Military Construction, Veterans Affairs, and 
Related Agencies will, please, come to order.
    We are here today to talk about President Biden's fiscal 
year 2024 Budget Request and fiscal year 2025 Advance 
Appropriations Budget Request for the Department of Veterans 
Affairs with Secretary McDonough.
    As we work to assess our Nation's needs for the year ahead, 
and return to regular order, and pass bipartisan funding bills 
in a timely manner, we have a very serious obligation to make 
sure we provide for the men and women who fought and sacrificed 
to keep our country safe, and their families.
    No one who has put their life on the line for our country 
should struggle to provide for their family, put a roof over 
their head, pursue a higher education, and good paying job, or 
get the health care they need.
    And upholding our promises to our veterans isn't just 
critical to our country; it is really personal to me. My dad 
was veteran. He fought in World War II. He was awarded a Purple 
Heart. And after he was diagnosed with MS, which eventually 
made it impossible for him to work, he was able to get the care 
he needed, thanks to his VA benefits.
    Knowing how important that care was to my family is part of 
why, in college, I chose to intern at the Seattle Veterans 
Hospital. And working there I saw firsthand the challenges that 
our veterans were dealing with, the physical and mental wounds. 
I have never forgotten what VA support meant for my dad. And I 
have never forgotten what it meant for the veterans at that 
hospital.
    And that is why I am always listening to veterans back in 
Washington State about the challenges they are facing, fighting 
to get their families the support they need, the support they 
deserve, and working to make sure we keep our promises to our 
veterans.
    That has been a priority of mine since my first day in the 
Senate, from my time serving as the first woman ever to lead 
the Veterans Affairs Committee, to helping establish and then 
expand the VA Caregivers Program, to working in a bipartisan 
way, just last year, to pass the PACT Act.
    And it will continue to be my priority as I lead the 
Appropriations Committee; and this important subcommittee, with 
Ranking Member Boozman, who I know also cares very deeply about 
our veterans.
    When it comes to our veterans, we cannot cut corners, we 
can't break our promises, and we can't let partisan politics 
get in the way of passing funding the VA needs.
    Let us be clear, anything other than a regular 
appropriations process will have negative impacts across the 
VA, and will hurt veterans back in our states who need to get 
their claims processed, benefit from medical and prosthetic 
research, and get care related to their toxic exposure.
    Bottom line, if we fail to fund the VA and in a timely way, 
it is our Nation's veterans who pay the price; we absolutely 
cannot let that happen, which is why today's hearing is so 
important.
    And I am pleased to say, President Biden's budget shows he 
also understands that when we make a promise to our veterans 
our word has to be ironclad. For starters, this budget once 
again considers VA medical care accounts separately from the 
rest of the nondefense discretionary budget.
    This is an important step to make sure that in delivering 
the care our veterans need, we are never forced to raid other 
essential programs that help them pursue an education, or buy a 
house, or start a business, and so much more.
    And when it comes to VA's overall funding level I am 
pleased to see this budget proposes a 5 percent increase across 
mandatory and discretionary accounts from the funding we 
provided in fiscal year 2023.
    It includes a proposal to expand child care sites at VA 
facilities to ensure that lack of affordable child care is not 
a barrier for veterans who are seeking care, and it includes 
much needed increases for veterans suicide prevention, 
homelessness prevention, gender-specific care- women, by the 
way, are the fastest growing demographic of veterans and for 
the Caregivers Program which I am pushing to strengthen.
    President Biden's budget also includes funding for 
structural needs, like improving VA infrastructure, and 
implementing the PACT Act, the largest expansion of veterans 
care in decades. And this is so important. Every single member 
of this committee voted to pass the PACT Act because we know 
veterans who are exposed to toxins in the line of duty deserve 
care.
    The bill we passed last year has the potential to make life 
better for many people in Washington State and across the 
country, but only if we make sure it is implemented to its full 
potential. And that means, we have to provide funding and 
accountability.
    Of course, the PACT Act was signed into law after the 
Department's request for discretionary funding for fiscal year 
2024 was submitted. So this budget accounts for that by moving 
some dollars meant for this work into the Toxic Exposures Fund, 
which did not exist when the funds were originally requested. 
And it puts forward a methodology and an estimate for the cost 
of providing this expanded care.
    These are import in steps, but next, VA must develop a 
system to collect data and track actual demand related to toxic 
exposures, and revise and strengthen their methodology going 
forward, as they have done for the MISSION and CHOICE 
expansions.I look forward to discussing this and the 
administration's request for the Toxic Exposures Fund, and 
working in a bipartisan way to make sure VA has what it needs 
here.
    I also expect to hear more about VA's Electronic Health 
Record System. As you know, the rollout at VA sites at 
Washington State has been an ongoing disaster, with new 
disruptions still happening.
    I have heard from providers who are burnt out trying to 
navigate this broken interface, patients who are unable to get 
medicine they rely on, because of system malfunctions, and even 
a patient who received a late cancer diagnosis because of flaws 
in the system. And that is just we what we know right now. It 
is unacceptable.
    I have been saying for quite some time now, that VA should 
halt future rollouts in Washington State, and focus on fixing 
the program where it already exists, like in Spokane and Walla 
Walla. So the Department's reset announcement last week to do 
just that, was certainly a sentiment that I agree with. But I 
still want to know more about how exactly the Department is 
planning to get things on track, including by negotiating 
stronger performance incentives and penalties in a new 
contract.
    I hope this reset means real results, but in the meantime I 
will continue working with my colleagues to pass legislation 
that implements the kind of aggressive oversight needed to fix 
the current EHR System so these kinds of failures never occur 
again.
    Mr. Secretary, I look forward to hearing more from you 
about those issues, and working with everyone on this committee 
to make sure we are providing the funding, and the 
accountability our veterans deserve, because this isn't just 
funding for these families, these are not just programs and 
contracts to them, it is whether they get the benefits they 
need to make ends meet, whether they get the prescriptions, and 
mental health care, and more, they need to stay healthy. And 
whether they get that cancer screening and start treatment 
early. In other words, it is often, literally, life and death.
    The stakes are so high for these families whom we owe so 
much. And as Chair of this subcommittee, and as a daughter of a 
veteran, I will do everything we can to live up to that 
obligation. Thank you.
    And with that, I will turn it over to Ranking Member 
Boozman.

                   STATEMENT OF SENATOR JOHN BOOZMAN

    Thank you, Madam Chair. And we appreciate your leadership 
in this very, very important hearing.
    Thank you, Mr. Secretary, for being here. We appreciate all 
of your hard work, and coming before us to discuss VA's fiscal 
year 2024 and 2025 Budget Request.
    The budget requests $324.5 billion in fiscal year 2024 for 
the Department of Veterans and Affairs, including medical care 
collections, the Transformational Fund, and the new Toxic 
Exposures Fund, representing a 5.4 percent increase over fiscal 
year 2023 enacted levels.
    This includes $137.9 billion in discretionary funds, a $2.9 
billion, or 2.2 percent increase over fiscal year 2023, the 
request includes $182.3 billion in mandatory funds a $14.6 
billion, or 8.1 percent increase over fiscal year 2023.
    Within this amount, it proposes $20.3 billion in the Toxic 
Exposures Fund (TEF), a $15.3 billion, or 305 percent increase 
over fiscal year 2023. And a new $1.9 billion request for major 
construction. The construction request is unusual as major 
construction projects are a base discretionary requirement.
    The budget also requests a total of $112.6 billion in the 
medical care advance appropriations, for fiscal year 2025, 
$15.5 billion less than the fiscal year 2024 advanced 
appropriation.
    Finally, the request includes $193 billion in advanced 
veterans' funding. We are spending a lot of money for veterans. 
That is not a bad thing.
    Mr. Secretary, you made some news last Friday that 
certainly got the attention of this subcommittee, the EHRM 
reset and immediate halt to all deployment and pre-deployment 
activities, a big step, and a necessary one. Over the last 6 
years this subcommittee has appropriated more than $10 billion 
towards this endeavor, and the persistent problems, as the 
Chairwoman outlined with the system, are more than troubling.
    Stepping back and working with the Oracle Cerner to get the 
system working efficiently and safely at the existing sites, is 
a responsible action. This decision has some budgetary effects, 
and I look forward to hearing from you what adjustments to the 
budget, either already appropriated, or in the future are 
needed.
    This budget seems to find VA in a period of transition, 
emerging from the pandemic, and finally return to normalcy and 
routine operations, while at the same time adjusting to and 
addressing the significant new requirements and workload, 
resulting from the enactment of the PACT Act.
    VA has asked for significant amounts in the TEF, $15.3 
billion more than last year, isn't lost on me though that the 
mechanical and technical details of this budget request 
indicate the VA has very large unobligated balances in its 
medical care accounts.
    I hope to learn more about how the large boost and the 
mandatory request plays in decisions about how to utilize 
existing unobligated balances in medical care.
    In addition to updates on these big-picture items, we also 
look forward to hearing details about the Department's request 
for mental health services, including efforts to combat opioid 
use disorder, and prevent veteran suicide, initiatives to 
prevent veterans' homelessness, and efforts to improve care for 
our rural veterans.
    We look forward to discussing these and other issues this 
morning. Again, thank you for your service, and thank you for 
being here.
    Thank you, Madam Chair.
    Senator Murray. Thank you, Senator Boozman.
    We are joined today by Honorable Denis R. McDonough, 
Secretary of Veterans Affairs.
    Thank you so much for being here, Mr. Secretary. You can 
now proceed with your opening statement.

               SUMMARY STATEMENT OF HON. DENIS MCDONOUGH

    Secretary McDonough. Thank you, Madam Chair. And Senator 
Boozman, thank you very much; all the Members of the Committee, 
thank you for the opportunity to appear before you today.
    Madam Chair, with your forbearance, I will forgo my oral 
statement. I will just ask that it be included in the record 
along with our written statement, and we get straight to your 
questions.
    Obviously all the issues that came up in the opening are, 
you know, front of mind for me as well. So I think it would be, 
maybe the best use of your time for me to just get right 
straight to your questions.
    [The statement follows:]
             Prepared Statement of Hon. Denis R. McDonough
    Chair Murray, Ranking Member Boozman and distinguished Members of 
the Subcommittee, thank you for the opportunity to testify today in 
support of the President's FY 2024 Budget and FY 2025 Advance 
Appropriations (AA) Request for VA and for your longstanding support of 
Veterans and their families.
    Our Nation's most sacred obligation is to prepare and equip the 
troops we send into harm's way and to care for them and their families 
when they return home. VA is honored to fulfill the promise made to 
care for our brave Veterans throughout their lives. Over the last 2 
years, we have delivered more care and more benefits to more Veterans 
than at any other time in our Nation's history. In FY 2022 alone, the 
Veterans Benefits Administration (VBA) completed more than 1.7 million 
disability compensation and pension claims for Veterans, and set a new 
VA record, breaking the previous year's record by 12%. VA is on track 
to set another year record in FY 2023. During this same period, the 
Veterans Health Administration (VHA) provided more than 115 million 
clinical encounters, with VA serving over 6.3 million patients. This 
included roughly 40 million in-person appointments; over 31 million 
tele-health and telephone appointments; and approximately 38 million 
community care appointments. VA's relentless commitment to Veterans and 
a continued emphasis on fundamentals contributed to VA meeting these 
goals.
    I am incredibly proud to report that for the 7th consecutive year, 
the National Cemetery Administration (NCA) received the top rating 
among participating organizations in the American Customer Satisfaction 
Index, with a score of 97 (out of 100), the highest result ever 
achieved for any organization in either the public or private sector. 
Committed to excellence and dignified committals, NCA interred nearly 
150,000 Veterans and eligible family members in our national cemeteries 
in FY 2022, the highest number of annual interments VA has ever 
recorded. NCA delivered more than 350,000 headstones, markers and 
columbarium niche covers around the world and provided nearly 12,000 
medallions in 2022 to mark the privately purchased headstones of 
Veterans.
    VA appreciates the tremendous work the Congress has done to enable 
VA to achieve these exceptional results and we will continue to partner 
with Congress to secure authorities needed to improve our agility, 
responsiveness and accessibility to more Veterans than ever before. 
Both the Veterans Access, Choice, and Accountability Act (Choice Act) 
of 2014 (Public Law 113-146) and the VA Maintaining Internal Systems 
and Strengthening Integrated Outside Networks (MISSION) Act of 2018 
(Public Law 115-182) made it easier for Veterans to receive care from 
non-VA community providers while continuing to benefit from VA's 
Veteran-centric care coordination. The Veterans Comprehensive 
Preventions, Access to Care and Treatment Act of 2020 (COMPACT Act; 
Public Law 116-214) enabled VA to provide healthcare services to all 
eligible individuals in acute suicidal crisis at no cost both in VA and 
in the community.
    The enactment of the Johnny Isakson and David P. Roe, M.D., 
Veterans Health Care and Benefits Improvement Act of 2020 (Public Law 
116-315) ushered in significant improvements to various GI Bill 
programs, expanded the Veteran Employment through Technology Education 
Courses (VET TEC) program and enhanced education benefits for Veterans, 
Servicemembers, families and survivors. Both the Commander John Scott 
Hannon Veterans Mental Health Care Improvement Act of 2019 (Hannon Act; 
Public Law 116- 171) and the Support the Resiliency of Our Nation's 
Great Veterans Act of 2022 (STRONG Veterans Act; Division V of Public 
Law 117-328) have broadened mental healthcare and suicide prevention 
programs and have advanced VA's efforts in promoting well-being among 
Veterans. The Joseph Maxwell Cleland and Robert Joseph Dole Memorial 
Veterans Benefits and Health Care Improvement Act (Cleland Dole Act; 
Division U of Public Law 117-328) will enhance VA's ability to furnish 
healthcare and benefits to Veterans, including rural Veterans. These 
authorities build upon VA's ability to meet the unique needs of the 
Nations' heroes and ultimately save lives.
    In 2022, Congress passed the Sergeant First Class Heath Robinson 
Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT 
Act; Public Law 117-168). The PACT Act represents the largest expansion 
of Veterans' benefits in a generation, and I am immensely proud that 
our broad efforts, spanning nearly every Administration and office 
within VA, have yielded positive results. We continue to see steady 
increases in the number of toxic exposure-related disability 
compensation claims filed and processed as Veterans' understanding of 
the PACT Act grows. Even with these early successes, there is more to 
do to ensure every possible eligible Veteran receives the benefits and 
healthcare they have earned. Our focus will remain on increasing 
Veteran outreach, processing claims timely, providing healthcare, 
modernizing our IT systems and having the right number of people in 
place to deliver on our promise to Veterans.
    VA greatly appreciates Congress' commitment to providing VA the 
necessary funding to support the PACT Act through its establishment of 
the Cost of War Toxic Exposures Fund (TEF). As we continue to learn 
what the full resource requirements are for this incredibly important 
support to Veterans, we remain committed to transparency and will work 
closely with our partners, as demonstrated through our recent publicly 
available dashboard. The 2024 President's Budget request, including our 
TEF request, will ensure VA fulfills our responsibilities to Veterans, 
Congress and American taxpayers.
                 fy 2024 budget and fy 2025 aa request
    The total 2024 request for VA is $325.1 billion (mandatory and 
discretionary, including collections and the Recurring Expenses 
Transformational Fund (RETF), a $16.6 billion or 5.4% increase above 
the 2023 enacted level. This includes a discretionary budget request of 
$142.2 billion (with $4.3 billion from medical care collections), a 
$3.4 billion or 2.4% increase above 2023. When combined with $600 
million from RETF, the total discretionary funding level is $142.8 
billion, including collections. The 2024 mandatory funding request is 
$182.3 billion, with $20.3 billion for the TEF, an increase of $13.6 
billion or 8.1% above 2023.
    The 2024 Budget again proposes to separate out the VA medical care 
program as a third category within the discretionary budget based on a 
recognition that VA medical care has grown much more rapidly than other 
discretionary spending over time, largely due to systemwide growth in 
healthcare costs. In 2024, the Budget reflects $128.1 billion in 
enacted AA for VA medical care programs, together with a proposed 
cancellation of $7.1 billion in unobligated balances, for a 
discretionary total of $121 billion for VA medical care, which is in 
addition to a $17.1 billion TEF request for medical care.
    The 2025 Medical Care AA request includes a discretionary funding 
request of $112.6 billion, together with a mandatory advance 
appropriation request of $21.5 billion for the TEF. The 2025 mandatory 
AA request is $193.0 billion for Veterans benefits programs 
(Compensation and Pensions, Readjustment Benefits, Veterans Insurance 
and Indemnities), which, together with the TEF, results in a combined 
mandatory total of $214.7 billion.
                                pact act
    The PACT Act is a major factor in the expansion of care and 
benefits to Veterans. In FY 2024, VA will continue to work to provide a 
``One-VA'' experience to all Veterans, survivors, family members and 
caregivers as we proactively work to deliver timely benefits, services 
and high-quality healthcare.
    VA began nationwide PACT Act-related disability compensation claims 
processing on January 1, 2023. As of April 15, 2023, VA has received 
more than 484,000 PACT Act-related claims since August 10, 2022 and 
completed over 227,000 claims. Using the new PACT Act authorities, VA 
has granted service connection for over 2,800 terminally ill Veterans.
    VA began a comprehensive, targeted outreach effort to encourage 
Veterans and survivors to apply immediately for PACT Act-related care 
and benefits. For example, VA hosted 127 PACT Act ``Week of Action'' 
events in all 50 States, the District of Columbia and Puerto Rico. More 
than 50,000 attendees participated in person or online. During these 
events, VA completed 5,600 toxic exposure screenings and received 2,600 
claims for benefits and more than 800 healthcare enrollment 
applications. As of April 19, 2023, more than 3 million toxic exposure 
screenings have been performed.
    VA has been running a robust advertising campaign to educate 
Veterans and their families about the PACT Act. To date, VA has spent 
over $4 million with digital, social and traditional media advertising 
across the country. The campaign's focus is on maximizing awareness of 
the PACT Act, and the call to action to all eligible Veteran survivors 
to apply for these benefits that they have earned and deserve. In FY 
2024, VA will continue to drive paid advertising campaigns as an 
important way to reach Veterans not currently connected with VA or 
Veterans Service Organizations (VSOs). VA will continue to focus on 
marketing efforts on reaching Veterans of all generations, races and 
genders.
    One of the biggest challenges VA will continue to face in FY 2024 
is identifying and contacting survivors, even more so now that many 
more are eligible for benefits under the PACT Act. We have mailed 
nearly 300,000 letters to potentially eligible survivors. VA is also 
leveraging social media and posting YouTube videos to provide easy to 
read information on the PACT Act. VA's goal in FY 2024 is to continue 
to provide information on the PACT Act, not just to survivors 
themselves, but to anyone who may know a survivor so that VA's message 
can reach as many impacted individuals as possible.
    To ensure all eligible Veterans obtain the benefits and care they 
earned through their service, the Budget for VA medical care provides 
$82 million for the Health Outcomes and Military Exposures (HOME) 
Office, an 85% growth over 2022. VHA will regularly screen enrolled 
Veterans for military-related toxic exposures and ensure clinicians 
understand how such exposures affect Veterans' health. VA is working to 
improve the Airborne Hazards and Open Burn Pit (AHOBP) registry and 
will track the VHA healthcare utilization of the PACT Act-eligible 
cohort. To ensure these Veterans receive the highest quality care 
available, the Budget also provides $68 million for Military 
Occupations and Environmental Exposures research, which will yield 
improvements in the identification and treatment of medical conditions 
potentially associated with toxic exposures.
    VA is also committed to recruiting, onboarding and integrating new 
employees across the enterprise to further implement the PACT Act for 
Veterans and survivors. In FY 2023, VA held a series of successful 
hiring fairs. Throughout the next year, VA will continue to hold hiring 
fairs across the country, with an emphasis on hiring Claims Examiners, 
HR Specialists, IT Specialists, nurses and more. In addition, VA has 
actively engaged the workforce through a variety of avenues and 
solicited feedback. These investments in employee engagement will 
continue to be critical as we look to continue to hire more employees 
than ever before. Under the initial TEF spend plan, Congressionally 
approved on October 6, 2022, VA allocated 1,871 positions towards 
claims processors and support staff. As of April 17, 2023, VA has hired 
1,530 of the 1,871 positions (82%). VBA also plans to hire another 
6,720 claims processors and support staff with the additional TEF 
funding provided in the FY 2023 appropriation. In addition, VBA Human 
Capital Services (HCS) secured a PACT Act direct hire authority (DHA) 
from the Office of Personnel Management (OPM) that will expedite the 
hiring of mission-critical occupations through September 30, 2027, for 
Human Resources Management, Human Resources Assistant, General Legal 
and Kindred and Veterans Claims Examining series positions. The DHA is 
used with a system of open continuous announcements that results in a 
steady flow of eligible and available applicants for selection at 
predetermined timeframes that suit the needs of the organization. VBA 
has also created opportunities to increase hiring by hosting on-site 
hiring events designed to connect job seekers nationwide with current 
PACT Act positions for Veterans Service Representative (VSR), Rating 
Veterans Service Representative (RVSR) and Legal Administrative 
Specialist (LAS) positions. VA will continue to leverage all available 
hiring options to ensure we meet our PACT Act hiring goals--including 
the use of expanded hiring authorities provided in Title IX of the PACT 
Act.
                        investing in our people
    Providing world class healthcare is only possible with an 
enterprise-wide team of the best and brightest in their respective 
fields. We are hiring more staff across the Department to ensure that 
care and benefits are delivered in a timely manner while also focusing 
on improving the employee experience to deliver positive outcomes for 
Veterans, their families, caregivers and survivors. VA is investing in 
our people by dramatically increasing hiring, holding surge events to 
onboard staff more quickly, increasing the use of incentives for 
recruitment and retention, maximizing pay authorities and scheduling 
flexibilities, expanding scholarship opportunities and providing more 
education loan repayment awards than ever before. For example, using 
the recently approved DHA for mission critical occupations, VBA was 
able to increase its total workforce by more than 5% (more than 1,300 
employees) in the first 4 months of FY 2023, compared to less than 1% 
growth in the workforce over the same time period in FY 2022.
    A nationwide onboarding event held in November 2022 resulted in 
onboarding more new staff in VHA in the first quarter of FY 2023 
(12,900 staff) than in the first quarter onboarding in any previous 
year. This was 86% higher than the historical average number onboarded 
in the first quarter. Onboarding for VHA continued to be high in 
January 2023 (5,603 new staff onboard, approximately 600 more than last 
January). VHA's emphasis on hiring has resulted in an overall net 
increase of onboard staff of 2.1% as of January 31, 2023. This is 
already two-thirds of VA's annual target of 3% growth just 4 months 
into the fiscal year.
    In FY 2022, VHA nearly doubled the number of scholarships for 
clinical education offered to employees and increased the number of 
Education Debt Reduction Program (EDRP) awards to over 3,000. 
Additionally, the percentage of staff receiving recruitment, retention 
and relocation incentives (3Rs) more than doubled from 5.9% to 12.2%. 
At rural facilities, the use of 3Rs increased from 4.3% to 18.9%. In 
addition, for
    some critical shortage occupations, such as housekeeping aides 
(10.5% to 35%) and food service workers (2.1% to 18.7%), the use of 3Rs 
increased even more dramatically. These incentives reduce losses in for 
critical shortage occupations and help VA successfully compete for 
healthcare and entry level staff.
                     focus on wellbeing of veterans
    VA's 2024 Budget will provide the resources to ensure we provide 
the benefits and services to support Veterans' health and economic 
wellbeing.
                           veterans benefits
    The 2024 Budget includes $3.9 billion in discretionary funding for 
the General Operating Expenses, VBA account, a $36 million increase 
over the 2023 Budget. This includes funds for the Veteran Transitional 
Assistance Grant Program (VTAGP) required under Public Law 116-315, 
Section 4304, and increased overtime funding to support the timely 
processing of claims.
    The President's Budget provides disability compensation and 
survivor benefits to over 6 million Veterans and their families; 
education and job training benefits to 928,000 Veterans and qualified 
dependents; guarantees about 553,000 home loans and funds 15.6 million 
total lives insured for Veterans, Service members and qualified 
dependents.
    Last fiscal year, VBA set a record for the highest claims 
production with more than 1.7 million claims completed. As of April 15, 
2023, VBA already has completed 1,008,879 claims, which is 13.1% more 
claims than last year at this time. Since the PACT Act was signed, as 
of April 15, 2023, Veterans and their survivors have filed more than 
1,473,655 total claims, an increase of more than 28.5% over the same 
period last year. As mentioned above, VBA continues to hire to increase 
its claims processing capacity in anticipation of the influx of claims 
filed due to the PACT Act. VBA developed a robust claims projection 
model which shows what the claims inventory will look like with the 
inclusion of PACT Act claims. In addition to hiring, VBA is reviewing 
processes and developing technology to address the growing complexity 
of claims. Using Automated Decision Support technology, VBA is 
automating multiple administrative tasks within the claims process such 
as locating and compiling information from Veterans' electronic 
records, verifying military service eligibility for PACT Act claimants, 
ordering examinations when required, and expediting claims that can be 
decided based on the evidence of record. The PACT Act authorizes the 
use of appropriations to modernize and expand the capabilities and 
capacity of information technology (IT) systems and infrastructure at 
VBA.
                        prevent veteran suicide
    VA has made suicide prevention a top clinical priority and is 
implementing a comprehensive public health approach to reach all 
Veterans. Funding for mental health, including suicide prevention, is 
$16.6 billion in FY 2024, up from $15 billion in FY 2023. Our 
commitment to a proactive, Veteran-centered Whole Health approach is 
integral to our mental healthcare efforts and includes online and 
telehealth access strategies.
    Whole Health can help Veterans reconnect with their mission and 
purpose in life as part of our comprehensive approach to reducing risk.
    Suicide is a complex issue with no single cause. Maintaining the 
integrity of VA's mental healthcare system is vitally important, but it 
is not enough. We know some Veterans may not receive any healthcare 
services from VA. To support this nationwide effort, the budget 
specifies $559 million for suicide prevention outreach programs, in 
addition to $2.5 billion in suicide-specific medical treatment, which 
includes a new $10 million program to further bolster these efforts 
under the authority of section 303 of the STRONG Veterans Act.
    In 2022 and 2023, VA conducted a $20 million open innovation grand 
challenge, known as ``Mission Daybreak'', to accelerate the development 
of solutions across the Nation to reduce Veteran suicide. ``Mission 
Daybreak'' is part of VA's 10-year strategy to end Veteran suicide 
through a comprehensive, public health approach. VA launched the 
multiphase challenge in May 2022, receiving more than 1,300 concept 
submissions from Veterans, VSOs, community-based organizations, health 
tech companies, industry startups and universities. Mission Daybreak 
Phase I selection of 30 Grand Challenge finalists was completed in 
November 2022 and 10 Mission Daybreak innovation winners were announced 
on February 16, 2023.
    The Staff Sergeant Parker Gordon Fox Suicide Prevention Grant 
Program (SSG Fox SPGP) awarded $52.5 million to 80 community-based 
organizations in 43 States, the District of Columbia and American Samoa 
in FY 2022. These organizations provide or coordinate the provision of 
suicide prevention services for eligible individuals, including 
Veterans and their families. VA has provided technical assistance to 
grantees, who began providing suicide prevention services in January 
2023. Twenty-one grantees serve Tribal lands including the Navajo 
Nation, Cherokee Nation, Choctaw Nation, Alaskan Native Tribes and 
others. Funding decisions prioritized grants to rural communities, 
Tribal lands, Territories of the United States, areas with medically 
underserved groups, areas with a high number or percentage of minority 
Veterans or women Veterans and areas with a high number or percentage 
of calls to the Veterans Crisis Line. In alignment with VA's National 
Strategy for Preventing Veteran Suicide, SSG Fox SPGP assists in 
further implementing a public health approach that blends community-
based prevention with evidence-based clinical strategies through 
community efforts. The FY 2024 Budget plans to award $52.5 million in 
grants.
    The Veterans COMPACT Act created a new authority in 38 U.S.C. 
Sec. 1720J for VA to provide healthcare services to all eligible 
individuals in acute suicidal crisis at no cost both in VA and in the 
community. This provision increases access to care and is in full 
alignment with VA's National Strategy for Preventing Veteran Suicide. 
VA published an interim final rule on January 17, 2023, and immediately 
began providing this new benefit to eligible individuals. As part of 
implementation VA developed a robust communications plan targeted 
toward eligible individuals, Veterans and community providers. VA 
continues to aggressively address critical cross-platform information 
technology enhancements to ensure that multiple administrative and 
clinical systems work seamlessly together to ensure timely and 
efficient care at no cost. We are committed to ongoing education and 
training efforts within VA and in the community as we deploy this new, 
life-affirming benefit in our ongoing suicide prevention efforts.
    Women Veterans carry an especially high burden of mental health 
conditions. These include gender-specific conditions associated with 
heightened suicide risk, such as premenstrual dysphoric disorder, 
postpartum depression and perimenopausal depression. Among eligible 
women receiving VHA care, nearly 60% are diagnosed with at least one 
mental health condition (as compared to 37.8% of eligible men), and 
many struggle with multiple mental health concerns, medical 
comorbidities and psychosocial challenges. VA has implemented numerous 
initiatives to ensure VHA mental health providers have the expertise to 
address women Veterans' unique and diverse treatment needs and assess 
and address their risk for suicide, and we are committed to expansion 
of these innovations. VA is also ramping up efforts to increase the 
visibility of all VA services for women Veterans, including developing 
a cadre of women Veteran- focused peer support resources and outreach 
campaigns. Today's women Veterans need to know what VA has to offer.
    Among the risk factors for suicide, substance use disorder (SUD) is 
strongly implicated. In addition, drug overdose fatalities inclusive of 
suicide have escalated. Therefore, the need for effective interventions 
to address substance use cannot be overstated. The President's Budget 
includes $254 million to improve VA's opioid safety initiative and to 
continue our joint work with DoD in the field of pain management, 
consistent with the requirements of the Comprehensive Addiction and 
Recovery Act of 2016 (Public Law 114-198, Title IX, Subtitle A, 
Sec. Sec. 911-912, the Jason Simcakoski Memorial and Promise Act). VA 
is also expanding evidence-based SUD treatment and harm reduction 
initiatives consistent with the Biden-Harris Statement of Drug Policy 
Priorities. The President's Budget includes $231 million supports VA 
staff initiatives to support Veterans specific needs, including 
employment, housing, case management, peer support, as well as in-
patient and out-patient care.
    Furthermore, VA's budget continues to support expansion of its 
Psychotropic Drug Safety Initiative to address the growing crisis of 
stimulant use overdose fatalities. This initiative ensures the safe and 
appropriate prescribing of stimulant medications as well as expanding 
Veterans' access to evidence-based treatments for stimulant use 
disorder. These include cognitive-behavioral therapy and contingency 
management, both of which are recommended by the 2021 VA-Department of 
Defense (DoD) Clinical Practice Guidelines for the Management of SUDs.
    President Biden's continued focus on the national mental health 
crisis recognizes that access to mental healthcare is challenging. VA 
continues to evaluate staffing needs and prioritizes mental health 
hiring and training. However, we recognize that hiring additional 
mental health staff in VA will not resolve the growing demand. To 
address President Biden's vision to increase system capacity, connect 
Veterans to care and create a full continuum of support for Veterans, 
VA is committed to being the Nation's leader in ongoing research 
enhancing current mental health treatment, identifying new mental 
health interventions and developing effective prevention and at- risk 
identification protocols. Ongoing Congressional support for VA Mental 
Health Centers of Excellence, the Mental Illness Research, Education 
and Clinical Centers, and mental health research initiatives through 
the Health Services Research and Development Service will be essential 
as VA continues to address access, mental healthcare and suicide 
prevention.
                       health care budget request
    Providing Veterans access to the soonest and best care is at the 
core of our mission. Over the last 2 years, VA has delivered more care 
to more Veterans through both VA and community care providers than 
during any time in the Nation's history.
    Veterans completed more than 73 million outpatient appointments in 
VA and an additional 38 million community care outpatient appointments 
in calendar year (CY) 2022. While enrolled Veterans continue to receive 
most of their outpatient care in VA, more than 3.5 million Veterans 
have completed at least one outpatient appointment with a community 
care provider since we implemented the VA MISSION Act of 2018. As such, 
more than one third of all Veterans enrolled in VA healthcare have been 
eligible for and chosen to receive at least one community care 
appointment at some point in the last 5 years.
    Veterans today have more options for care through VA than ever. 
This includes care delivered both in-house and by our network of 
community providers. More specifically, VA has more than 1,100 VA 
medical centers (VAMCs) and community- based outpatient clinics (CBOCs) 
in which Veterans may receive their care. VA offers care in-person, 
over the phone or through video appointments as clinically appropriate. 
VA's community care network has more than 1.3 million community care 
providers across all 50 States, Territories and possessions of the 
United States, The District of Columbia and the Commonwealth of Puerto 
Rico. Enrolled Veterans also have access to community urgent care, and 
all eligible individuals have access to emergent suicide care.
                              whole health
    Whole Health is an approach to healthcare that empowers and equips 
Veterans with the ability to take charge of their health and well-being 
and to live their life to the fullest. Transforming VA into a Whole 
Health system of care has successfully launched and is receiving full 
support at both the national and local levels, including strong 
endorsement in a recent National Academy of Medicine report. In FY 
2022, 16.3% of all Veterans receiving care through VA also received 
Whole Health services. This care was delivered to 1.1 million Veterans 
through 3,998,602 encounters which were both Whole Health-specific and 
which integrated the Whole Health approach into routine clinical 
encounters. Tele-Whole Health encounters have grown to include 98,000 
unique Veterans participating in 513,000 encounters in FY 2022, an 
increase of 39.0% unique patients and 32.9% of encounters over FY 2021. 
Robust formal evaluations continue to focus on outcomes for Veterans 
and employees, which includes a review of specific cost avoidance that 
is traceable to implementation of Whole Health Services (e.g., opioid 
use reduction, decrease in spinal procedures). The 2024 President's 
Budget for Whole Health includes $108 million. VA is fully committed to 
making the Whole Health approach an integral part of how we deliver 
care to Veterans and our employees.
                             women veterans
    Women make up 17.2% of today's Active Duty military forces and 
21.1% of National Guard and Reserves. VA continues to reach out to 
women Service members and Veterans, to encourage them to enroll and use 
the services they have earned. As a result, the number of women 
Veterans enrolling in VA healthcare is rapidly increasing.
    More women are choosing VA for their healthcare than ever before, 
with women accounting for over 30% of the increase in Veterans served 
over the past 5 years. Investments support comprehensive specialty 
medical and surgical services for women Veterans at a VA facility or 
through referrals to the community. The number of women Veterans using 
VA services has more than tripled since 2001, growing from 159,810 to 
more than 625,000 today. VA is committed to providing high quality, 
equitable care to women Veterans at all sites of care.
    The Budget requests $257 million for women's health and childcare 
programs, a 66% increase over 2023. This increase supports $174 million 
for the Women's Health Innovation and Staffing Enhancement Initiative. 
VA is strategically enhancing services and access for women Veterans by 
hiring women's health personnel nationally to fill any gaps in capacity 
across all Veterans Integrated Service Networks (VISNs). In FY 2023 VA 
is providing funding for a total of over 1,000 women's health personnel 
nationally: primary care providers, gynecologists, mental health 
providers and care coordinators.
    VA is also addressing clinical equipment needs such as those for 
mammography, exam tables designed for women with low mobility, and 
breastfeeding privacy pods. VA is also expanding childcare benefits 
beyond the current pilot sites.
    To support pregnant and postpartum Veterans, VA has developed a 
Maternity Care Coordination (MCC) program in all VA healthcare systems 
to ensure coordination of care both in VA and in the community. This 
program includes expanding follow-up with Veterans for the particularly 
vulnerable first year postpartum, as well as providing lactation 
services, training, toolkits and support community of practice.
    VA is focusing on enhancing care coordination for preventive care, 
such as breast cancer screening. VA is implementing the Dr. Kate 
Hendricks Thomas Supported Expanded Review for Veterans in Combat 
Environments Act (SERVICE Act, Public Law 117-133); beginning in March 
2023, VA is providing SERVICE Act breast cancer risk assessments to 
Veterans eligible under that Act (generally those who served in certain 
locations where burn pits were used during the Gulf War and the Post-9/
11 era) with referral for mammography as clinically indicated. Breast 
and cervical cancer screening programs require meticulous tracking to 
ensure that all eligible Veterans receive appropriate screening and 
receive results of screening tests, and that follow-up care is arranged 
as needed. VA policy requires each facility to have a process for 
tracking results and timely follow-up for breast and cervical cancer 
screening. VA policy also requires that facilities have personnel 
assigned to breast and cervical cancer care coordination. To ensure 
accuracy, timeliness and reliability, VA tracks the provision of breast 
and cervical cancer screening and the availability of breast and 
cervical cancer care coordinators across the system. VA is also 
implementing section 603 of the PACT Act by conducting toxic exposure 
screening for all enrolled Veterans, including women Veterans. The 
Breast and Gynecologic Cancer System of Excellence is providing state- 
of-the-art breast and gynecologic cancer care and care coordination 
across the system through VA's tele-oncology program.
                           homeless programs
    VA's longstanding support for Veterans who are homeless or at risk 
of homelessness is enhanced through taking a Whole Health approach. VA 
will ensure Veterans who are housed in VA programs do not return to 
homelessness by implementing a case management model to mitigate risk 
factors. VA will also leverage its existing programs through targeted 
outreach to reduce the number of unsheltered Veterans.
    The 2024 Budget increases resources for Veterans' homelessness 
programs to $3.1 billion, with the goal of ensuring every Veteran has 
permanent, sustainable housing with access to high-quality healthcare 
and other supportive services to end and prevent future Veteran 
homelessness. This Budget includes funds to assist with the design and 
development of expanded services for aging and disabled Veterans, a 
growing need and area of focus for the Department of Housing and Urban 
Development (HUD)-VA Supportive Housing (VASH) program. In addition, 
funds will be used to provide a medical home model and population 
tailored approach to provide in-home primary care and wrap around 
services to Veterans actively enrolled in the HUD-VASH program, provide 
additional resources to increase outreach and community engagement 
efforts, as well as expansion of Veteran justice services, such as 
treatment courts and Veteran-focused criminal justice initiatives. 
Funding will also support the VA Grant and Per Diem (GPD) program to 
increase per diem rates to community partners actively supporting VA's 
effort to end Veteran homelessness.
    On a single night in January 2022, there were 33,129 Veteran 
experiencing homelessness in the U.S. However, significant progress is 
being made to prevent and end Veteran homelessness. Since 2010, efforts 
by VA and our Federal partners have led to a more than 55% reduction in 
Veteran homelessness. Since 2015, there have been 83 communities and 
three States (Delaware, Connecticut and Virginia) that have met the 
criteria and benchmarks established by the U.S. Interagency Council on 
Homelessness, for effectively ending Veteran homelessness. 
Additionally, in CY 2022, VA permanently housed more than 40,000 
homeless Veterans, exceeding our permanent housing goal for CY 2022 by 
more than 6%.
                                research
    The 2024 Budget requests a total of $984 million for research 
through the Medical Prosthetics and Research account and TEF. These 
combined resources will improve Veterans' health and well-being via 
basic, translational, clinical, health services, rehabilitative, 
genomic and data science research; apply scientific knowledge to 
develop effective individualized care solutions for Veterans; attract, 
train and retain the highest- caliber investigators and nurture their 
development as leaders in their fields; and ensure a culture of 
professionalism, collaboration, accountability and the highest regard 
for research volunteers' safety and privacy.
                    military environmental exposures
    In FY 2024, the Office of Research and Development (ORD) will 
expand its investment in this important area and to coordinate with 
environmental exposure focused programs as part of the implementation 
of the PACT Act. Critical components of this effort in FY 2024 are 
building capacity (including the number of researchers funded to 
conduct military exposures research) and building inter-governmental 
partnerships. One major step forward is convening an interagency 
workgroup on toxic exposure research, called for in Section 501 of the 
PACT Act, to identify evidence gaps and craft a strategic plan to 
address gaps.
               traumatic brain injury (tbi)/brain health
    Increased investment in TBI remains critical as it is the signature 
injury of post- 9/11 Veterans who served in the wars in Iraq and 
Afghanistan. While the acute care of TBI has improved, treatments for 
the longer-term consequences most relevant to Veterans have proven 
elusive. This injury can lead to lifelong disabilities that can vary by 
severity, the characteristics of the event or events that caused the 
injury (e.g., blast versus blunt force) and the number of incidents of 
injury.
  mental health, including continued execution of projects under the 
                               hannon act
    This request supports mental health and suicide prevention 
research, including the Hannon Act. This effort also includes clinical 
trials and epidemiological studies on risk and prevention factors, as 
well as biomarker-driven precision mental health projects done in 
collaboration with VHA's Office of Mental Health and Suicide 
Prevention.
                     cancer and precision oncology
    VA is committed to promoting measurable progress toward President 
Biden's Cancer Moonshot initiative. To that end, VHA's research and 
clinical oncology programs both collaborate with the National Cancer 
Institute (NCI) and other external entities to maximize Veterans' 
benefit from cutting edge improvements in oncology care (for example, 
by increasing Veterans' access to clinical trials). The 2024 Budget 
includes $94 million to support 369 research projects to improve our 
ability to diagnose and treat cancers.
    Clinical trials are often part of standard clinical care for 
patients with cancer and are a second area of clinical-research 
integration in Precision Oncology. Together, these elements form a 
System of Excellence for the full spectrum of care for a particular 
cancer type. Systems of Excellence are established for Prostate/
Genitourinary Cancers and Lung. In 2024, VA will expand on the Rare 
Cancers System of Excellence, add additional molecular testing 
capabilities, enhance the pathology and laboratory infrastructure and 
partner with DoD and others to improve cancer care through the White 
House Cancer Moonshot.
    The Budget invests $33.3 million within VA's cancer research 
programs, together with $215.4 million within the VA medical care 
program, for precision oncology to provide access to the best possible 
cancer care for Veterans. The vision of VA's Precision Oncology 
Initiative is for Veterans to have access to care as close to their 
homes as possible that is comparable to the Nation's leading cancer 
centers. Funds support research and programs that address cancer care, 
rare cancers and cancers in women, as well as genetic counseling and 
consultation that advance tele-oncology and precision oncology care. 
The 2024 investment for precision oncology represents a 31% increase 
over 2023.
                               caregivers
    VA expanded its Program of Comprehensive Assistance for Family 
Caregivers (PCAFC) to eligible family members and eligible Veterans of 
all service eras on October 1, 2022. From that date through February 8, 
2023, VA received over 44,300 applications. Originally, PCAFC was only 
available to eligible Veterans who incurred or aggravated a serious 
injury in the line of duty on or after September 11, 2001. On October 
1, 2020, VA expanded the program to eligible Veterans who incurred or 
aggravated a serious injury in the line of duty on or before May 7, 
1975, or on or after September 11, 2001. As of February 8, 2023, there 
are over 45,500 Veterans participating in the PCAFC across the country, 
including U.S. Territories and 98% of PCAFC applications are 
dispositioned in under 90 days.
    The Budget recognizes the important role of these family caregivers 
in supporting the health and wellness of Veterans. The $2.4 billion 
included in this Budget supports staffing, stipend payments, the 
Program of General Caregiver Support Services (PGCSS), training and 
education, as well as other services to empower family caregivers of 
eligible Veterans. In addition, this funding allows for further 
improvements and enhancements, such as extending telemental healthcare 
to caregivers, allowing VA to reach and support more caregivers than 
before.
    VA is currently undertaking a broad programmatic review of the 
PCAFC to ensure it meets the needs of Veterans and their family 
caregivers. While this review is underway, VA has suspended annual 
reassessments for participants of the PCAFC. VA will not discharge or 
decrease any support to PCAFC participants and their family caregivers, 
based on reassessment, to include monthly stipends paid to primary 
family caregivers, as the current eligibility criteria are examined.
    As we look to the year ahead, VA seeks to build upon the CSP 
program with an emphasis on the ``Year of the Caregiver.'' The Year of 
the Caregiver is about ensuring caregivers know they belong to a 
community that cares. Through this theme, VA is not only adding to what 
it offers to caregivers but focusing on how it is offered and 
implementing and improving support and services for caregivers of 
Veterans.
          transforming systems, processes, and infrastructure
    VA is transforming systems, processes and infrastructure in order 
to achieve operational excellence, increase productivity and ensure 
that systems and processes are easy to use by both the staff and the 
Veterans we serve. Outcomes for Veterans drive everything we do--
because Veterans are the ultimate judges of our success.
                         digital transformation
    VA continues its Digital Transformation journey with the Office of 
Information and Technology (OIT) providing the infrastructure, 
engineering, leadership and functions to deliver world-class IT 
products and services and to improve the end-user experience for 
Veterans, their families, caregivers and survivors.
    Modern Veteran IT services include telehealth services with VA care 
teams, seamless transition of healthcare information from DoD to VA 
systems, acceleration of benefit claims processing, and improved 
customer digital interactions. To become the Best IT Organization in 
Government, OIT's 2024 Budget includes $6.4 billion in discretionary 
funding for continued transformation efforts from modernization of 
aging infrastructure, efficient delivery of IT services to VA employees 
and enhancement of the Veteran experience.
    The Budget prioritizes Cybersecurity, the Infrastructure Readiness 
Program (IRP) to reduce technical debt, Financial Management Business 
Transformation (FMBT), Human Resource IT Solutions, Telehealth Services 
and Claims Automation that allows for timely access to benefits and 
care for Veterans. Notably, the cybersecurity budget includes $927 
million (combined Base Budget and TEF) to deliver enterprise-wide 
cybersecurity strategies, policy, governance and oversight to protect 
Veteran data and VA critical information systems. Also, the 2024 Budget 
invests in the implement of Zero Trust Architecture (ZTA) principles. 
Our goal is to secure Veterans' data--where it may live--while allowing 
legitimate access to Veteran and VA data.
    Further, the 2024 Budget includes re-platforming for VA's oldest 
legacy systems onto modern low-code/no-code Platform as a Service 
(PaaS) and Software as a Service (SaaS) solutions. This will satisfy 
the increased demand for new IT capabilities, free space for clinical 
purposes and enhance IT infrastructure services.
             electronic health record modernization (ehrm)
    We readily acknowledge there have been challenges with our efforts 
to modernize VA's electronic health record (EHR) system. As we work 
through the challenges, our commitment remains unwavering--to provide 
world-class patient care and prioritize patient safety for the Veterans 
we serve. Though there is still a lot of work to do, important progress 
has been made since our first go-live in Spokane. For example, VA 
requested corrective actions within the Oracle Cerner database 
configuration that resulted in an 8-month period without a complete 
outage. We also continue to improve the system based on feedback from 
our healthcare personnel in collaboration with Cerner. On February 17, 
2023, the three priority pharmacy enhancements were installed as part 
of the Block 8 upgrade to the EHR system. These enhancements are an 
important step in resuming EHR system deployment and will reduce burden 
on personnel at the five sites using the new EHR.
    Last week, I announced that future deployments of the new EHR will 
be halted while we prioritize improvements at the five sites that 
currently use the new EHR, as part of a larger program reset. During 
this reset, we are focused on assessing and remediating any identified 
issues at live sites, with a continued focus on patient safety. When we 
move forward with deployments, we will, of course, incorporate lessons 
learned and implement continued improvements we have identified, so 
that we can achieve the benefits of a modern EHR system. We strive to 
have a system that will support improved access, outcomes and 
experiences for Veterans, through a single health record from entry 
into military service through their VA care.
    VA and Cerner are currently working toward an amended contract that 
will increase Cerner's accountability to deliver a high-functioning, 
high-reliability, world-class EHR system. Also, as part of the reset, 
VA is committed to working with Congress on resource requirements. VA 
estimates FY 2023 costs will be reduced by $400 million.
    In addition to the funding requested for the EHRM account, VHA's 
Medical Facilities request includes $750 million in Non-Recurring 
Maintenance (NRM) funding for facility EHR infrastructure projects, 
which will also support IT operational improvements.
    The EHR has been deployed to five VAMCs, including 22 CBOCs and 52 
remote sites with more than 10,000 medical personnel using the system, 
serving more than 200,000 Veterans. As improvements continue to be made 
over the next few months, VA will continually evaluate the readiness of 
each site as well as the EHR system to ensure success. To be clear, we 
will not go live at any site with unresolved safety critical findings, 
yet we remain firm in our resolve to continue modernizing the EHR.
                                  fmbt
    The FMBT program is increasing the transparency, accuracy, 
timeliness and reliability of financial and acquisition activities 
across the Department. The 2024 Budget includes $394.7 million 
(including General Administration, Information and Technology, Supply 
Fund and Franchise Fund sources) for FMBT, a program that is improving 
fiscal accountability to taxpayers and enhancing mission outcomes for 
our employees who serve Veterans. So far, we have completed five 
successful deployments of the new Integrated Financial and Acquisition 
Management System (iFAMS) across NCA, VBA and staff offices, all of 
which have provided invaluable lessons learned and numerous 
opportunities to improve our approach. As part of FMBT's commitment to 
continuous improvement, we continue to work with stakeholders and end 
users to proactively adjust our deployment approach to better manage 
the complexities inherent in a financial and acquisition system 
transformation effort of this magnitude. Each implementation brings us 
one step closer to providing a modern, standardized and secure 
integrated solution that enables VA to meet its objectives and fully 
comply with financial management and acquisition mandates and 
directives. As of February 2023, there have been over 2.1 million 
transactions successfully processed in iFAMS, and over $6 billion in 
payments made through the Department of the Treasury.
    Deployment of iFAMS is taking place in phased implementations, 
called ``waves,'' across VA administrations and staff offices. In just 
a few months, we will go live with our largest system rollout yet. This 
includes some of VA's largest staff offices and will increase the 
current iFAMS user base by almost 50%. In December 2023, we will 
deliver an iFAMS upgrade, which will provide substantial enhancements 
to system performance, functionality and ease of use. iFAMS will also 
go live for VBA Loan Guaranty later in FY 2024 and continue system 
rollouts across the remaining VA administrations and staff offices 
until enterprise-wide implementation is complete.
                             infrastructure
    The President's 2024 Budget includes $4.1 billion for construction 
requirements--$3.5 billion in Major and Minor Construction 
appropriations in addition to $600 million in estimated unobligated 
balances from RETF planned for Major Construction requirements. Funding 
for two major medical facility projects, including the St. Louis 
Replacement Bed Tower, Clinical Building Expansion, Consolidated 
Administrative Building and Warehouse, Utility Plan and Parking Garages 
project supporting over 149,000 Veteran enrollees, and two national 
cemetery expansion projects are included in the request. The 2024 
Budget includes $112 million in major construction funds for a 
gravesite development project at Tahoma National Cemetery and a 
gravesite expansion project at Jefferson Barracks National Cemetery. 
The Budget also includes $182.6 million in Minor Construction funds for 
gravesite expansion and columbaria projects to keep existing national 
cemeteries open and for projects that address infrastructure 
deficiencies and other requirements necessary to support national 
cemetery operations. RETF will provide funding for eight additional 
medical facility Major Construction projects, bringing the total to 12 
major construction projects funded in FY 2024. In addition, VHA's 
Medical Facilities account includes $5.75 billion for NRM.
    VA's robust FY 2024 capital request reflects infrastructure's 
importance in enabling the delivery of care and benefits and doing so 
in ways that are sustainable and resilient as guided by Executive Order 
14057. For example, the PACT Act significantly expands benefits, and VA 
must plan for infrastructure required to support this increase in 
healthcare for Veterans.
    The VA infrastructure portfolio consists of approximately 184 
million owned and leased square feet which is one of the largest in the 
Federal Government, but is rapidly aging and deteriorating. While the 
median age of U.S. private sector hospitals is 13 years, the median age 
of VA's portfolio is 60 years. With aging infrastructure comes 
operational disruption, risk and cost. VA's 2024 Budget highlights the 
importance of modernizing our infrastructure to maintain and expand our 
portfolio and support the continuing mission growth.
    As part of our Budget request, the Department has included 
mandatory funding for one ongoing Major Construction project and the 
completion of various Minor Construction projects that improve VHA 
facilities. This mandatory funding helps ensure appropriate and 
required investment in the infrastructure to prevent service delivery 
disruptions in the future.
    Also included in VA's 2024 Budget request are 10 major medical 
facility leases totaling over 1.5 million square feet of space 
supporting cutting-edge research and a workload of over 1.7 million 
outpatient stops and bed days of care. These leases are key to 
modernizing VA's clinical points of care and increasing access for the 
increasing number of Veterans anticipated to access VA care because of 
benefit expansion offered by the PACT Act. These leases will also be 
the first to go through the new PACT Act committee resolution approval 
process.
    VA has previously presented the need to fully upgrade and modernize 
our facilities to meet the service delivery objectives expected of 
modern healthcare delivery infrastructure, bringing them up to the 
standards Veterans deserve. VA's aggressive 2024 Budget sets us on this 
path to modernize or replace outdated VAMCs with state- of-the-art 
facilities. Additionally, VA is aggressively working to pursue 
implementation of the goals of Executive Order 14057, which creates a 
broad set of challenging goals and requirements for Federal agencies to 
eliminate their carbon footprint and make their operations more 
sustainable and resilient.
                      honoring veterans' legacies
    The President's 2024 Budget includes $480 million for NCA's 
operations and maintenance account, an increase of $50 million (11.6%) 
over the 2023 Budget, to ensure Veterans and their families have access 
to exceptional burial and memorial benefits including expansion of 
existing cemeteries as well as new and replacement cemeteries. With 
this Budget, NCA will provide for an estimated 140,472 interments, the 
perpetual care of almost 4.3 million gravesites and the operations and 
maintenance of 158 national cemeteries and 34 other cemeterial 
installations in a manner befitting national shrines. This request will 
fund 2,331 full-time equivalents needed to meet NCA's increasing 
workload, while maintaining our reputation as a world-class service 
provider.
    While every eligible Veteran may be interred at any one of VA's 
open national cemeteries and a significant majority of the 122 VA 
grant-funded Veterans cemeteries, VA realizes that proximity to a 
cemetery is an important consideration in whether Veterans and family 
members choose a VA-funded cemetery for their final resting place. For 
this reason, NCA is committed to providing 95% of the Veteran 
population with access to first interment burial options (for casketed 
or cremated remains, either in- ground or in columbaria) in a national 
or State Veterans cemetery within 75 miles of the Veteran's place of 
residence. VA has made continuous, significant progress towards meeting 
that target. In 2024, 93.9% of the Veteran population will be served 
with such access. The 2024 Budget also includes $60 million for the 
Veterans Cemetery Grants Program to continue important partnerships 
with States and Tribal organizations. This grants program plays a 
crucial role in achieving NCA's strategic target of providing 95% of 
Veterans with reasonable access to a burial option.
    Additionally, the 2024 Budget continues NCA's implementation of the 
Veterans Legacy Memorial (VLM), the Nation's first digital platform 
dedicated to the memory of more than 4.5 million Veterans interred in 
VA's national cemeteries and VA-funded state, territorial and tribal 
Veterans cemeteries. VLM allows family, friends and others to preserve 
their Veteran's legacy by posting tributes. NCA will also use grant 
funding requested in the 2024 Budget to provide Veterans Legacy Grants 
to tell the stories of Veterans interred in our national and grant-
funded cemeteries, with an emphasis on those from underrepresented 
communities.
                               conclusion
    Chair Murray, Ranking Member Boozman, thank you for the opportunity 
to appear before you today to discuss our progress at the Department 
and how the President's FY 2024 and FY 2025 Advance Appropriations 
Request will serve the Nation's Veterans.

    Senator Murray. Well, thank you very much, Mr. Secretary. 
We all do have your opening statement. Members are encouraged 
to read it, and I appreciate that consideration.
    So we will now begin a round a five-minute questions on our 
panel. And I ask my colleagues to keep track of your clock, as 
always.
    Mr. Secretary, over the last few years our veterans medical 
needs have really grown, which has, of course, required more 
funding to ensure that they are getting the care they need, and 
this growth in spending has put significant pressure on our 
nondefense discretionary budget.
    Medical care is an earned benefit of service, and this 
committee has always ensured that VA has the resources to meet 
our veterans' medical needs. This year's budget request assumes 
relatively flat funding in discretionary medical care accounts, 
and a higher rate of growth in spending on treatment for toxic 
exposed veterans in the Toxic Exposures Fund. Can you tell us 
what is driving that assumption?
    Secretary McDonough. Yeah. The main issue is the one that 
you identified in your opening statement, which is that our 
initial requests were submitted before the establishment of the 
TEF. We have a very simple principle at the Department, which 
is that we are going to use TEF for TEF. Meaning, as The PACT 
Act envisioned, any incidental dollar above fiscal year 2021 
base for toxic exposure, will be funded through the Toxic 
Exposure Fund.
    We think that is in keeping with the statute, therefore, in 
keeping with what Congressional intent was. But also allows us, 
as we have in the past, for example with the MISSION Act, and 
before that with the CHOICE Act, to establish very clearly 
where those additional dollars are going. And so we have talked 
through this methodology that the way we have come to the $20 
billion marker in the TEF with your teams, we will continue to 
work through that with them.
    My commitment to each of you, going back to last summer; 
that we will be very transparent about how we spend the money 
in that TEF, remains. I have also had conversations with our 
Inspector General to ask him to increase his oversight, as it 
relates to our use of the TEF; but that is the real issue, it 
is an accounting issue, and it is our desire to try to be 
consistent with Congressional intent in the PACT Act from last 
summer.
    Senator Murray. Okay. And given the relatively low growth 
between fiscal year 2024 and 2025 in advance, is VA 
anticipating a large second bite request next year?
    Secretary McDonough. No. In fact, you know, we will 
obviously, we do not anticipate that today, we will obviously 
be clear with you, and transparent with you, if we get a sense 
that we will need it but--and I know, you know, you don't 
traditionally appreciate the second bites.
    We don't, necessarily, anticipate one today. That is 
because of range of things, including one of the issues that 
Senator Boozman raised, which is, we do have some unobligated 
funds from the pandemic. We anticipate using all of those, and 
that will and obviate the need for us to come ask for a second 
bite. And I never want to say never, but we feel pretty good 
about how this year, and the out-year look.
    Senator Murray. Okay. And as we have talked about last year 
Congress did pass the PACT Act, so we can fulfill our 
commitment to make sure veterans receive the care and support 
they earned, including veterans who experience toxic exposures. 
And I really do appreciate VA's commitment to implement the law 
swiftly to make sure our veterans get this care.
    Based on what the Department has experienced to date, what 
is the demand for health care and benefits related to the PACT 
Act, and how does it compare to your initial projections?
    Secretary McDonough. Yeah. We have anticipated--we have 
kind of two projections that we are tracking, one is claims 
filed, and how a subcategory of that is how we anticipate the 
backlog tracking with claims filed. So far, on both of those 
things, we are about spot on, on our assessment for how many 
claims we anticipate being filed this year. We are about 30 
percent above where we were a year ago today.
    The backlog we are a little bit ahead meaning we are over 
performing our assessment as related to how much backlog we 
anticipate. Nevertheless, we will continue to track that 
closely. We published that number every Monday morning on our 
website. We will continue to brief your teams about that. That 
is on the claim side.
    On the care side, you know, we anticipated veterans using 
this open enrollment period during this year, as anticipated in 
the Act, to come in and seek additional care. To be honest, I 
think we are a little softer in terms of new care being 
provided to veterans in this window than we would have 
anticipated, but again it is pretty early in this process.
    Senator Murray. Meaning, there is fewer?
    Secretary McDonough. Meaning, there is fewer than we 
anticipated.
    Senator Murray. Mm-hmm.
    Secretary McDonough. But we still see net-net. Over 10 
years, we are looking at between, you know, three-quarters of a 
million, and a million new veterans, and then obviously an 
intensification of services among veterans already in our care.
    Senator Murray. Okay. Thank you very much.
    Senator Boozman.
    Senator Boozman. Thank you, Madam Chair. Over the last 
several years in this Committee, and in the Authorizing 
Committee, many of us are on both. We have heard about the 
difficulties in hiring that you have experienced. We have given 
you some flexibility, and as a result of that the VA has become 
a more attractive place to work.
    Particularly in light of the PACT Act, is VA meeting its 
hiring goals, both on the clinical side and the benefits side? 
And are you still seeing clinical staff shortages in rural 
areas, and what more can we do, as a committee, to help you?
    Secretary McDonough. Senator Boozman, thank you very much 
for the question. We feel like we are making good progress on 
our hiring goals. The assessments that I just talked about with 
Chairwoman Murray, really recognize that the experience at VA, 
although we are making progress on automating certain pieces of 
our claims process, for example, we are of still a very people-
intensive agency.
    So we have very aggressive hiring goals for this year in 
Veterans Health Administration (VHA) and in Veterans Benefits 
Administration (VBA), and so far, to date, halfway through the 
fiscal year, a little bit more than halfway through the fiscal 
year, we are ahead of those goals. Importantly, we feel like we 
have had a good first-half of the year on priority clinical 
roles including nurses. We have hired 5,473 RNs, registered 
nurses, 1,009 LPNs, and 1,524 nursing assistants.
    In a system as large as ours, those numbers may not sound 
that impressive, until you recognize that last July was the 
first month, in a couple of fiscal years, that we hired more 
nurses than we lost.
    And so we are seeing something change in the nursing 
market, we are very excited about that, much of that is related 
to the authorities that you have given us in the PACT Act, and 
the authorities you gave us in the RAISE Act last year.
    Now, this is lumpy, meaning there are still places in the 
country where the nursing market is very, very tight and so we 
have vacancies. We also have places where specialists are very, 
very tight. And this a place where we still need some help.
    Senator Tester and you have been helping us on something 
called the VA CAREERS Act, which will get us out from under an 
antiquated way of paying many of our physician specialists, and 
many of our hospital CEOs, which requires us to top them out at 
$400,000 a year. And in this healthcare market we are just not 
competitive at that level, so we could use some relief there.
    Lastly, at VBA, the Veterans Benefits Administration, we 
have, over the course of the last about 14 months, hired net 
about 4,200 personnel. We are very competitive there, we are 
adding people, and importantly, we are getting them trained and 
on the job, which is why this year, for the first fiscal year 
ever, we have had 38 days of more than 8,000 claims processed 
in a day.
    The most we have had, until this year, has been six days in 
an entire fiscal year. We are just halfway through; we have 
already had 38 days, at more than 8,000 claims.
    Senator Boozman. Very good. Well, that is encouraging.
    Secretary McDonough. Yeah.
    Senator Boozman. Again, especially in such a difficult 
labor market, particularly, concerning health care.
    Secretary McDonough. Yes.
    Senator Boozman. Tell me about the $1.9 billion in 
mandatory major construction funds, most of which is for a new 
hospital in St. Louis, and some of which is to cover cost of 
inflation for existing projects. Major construction is usually 
a base discretionary requirement, and the St. Louis Hospital 
has been a known requirement for many years.
    Why did the Department choose to request those in mandatory 
funds?
    Secretary McDonough. Yeah. That is a great question, and I 
appreciate it. I appreciate both the question and the comments 
you made in your opening. I acknowledge that it is an unusual 
way to fund the major construction account, but it is that 
because, frankly, the way we have funded infrastructure, 
particularly major construction infrastructure projects at VA, 
has not served us well.
    The best indication of that, is in the last 10 years we 
have built only four new hospitals, and that is in a system 
where the median age of our hospital is 62 years old, and if we 
continue to build the major construction projects at that rate, 
there is no way we will keep up with current demand, let alone 
the demand that is going to come from an aging of our older 
veterans, and then, hopefully, if we continue implementing the 
PACT Act as well, and as aggressively as we are, the increased 
demand will come from those new entrants into our care.
    So we went with a mandatory request because we recognized 
that the discretionary requests and the discretionary process 
that we followed for the last many years, which each year you 
all, very generously, fund at the levels we request, and each 
year, each of the first 2 years of the Biden request, we asked 
for historically high levels, and you gave it to us.
    But what we have noticed is at those levels, we are just 
not able to meet the demands that we have in a system with such 
aging facilities.
    Senator Boozman. Okay. Thank you, Madam Chair.
    Senator Murray. Thank you. Senator Tester.
    Senator Tester. I want to start by thanking both you and 
the Ranking Member for having this hearing, and thank you both 
for the work that you do on the Senate Veterans Affairs 
Committee. I very much appreciate it.
    Secretary McDonough, it is good to have you here. The newly 
released House budget plan called the Limit, Save, Grow Act 
would cap 2024 discretionary spending at 2022 levels for 
everything but defense. And Senator Collins and I appreciate 
that they didn't cap defense.
    But in my real life I am a farmer, so things like the Farm 
Bill are pretty important, and when I did a Farm Bill listening 
session in the most conservative part of our State of Montana, 
not one person came up and said we want to cut it, all of them 
said----
    Secretary McDonough. It is very important.
    Senator Tester. What is that?
    Secretary McDonough. I said the Farm Bill is very 
important.
    Senator Tester. Yeah, it is. And that is exactly right, and 
Ranking Member would know that too. How we manage our forest 
land is very important. How we put we will put money in 
domestic infrastructures, the Bipartisan Infrastructure Bill, 
very important. And not the last, but the PACT Act is pretty 
darn important, and we did some really good work on the PACT 
Act, both the folks to my left, all the folks to my left did 
some great work on it, and we end up--and the right too, by the 
way--and we end up, and we end up with a proposal that is going 
to cut the funding.
    Could you talk to me about what this does to your budget, 
and what the impacts are to Veterans? I don't care about your 
agency, tell me what the impacts are to the veterans you serve?
    Secretary McDonough. Yeah. Thank you very much. Very 
concretely, if you were just to take what we just talked about, 
in terms of our hiring success for VBA, the numbers anticipated 
in the bill being debated in the House would force us to 
reduce, by 6,000, the claims personnel in VBA, which is 
meaningful for veterans, because we need those increased 
numbers of personnel that we hired, 4,500 in the last--4,400 in 
the last 14 months, to process claims.
    That is how we are processing more than 8,000 claims a day. 
So what we will see is the backlog of claims grow, and what 
that means is, veterans having to wait for those compensation 
payments until we can work through that longer list.
    Secondly, on health care, we anticipate that the numbers, 
currently being debated in the House, may result in 30 million 
fewer outpatient visits. And again even in a system as big as 
ours, 30 million fewer outpatient health care appointments is a 
very meaningful diminution and access to care. It means fewer 
cancer screenings, means fewer wellness visits, mean fewer 
mental health care treatment, and substance use disorder 
treatment appointments.
    That just gives you a sense of some of the concerns that we 
have on the benefits on the health care side.
    Senator Tester. I want to talk a little bit about building 
needs, mandatory, discretionary, when you put them all together 
does this budget decrease the amount for building hospitals, 
and you said there was four over the last 10 years. And by the 
way, you said they were 62 years of age. And I am here to tell 
you 62 is not old.
    But does the discretionary and the mandatory--is that a 
reduction of 36 percent? Or do those two balance one another 
out so that you can address, I believe it is $130 billion over 
the next 10 years for building projects?
    Secretary McDonough. Yeah. So in fact, when we take the 
request all in----
    Senator Tester. Yes.
    Secretary McDonough. [continuing]. We anticipated a $10 
billion infrastructure request for this year. That is for 
nonrecurring maintenance for minor and for major construction. 
And the reason that each of those is important is the 
nonrecurring maintenance, which is large, more than $5 billion, 
almost $6 billion when you anticipate the cost associated----
    Senator Tester. Okay.
    Secretary McDonough. [continuing]. For non-recurring 
maintenance with EHRM, allows us to keep these existing 
facilities up to clinical standard.
    Senator Tester. Right.
    Secretary McDonough. The minor construction is new clinics 
like the ones in Montana, the major construction is, 
overwhelmingly, for St. Louis, and we have to prove concept 
that we can build new hospitals in a timely way under budget, 
which I think we have done in the course of the last couple 
years.
    Senator Tester. So is that compared to last year's budget, 
2023 budget.
    Secretary McDonough. Yes.
    Senator Tester. Is the $10 billion the same, less, or more 
than.
    Secretary McDonough. More.
    Senator Tester. Okay. All right; sounds good. So I want to 
talk about workforce just for a second--oh, no. I am not. I am 
out of time. Well, I will put it for the record, and we will go 
from there. I know you need a lot of folks.
    Secretary McDonough. Thank you.
    Senator Tester. Thank you.
    Senator Murray. Senator Collins.
    Senator Collins. Thank you, Madam Chair. Like the Chair, I 
am the daughter of a World War II veteran who fought in the 
Battle at the Bulge, was wounded twice, earned two Purple 
Hearts and a Bronze Star. So making sure that our veterans 
receive the care that they have earned is personally very 
important to me.
    Last year, Maine Veterans' Homes, announced its intention 
to close two of the six veterans homes around the state. 
Fortunately, these proposed closures, which would have been 
devastating for our veterans and for their families, were 
blocked.
    Maine Veterans' Homes facilities in rural parts of our 
state fill a critical need, and they allow our veterans to stay 
close to their loved ones. One of the homes targeted for 
closure was in my hometown of Caribou, where my father spent 
the last months of his life.
    At my request last year the fiscal year 2023 Appropriations 
Bill directed the VA to report on various actions the 
Department or Congress could take to expand support for state 
veterans' homes, especially in rural areas at risk of closure. 
Possible solutions include, increasing the per diem 
reimbursement rates, expanding eligibility for care, and 
actions to address the critical shortage of health care 
professionals.
    That report is due to be delivered to Congress at the end 
of this month. In the meantime, can you share with us your 
suggestions for ways that we can partner to support these rural 
state veterans' homes that are so vital to our veterans?
    Secretary McDonough. Yeah. Well we, I think we are very 
proud of our partnership with the states and our joint efforts 
to fund the state veterans' homes. We have, mindful of the 
demands in the states, we have now maxed out what we can do for 
per diem, which is one way that allows us to support veterans 
in state-run homes. And then we are looking for ways to 
increase the grant funding that we make to the states every 
year.
    So you will see that the President's request this year 
anticipates an increase on last year's investment for the state 
grant levels. Last year, itself, was an increase, and a 
historically high one at that. So we are continually looking 
for ways to increase our partnership, and the Federal portion 
of that partnership, either through per diem, or through grants 
as we develop new facilities.
    Lastly, that nonrecurring maintenance, which is a big part 
of our infrastructure request at 5.2 billion, envisions us, 
making sure that we are doing our part in facilities, including 
in places like Maine where, given extreme weather, we have 
fairly significant nonrecurring maintenance requirements. So in 
each of these channels we are trying to crank the volume as 
much as we can.
    Senator Collins. Thank you. Another action that would help 
our state veterans' homes, would be for the VA to finish 
quickly its rulemaking to implement legislation--
    Secretary McDonough. Great.
    Senator Collins [continuing]. I authored, that was enacted 
into law in December of 2020. This law requires the VA to 
implement a waiver authority to provide the flexibility to pay 
per diem for veterans with the early-stage dementia, when that 
is in the best interest of the veteran.
    However, more than 2 years have passed since the enactment 
of this legislation, and the VA is still in the rulemaking 
process. Why has it taken so long to complete this rulemaking? 
And could you give us an update?
    Secretary McDonough. Yeah. Well, the update I can give you 
is that, I am as frustrated as you are with the slowness of it. 
So my commitment to you is that we get--we will get this done 
with dispatch. And you know, we do have a stack up of 
regulations, especially out of the big statutory packages at 
the end of 2020, and at the end of 2022. But that is no excuse. 
We will make sure that we get this done.
    Senator Collins. Thank you. I know my time has expired, so 
I will submit the rest of my questions for the record. I would 
note that the Office of Rural Health has been flat-funded in 
the President's budget, and that is of great concern to me.
    Secretary McDonough. Yeah. You know, that is, last year we 
saw a significant increase in the office, so what you see is 
us, over the course of a couple of years, significantly 
increasing funding for that office. So I acknowledge that it is 
flat this year. Last year was a historically high-level 
increase, and obviously we fund investments in our rural 
communities through a variety of channels.
    So we will stay on top of this, and if you see something 
that we are not funding, an otherwise, very generous request, 
we will obviously adjust to that. But we thought that after 
historically high levels last year, we couldn't necessarily 
justify a similar increase this year.
    Senator Collins. Thank you.
    Senator Murray. Thank you. Senator Baldwin.
    Senator Baldwin. Thank you, Madam Chair.
    Welcome Mr. Secretary.
    Secretary McDonough. Thank you.
    Senator Baldwin. As we have discussed, I have been working 
with Wisconsin veterans, who raised concerns about the quality 
of the compensation and pension exams that they receive for 
traumatic brain injury, and other neurological disorders. 
Although the VA considers these exams administrative rather 
than clinical, I learned from these veterans that an erroneous 
negative opinion, not only impacts disability claim decisions, 
can have substantial impacts on the veteran's mental health, or 
the likelihood that they will seek additional medical care for 
the condition that they have been, incorrectly, told that they 
do not have.
    What is the VA doing to improve the compensation and 
pension exam process, and achieving better oversight of this 
critical part of the disability claims process?
    Secretary McDonough. Yeah. Thank you, Senator. Obviously, 
this is a significant concern, as I have characterized to you 
in private setting as well. And we see this as a challenge, and 
hear from veterans that this is a challenge, including, 
although we are making good progress on this, in cases of 
military sexual trauma.
    The same thing where a veteran is denied, probably 
unjustifiably, and that has not insignificant mental health 
impacts, as well as knock-on health impacts, but we--and our 
Acting Under Secretary, Josh Jacobs, has taken this issue on 
very aggressively. We are building incentives and disincentives 
into our C&P Exam contracts. This is a function that is 
overwhelmingly carried out by contractors although that was not 
the case in Tomah.
    Senator Baldwin. In response to--
    Secretary McDonough. So we are trying to increase our--we 
are actively increasing our oversight of the conduct of the 
exams, and that we are building in quality metrics, incentives 
to increase quality, and then disincentives, obviously to 
``disincent'' what are, obviously, shoddily carried out C&P 
Exams. This is a perennial challenge for us, and we will stay 
on top of it.
    Senator Baldwin. Thank you. Secretary McDonough, I want to 
thank you for your strong support in the budget for the Jason 
Simcakoski Memorial and PROMISE Act; this law continues to hold 
the VA accountable and strengthens oversight of provider opioid 
prescribing practices, and provide safer care for our veterans.
    There have been significant improvements in the VA since 
Jason's law was first implemented, but there is still work that 
needs to be done. I would ask for your commitment to briefing 
my staff on how the VA is enforcing compliance and 
accountability for providers when prescribing opioids. And I 
might note the measure also looks at the interaction between 
opioid prescribing and benzodiazepines.
    But I would ask that you update my staff on that 
compliance, and the progress that we are making since that law 
was passed.
    Secretary McDonough. You have my commitment.
    Senator Baldwin. Thank you. And my last area is to note 
that I was pleased to see strong support in your budget for 
community-based suicide prevention efforts. In addition, to our 
great veterans' service organizations, county and tribal 
veteran service officers play a crucial role in ensuring that 
our veterans receive the benefits and care that they deserve.
    A modest 1,700 accredited service officers, nationwide, are 
actually responsible for processing more than $42 billion in 
claims annually. Those veteran service officers at the county 
and tribal level, are basically funded locally. And so my 
bipartisan bill, the Commitment to Veterans Support and 
Outreach Act, would authorize the VA to provide grants for 
county and tribal VSOs to better support our Nation's veterans.
    And I am hopeful that the Senate is on track to pass this 
legislation this week or next. Would you support the additional 
resources, and support to county and tribal veterans service 
officers authorized in my bill?
    Secretary McDonough. We have made it a priority to support, 
and tightened the partnership with county VSOs, and we have, 
for the first time ever, dramatically expanded the 
authorization of new tribal VSOs, we did that first in New 
Mexico with Senator Heinrich. We are doing it now in Alaska, 
and so we are all for this. I think in the past we have had our 
support for your bill, contingent on getting additional 
resources to help us pay for it.
    We, you know--it is a little bit embarrassing to 
acknowledge that in a budget this big that we don't see the 
overhead to cover it, but we think it is important. We will 
find the money to--we would like to make sure that it comes 
with money to fund the authorizations. But in all cases these 
are really important partners to us, and we are looking for 
ways to increase that partnership.
    Senator Baldwin. Thank you.
    Senator Murray. Senator Hoeven.
    Senator Hoeven. Thank you, Madam Chair.
    Secretary, thanks for being here this morning, appreciate 
it.
    Secretary McDonough. Thank you.
    Senator Hoeven. Appreciate your work on behalf of our 
veterans. I know you are very familiar with the Rural Cemetery 
Initiative Program, and the first rural initiative cemetery is 
Fargo National Cemetery, which I know you are also familiar 
with, coming from the part of--our part of the country.
    This cemetery actually serves North Dakota, probably much 
of South Dakota because their cemetery is way on the west side, 
and all of Western Minnesota. So already, we are expanding it. 
And you know, it is really good news in that the National 
Cemetery Association is acquiring another 30 acres to expand, 
which is fantastic. And the veterans' groups, the local 
veterans' groups and the community want to take steps to 
further enhance it.
    And so we are challenged in terms of how to do that. We are 
looking at either an option for maybe the city to acquire some 
of that land from the cemetery, so they could put some nice 
facilities on it, or provide a matching grant, or something 
like that. But we are running into problems with the ``how''.
    And I am certainly willing to come back here, and add some 
legislation, or whatever we need to do, if that is required. 
But I guess my ask would be, if I could just--and Secretary 
Quinn--Assistant Secretary Matthew Quinn has been really good 
to work with. I want to commend him and thank him. But I would 
really like to sit down with you, and find out what you think 
would work best, and make sure it is something you support so 
we can move forward. So that would be my ask.
    Secretary McDonough. You have got my commitment on that. 
Yeah.
    Senator Hoeven. Thank you so much for that. And again it--
this is just a great example of what the Rural Cemetery 
Initiative was designed to do. So we are we are very excited 
about it, and very appreciative. The other thing I want to ask 
you about is, this was kind of a complicated one but, it is in 
regard to trying to make sure that veterans can use their VA 
benefits when they go into a nursing home.
    And so often they can't because a nursing home won't accept 
VA reimbursement, because in addition to all of the reviews 
they have to do for Medicare or Medicaid under CMS, if they use 
VA reimbursement then they also are subject to the Office of 
Federal Contract Compliance Programs (OFCCP), which, you 
probably know exactly what that is, but it is such a--anyway it 
is a whole another set of requirements, which requires an 
additional review, and additional standards for these nursing 
homes. So very often they won't take VA reimbursement.
    That is a big problem for our veterans, because they have 
to dissipate all their resources before they would go on 
Medicaid if they go in the nursing home, whereas, they don't if 
they can use their VA benefit, you know, provided they qualify 
based on service.
    So the VA put a moratorium on that in place. In other 
words, they exempted TRICARE from OFCCP, permanently, but they 
just put a moratorium on for the nursing homes, and that 
expires on May 7th.
    Secretary McDonough. Yeah just in a couple weeks.
    Senator Hoeven. So I just want to urge you to take a hard 
look at that, because we are trying to get more nursing homes 
to take VA, you know, reimbursement for the reasons I 
mentioned, not less. So I welcome any thoughts you have, but 
that is a really important issue. It is one I have worked on 
for quite some time.
    Secretary McDonough. Yes.
    Senator Hoeven. We did pass legislation in the MISSION Act 
that gives you the ability to do this.
    Secretary McDonough. Yes.
    Senator Hoeven. And you have already done it for TRICARE.
    Secretary McDonough. Yes. So I think it is DOD who did the 
action for TRICARE.
    Senator Hoeven. Okay.
    Secretary McDonough. And we are--I just got your letter on 
this the other day. I appreciate you raising it.
    I was not tracking the issue, but I am now, so you asked us 
to look hard at it. I will. And I will make sure that we get 
back in touch with you before this May 7th, yes.
    Senator Hoeven. And really the requirements, I mean, are 
covered under Medicare and Medicaid because the nursing homes 
are subject to those rules already.
    Secretary McDonough. Right.
    Senator Hoeven. So it is a redundancy that creates a whole 
another exam, and sometimes additional requirements.
    Secretary McDonough. Yes.
    Senator Hoeven. Because you have got a different exam team, 
and all that kind of thing.
    Secretary McDonough. Yes.
    Senator Hoeven. The last thing I would just mention, is 
also in Fargo we are working on a Fisher House. And again, this 
is kind of a layup, but just your support to keep you got that 
moving.
    Secretary McDonough. You got it.
    Senator Hoeven. What a great program.
    Secretary McDonough. Yes. Fisher House, that their 
generosity, and what it means for veterans and their families 
is just terrific. And so we are trying to deepen that, and make 
that as robust as we possibly can.
    Senator Hoeven. Yes. For veterans and their families, it is 
a great program.
    Secretary McDonough. Awesome.
    Senator Hoeven. Yes. Thank you Secretary, very much.
    Secretary McDonough. Thank you.
    Senator Murray. Thank you. Senator Peters.
    Senator Peters. Thank you, Chair Murray.
    Secretary McDonough, great to see you, and, you know, 
excellent care for Michigan's more than 500,000 veterans is a 
priority for me. And you and I have spoken about those veterans 
many times. And I know that that is a priority for you as well. 
It is something week we clearly share.
    But back in September of last year, Senator Stabenow and I 
were alarmed to learn about the Office of Medical Inspector 
Report that revealed a crisis of care at the John Dingle VA 
Medical Center in Downtown Detroit. Leadership and managerial 
failures at the facility exacerbated shortcomings in care 
leading to, basically, a culture of distrust, and low-patient 
as well, as employee morale.
    In September, Senator Stabenow and I called on the VA's 
Inspector General to conduct an independent investigation into 
allegations of misconduct at the facility, and an investigation 
was launched shortly after that, although we are still awaiting 
the results of that investigation.
    More recently, Senator Stabenow and I have also called for 
the VA to initiate, as soon as permissible, the process of 
appointing permanent leadership at the facility capable of 
delivering the world-class care that our nations certainly have 
earned, and I know you are committed to provide.
    So my question for you, Mr. Secretary, is I understand that 
the recommended reforms in the Office of Medical Inspector have 
now been implemented. I want to know, are those reforms leading 
to documented improvements in veteran care and culture at that 
facility at this time? What is your assessment?
    Secretary McDonough. Yes. Thanks very much. Obviously, we 
have been, and I continue to be, very alarmed about the 
reporting out of Detroit and we are taking every step to get to 
the bottom of it, to ensure that good care continues, and as 
importantly, to ensure that veterans have confidence that they 
will get good care when they go.
    The recommended improvements laid out by the office of the 
medical inspector are in--have been implemented, but what we 
have asked, and based on your interjection and ours, the IG is 
doing, the Inspector General is doing, is assessing whether--
how effectively those changes have been implemented.
    So I just talked to him about this on Monday of this week. 
He and I have a very active dialogue on Detroit in particular. 
And so rather than me give you our view of how it is going 
there, I think it is really important that we get the IG's 
independent look at whether our performance, as against those 
recommended steps, is what it should be.
    So I anticipate that happens in the relatively near future. 
I think we are talking about weeks or months, rather than 
months or years on that. So I hope we have news on that soon.
    Senator Peters. Right, great.
    Secretary McDonough. Okay.
    Senator Peters. And you have expressed to me, your 
intention to visit the Detroit VA Medical Center to meet with 
the veterans and staff I think quite soon?
    Secretary McDonough. Yes. You asked for my commitment on 
that. I gave it. And you invited me, but I understand what 
those kind of invitations mean, which is like, I better get 
myself out there, so.
    Senator Peters. Yes. Thank you for that.
    Secretary McDonough. Yes.
    Senator Peters. I appreciate that. And hopefully we can do 
that soon.
    Secretary McDonough. Yes.
    Senator Peters. Last year, I led a letter on behalf of 28 
bipartisan senators calling for robust funding for the VA State 
Veterans Home Construction Grant Program.
    Secretary McDonough. Yes.
    Senator Peters. And as you know, that program allows states 
to modernize their existing facilities, and begin construction 
of new sites. Currently, there are more than $600 million in 
unfulfilled grant requests by the states. I think that clearly 
demonstrates the states are eager?
    Secretary McDonough. Yes.
    Senator Peters. And willing and prepared to take on this 
important responsibility, as well as a share of the cost for 
caring for these veterans. In Michigan the grant program has 
allowed for replacing the Michigan Veterans Home in Grand 
Rapids, and constructing a new Veterans Home in Macomb County.
    In addition, the Michigan State Legislature recently 
appropriated funding for a long, long overdue replacement of a 
Veterans Home in Marquette, in Michigan's Upper Peninsula, 
while breaking ground on the facility is contingent on 
receiving a Federal Grant.
    So my question for you, Mr. Secretary, is: Can you speak to 
the importance of adequate funding for the VA State Veterans 
Home Construction Grant Program, as we look at a very lengthy 
list from states for these improvements?
    Secretary McDonough. Well, we think it is a really--as I 
was just saying to Senator Collins, we think this is a very 
successful program. We think that the way we structure this, 
whereby, the states put in 35 percent of the cost, and then we 
had VA, with the generosity of the taxpayer, cover the other 65 
percent has, you know, a very concrete manifestation of that 
partnership.
    We obviously though, given the enormity of the list have to 
prioritize those requests from the states. And we have an 
elaborate very transparent process that allows us to do that. 
But we can only get so far down the list, and this is why the 
President has asked for another increase in that grant-funded 
program this year.
    I know that you have been supportive in the past of 
increasing that, I have told you privately, and I reiterate 
publicly, our appreciation for that. And hope that we can 
continue to grow that, so we can get more and more of our 
senior vets into quality long-term care.
    I will just say, this is one of the real sleeper challenges 
for us at VA which is senior veterans experiencing mental 
health crisis.
    Senator Peters. Mm-hmm.
    Secretary McDonough. Perhaps with no family, or estranged 
from family, with a history of behavioral health challenges, we 
end up having, in many markets, in many cities, that is the 
fastest growing cohort of our homeless veterans: geriatric, 
seniors--geriatric veterans with acute mental health disorder.
    Our partnership with the states helps that, our work with 
HHS helps that, our own Community Living Centers helps that, 
but we have got to get ahead of this, because it is the start 
of this crisis. It is not the end of it,
    Senator Peters. Right. Well, I appreciate your commitment.
    Thank you, Chair Murray.
    Senator Murray. Thank you. Senator Fischer.
    Senator Fischer. Thank you, Madam Chairman, and Ranking 
Member.
    Thank you for being here today, Mr. Secretary.
    Secretary McDonough. Thank you.
    Senator Fischer. I certainly appreciated the call that we 
had last week. Many veterans, including 40 percent of veterans 
in Nebraska live in rural areas, often hours away from the VA 
health facilities that are available. And this means that many 
of these veterans rely on the VA Community Care Program to 
receive the health care services that they need.
    Unfortunately, at issue, that I continue to hear about from 
veterans and providers in Nebraska; are the problems with 
communication between the community care providers and the VA, 
providing veterans with timely referrals for care that they 
could receive in their own communities.
    The VA has carried out pilot projects in Orlando, Florida, 
and Columbia, South Carolina, to improve communication, and 
that coordination between the VA and those community care 
providers. However, the VA has not carried out a similar 
project that especially focuses on rural areas.
    Secretary McDonough. Right.
    Senator Fischer. Do you believe that a similar project 
focusing on improving communication and coordination between 
the VA and these community care providers, such as, critical 
access hospitals would be beneficial?
    Secretary McDonough. You know, it may be, but the period, 
and I think the most effective thing we can do is just 
implement the overall project, and the overall program more 
effectively. I hate to think that we have to keep doing pilot 
projects. And so maybe the thing to do is that we work with the 
Nebraska leadership, and we just select a handful of the 
problem cases that you are hearing about. And we first fix 
them. And then do some kind of root cause analysis to say: What 
was the issue in the first instance here?
    I think the reason I raise that is because, frankly, what 
we see in different states, is that everybody is different, 
whether they are rural, highly rural, urban, suburban, and I am 
kind of, to be honest, as much investment as we make in the 
community health program, I am getting, as I know you are, 
tired of having to develop new pilots or new programs. We just 
need to implement this program effectively.
    So I guess what I am saying is: Maybe we just go jointly 
together and figure this out with some with some of those cases 
rather than, you know, retrospectively, so as to fix it going 
forward, rather than build a whole new pilot to execute.
    Senator Fischer. Yes. I would look forward to working with 
you on that. And as I said we have a number of critical access 
hospitals all across the State of Nebraska.
    Secretary McDonough. Yes.
    Senator Fischer. I know of one in particular, they are very 
interested in being able to serve as a regional hub, so that 
veterans can access that care, and as I said, have that 
communication that is vital for them to get their needs met.
    Secretary McDonough. Yes.
    Senator Fischer. So yes. I would welcome the opportunity to 
work with you.
    Secretary McDonough. Maybe I will come--we visited one such 
hospital--I visited one such hospital with Senator Moran, in 
Kansas. And it was actually very informative to me. So maybe we 
just--let us figure out a time, I will come out, we will go to 
that hospital, and let us get to the bottom of it.
    We are spending more and more every month in the community, 
and I am worried about that for a lot of reasons.
    Senator Fischer. Mm-hmm.
    Secretary McDonough. Mostly for sustainability reasons, but 
we still have problems with our partners. And so it is not for 
a lack of funding, it is clearly for lack of mechanics, and we 
just have to fix this. You know?
    Senator Fischer. Okay.
    Secretary McDonough. And I would like to get to the point 
where you guys don't feel like you have to pass a new law to 
force us to do this. So let us see if we can do this together.
    Senator Fischer. I would too. I would too.
    Secretary McDonough. Yes.
    Senator Fischer. I would welcome you to Nebraska.
    Secretary McDonough. Good.
    Senator Fischer. Let us work on that?
    Secretary McDonough. Good.
    Senator Fischer. Great. Also the Veterans Cemetery Grant 
Program, we talked about that as well. These are for--to help, 
I guess, to ensure that veterans who live far away from a VA 
National Cemetery, for them to be able to have that access to a 
dedicated cemetery. But unfortunately, in recent years, there 
is a backlog that we are seeing on those projects, moving 
forward.
    Can you talk about the importance that you see in 
increasing the funding for that grant program; and how the VA 
intends to address the growing backlog that we have there?
    Secretary McDonough. Yes. Thank you very much. As I 
indicated to you privately, you know, each Memorial Day I go to 
a new state-funded cemetery that we that we are adding grant 
funding to. I think it is a really important manifestation of 
our personal commitment to that, and this is similar to the 
state veteran homes, which is, there is just an increasing 
number of requirements as against a program that, historically, 
you know, we are finding ourselves having to grow. So the whole 
question here is: Can we grow the size of that program to get 
farther down the backlog every year.
    And so, we feel our responsibility is to show that the 
program works, make it work effectively, and efficiently. We 
have this back and forth with OMB, and then we will, obviously, 
have a back and forth with you guys to prove to you that we can 
invest those dollars wisely. We think this is a good investment 
and, you know, the states put some money in--some skin in the 
game, and we do too, and we think it is a good program.
    Senator Fischer. Okay. Thank you very much.
    Thank you, Madam Chair.
    Senator Murray. Thank you. Senator Heinrich.
    Senator Heinrich. Secretary, earlier in this hearing you 
detailed some of the national progress you have been able to 
make on hiring.
    Secretary McDonough. Yes.
    Senator Heinrich. But you and I both know that there are 
particular communities, especially some with CBOCs that are 
hard to hire in, really hard to hire in. And you know, I 
appreciate that you visited the Gallup CBOC with me back last 
year, I think it was June. We both talked at that point about 
the lack of a physician at that facility, where 9 months later 
we still don't have a physician at that facility; far into New 
Mexico, similar situation with a psychiatrist position.
    What can we do to give you tools to be able to address some 
of the particular communities where it is hard to hire in? The 
ones that have either a shortage of housing which many of us 
are experiencing now, or because of their remoteness, it is 
particularly hard to get professionals to move to? How can we 
crack some of these nuts in rural, really hard-to-staff 
locations?
    Secretary McDonough. Yes. So yeah, thank you. And I want to 
make sure that I wasn't unclear. That as enthusiastic as I am, 
and as proud as I am of the two best hiring quarters that we 
have had in VA in 25 years, I also acknowledge that there are 
still--it is very lumpy meaning--
    Senator Heinrich. Yes.
    Secretary McDonough. [continuing]. There are places where 
there are still huge vacancies.
    Senator Heinrich. Right.
    Secretary McDonough. Obviously, Gallup is one of those. And 
I acknowledge that again. You gave us the ability in the PACT 
Act to use things like the relocation bonus, the retention 
bonus, to use those more effectively. That helps. We do need 
authority for, and this is what Senator Boozman and Senator 
Tester are getting at with the VA CAREERS Act, for certain of 
our providers, and included in this are psychiatrists, to not 
be capped out at $400,000 a year.
    And there are plenty of places where that the rurality 
combined with the noncompetitive salary just makes it an 
impossible nut to crack. So we need to get out from under that 
cap, that second point.
    So more effective use of the bonuses you have given us. We 
need more authority for specialists in particular, and we are 
hopeful that we get some progress there.
    Then we have to look at, what are the specifics in each 
individual market. And sometimes that is going to be housing, 
and I think we have tools that we can use there, sometimes that 
is going to be locality pay, and that is just too slow, you 
know, and this is a big issue for you, and this came to my--it 
came into stark relief when we were together in New Mexico. And 
we need some help from OPM on that, but we are moving that 
dial.
    And then the last thing is special incentives like housing. 
We do have housing in the National Cemeteries Administration 
(NCA), in some cases. So we are looking at whether there are 
not similar authorities available to the Veterans Health 
Administration, for example, to allow us to house professionals 
the way we do, in some cases, cemetery directors, in highly 
rural settings. So I don't have news for you on that, but that 
is that is an example of things that we are doing.
    Senator Heinrich. I look forward to working with you on 
that. I know it is an issue that touches many of the folks on 
this committee. I am incredibly proud of what we did last year 
in passing the PACT Act. But I have been surprised that I have 
actually heard from a number of veterans who are not on social 
media, some who don't have reliable Internet, for example, who 
were not even aware of the PACT Act's passage.
    We need to reach those folks. We need to make sure that 
they know that some of these exposures are covered. How are we 
going to do that for those particularly, you know, not social 
media connected, sometimes not Internet connected veterans in 
rural and tribal areas, who don't yet know that their exposure 
to burn pits, their exposure to radiological events, is covered 
under this new law?
    Secretary McDonough. Yes. We just have to keep working 
this. And it is true that we have deployed some interesting 
social media tools, but that is by no means the extent of what 
we are doing, we are doing, you know, traditional media, we are 
doing mailings. I want to get to the point, where, because of 
performance at VA, veterans talk to each other that: Hey, you 
know, I had a bad experience but I gave it another look, and 
when I went in they actually resolved my claim.
    So we recognize that this is kind of all--we need to 
communicate on all channels. We want to work with you, as we 
have talked about. We want to work with the House members, we 
are working with the state directors of Veterans Affairs, we 
are working with the governors, and we are working with veteran 
serving--service organizations, and veterans serving 
organizations to get out there.
    Senator Heinrich. Great.
    Secretary McDonough. I was just here in Northeast 
Washington on Saturday at a volunteer event. These are social-
media-connected veterans. They had no idea about the PACT Act 
either. So this is in every corner, we have to get better at, 
you know, connecting with what we call ``untethered veterans''; 
veterans not currently in our care. And when we do that then we 
will have realized the promise of this Act. Until then, we 
won't.
    Senator Heinrich. Madam Chair, I am out of time here. I am 
going to have a question on genomic sequencing in the Million 
Veteran Program.
    Secretary McDonough. Yes.
    Senator Heinrich. That I will be sure and submit for the 
record. Thank you, Secretary.
    Secretary McDonough. Great. Thank you.
    Senator Murray. Thank you. Senator Murkowski.
    Senator Murkowski. Thank you, Madam Chair.
    Mr. Secretary, good to see you. Thank you for coming to 
Alaska. I appreciated the fact that you followed through on 
your commitment from this last budget hearing, that you were 
going to come to Alaska. And you said you wanted to do it in 
winter. You did it. And I really appreciated the fact that you 
made that trip. And I know that your presence was also 
appreciated at the renaming of the Colonel Mary Louise 
Rasmuson, a VA Medical Campus there. So thank you very much.
    Tying into what Senator Heinrich has mentioned, just in 
terms of how we reach our veterans, whether it is to explain to 
them the opportunities under the PACT Act, is what we can be 
doing with those who are off-road. And well, you didn't quite 
make it out to the smaller villages. You made it out to Bethel; 
you got a sense as to the lack of connection that so many of 
our veterans feel in a highly rural state.
    So I want to thank some of your team in Alaska, for I think 
being creative, looking to find some surplus funds to get out 
there, and meet veterans where they are. I have proposed the 
creation of an Off-Road Veterans Outreach Program, some support 
funding to get out, and then get those vets who can't drive, to 
a facility, so that they can get their questions answered.
    I am assuming that that is something, that kind of an 
outreach is something where you guys could be helpful with 
this. I look forward to working with you on that.
    We had an opportunity, after your trip, we talked a little 
bit about the Palmer Pioneer Home, and the situation that they 
are facing. They had a tough winter out there. The roof is 
desperately in need of repair. And I had asked you if you felt 
that this facility was going to be high enough up on the list 
where they could receive some program funding for this year.
    And I don't know if we are going to be in a better place. 
But I guess the question to you would be is: What level of 
funding does this subcommittee need, to fund this program, so 
that projects like a really significant roof failure, could 
mean?
    Secretary McDonough. Yeah. That is a fair question, and I 
don't I didn't come with an answer on that.
    Senator Murkowski. Okay.
    Secretary McDonough. So why don't you let me--if it is okay 
with you--let me take and talk with our team, and send you an 
answer to that question. And we will send it to the Chair, and 
Senator Boozman, too.
    Senator Murkowski. Yes. I would appreciate that. I think 
you recognize that we don't have much of a contingency plan 
there in Alaska. This is it.
    Secretary McDonough. Yes. It is cold up there.
    Senator Murkowski. There is one facility there with limited 
numbers of beds, and you just don't, literally, need the roof 
falling in.
    Secretary McDonough. Yes.
    Senator Murkowski. So if you can help us out with getting 
back on that. VA air ambulances--recently VA issued a final 
rule that would reduce the reimbursement rate of emergency air 
medical services to the Medicare rates, which, there is a real 
fear that this is not going to be covering the actual cost of 
the transport. We have heard from a lot of vets who are hearing 
about this.
    They are really concerned because, again, coming from 
Bethel, you have got to have an air medivac. Coming from any of 
the villages it is air medivac. Has VA considered what the 
impact could be on the lives of some of our rural veterans who 
could lose this emergency access to air? Are you guys looking 
at that?
    Secretary McDonough. Yes. Look, I am really glad you raised 
this, because I have heard from several members in both 
chambers about this. Just to be clear what the rule does. The 
rule says: Unless you have a contract with VA, your local VA 
hospital, we will pay you what--you know, we will pay you the 
CMS reimbursement rate.
    In something like two-thirds of our facilities, we have 
contracts with providers. In those other one-third, we are 
paying cash, run-by-run. We have not been able to find another 
medical system in the country that runs their air ambulance 
service that way; so much so that the IG criticized us for 
running it this way.
    So the rule is in reaction to IG oversight that says: Hey, 
just negotiate a contract with your providers. Each market by 
market; so in Bethel in Alaska this would be something that Tom 
would work with the providers in Alaska. This won't be like, 
Minnesota dictating to Alaska what the reimbursement rate will 
be.
    So what we really want. And this is why the rule has a 1 
year pendency, we want our medical centers and the contractors 
to use that year to develop a contract, and to figure out what 
the individual economics of each market are, because running it 
the way we do, you know, gets us nasty grams from the IG, which 
is not great, but also just doesn't get us the best value for 
the vet.
    And so that is what the rule does. So back to the first 
question: Does this mean that we anticipate somebody 
negotiating a contract that would not cover their costs? I 
can't imagine, right. And then about two-thirds of our 
hospitals they have arrangements that meet their needs. And so 
we feel like this is a good step not only that we have a year 
to implement it. And if you get the sense that there is 
somebody up there who feels they are at risk as a result of 
this, let us get with Tom, and let us work this out.
    Senator Murkowski. Well, we will stay very close on this.
    Secretary McDonough. Yes.
    Senator Murkowski. Because as you can assume, I mean, 
oftentimes--
    Secretary McDonough. We are not going to string anybody 
along there, definitely.
    Senator Murkowski [continuing]. Oftentimes, we are looking 
at an air medivac that is costing $60,000 to $80,000, you know.
    Secretary McDonough. Totally.
    Senator Murkowski. That scares people.
    Secretary McDonough. Yes.
    Senator Murkowski. And justifiably so.
    Secretary McDonough. And we are not going to leave--we are 
not going to leave them. And so, look, and I raise it--I say I 
am grateful that you raise it, expressly for this reason.
    Senator Murkowski. Good.
    Secretary McDonough. I am not trying to cut anybody's 
corner here, but we are trying to run this in a more 
sustainable, defensible way.
    Senator Murkowski. Okay. We will keep posted with you. 
Thank you for coming north, you can come back anytime.
    Secretary McDonough. Okay. I just want the record to show 
that when I was in Alaska my brothers and sisters in Minnesota 
kept sending me texts to say that it was colder in Minnesota 
than in Alaska. So the timing was right, I think.
    Senator Murkowski. Come back.
    Senator Murray. Senator Schatz; on the other end of the 
temperature scale.
    Senator Schatz. Thank you. Thank you, Chair.
    Thank you, Secretary, for being here. I want to start with 
the Restore Honor to Service Members Act.
    Secretary McDonough. Yes.
    Senator Schatz. You are familiar with it, many veterans who 
were discharged because of their sexual orientation don't know 
that there is a way to update their records and restore their 
benefits and some who are aware are sort of running into the 
same impediments that that people under VA care run into, which 
is the sort of fear of the bureaucracy.
    Secretary McDonough. Yes, and makes them suspicious and 
mistrustful. Yeah.
    Senator Schatz. And they, you know, listen if you were--if 
you did serve honorably, but you were discharged for so-called 
``homosexual behavior'', you may not want to re-litigate that 
15 or 20 years, or 30 years on, if your life has moved on.
    Secretary McDonough. Yes.
    Senator Schatz. So what is VA doing to two things: Make 
sure all affected veterans know that this is available to them? 
And then re reduce barriers to entry once they know that this 
is something that they can pursue? If they fit the rather 
narrow definition of someone who was, other than honorably, or 
dishonorably discharged, exclusively for so-called ``homosexual 
behavior''?
    Secretary McDonough. Yes. Well, so we take this really 
seriously. And I have a whole sheet of the things that we have 
done. So we will get those to you, rather than me read them off 
to you. But I do want to say that we did see a 90 percent 
increase in change of discharge determinations, from 21 to 22, 
which is at least some data that suggests we are reaching some 
veterans.
    All those things you raise go to really important 
questions: Do they know? Do they trust us? And once they go 
through it, does it actually work? And so I think those are the 
most important things for us to address.
    And we are taking steps here. I want to make sure that we 
talk to you and your team, to find out if there are steps in 
addition to these that we should be taking, whether we--why we 
aren't taking them, and we will. And then the next question is: 
What about the number from fiscal year 2022 to 2023?
    The last point I want to just make is, that you make the 
point about the narrow definition, but a veteran who has other 
than honorable, irrespective of what he or she understands to 
be the basis for that, we urge them to come in to see us 
because we are trying to address this across the board, not 
just for, you know, quote-unquote, ``homosexual activity'', but 
irrespective of the basis, because the law and our regulations 
do allow us to provide care for, and get benefits to other than 
honorables. And in some cases, those are the veterans who need 
us most.
    Senator Schatz. Amen. Thank you. Let us talk a little bit 
about telehealth. I have been pushing for telehealth for a long 
time?
    Secretary McDonough. Yes.
    Senator Schatz. You have had a success story, your budget 
request puts another $100 million towards telehealth over the 
next 2 years.
    Secretary McDonough. Yes.
    Senator Schatz. What are you going to do with it? I think 
this is a good-news story across the health care system. 
Telehealth is bipartisan.
    Secretary McDonough. Yes.
    Senator Schatz. It works; it reduces the cost, and 
increases the quality and availability of health care.
    Secretary McDonough. Yes.
    Senator Schatz. But I think about far-flung areas where our 
veterans could really use the ability to even dial in, because 
I think one thing I want to make clear is, you know, 5G, high, 
you know, fast connectivity, can facilitate telehealth, but it 
is not always a necessary step. There is store-and-forward 
technology, there is just using the telephone.
    Secretary McDonough. Yes.
    Senator Schatz. There is remote patient monitoring, none of 
that requires a particularly fast connection. So I don't want 
you to allow anyone to use: Well, we have no broadband over 
there as an excuse.
    Secretary McDonough. Yes.
    Senator Schatz. A long-winded question: What are you going 
to do with this money for telehealth?
    Secretary McDonough. Well, we are gonna we are going to 
increase access, is what we are going to do. And the most 
exciting thing about telehealth is that it reduces the barrier 
to access. So for example, what we are seeing is maybe a 
reduction in interest in seeking care for mental health, goes 
away when somebody, doesn't have to kind of walk into a 
building.
    Senator Schatz. Walk into the hospital.
    Secretary McDonough. They can take their appointment from 
their car, or from their home, or wherever, so we are going to 
increase access. We are going to smooth out access, what it 
allows us to do, and our clinical resource hubs are really cool 
innovation. I visited the one in Boise, which allows us to use 
excess capacity in mental health, specialty care, primary care, 
and through telehealth, get veterans in other parts of that 
VISN, and that region, in VISN 20 get them care where they 
wouldn't otherwise have access in a very timely way.
    So it is going to smooth out that access and get it into 
rural settings, and then ultimately, it is going to increase 
our connectivity with veterans, because we reduced the barrier 
to that contact. And what we know is, veterans who are in more 
regular contact with us, perform better, ultimately, on their 
treatments.
    And so we will reduce access or we will increase access, we 
will increase access to specialty providers, and then we will 
increase our connectivity with our veterans, thereby increasing 
health outcomes, which is, at the end of the day, the name of 
the game.
    Senator Schatz. Thank you.
    Senator Murray. Thank you. Mr. Secretary, I can't let you 
leave without a discussion about EHR.
    Secretary McDonough. Yes.
    Senator Murray. It has been almost 5 years since the VA 
signed a contract with Cerner to implement this new electronic 
health record, as you well know. And as you also know, I have 
raised concerns for my constituents in Spokane and Walla Walla, 
about the usability and reliability of the system and some very 
serious patient safety concerns. You have announced a reset of 
the EHR Program which follows an access--an address period 
after an extended pause.
    And I do support efforts to move forward only after you are 
confident about the safety and effectiveness of the system. VA 
and Oracle Cerner are responsible for the system not working 
the way it should. You have said that during this reset period 
we are now in, the VA will prioritize stabilizing existing 
sites. How is that different from the pause, and the assessment 
address periods, and when will we see Spokane and Walla Walla 
back to pre-EHR productivity?
    Secretary McDonough. Yes. Thank you. Thank you very much. 
The main difference is that we have said very clearly that we 
are not going to try to do both these things at the same time. 
Namely, continue to prepare for further deployment, and make it 
right in Spokane, Walla Walla, White City, Roseburg, and 
Columbus.
    The bottom line is, we are going to invest in those five 
sites to make sure that we get it right, and if--you know, to 
make sure that we know this is to get it ``rightable.'' And I 
was just in Roseburg last week hearing directly from our 
clinicians there. The whole point is, to focus just there to 
prove concept.
    I will say this. We had had 7 months with no system-wide 
outages. Unfortunately, in the last two weeks, including 
yesterday, when we had an outage for 224 minutes across the 
entire VA and DOD system, we now reset that back to zero. The 
most important thing--meaning, set it back to zero from 7 
months of actually, at least no outages, that doesn't mean 
across the system it was functioning perfectly even.
    So I am extraordinarily frustrated with this. I know our 
providers and our veterans in Washington, and in Oregon, and in 
Ohio are extraordinarily frustrated with us.
    The whole point of this assessment--this whole point of 
this reset is: Clear away everything else. Let us focus on the 
five. Let us get it right, and then we will talk about onward 
deployment.
    Senator Murray. Okay. And how does that affect your fiscal 
year 2024 budget request?
    Secretary McDonough. Well, we want to work through that 
with you. We know that for fiscal year 2023, in the first 
instance, we estimate that there is probably $400 million that 
we won't need in light of this decision, and that we will want 
to work through with you the specifics on the fiscal year 2024 
request. But the bottom line is, I think it stands to reason 
that that request will look different.
    Senator Murray. Okay. Look forward to working with you on 
that. I just want to mention child care today.
    Secretary McDonough. Yes.
    Senator Murray. This is such a challenge for families.
    Secretary McDonough. Totally.
    Senator Murray. People totally are not taking their 
appointments, can't get to appointments, child care is an 
issue. And I was really pleased, as I mentioned in my opening 
remarks, that the budget outlined a plan to extend the Child 
Care Pilot.
    American Lake, in my home state, participated in that, but 
I understand that we don't have regulations, and dedicated 
resources to IT development, so we can expand that. What is 
your time line on doing that?
    Secretary McDonough. Well, we do want to be fully 
operational in 2026, and we think that that will mean 300,000 
veterans with access to this. But to get fully operational in 
2026, we need to see functioning sites in 2024. So it is true 
that the regulation writing is lagging right now. But I think 
to a certain extent that is to be expected with a new 
nationwide program.
    But our commitment is to get this deployed in 2024, 
eventual to full deployment in 2026, with two options for 
veterans: drop-in services when you are coming in for a covered 
appointment, or contracted services. It is the contracted 
services that need the IT help, and so we are working with the 
Office of IT on that.
    And I was just in Seattle and met with the team that had 
run the pilot, so I am continuing to keep pressure on our team 
here. We are determined to meet these goals laid out in the 
program, because the President expects us to, but as 
importantly, because our vets need it.
    Senator Murray. Thank you. Senator Boozman.
    Senator Boozman. Thank you, Madam Chair. I don't have any 
additional questions. But I do appreciate the questions about 
Oracle Cerner, and helping us better understand what is going 
on. I know that is a difficult situation.
    Secretary McDonough. Yes.
    Senator Boozman. But again, I think you are doing the right 
thing.
    Secretary McDonough. Thank you.
    Senator Murray. Thank you. That will end our hearing today. 
And I want to thank the Secretary, and all my colleagues for 
participating in today's hearing. I look forward to working 
together on this year's Appropriations Bill to make sure we are 
providing the Department, our veterans, and their families with 
the benefits, care, and support that they need.

                     ADDITIONAL COMMITTEE QUESTIONS

    I will keep the hearing record open for one week. Committee 
members who would like to submit written questions for the 
record should do so by 5:00 p.m., Wednesday, May 3rd.
    We appreciate the Department responding to all of those in 
a reasonable amount of time.
              Questions Submitted by Senator Patty Murray
    Question. The Budget requests an historic investment to support 
infrastructure, particularly construction, in what will presumably be a 
years-long process. In the past, VA indicated infrastructure 
improvements were in part hampered by VA's capacity to oversee 
projects, and that even if there were unlimited resources, VA could 
only oversee a certain number of projects per year. Given all of the 
resources requested, and limitations due to staffing, what can the 
Department reasonably obligate in FY 2024?
    Answer. The Fiscal Year (FY) 2024 Budget requests $4.1 billion in 
major and minor construction funding for the Department of Veterans 
Affairs (VA). This includes $3 billion in major construction funding 
and $1.1 billion in minor constructing funding, which includes 
discretionary, mandatory and Recurring Expenses Transformational Fund 
(RETF) funding. Assuming funds are available at the start of the FY, 
the total planned 2024 major construction obligation amount, including 
carryover, is $3.17 billion (includes discretionary, mandatory and RETF 
funding) and the total planned minor construction obligation amount, 
including carryover, is $838 million (includes discretionary and 
mandatory funding). Remaining balances will be carried over into future 
years for identified requirements.
    The President's Budget shows total obligations of $5.75 billion in 
2024 for Non- Recurring Maintenance (NRM), of which $750 million is for 
Electronic Health Record Modernization (EHRM) NRM. The Budget also 
requests that of the resources available to Medical Facilities (post-
transfers) in 2024, $4.769 billion be provided with a period of 
availability of 5 years. These two subjects are related: in the event 
of not all $5.75 billion being obligated in 2024, then there will not 
be lapse pressure on the Medical Facilities account.

                                 ______
                                 

               Questions Submitted by Senator Jon Tester
    Question. VA expects to require more than 450,000 staff to support 
its mission in FY 2024. More than 380,000 of those are VHA staff. How 
does VA's budget request account for the human resources and hiring and 
retention incentives needed to support hiring and retaining that many 
staff?
    Answer. The Department of Veterans Affairs (VA) utilizes existing 
pay authorities to strategically address hiring and retention 
challenges in any Veterans Health Administration (VHA) occupation. VA 
Medical Centers (VAMCs) are advised to ensure the preferred order of 
pay incentives are used for maximum benefit when developing recruitment 
strategies for each position. These pay incentives include individual 
recruitment, relocation and retention incentives, appointments above 
the minimum step of the grade, critical skills incentives, special 
salary rates and group retention incentives. Facilities are encouraged 
to utilize these pay flexibilities to recruit and retain employees in 
support of VHA's mission. The use of various compensation authorities 
and additional labor costs are embedded in the Budget request. Specific 
requests are in VA's budget tied to scholarship programs and the 
Education Debt Reduction Program, both of which account for expanded 
needs as the workforce continues to grow. VA continues to evaluate 
budget, staffing needs, and priorities to provide the top-notch human 
resources personnel with a focus on strategic hiring that supports 
expansion of Veteran access to care and services.
    Question. The President's Budget proposes to expand rental 
assistance to extremely low-income veteran families, which would 
include 50,000 new targeted housing vouchers available to veterans 
starting in 2025. VA already struggles with hiring and retaining case 
managers to support HUD-VASH vouchers. Has VA asked for adequate funds 
to support this effort?
    Answer. VA does not understand the 50,000 new targeted housing 
vouchers to be an expansion of rental assistance provided by the 
Department of Housing and Urban Development (HUD) VA Supportive Housing 
(VASH) permanent supportive housing program. Rather, VA understands 
this to be an expansion of HUD's existing Housing Choice Voucher (HCV) 
program. The 50,000 new housing vouchers will be provided by HUD in 
Fiscal Year (FY) 2025 through HUD's HCV program, which offers rental 
assistance without corresponding clinical and supportive services. VA 
will not need to provide clinical support for these vouchers and has 
not requested funding to support staffing. VA continues to prioritize 
recruitment and retention of HUD-VASH staff with a goal of fully 
utilizing all available HUD-VASH vouchers.
    Regarding hiring and retaining case managers to support HUD-VASH 
vouchers, over the past three years VA has seen a multitude of barriers 
to hiring and retaining highly qualified individuals to serve this 
vulnerable population. These include a lack of qualified applicants, 
lengthy hiring delays, lack of competitive salaries with the private 
sector, etc. However, these barriers are not unique to VA, as community 
partners have expressed similar concerns regarding staffing. Throughout 
the calendar year 2023, VA prioritized the filling of vacancies in the 
HUD-VASH and Health Care for Homeless Veterans (HCHV) programs to 
support case management services. VA is strongly encouraging the use of 
all available recruitment, relocation, and retention incentives, as 
well as the authorization for Critical Skills Incentives provided by 
the Sergeant First Class Heath Robinson Honoring our Promise to Address 
Comprehensive Toxics Act (PACT Act, P.L. 117-168), for any VAMC 
struggling to fill or retain HUD-VASH and HCHV staff.
    Question. The HUD-VASH program is beginning to see a slow increase 
in staffing-filled rates as compared to last year, with 85% of 
positions filled as of July 31, 2023, as compared to 83% at the end of 
FY 2022. This includes positions awarded in late FY 2022 and early FY 
2023 to support new HUD-VASH voucher awards and enhanced staffing for 
project- based voucher sites serving aging and disabled Veterans.
    What is VA's plan to fill the additional case managers positions 
needed?
    Answer. The VHA FY 2024 Budget request will provide sufficient 
funding to fill needed case management positions for the HUD-VASH 
program in FY 2024. However, the expansion of the rental assistance 
noted above will be operated solely by HUD and does not impact VA's 
staffing needs. As such, VA has not requested staffing to support the 
HUD HCV program expansion.
    Question. Earlier this year, VA issued a final rule on air 
ambulance reimbursement rates. This rule is likely to have significant 
impact on access to this emergency service especially in rural America, 
despite VA's claims to the contrary. The final rule provides a 1-year 
delay. I and many of my colleagues on this Committee have urged you to 
use this time to engage with Veteran Service Organizations and the air 
ambulance industry to ensure access to care is not impacted. Some of 
these groups have reached out to VA repeatedly to start a dialogue and 
received minimal or no response. Does VA plan to sit down with 
stakeholders to discuss the implications of the rule on veterans and 
their access to emergency, life-saving care?
    Answer. Yes. An Integrated Project Team (IPT) was implemented on 
February 9, 2023, to work to ensure minimal impact on Veterans, to 
provide industry stakeholders information on the impact of the rule and 
to provide maximum opportunity for each VAMC to acquire contracts for 
ground and air ambulance services. To ensure interested vendors are 
apprised of contracting opportunities, even if already under contracts 
within their local VA markets, the first virtual Industry Day was held 
on May 25, 2023, with more than 400 participants in attendance. A 
second Industry Day was held on July 20, 2023, with slightly under 400 
participants. A third Industry Day was held on August 30, 2023, with 
109 participants.
    Question. Please share a list of the VA facilities that have 
contracts with air medical providers, and of those who do, what are the 
number of veteran transports that they have made that were subject to 
that contract?
    Answer. As of September 30, 2023, there are eleven active air 
ambulance contracts in seven Veteran Integrated Service Networks 
(VISNs), as reported by the VHA Office of Procurement and Logistics 
(P&LO). In FY 2022, there were 211 air ambulance transports subject to 
contracts in place at that time.

 
 
------------------------------------------------------------------------
                   VISN                           No. of Contracts
------------------------------------------------------------------------
VISN 1....................................  ............................
Covers entire VISN........................  1
VISN 6....................................  ............................
659-Salisbury, NC.........................  1
VISN 15...................................  ............................
Covers entire VISN........................  1
VISN 17...................................  ............................
519-West Texas HCS........................  1 contract-2 facilities
504-Amarillo, TX..........................  ............................
756-El Paso, TX...........................  1
VISN 21...................................  ............................
570-Fresno, CA............................  1
640-Palo Alto, CA.........................  1
654-Sierra Nevada (Reno)..................  1
662-San Francisco, CA.....................  1
VISN 22...................................  ............................
678-Tucson, AZ............................  1 contract-3 facilities
649-Prescott, AZ..........................  ............................
644-Phoenix, AZ...........................  ............................
VISN 23...................................  ............................
Covers entire VISN........................  1
    Total Contracts:......................  11
------------------------------------------------------------------------

    Question. Also, what percentage of these contracts are between VA 
facilities?
    Answer. As of September 30, 2023, there are five contracts out of 
the eleven reported by VHA P&LO, which cover multiple or all facilities 
within the given VISN.
    Question. What happens if a veteran is transported from an air 
provider outside the contract/independent of the VA facility?
    Answer. On December 29, 2023, VA published a rule that delays the 
effective date to February 16, 2025, for changes in reimbursement rates 
VA pays for special modes of transportation. Beginning on February 16, 
2025 (not February 16, 2024), VA will pay the lesser of the billed 
charges or 100% of prevailing Centers for Medicare and Medicaid 
Services (CMS) Ambulance Fee Schedule. This rule does not change 
current payment rates under Title 38, U.S.C. '' 1725 or 1720J. 
Reimbursement rates for these sections will remain at the lesser of the 
billed charges or 70% of the CMS Ambulance Fee Schedule. Until the new 
rates take effect on February 16, 2025, current payment practices will 
continue.
    Question. Most veteran air ambulance transports are either to or 
from non-VA facilities, using non-VA hospitals or facilities. Since 
most emergency air ambulances are not tied to a hospital and have no 
control over who they pick up (since they don't self-dispatch) how 
would this work?
    Answer. VA coordinates with non-VA facilities, non-contracted 
vendors and Veterans in coordination of care under existing authorities 
for the submission of reimbursement of unauthorized emergency care and 
related transportation under Title 38, U.S.C. '' 1725; 1728; 1703; and 
1720J (see Emergency Medical Care--Community Care (va.gov)).
    Question. Most VA dental clinics currently run at or near full 
capacity, and the number of veterans eligible for VA dental care 
continues to increase by approximately 8.5 percent each year. Of the 
over 600,000 veterans who received dental care paid for by VA in FY 
2022, nearly 400,000 received this care exclusively at a VA facility. 
Despite these trends, the President's FY 2024 Budget requests a 
decrease of $76.8 million for VA in-house dental care, compared to FY 
2023 levels. How does VA plan to maintain its current state of in-house 
dental care with a decrease in funding from FY 2023 levels?
    Answer. VA will maintain its current state of in-house dental care. 
Because funds are distributed in the Veterans Equitable Resource 
Allocation (VERA) as a lump sum to VAMCs for all activities, there is 
no danger of a shortfall for in-house dental services. All health care 
services cost growth projected by the Enrollee Health Care Projection 
Model (Base Year 2021) was accounted for in the FY 2024 request.
    Please see the table from page VHA-98: https://www.va.gov/budget/
docs/summary/fy2024-va-budget-volume-ii-medical- programs.pdf.

                                 ______
                                 

              Questions Submitted by Senator Brian Schatz
    Question. Veterans Educational Benefits: The promise of a college 
education has been a great tool for recruiting and retaining service 
members for decades. But, they need to be able to use their education 
benefits efficiently when their terms of service expire. Predatory for-
profit institutions have habitually taken advantage of veterans looking 
to use their education benefits. What is the VA doing to help veterans 
make informed decisions about how to use their educational benefits and 
specifically what role does the GI Bill Comparison Tool play in that 
effort?
    Answer. The Department of Veterans Affairs (VA) is committed to 
providing oversight and protecting the integrity of the GI Bill 
program for GI Bill beneficiaries, as well as ensuring good stewardship 
of taxpayer dollars. VA continues to review and monitor the compliance 
of all schools that are approved for GI Bill benefits with applicable 
statutes and regulations, and when necessary will take appropriate 
remedial action, including referring matters to the appropriate law 
enforcement agency.
    As part of our protection activities, VA uses the GI Bill Feedback 
Tool for the intake of complaints by GI Bill beneficiaries regarding 
programs approved for GI Bill benefits. All complaints are reviewed 
and, depending upon the severity, are referred to the educational 
institution for resolution, trigger a compliance action, or trigger a 
referral to one or more trusted Federal partners. The complaints are 
stored in a database, which allows for trend analyses and the 
generation of reports within Education Service. Complaints are also fed 
into the Federal Trade Commission's Sentinel database. VA posts Caution 
Flags to the public-facing GI Bill Comparison Tool to forewarn 
potential students of court judgements, settlements, adverse actions, 
or increased regulatory or legal scrutiny by VA and other Federal 
agencies. These actions help Veterans, Service members and their 
eligible family members make informed decisions on which institution to 
attend in pursuit of their education goals.
    VA continuously takes strides towards ensuring Veterans and 
beneficiaries can make wise and informed decisions regarding their 
education. We aim to assist Veterans in selecting an educational path 
that is data driven, easy to navigate and tailored towards pursuing 
their personal passions. The following are some of our daily activities 
and recent achievements:

  --On a weekly basis, VA collaborates with multiple internal and 
        external stakeholders to ensure the Comparison Tool is up to 
        date with timely and relevant data for Veterans. If data 
        discrepancies are identified, we aim to address and resolve 
        these issues within 1-2 business days. If needed, as a 
        proactive measure we will communicate to Veterans about the 
        issue and that we are working to resolve it.
  --Data files are extracted on a regular basis directly from the 
        Department of Education, which contain a plethora of statistics 
        that assist with Veterans' education benefit selections. 
        Specifically, we extract Comparison Tool data that illustrates 
        several data elements, which include items such as caution 
        flags identified (e.g., accreditation issue, heightened cash 
        monitoring) and complaints that have been addressed and closed.

  --VA implemented the GI Bill Comparison Tool updates per Section 3 of 
        the Training in High-Demand Roles to Improve Veteran Employment 
        Act (Public Law 117-16). It added new categories and 
        information to the GI Bill Comparison Tool, specifically 
        reflected under Title 38, U.S.C. ' 3698. As of November 22, 
        2022, the ability to filter institutions by Historically Black 
        Colleges and Universities, religious-affiliated schools, 
        gender-specific institutions, Hispanic-serving, Native 
        American-serving, Alaska Native-serving, and Asian American and 
        Native American Pacific Islander-serving institutions have all 
        been deployed.

  --In January 2022, VA launched the redesign of the Comparison Tool 
        after years of research and development work. Some of the new 
        features include a user interface overhaul along with a 
        complete review to modernize the tool and make it more 
        accessible to all users per Section 508 of the Rehabilitation 
        Act of 1973 (Public Law 93-112), as well as the ability for a 
        user to search and compare up to three institutions in a list 
        view, the ability for a user to search institutions via a map 
        view within various radii and the ability for users to navigate 
        the GI Bill Comparison Tool on mobile devices. During Fiscal 
        Year 2023, the GI Bill Comparison Tool's website had more than 
        2 million page views, of which 1.8 million were unique.
    Question. How is the VA working with the Department of Education to 
prevent predatory institutions from targeting veterans?
    Answer. VA has regular engagements with trusted Federal partners 
from multiple departments, entities and law enforcement agencies (such 
as the Departments of Education, Defense and Justice; as well as the 
Federal Trade Commission and VA's Office of Inspector General) as part 
of VA's oversight activities and enforcement actions related to 
violations of GI Bill requirements codified in Title 38 and 
corresponding regulations. Practices that are a shared focus of VA's 
ongoing collaboration with the Department of Education include, but are 
not limited to, false or misleading advertising, aggressive recruitment 
and incentive compensation based on securing student enrollments; 
including those activities performed by third parties. In addition, VA 
is providing GI Bill benefit payment information that for-profit 
schools are required to report to the Department of Education due to 
recent changes to the 90/10 rule.

                                 ______
                                 

              Questions Submitted by Senator Tammy Baldwin
    Question. The Wall Street Journal reported that since 2009, 
McKinsey & Co. has been a consultant to the U.S. Department of Veterans 
Affairs, the federal agency that oversees healthcare for millions of 
retired military service members. During part of that time, McKinsey 
also developed strategies for the world's biggest opioid producers to 
target veterans for sale of their products. America's veterans were 
``an important sales target'' for addictive opioids. Last month, the 
WSJ reported that McKinsey did something similar to America's veterans, 
at the same time they worked the Department of VA on healthcare, 
McKinsey developed sales strategies to increase opioid sales by 
targeting military veterans. When it signed contracts to work for the 
VA did McKinsey ever disclose to your agency that they were also 
working for Purdue Pharma as is required under federal acquisition 
regulations?
    Answer. The solicitation/contract with the Department of Veterans 
Affairs (VA) was for epidemiological data modeling for the Coronavirus 
Disease 2019 (COVID-19) Pandemic. Therefore, McKinsey & Company 
(McKinsey) would not have disclosed its work with Purdue Pharma to VA 
as it was not relevant to this contract and any such disclosure was not 
required.
    Question. How can the federal government, specifically your agency, 
pay McKinsey at least $117 million related to healthcare services for 
veterans at the same time that very company is getting paid to develop 
strategies to sell opioids to veterans?
    Answer. During the COVID-19 pandemic, VA awarded a contract 
directly with McKinsey for epidemiological modeling of the disease. 
Also, during the planning phase of the follow-on contracting action 
that VA planned to recompete competitively, the contracting officer 
conducted an internal VA Acquisition Regulation (VAAR) ' 852.209-70, 
Organizational Conflicts of Interest (OCI) review to determine if an 
OCI existed based on the previous direct awards to McKinsey and if 
McKinsey and its sub- contractors were eligible to respond to a 
solicitation, once released. That review determined that an OCI did not 
exist. VA subsequently released the solicitation with a statement that 
McKinsey and its subcontractors were eligible to propose.
    Question. Given McKinsey's central role in the opioid epidemic, has 
the VA investigated what advice McKinsey gave the VA and what sensitive 
and proprietary information McKinsey may have gleaned from the VA that 
may have been passed on to opioid producers?
    Answer. In response to these serious concerns expressed by Members 
of Congress, VA requested in May 2023 that the VA Office of Inspector 
General (OIG) undertake a review of these allegations to determine if 
any legal, policy or ethical violations occurred because of McKinsey's 
actions. OIG reviewed the available documentation in VA's Electronic 
Contract Management System to identify contracts awarded to McKinsey 
from 2013 to May 2023. OIG declined further review given that there was 
no identifiable nexus to the opioid-related concerns. The contracts 
during this period pertained to process enhancements for VA's Office of 
Information and Technology (OIT) as well as data modeling for COVID-19.
    Question. What assurances can the VA make that McKinsey and 
companies like it will be permanently banned from working with the VA 
in the future?
    Answer. VA is committed to following all applicable acquisition 
laws and regulations, including those regarding contractor 
qualifications, suspensions and debarments. If in the future McKinsey 
is excluded, debarred or suspended, VA will cease any new contract 
awards to the company.
    Question. I was proud to lead the bipartisan legislation that 
transitioned the VA Crisis Line to the national suicide prevention 
hotline 988 number, a program that went live last July enabling 1,000s 
of veterans to call or text 988 and be transferred to the Veterans 
Crisis Line team. I support continuing the funding we need to ensure 
the Veterans Crisis Line is equipped, staffed, and maintained.Since 
going live in July, was last year's funding sufficient in supporting 
this transition, and does the President's budget support continuing to 
build and refine the current system in place?
    Answer. Yes, last year's funding was sufficient in supporting the 
transition and ongoing management of Dial 988, Then Press 1, in Fiscal 
Year (FY) 2023. The FY 2024 President's Budget is anticipated to be 
sufficient to support continued refinements and growth of Veterans 
Crisis Line (VCL) capacity, given current projections of need.
    Question. Can you describe the challenges in implementation of this 
transition, and how the budget supports efforts to mitigate issues such 
as increased volume of calls and texts from Veterans in crisis?
    Answer. The notable successes of awareness campaigns prior to the 
launch of Dial 988, Then Press 1, produced a 12% increase in calls, 10% 
increase in chats and 33% increase in texts year-over-year through 
April 2023. In advance of the roll-out of Dial 988, Then Press 1, VCL 
proactively anticipated challenges and outlined mitigation plans to 
increase capacity and facilitate care coordination, continuity and 
communication across the Nation. Budget supports have been critical for 
maximizing growth while maintaining the high-quality assurance 
standards expected of the VCL. Steps implemented in advance of the 
transition included the compilation and analysis of complex data 
projections, detailed staffing and hiring plans, comprehensive training 
and the development of robust quality control processes to streamline 
services. The increased budget has been instrumental in funding the 
additional staff necessary to ensure that all contacts to VCL are 
answered timely and thoroughly.
    Question. I read the recent VAOIG report that indicated the Medical 
Disability Examination Office (MDEO) is not tracking whether contracted 
C&P examiners are gaining consent from Veterans who have been scheduled 
to travel excessively long distance for exams. Are C&P examiners made 
aware of this requirement to gain consent through their training and 
onboarding process? And if so, why does this issue persist?
    Answer. Per the Veterans Benefits Administration's (VBA) contract 
with the contract vendors, which are Optum Serve Health Services 
(OSHS), Veterans Evaluation Services (VES), Quality, Timeliness, 
Customer Service (QTC) and Loyal Source Government Services (LSGS), 
travel greater than 50 miles for non-specialist examinations or 
diagnostics and 100 miles for specialist examinations or diagnostics 
requires the Veteran's expressed consent. This expressed consent 
indicates the Veteran?s verbal or written expression of willingness to 
exceed the above limits. That consent must then be uploaded to the 
Veterans Benefits Management System (VBMS) eFolder, Veteran Portal and 
Contractor Portal.
    In October 2022, VBA began auditing OSHS, VES and QTC (LSGS did not 
begin conducting C&P examinations until December 2022) to determine if 
expressed consent was obtained in a sampling of over-mileage 
examinations and if consent documentation was uploaded to the VBMS 
eFolder and Contractor Portal. If discrepancies were found, they were 
communicated to the contractor for corrective action. Once corrective 
action was taken these actions were verified by VBA staff.
    In February 2023, VBA modified the contract with the third-party 
auditing vendor, Cathexis, to take over this process. This audit now 
included all contract vendors including LSGS. The purpose of this 
modification was to have a statistically significant sampling of all 
expressed consents audited. Cathexis would then identify any errors and 
communicate those to the contract vendor for corrective action. Upon 
receipt of the corrective action from the contract vendor, Cathexis 
would verify that the actions were taken.
    Question. Can you discuss what the VA?s course of action is to 
remedy this issue?
    Answer. As noted above, in February 2023 VBA's Medical Disability 
Examinations Office (MDEO) modified the contract with the third-party 
auditing vendor, Cathexis, which does a statistically significant 
sampling of all over-mileage examinations. This sampling varies by 
month given the number of over-mileage examinations conducted that 
month. These audits by Cathexis will continue in order to ensure that 
any deficiencies in the contract vendors procedures in obtaining 
expressed consent are identified and corrected. The results of these 
audits are available to MDEO to determine if further corrective action 
is required.

                                 ______
                                 

             Questions Submitted by Senator Martin Heinrich
    Question. Genomic Sequencing: The Million Veteran Program (MVP) has 
been operational for more than 10 years and has collected nearly 
900,000 blood samples. But less than 200,000 of those samples have been 
sequenced. I understand that the pace of generating this year is slower 
than in previous years. How long will it take the VA to sequence the 
remaining samples in storage?
    Answer. The work of the Million Veteran Program (MVP) is pushing up 
against the largest-scale analyses of whole genome sequencing. The goal 
of MVP is for the Department of Veterans Affairs (VA) to generate the 
most comprehensive, high-quality, high-density data on our 
participants, which advances scientific discovery and clinical 
translation for improved precision health care. For data derived from 
the biospecimens, this includes genetic data (genotype, whole genome 
sequence [WGS], methylation etc.,) as well as metabolomic and proteomic 
data, depending on the resources available.
    The technologies for generating each of these different types of 
data from the biospecimens, processing the data, curating it, 
conducting quality assurance/quality control (QA/QC), making them 
research-ready and finally analyzing the data in combination with 
health factors, are each in different stages of maturity, especially at 
scale. The cost of generating and processing such data to make them 
research-ready also differ for the different types of data. We have 
taken the approach of maximizing the data for MVP by balancing the 
state of maturity of each technology at scale and the cost.
    The technologies for generating high-quality, research-ready data 
and the availability of tools for analyses are the most mature for 
genotype data, and that is the reason we have been able to generate 
this data on all participants and have curated, research- ready data on 
roughly 650,000 participants and have provisioned them for research 
studies. The approximately 765,000 genetic markers on the MVP genotype 
array have been imputed and increased to about 25 million markers on 
the human genome. The cost of generating genotype data is roughly $50/
sample.
    Whole genome sequencing undoubtedly provides the highest density 
genetic data and the cost of initial data generation has dropped in 
recent years. Our current cost is $600/sample. However, the cost of 
generating WGS data is only one factor. While the technologies for 
generating WGS data efficiently have rapidly advanced in recent years, 
the technologies, tools and pipelines for efficiently processing large 
numbers of whole genomes to derive meaningful genetic variants (variant 
call files, VCFs) are still evolving. Software tools for analyzing 
large numbers of whole genome sequence files at scale for association 
with clinical phenotypes are further behind. The largest association 
analyses using WGS data is a recently published meta-analysis on 
genetic association of lipids with approximately 30,000 whole genomes. 
Please see: Powerful, scalable and resource-efficient meta-analysis of 
rare variant associations in large whole-genome sequencing studies-PMC 
(nih.gov).
    One of the goals of MVP is to generate the maximum data possible 
from a subset of 100,000 participants and provide them for research; 
assess what the most useful datasets are to expedite and enhance 
scientific discovery, as well as to translate research findings for 
application in the clinic to improve health care delivery; and align 
our future investment depending on the resources available.
    We therefore set an initial goal of generating at least 100,000 
whole genome sequences and, based on the resources available, we have 
progressed to more than 150,000. In the last few years, we decided to 
slow down to focus on making these data available for research and 
seeing how researchers use the data and what analytical tools are 
needed. For this, we turned our attention and resources to processing, 
curating, conducting QA/QC, assessing the best analytic pipelines at 
scale and the most efficient and secure computing environment to 
conduct the research.
    In 2022, we provided VCFs from 10,000 whole genome sequences for 
our ongoing research projects in on-prem servers within the secure 
Genomic Information System for Integrative Sciences' Scientific 
Computing platform at VA. Based on the initial feedback from 
researchers on what would be most useful, we are currently testing 
tools/pipelines for mapping Mitochondrial DNA variants, structural 
variants (deletions, insertions and duplications in the sequence) and 
rare variants (all of these cannot be obtained from genotype data; WGS 
data are the best suited). Further, we are testing the above within the 
VA Enterprise Cloud (VAEC).
    MVP?s goal is to provision research-ready variant calls from 
100,000 whole genome sequences for genetic association analyses with 
phenotypes within the VAEC by the beginning of calendar year 2024. As 
the number of analyses increase, there will be a need for increased 
funding for cloud credits.
     future vision for sequence and other molecular data generation
    Based on the outcomes of research with the released sequence data 
from 100,000 over the next few years and maturity and availability of 
analytic tools for at-scale analyses, MVP will begin to ramp up 
generation of whole genome sequence data. The time needed to sequence 
all samples will depend on when the cost of sequencing, the increased 
maturity of technologies for analyses and the resources available to 
MVP all align. We will be able to better predict the trajectory in two 
to three years. Another factor to take into consideration is the cost 
of storage for large numbers of whole genome sequence data as we begin 
to ramp up the numbers beyond 200,000-250,000.
    MVP has set a goal of establishing a deeply characterized dataset 
on at least 100,000 samples over the next three to five years. Towards 
this end, of the 150,000 samples sequenced, we have generated 
metabolomic data on 60,000 samples thus far. In 2022, we also began 
piloting generating proteomic data on two different technology 
platforms and are currently in the process of conducting QA/QC and 
validation. Depending on the outcome of the pilot validation, our 
future plans for expanding proteomics on 100,000 samples will be 
determined.
    Question. What challenges are delaying the Department from 
fulfilling this sequencing work?
    Answer. Our answer is outlined in 1a.
    Question. Access to Care for Rural and Tribal Veterans: I 
understand that the VA Budget request did not include funding for the 
Asset and Infrastructure Review (AIR) Commission and the previously 
appropriated funding has been rescinded. But, I am still concerned 
about the closure of facilities based on the initial market assessment 
from the AIR Commission. Can you share how the Department plans to 
maintain care for veterans, particularly those who live in rural and 
Tribal communities, when the data being used for the market assessment 
is the same data from the AIR Commission?
    Answer. Pursuant to Section 126 of the Joseph Maxwell Cleland and 
Robert Joseph Dole Memorial Veterans Act of 2022 (Cleland-Dole Act, 
Division U of P.L. 117- 328), VA has drafted a Realignment Plan to 
ensure that Veterans do not experience a lapse of care when facilities 
are realigned (including relocations and/or closures). This Realignment 
Plan will be provided to Congress upon completion and will be updated 
periodically.

                                 ______
                                 

              Questions Submitted by Senator Gary Peters:
    Question. On March 17, I requested a full, un-redacted copy of the 
April 16, 2022, Veterans Health Administration?s Office of the Medical 
Inspector (OMI) report entitled, ?Report to the Under Secretary for 
Health, John D. Dingell Veterans Affairs Medical Center Detroit, 
Michigan Report? (TRIM 221-C-51). This report has already been provided 
to the Veterans' Affairs Committee and a redacted version of the report 
has now been provided to an organization through a records request. Six 
weeks have now passed since this request, and I have not yet received a 
copy of the report. When will a copy of this report be made available 
to me?
    Answer. The redacted report is provided below. VA is only able to 
provide the unredacted report to a Committee in response to a letter 
from the Committee Chair.

                                 ______
                                 

              Questions Submitted by Senator John Boozman
    Question. Secretary McDonough, Focused Ultrasound Therapy is a non- 
invasive, non-pharmacological, safe treatment method for patients 
suffering from conditions like Parkinson's disease, prostate cancer, 
and essential tremor. Ongoing research is showing promise in additional 
areas that overwhelmingly impact our Veterans, like traumatic brain 
injuries, PTSD, and pain. Can you please describe what steps the VA is 
taking to ensure this cost-effective treatment option is available to 
our Veterans?
    Answer. The use of Focused Ultrasound (FUS) is best established for 
Parkinson?s Disease (PD) and essential tremor (ET), and is part of the 
armamentarium for these disabling movement disorders. Nevertheless, 
deep brain stimulation (DBS) remains a mainstay of, and one of the gold 
standards in, treatment for those patients with movement disorders 
difficult to effectively treat through medications alone. DBS has 
advantages over FUS of being reversible (unlike FUS) and programmable 
(settings can be adjusted, so it is not a one-size-fits-all as FUS is). 
Nevertheless, the Department of Veterans Affairs (VA) Parkinson's 
Disease Research Education and Clinical frequently refer Veterans for 
FUS treatment, and remain committed to offering FUS for PD or ET when 
clinically appropriate.
    The following applies to the use of FUS for the treatment of 
posttraumatic stress disorder (PTSD) and other mental health disorders 
in VA. According to the Focused Ultrasound Foundation, research on FUS 
has not moved beyond the pilot stage for mental health disorders other 
than depression and obsessive-compulsive disorder (OCD) Please see: 
Diseases and Conditions - Focused Ultrasound Foundation 
(fusfoundation.org). Also, the Defense Health Agency (DHA) does not 
recommend low- intensity FUS for the treatment of PTSD (https://
www.health.mil/Reference- Center/Publications/2021/04/26/PHCoE-
Evidence-Brief-Low-Intensity-Focused- Ultrasound-for-Posttraumatic-
Stress-Disorder-508). In addition, we could not find any published 
studies on the use of FUS for PTSD to date.
    To determine clinical safety and effectiveness with our Veteran 
population, VA's Office of Research and Development (ORD) is currently 
funding the following three studies utilizing FUS:

  --Low Intensity Focused Ultrasound for Tobacco Use Disorder: High 
        Resolution Targeting of the Human Insula;

  -- Low Intensity Focused Ultrasound for Chronic Pain: High Resolution 
        Targeting of The Human Insula; and

  -- Novel Drug Delivery Strategies for Treatment of Breast Cancer 
        Brain Metastases

    Additionally, research on FUS for depression and OCD is in the 
early clinical trial stage and is being monitored by the Office of 
Mental Health and Suicide Prevention (OMHSP).
    The use of FUS for the treatment of chronic pain is also considered 
investigational at this time. These treatments will be considered for 
clinical deployment in VA once their safety and effectiveness are 
clearly determined.
    Question. Per a 2021 GAO report, the VA projects a 32% increase in 
outpatient mental health care over the next 10 years. As you know, 
Physician Assistants (PA) are educated, trained, and licensed to 
diagnose, treat, and prescribe medications for mental health disorders. 
About 10% of the current VA PA workforce works in mental health, and 
the VA has post-graduate mental health fellowships for PAs. Despite 
this, since 2015 the VHA handbook does not include PAs as a Core Mental 
Health Profession. Given these factors, is there a reason why PAs are 
not considered as a VA core mental health discipline under the VHA 
Directive 1165?
    Answer. Veterans Health Administration (VHA) Directive 1165, 
Leadership Positions in Mental Health, defines six core mental health 
disciplines (psychiatry, psychology, social work, nursing, marriage and 
family therapy, and licensed professional mental health counseling) to 
require recruitment from a variety of disciplines for mental health 
leadership positions within VHA, as also defined in the directive. The 
rationale is that these six disciplines are either mental health 
professions by definition (e.g., psychiatry) or are necessary for the 
conduct of team-based mental health care (e.g., nursing). There are 
many other disciplines (including physicians assistants, PAs) that are 
important contributors to mental health care in VA but do not meet 
these criteria. Please note that Directive 1165 provides VHA facility 
leadership the discretion to include additional disciplines (e.g., PA, 
Clinical pharmacist) generally and specifically in recruitment for 
facility mental health positions.
    Question. If a change can be made to VHA Directive 1165, in the 
interim would the VA be willing to utilize more PAs in mental health to 
improve Veterans access to care?
    Answer. There is no barrier to facilities utilizing more PAs in VA 
mental health settings. PAs working in these settings are hired to 
provide medical services, mental health services, or in some cases 
both.
    Question. Regarding the Oracle Cerner contract negotiations, 
deployment, and funding of the EHR program, the largest issues facing 
the program are related to the deployment of an enterprise system in a 
decentralized operating structure.Will you commit to driving an equal 
amount of accountability and transparency into VA to speed decision 
making, establish a single set of readiness criteria, and maintain 
enterprise standards?
    Answer. VHA, the Office of Information & Technology (OIT) and the 
Electronic Health Record Modernization Integration Office (EHRM-IO) are 
working jointly together in a collaborative fashion to address program 
accountability, integrated readiness criteria and enterprise standards. 
This will be further defined during the reset period to support future 
deployments of the new Electronic Health Record (EHR).
    Question. What type of changes are you looking to make internally 
to drive accountability within VA and through the layers of governance 
across sites to drive the enterprise vision necessary for success?
    Answer. VHA has already made internal changes to further drive 
accountability across the enterprise. EHRM-IO and VHA are developing 
more robust system-lifecycle governance that clarifies the business 
need/issue, prioritizes solutions for development, and gets customer 
agreement and signoff on user acceptance criteria. VHA EHRM National 
Councils will represent the customer for this purpose. Additionally, 
VHA is planning to develop oversight programs for compliance with user 
acceptance and realization of business goals, which will be reported to 
committees of the VHA Governing Board.
    During the recent EHRM Sprint Project, the Governance Group was 
tasked with ensuring that processes and groups within are in place to 
support rapid decision-making regarding EHRM concerns. To meet this 
objective, the Governance Group established two VHA EHRM teams ? the 
Decision Support Team and the Interdisciplinary Decision Group ? to 
coordinate the decision-making processes across the enterprise and 
better coalesce all the groups working on this vital mission. 
Additionally, VA has developed a comprehensive plan to transition the 
National Councils from EHRM-IO to VHA, which will continue beyond the 
Sprint Project in better supporting EHRM development and 
accountability.
    All of these Governing Groups work alongside and collaboratively 
with the field operatives and informaticists within VA Veteran 
Integrated Service Networks (VISNs) by ensuring the following:

  --Accuracy, enterprise standardization and reliability of data 
        collected for upload to the new system in Data Collection 
        Workbooks (DCW). This includes extra checks to ensure that the 
        right data are uploaded.

  --Management of clinical and administrative orders. This includes 
        ensuring that when a VA employee needs to place an order for a 
        Veteran, they can easily find the right order and it goes where 
        it needs to go.

  --Standardization of EHR Naming conventions, including for locations, 
        to ease cognitive burden and better support VA?s enterprise 
        scale.

    Question. The DoD has successfully launched EHR at another 124 
sites adding another 12,000 end users. What do you think the VA EHR 
program is missing that DoD seems to have? How often are you and your 
direct reports meeting with your DoD counterparts on EHR modernization?
    Answer. VA is tightly integrated with the Department of Defense 
(DoD), regularly collaborating with and benefiting from DoD?s lessons 
learned from their EHR deployments.
    Implementing a new EHR system in any organization is difficult, but 
implementing one in a health care system as large and complex as VA's 
system is unprecedented. We are transitioning from the current, nearly 
40-year-old EHR system, Veterans Health Information Systems and 
Technology Architecture (VistA), comprised of 130+ separate and 
customizable EHR instances, to a single EHR product with enterprise-
wide standardized workflows and configurations. This is a significant 
change.
    There are some important differences between DoD and VA. For 
example, VA offers a broader range of health care than DoD and required 
additional components of the EHR system to meet the unique needs of 
Veterans. Additionally, DoD is further along in the implementation life 
cycle than VA. DoD also encountered challenges in its initial 
deployment of the EHR system and likewise took a pause to address 
issues before restarting deployments. DoD's implementation, and those 
of similar organizations, demonstrate that it typically takes multiple 
deployments, during which lessons are learned and adjustments made, to 
successfully optimize use of a new EHR system within the unique culture 
of and accommodating the unique requirements of a given health care 
system.
    VA incorporated the lessons learned from DoD into its deployment 
strategy and processes, and we continue to work with DoD to benefit 
from their lessons learned. VA meets with DoD frequently, including 
various meetings on a daily, weekly (e.g., Release and Change 
Coordination, Captain James A. Lovell Federal Health Care Center 
deployment coordination) and monthly (e.g., future strategy) basis. VA 
and DoD also meet regularly with the Federal Electronic Health Record 
Modernization (FEHRM) office, which leads DoD, VA and other Federal 
partners in implementing a single, common EHR that enhances patient 
care and provider effectiveness, wherever care is provided. Monthly 
EHRM Collaboration meetings hosted by FEHRM also includes stakeholders 
from the Coast Guard, currently housed in the Department of Homeland 
Security. VA and DoD also engage in additional ad hoc meetings, calls 
and interactions to exchange information as necessary.
    Question. There has been a lot of discussion on the costs of the 
EHR modernization effort. As the task orders for this program get 
awarded, it seems the main driver of these costs are new requirements 
being added by VA. What mechanisms are in place to control costs and to 
ensure we are prioritizing dollars for enterprise capabilities and not 
the customized needs of every site?
    Answer. VA is committed to fiscal responsibility as we implement an 
enterprise EHR system that meets the combined needs of Veterans and the 
medical professionals serving them. VA is continually driving towards 
meaningful standardization and accordingly prioritizes which system 
changes are most important, to include considering potential costs, 
with the end goal of having a system that can support improved access, 
outcomes and experiences for Veterans through a single health record 
from entry into military service to VA care.
    Question. Secretary McDonough, the Fiscal Year 2023 Mil-Con VA 
appropriations bill included report language encouraging the VA to 
support efforts to provide produce prescriptions to veterans with diet-
related conditions. The report provided up to $2 million for the VA to 
provide guidance and resources to VA facilities to work with community 
providers on local produce prescription programs for veterans. We have 
a terrific program in central Arkansas called Well Fed that has been 
working with the VA Medical Center in Little Rock. We understand these 
efforts have been slow going due to regulatory barriers and policies 
that have hindered the VA's ability to contract with local produce 
prescription providers. Could you please provide an update on the VA's 
efforts to implement the FY23 report language?
    Answer. In Fiscal Year (FY) 2022 and FY 2023, VHA funds were used 
to support the detail assignment of VHA staff to establish the work of 
the VHA Food Security Office (FSO). This work included but was not 
limited to the following:

  --Established data tools for use by clinicians and facilities. One of 
        the tools FSO created is the Food Security Data Dashboard. The 
        dashboard provides information on the total number of food 
        security screenings conducted by VHA and is accessible across 
        the Department. Data from the dashboard can be sorted in a 
        variety of ways, including by national, regional and local 
        facility levels. Positive screens can be further reviewed by a 
        number of demographic identifiers including gender, age, period 
        of service and ethnicity (to some extent). The tool also allows 
        FSO to review who completed each food security screen. The 
        dashboard is still very much in the prototype phase and FSO 
        continues to make adjustments as it comes across issue areas.

  --Developed field resources such as the Food Hub Playbook, which is 
        currently in the pilot phase. This resource is meant as a guide 
        for facilities on how to set up a food hub. A food hub is 
        similar to a food pantry but includes services such as access 
        to a social worker and/or a dietitian who can provide patient-
        centered care to the Veteran. An example of this is connecting 
        Veterans' medical nutrition needs to food available in the food 
        hub or assisting them with applying for Supplemental Nutrition 
        Assistance Program (SNAP) benefits and finding transportation 
        to and from appointments. FSO also developed a SharePoint site 
        which contains a variety of resources including information on 
        SNAP eligibility, the Hunger Hotline, Feeding America and the 
        FSO webpage. The FSO webpage contains resources with 
        information on how to shop on a budget, budget friendly meal 
        planning, nutrition tips for Veterans without a home and a 
        variety of other useful information and VA points of contact.

  --Conducted outreach to a wide variety of partners in the food 
        security space. During FY 2023, FSO conducted outreach to more 
        than 123 internal and external organizations in an effort to 
        promote the FSO and raise awareness of Veteran food insecurity. 
        Outreach included internal organizations such as program 
        offices, VISN clinical leadership and Federal agency partners 
        such as the Government Accountability Office (GAO), the 
        Department of Agriculture (USDA) and the Department of Health 
        and Human Services (HHS). Examples of external nonprofit 
        organizations include The White Oak Collaborate, God?s Love We 
        Deliver and Capital Area Food Bank.

  --Established and supported partnerships with outside organizations, 
        such as the partnership recently announced with the Rockefeller 
        Foundation to open Produce Prescription Pilot Programs in Salt 
        Lake City and Houston.

  --On September 12, 2023, FSO hosted the 2023 Veteran Food Security 
        Summit, targeting VISN clinical leadership to provide 
        information to the field on partnerships, data management and 
        research/education. The summit was one of VA's responses to the 
        White House?s requests outlined in the National Strategy on 
        Hunger, Nutrition and Health. During the summit, a formal 
        Memorandum of Agreement (MOA) was signed between VA and USDA to 
        demonstrate commitment, partnership, and a whole-of-government 
        approach to addressing Veteran food insecurity.

    The VHA FSO is now fully staffed. Staff include a dietitian, social 
worker, executive officer, nurse, program support assistant and a 
director.
    Question. What guidance has central VA given to regional VA 
facilities that are interested in establishing produce prescription 
programs in their area?
    Answer. Through the VHA Nutrition and Food Services Strategic Goals 
2023, each facility?s Nutrition and Food Services has been provided 
suggested activities to accomplish around Veteran food security. As 
part of these goals, facilities are also encouraged to consult with the 
VHA FSO with any interest or questions they have about Produce 
Prescription programs or other food security projects to meet the 
regional or local needs of their Veterans. FSO has established a formal 
relationship with the Rockefeller Foundation to provide Produce 
Prescription Pilot Programs with associated research at a number of VA 
facilities. The outcomes of these pilots will provide significant 
lessons regarding how to establish and implement Produce Prescription 
programs in future locations. As mentioned, VA held a national summit 
on Veterans Food Security. The summit?s objectives were directly 
aligned with the all-government approach and White House commitments in 
the National Strategy on Hunger, Nutrition and Health. The focus of the 
summit was to increase VA leadership knowledge of partnerships, 
research, interventions, innovations and promising practices related to 
ensuring Veteran food security.
    Question. How does the VA plan to allocate funding and track 
results?
    Answer. Grants or funding are not being made by VA Central Office 
to the facility level. Most activities are externally funded because 
internal VA funding is only allowed when food is provided as part of 
medical care and treatment (e.g., in the inpatient setting, or in 
conjunction with nutrition education programs such as Nutrition and 
Food Services Healthy Teaching Kitchens). Results from the pilot 
programs funded by the Rockefeller Foundation will be shared with VA as 
part of that formal partnership; research will entail specific 
questions and associated metrics on Produce Prescription programs as 
part of the pilots. The results will be shared with the field as they 
become available. FSO has also developed a Food Hub pilot play book; 
this likewise has associated metrics to track outcomes of the Food Hub 
pilot that will be shared on a regular basis with the field. Results 
from all pilots will be reviewed for trends and lessons in efficacy and 
Veteran experience. FSO is working on the implementation of the FY 2023 
National Defense Authorization Act legislation that will allow for the 
provision of food insecurity pilots with funding.
    Question. Lastly, are there additional policies or legislative 
changes that are necessary to enable these programs to move forward?
    Answer. Not at this time. Pilot evaluation of these Produce 
Prescription programs is the first step and activities are currently 
possible through partnerships.
    Question. It has come to my attention that Senator Grassley has 
sent the VA six oversight letters over the course of two years, raising 
a host of issues. These include a conflict of interest by a former VA 
official, who resigned rather than cooperate with the Inspector 
General, potentially enabling insider trading, and potential 
whistleblower retaliation. Most recently, he?s raised credible 
allegations of potential contract irregularities, with evidence that 
lucrative contracts were awarded to former VA officials who resigned 
under an ethical cloud. Inspector General Missal earlier this month 
sent a letter saying these allegations ?may implicate criminal 
violations.? Senator Grassley?s office states that there are over 30 
outstanding questions that VA has not fully answered. Mr. Secretary, 
these inquiries were addressed to you. What are you doing to 
investigate these potential criminal violations?
    Answer. VA previously sent detailed, substantive responses to 
Senator Grassley from Assistant Secretary Ross on December 23, 2021, 
and September 1, 2022, that addressed each of his oversight questions 
from 2021 and 2022. In addition, VA reviewed tens of thousands of 
documents and produced hundreds of pages to the Senator under separate 
cover. Regarding Senator Grassley?s most recent letter raising issues 
of alleged conflicts of interests and contractual irregularities, VA 
has fully responded to that letter, answering all of his questions and 
providing requested documents. As you note, Senator Grassley sent his 
letter raising these allegations to VA Inspector General Michael J. 
Missal. VA agrees that OIG is the appropriate entity to investigate any 
such potential criminal violations.
    Question. In an email to you on April 6, 2021, a senior VA official 
named Thomas Murphy admitted to firing the person he suspected was a 
whistleblower. What steps did you take to investigate this potential 
retaliation?
    Answer. Senator Grassley?s concerns about potential retaliation by 
Mr. Murphy were referred to the VA Office of Accountability and 
Whistleblower Protection (OAWP). As of December 14, 2023, the former 
employee has open cases currently under litigation with both the Equal 
Employment Opportunity Commission (EEOC) and the Merit Systems 
Protection Board (MSPB). Consistent with VA Directive 0500, OAWP does 
not further investigate matters complainants have filed in other 
remedial administrative forums and/or are under litigation.
    Question. In 2021 the Department responded to a question from the 
Senate Veterans Affairs Committee on air ambulance reimbursement as 
follows:In the Economic Regulatory Impact Analysis cited in response to 
question 12, VA used aggregated data for ground and air ambulance 
transportation due to VA's data challenge isolating specific air 
transports. VA does not have the ability to determine payments made by 
individual facilities by applicable reimbursement code but determined 
that Centers for Medicare & Medicaid Services (CMS) reimbursement rates 
are on average 13.68% lower than costs being reimbursed under the 
current regulations (i.e., billed charges).? All healthcare providers 
use diagnostic codes to document and bill for their services. Will you 
explain why the VA does not use diagnostic codes to document and bill 
for these services, which would differentiate between ground and air 
ambulance services, and measure reimbursement costs for these services 
separately?
    Answer. VA has not historically utilized an invoice processing 
system based upon diagnostic (Current Procedural Terminology, CPT) 
codes for contract claims, which identify the type of transportation 
for ground and/or air ambulance reimbursement. However, with the 
initiative to establish contracts for ground and air ambulance services 
for most VA Medical Centers (VAMCs), VA will be using the VetRide 
Third Party Portal for contract vendors to submit invoices with 
information from the Health Insurance Claim Form 1500, which includes 
CPT codes.
    Non-contract claims will continue to be processed through the eCAMS 
system, which does have CPT codes but provides a limited data recovery 
capability.
    Question. Since this was called to VA's attention in 2021, has the 
VA begun to keep data on air and ground ambulances separately?
    Answer. While this remains a systemic challenge, VA is in the 
process of determining pathways to refine its systems capability to 
accurately capture and report such data. One such effort is with the 
adoption of third-party software, VetRide. Each transport will be 
entered into this system, which will enable VA to accurately capture 
every individual mode of transportation inclusive of whether it was a 
ground or air transport, mileage, CPT code (for Special Mode 
Transportation), pick-up location, destination, costs, etc.
    Question. VA asserts that its new final rule on reimbursement for 
beneficiary travel by air ambulance will not have a substantial effect 
on the provision of such services because most services are provided 
under contract. Can you please provide us with the number of contracts 
that the VA has which cover air ambulance services, the geographic 
coverage of such contracts for air ambulance services, the number of 
transports that were performed for beneficiary travel in 2020, 2021, 
and 2022 under such contracts, and the total number of such transports 
in such years, whether in or out of contract?
    Answer. As of September 30, 2023, there are eleven active air 
ambulance contracts in seven VISNs, as reported by the VHA Office of 
Procurement and Logistics (P&LO).
    The list below shows the number of transports associated with 
contracts for FY 2020--FY 2023.

 
 
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                           Station                                         FY20 # of   FY21 # of   FY22 # of   FY23 # of
                          VISN                              Number                 Facility               Transports  Transports  Transports  Transports
--------------------------------------------------------------------------------------------------------------------------------------------------------
15.....................................................        589A5                  Eastern Kansas HCS           2           1           0           2
7......................................................          519                          West Texas          18          30          25          22
17.....................................................          756                         El Paso, TX           3           5           6           6
21.....................................................          459                 Pacific Islands HCS          93          76          77           0
21.....................................................          570                          Fresno, CA           0           0           0           4
21.....................................................          593                       Las Vegas, NV          25          34          24          11
21.....................................................          640                       Palo Alto, CA          13           4           8           7
21.....................................................          654                Sierra Nevada (Reno)          38          25          45          28
21.....................................................          662                   San Francisco, CA           9           0           3           3
22.....................................................          678                          Tucson, AZ          18          14          12           7
23.....................................................          618                     Minneapolis, MN          22           3          11          11
    Total Transports:..................................          241                                 192         211         101
--------------------------------------------------------------------------------------------------------------------------------------------------------
*Note some contracts may have ended.

    The chart below illustrates the breakout of contract and non-
contract Special Mode Transportation (SMT) payments, inclusive of 
ground and air ambulance, as well as a full breakdown of the number of 
claims processed under each authority (Title 38, U.S.C. '' 111, 1725, 
1720J, 1703 and 1728) and accompanying expenditures for SMT for FY 
2022. VA is currently pulling the requested information for FY 2020 and 
FY 2021 and will provide separately, once obtained. Please note, there 
remains data challenges with pulling some of the specific information 
requested related to air ambulance services.
    Question. At least one air ambulance operator needs responses to a 
FOIA request made to VA in order to understand how best to provide 
vital services to Veterans. This request has been pending for three 
months. Can I get your commitment to expedite the needed response for 
air ambulance services provided under contract?
    Answer. VA remains committed to providing access to care for 
Veterans and to providing timely responses to requests filed under the 
Freedom of Information Act (FOIA, P.L. 89-487). A FOIA request for data 
was received and coordinated with VHA Integrated Veteran Care and VHA 
Finance. The FOIA Request was closed on September 5, 2023.

                                 ______
                                 

             Questions Submitted by Senator Lisa Murkowski:
    Question. A 2019 study by the VA found that the presence of an 
adverse social stressor such as unemployment, housing, or financial 
instability was related to a 64% increase in the likelihood of suicidal 
ideation. A GAO report found that the federal government has 45 federal 
programs that provide career and employment assistance administered by 
11 agencies; however, these programs constantly overlap, lack 
monitoring and evaluation, and the GAO even found that eight have no 
goals that define program achievements. While I appreciate the work 
these federal programs do, numerous non-profits also do this work with 
a strong success rate. In Alaska, for instance, we have a really great 
group called VIPER Transitions. Their goal is to end veteran suicide by 
combating unemployment, underemployment, substance abuse, homelessness, 
and a fractured support system. They do this by providing pre-
employment training, resource networking, outreach, and the inclusion 
of military spouses in their programs. How does this budget request 
empower the VA and its Community Engagement and Partnership 
Coordinators to seek out worthwhile organizations to form coalitions 
that support these kinds of initiatives?
    Answer. The Department of Veterans Affairs (VA) Fiscal Year (FY) 
2024 Budget request continues to fund the Community-Based Interventions 
for Suicide Prevention (CBI-SP), including the Governor?s Challenge 
priorities (which have recently expanded to encompass all 50 states) 
and coordination of care in the community through the work of Community 
Engagement and Partnership Coordinators across VA. To date, there are 
more than 1,360 local coalitions in 50 states and 5 territories 
actively engaged in collaborations to coordinate Veteran suicide 
prevention efforts across Federal, state, tribal, local and community 
agencies. Coalitions are encouraged to adapt interventions to local 
needs and build broad, diverse representation from multiple sectors. 
This allows coalitions to address risk and protective factors in ways 
that make sense locally and maintain ownership of the work they are 
doing. Furthermore, through Section 201 of the Commander John Scott 
Hannon Veterans Mental Health Care Improvement Act of 2020 (P.L. 116-
171) and the Staff Sergeant Parker Gordon Fox Suicide Prevention Grant 
Program (SSG Fox SPGP), VA launched 80 community sites designed to 
focus on community-based suicide prevention outreach, services and 
access to life-saving services for Veterans and their families. These 
grants currently serve high-need communities across 43 states, 
Washington, DC and American Samoa. 21 of these community-based sites 
are on tribal lands, including two organizations serving Veterans and 
their families in Alaska (the Aleutian Pribilof Islands Association and 
Blue Star Families).
    Question. What is the VA doing to better meet the needs of their 
community partner organizations?
    Answer. The coalitions facilitated by the CBI-SP program are led by 
residents of the community, providing important opportunities to bring 
a diverse group of stakeholders to the table and work towards ending 
Veteran suicide. While there is an evidence-informed model providing a 
framework for the work, the relationships built as part of the 
coalition-building process are creating new opportunities for VA and 
the community to work together and better understand the full landscape 
of resources available within the community.
    Additionally, community-based SSG Fox SPGP sites provide suicide 
prevention outreach, emergent care services and connections to VA and 
community resources in high need areas across the country. These 
services are strategically placed to expand services to those at 
highest risk for suicide who are not receiving health care or other 
services furnished by VA. These services include education on suicide 
risk and prevention to families and community providers, baseline 
screening for risk, case management services to address unique drivers 
of risk (such as homelessness, food insecurity, legal challenges, 
familial instability, financial planning, etc.), peer support services, 
nontraditional services and emergent services for those at immediate 
risk of self-harm. Through the first six months of the program, these 
community partnerships have resulted in more than 156 emergency service 
referrals for Veterans identified at imminent risk of self-harm, more 
than 1,000 non-emergency service referrals, more than 1,700 social 
service referrals to proactively address drivers of risk and more than 
10,600 Veteran engagements.
    Question. Rural Alaskan veterans stand to benefit greatly from the 
expansion of telehealth services offered by the VA. When does VA expect 
to issue new regulations for the Caregivers Program, to include a 
virtual visit option?
    Answer. Individuals participating in VA's Program of Comprehensive 
Assistance for Family Caregivers (PCAFC) and Program of General 
Caregiver Support Services (PGCSS) have access to a variety of supports 
and services. Several of these supports are available virtually, 
including education and outreach. In FY 2023, the Caregiver Support 
Program partnered with VA's OMHSP and Clinical Resource Hubs to 
develop, implement and launch virtual psychotherapy services that are 
available to, and focused on, the unique mental health needs of Family 
Caregivers participating in PCAFC. This resource is being rolled out 
across each Veteran Integrated Service Network (VISN) in a phased 
approach. VA expects this resource will be available for Family 
Caregivers throughout all VISNs by the end of FY 2024.
    Additionally, for the duration of the COVID-19 National Public 
Health Emergency (PHE), VA relaxed certain requirements related to in-
person home visits required for PCAFC. Specifically, through 
regulations at Title 38, C.F.R. 71.60, VA was authorized to complete 
PCAFC home visits through videoconference or other available telehealth 
modalities. VA's flexibility under this authority expired on May 11, 
2023. It is important to note that in-person home visits enhance the 
PCAFC experience by providing an opportunity for VA to conduct 
comprehensive and holistic assessments of Veteran and caregiver needs. 
However, we recognize the benefit of virtual options in certain 
circumstances. We are continuing to consider and explore whether to 
support such flexibilities in the future.
    Question. What accommodations will be included in the new 
regulations for veterans who are highly rural but also don?t have 
regular access to broadband services or an internet connection?
    Answer. VA understands that Veterans who live in rural and highly 
rural areas may not have reliable internet access. VA is establishing a 
telehealth grant program wherein VA will provide grants to 
organizations that will establish telehealth access points. To the 
extent practicable, VA will prioritize those organizations that will 
serve Veterans in rural, highly rural, and medically underserved areas.
    Question. An authority granted under the soon-ending public health 
declaration for COVID-19 allowed the VA to reimburse transitional 
housing facilities which house homeless veterans from 115% to 200% of 
the standard rate. There is only one facility in Alaska that provides 
this service. How are veterans transitional housing facilities going to 
be impacted if this authority is allowed to expire?
    Answer. Transitional supportive housing facilities for Veterans 
will be impacted significantly now that the authority has expired.
    Veterans are impacted because grantee organizations who cannot find 
alternative funding sources to support their operational costs may have 
to reduce the services they provide to Veterans in the program. For 
example, grantee organizations may have to recruit fewer staff, may 
have to limit the qualifications of the staff they recruit, or may have 
to offer fewer comprehensive services to vulnerable Veterans. In fact, 
at least six grantees recently withdrew from their Grant and Per Diem 
(GPD) grants, citing insufficient funding as a significant reason for 
their decision.
    Nearly 1,200 per diem rate modifications were requested by 
community providers during the COVID-19 PHE. Many grantees have 
expressed concern that the cost of providing quality housing, staffing 
and services, especially in less congregate settings, is prohibitive 
under the statutory per diem rate limits that are currently in effect 
now that the authority has expired.
    In anticipation of the end of the COVID-19 PHE, GPD submitted 
legislative proposals for FY 2024. It was proposed to change the 
authority (38 U.S.C. ' 2012) to allow for an increase to the maximum 
per diem rate of up to 200% of the State Home rate for domiciliary care 
starting in FY 2024 and for the corresponding change to increase the 
authorization of appropriations authority (38 U.S.C. ' 2016). An 
overall update to GPD?s authorization of appropriations and FY 2024 
funding allocations is needed to align with pending legislative 
changes. These authorities, subject to funding availability, would help 
ensure that community organizations have sufficient resources to 
provide quality housing, staffing and services for Veterans 
experiencing homelessness.
    Also, VA is aware of bills, such as Return Home to Housing (H.R. 
491) and S. 1436 sec. 201, which allow for per diem rates to remain 
elevated beyond the end of the COVID-19 PHE. Bills such as these that 
propose an increase not only to 38 U.S.C. ' 
2012(a)(2)(B)(i)(II)(aa)(BB) (GPD Per Diem Only rate), but also to ' 
2012(a)(2)(B)(ii) (GPD Transition In Place rate) would address the 
concerns of most transitional housing providers related to the rising 
cost of staffing and services associated with operating these programs 
post-pandemic.
    Question. What is the predicted impact to homeless veterans if this 
authority is allowed to expire?
    Answer. The quality of staffing and services offered by 
transitional supportive housing providers is a significant factor in 
determining successful outcomes for Veterans. It impacts the degree to 
which Veterans exit GPD programs into permanent, stable housing. 
Funding is needed to allow grantees to innovate and enhance services to 
effectively support Veterans and prevent returns to homelessness. To 
achieve this, additional staff is needed, and the cost of delivering 
this care and hiring quality staff continues to rise. The standard per 
diem rate is insufficient to meet current demands.
    If authority and funding were provided for the GPD maximum per diem 
rate to be increased from 115% or 150% to 200% of the State Home 
domiciliary rate, then VA would be able to adequately compensate for 
the services needed to support Veterans experiencing homelessness as 
they move to stable housing.
    A continuation of the elevated per diem rates is needed to ensure 
VA is able to provide sufficient high quality transitional housing with 
supportive services for our Veterans experiencing homelessness.
    With the expiration of the COVID-19 PHE, GPD reimbursement has 
returned to the standard rate of up to 115%. GPD consults directly with 
grantees that are struggling to provide housing and services to 
Veterans under their program as a result of the drop in per diem rates 
to explore options to modify their program scope, identify alternate 
sources of funding and/or develop collaborations within their 
community.
    Question. Last year, this committee made sure that the VA State 
Home Construction Grant Program was fully funded to the President's 
budget request. I have recently come to learn that despite fully 
funding this program last year, the Palmer Pioneer Home is likely going 
to be ranked too low on the priority list to receive funding through 
the program this year despite having a severe and dangerous icing 
situation with their roof that impacting the safety of the facility and 
the health of the residents. What level does this subcommittee need to 
fund this program to in order to guarantee the Palmer Pioneer Home gets 
the funds it needs from the VA to replace its roof?
    Answer. The roofing renovation project at the Alaska Veterans & 
Pioneers Home (FAI 02-002) in Palmer is ranked 20th on the FY 2023 
priority list. Alaska?s project is ranked 1.4D under Title 38 C.F.R. 
59.50 (a) (1) (iv): ?Priority group 1 subpriority 4. A ranking of 1.4D 
is defined as an application from a State for renovations to a State 
Home facility other than renovations that would be included in 
subpriority group 1 of priority group 1. Projects will be further 
prioritized in the following order:

                A. Adult day health care renovation and construction of 
                a new adult day health care facility that replaces an 
                existing facility;

                B. Nursing home renovation (e.g., patient privacy) and 
                construction of a new nursing home that replaces an 
                existing nursing home;

                C. Code compliance under the Americans with 
                Disabilities Act;

                D. Building systems and utilities (e.g., electrical; 
                heating, ventilation and air conditioning; boiler; 
                medical gasses; roof; elevators);

                E. Clinical-support facilities (e.g., for dietetics, 
                laundry, rehabilitation therapy); and

                F. General renovation/upgrade (e.g., warehouse, 
                storage, administration/office, multipurpose).?

    The Alaska Veterans & Pioneers Home (FAI 02-002) in Palmer is 
ranked among other projects with the same designation, in accordance 
with the date of the application. VA cannot state the amount needed to 
fund the grant program for FY 2024, as the FY 2024 priority list has 
not been completed and this project?s ranking has yet to be determined.

                                 ______
                                 

             Questions Submitted by Senator Susan Collins:
    Question. In 2022, the third-party administrator responsible for 
developing and administering Community Care Network claims in Regions 
1, 2, and 3, eliminated the Standardized Episodes of Care code for 
intensive mental health in-home case management services, without 
issuing a new code. Veterans receiving these management services are 
typically those diagnosed with severe and persistent mental illness, 
and often have difficulty leading normal daily lives. This code was 
critical to ensuring these veterans receive the care they so 
desperately need, and without issuing a new code, VA by its own 
admission is unable to reimburse community health care providers who 
provide services to veterans living with severe mental illness across 
Maine. Since VA is unable to internally accommodate these veterans, 
what steps is the VA taking to ensure that veterans have access to 
intensive, community care supports, such as those that were previously 
available under the eliminated code?
    Answer. Case management can have different meanings. Case 
management as defined in this request includes the following: making a 
grocery list, taking shopping, teaching how to cook, teaching life 
skills to gain employment and support living in a group home or in a 
home. There have been multiple discussions in the past between Office 
of General Counsel (OGC), Geriatrics and Extended Care Services (GEC) 
and Mental Health, Policy and Clinical Integration (now known as the 
Office of Integrated Veteran Care) regarding these policies. The result 
of these conversations was that non- clinical case management services, 
as defined in this paragraph, fall outside the umbrella of clinical 
case management and therefore are not paid for under the Veterans 
Community Care Program. Instead, these services would fall more under a 
typical Medicaid benefit including social support benefits, life skills 
assistance, or daily skills support.
    In reference to the codes that have been used by sites in the past, 
T2022 was never on the Standardized Episodes of Care (SEOC). T1016 and 
T1017 were initially on the Mental Health Intensive Outpatient SEOC, 
until they were removed in 2020 once the decision was made.

                                 ______
                                 

              Questions Submitted by Senator Bill Hagerty
    Question. Secretary McDonough, in recent remarks regarding the on-
going Oracle Cerner contract negotiation, you outline the need to drive 
accountability into in the EHRM contract but that is only half of the 
equation. The largest issues facing the program are related to the 
deployment of an enterprise system in a decentralized operating 
structure. Will you commit to driving an equal amount of accountability 
and transparency into VA to speed decision making, a single set of 
readiness criteria, and an enterprise standard?
    Answer. Within the Department of Veterans Affairs (VA), the 
Veterans Health Administration (VHA), the Office of Information & 
Technology (OIT), and the Electronic Health Record Modernization 
Integration Office (EHRM-IO) are working jointly together in a 
collaborative fashion to address program accountability, integrated 
readiness criteria and enterprise standards. This will be further 
defined during the reset period to support future deployments of the 
new Electronic Health Record (HER) across VA.
    Question. What metrics are you requiring of your VA team that 
ensures accountability?
    Answer. Accountability metrics will be further defined during the 
reset period to support future deployments.
    Question. What types of changes do you plan on making internally to 
drive accountability within VA and through layers of governance across 
sites to drive the enterprise vision necessary for success?
    Answer. VHA has already made internal changes to further drive 
accountability across the enterprise. EHRM-IO and VHA are developing 
more robust system-lifecycle governance that clarifies the business 
need/issue, prioritizes solutions for development, and gets customer 
agreement and signoff on user acceptance criteria. VHA EHRM National 
Councils will represent the customer for this purpose. Additionally, 
VHA is planning to develop oversight programs for compliance with user 
acceptance and realization of business goals, which will be reported to 
committees of the VHA Governing Board.
    During the recent EHRM Sprint Project, the Governance Group was 
tasked with ensuring that processes and groups within are in place to 
support rapid decision-making regarding EHRM concerns. To meet this 
objective, the Governance Group established two VHA EHRM teams ? the 
Decision Support Team and the Interdisciplinary Decision Group ? to 
coordinate the decision-making processes across the enterprise and 
better coalesce all the groups working on this vital mission. 
Additionally, VA has developed a comprehensive plan to transition the 
National Councils from EHRM-IO to VHA, which will continue beyond the 
Sprint Project in better supporting EHRM development and 
accountability.
    All of these Governing Groups work alongside and collaboratively 
with the field operatives and informaticists within VA Veteran 
Integrated Service Networks (VISNs) by ensuring the following:

  --Accuracy, enterprise standardization and reliability of data 
        collected for upload to the new system in Data Collection 
        Workbooks, or DCWs. This includes extra checks to ensure that 
        the right data are uploaded.

  --Management of clinical and administrative orders. This includes 
        ensuring that when a VA employee needs to place an order for a 
        Veteran, they can easily find the right order and it goes where 
        it needs to go.

  --Standardization of EHR Naming conventions, including for locations, 
        to ease cognitive burden and better support VA's enterprise 
        scale.

    Question. During the Department of Defense?s initial rollout of MHS 
Genesis and Oracle Cerner?s EHR, there were some issues during the IOC 
employment. Last month, the DOD EHR went live at another 124 sites, 
adding an additional 12,000 end users. In your recent announcement 
regarding the continuation of the pause on EHRM deployments, you 
mentioned that VA deployment at the Lovell Facility in North Chicago 
will not be impacted. What is the VA program missing that the 
Department of Defense system benefits from?
    Answer. VA is tightly integrated with the Department of Defense 
(DoD), regularly collaborating with and benefiting from DoD?s lessons 
learned from their EHR deployments.
    Implementing a new EHR system in any organization is difficult, but 
implementing one in a health care system as large and complex as VA?s 
system is unprecedented. We are transitioning from the current, nearly 
40-year-old EHR system, Veterans Health Information Systems and 
Technology Architecture (VistA), comprised of 130+ separate and 
customizable EHR instances, to a single EHR product with enterprise-
wide standardized workflows and configurations. This is a significant 
change.
    There are some important differences between DoD and VA. For 
example, VA offers a broader range of health care than DoD and required 
additional components of the EHR system to meet the unique needs of 
Veterans. Additionally, DoD is further along in the implementation life 
cycle than VA. DoD also encountered challenges in its initial 
deployment of the EHR system and likewise took a pause to address 
issues before restarting deployments. DoD?s implementation, and those 
of similar organizations, demonstrate that it typically takes multiple 
deployments, during which lessons are learned and adjustments made, to 
successfully optimize use of a new EHR system within the unique culture 
of and accommodating the unique requirements of a given health care 
system.
    VA incorporated the lessons learned from DoD into its deployment 
strategy and processes, and we continue to work with DoD to benefit 
from their lessons learned. VA meets with DoD frequently, including 
various meetings on a daily, weekly (e.g., Release and Change 
Coordination, Captain James A. Lovell Federal Health Care Center 
deployment coordination) and monthly (e.g., future strategy) basis. VA 
and DoD also meet regularly with the Federal Electronic Health Record 
Modernization (FEHRM) office, which leads DoD, VA and other Federal 
partners in implementing a single, common EHR that enhances patient 
care and provider effectiveness, wherever care is provided. Monthly 
EHRM Collaboration meetings hosted by FEHRM also includes stakeholders 
from the Coast Guard, currently housed in the Department of Homeland 
Security. VA and DoD also engage in additional ad hoc meetings, calls 
and interactions to exchange information as necessary.
    Question. What mechanisms are in place to 1) control costs and 2) 
ensure we are prioritizing dollars for enterprise capabilities and not 
the customized needs of each individual site?
    Answer. VA is committed to fiscal responsibility as we implement an 
enterprise EHR system that meets the combined needs of Veterans and the 
medical professionals serving them. VA is continually driving towards 
meaningful standardization and accordingly prioritizes which system 
changes are most important, to include considering potential costs, 
with the end goal of having a system that can support improved access, 
outcomes and experiences for Veterans through a single health record 
from entry into military service to VA care.
    Question. I was pleased to see the Department publish the 2022 VA/
DoD Guideline for the Use of Opioids in the Management of Chronic Pain. 
It is my understanding that the Guidelines report 20 recommendations, 
including ?For patients receiving daily opioids for the treatment of 
chronic pain, we suggest the use of buprenorphine instead of full 
agonist opioids due to lower risk of overdose and misuse?. In light of 
this recommendation, is the Department working to ensure our Veterans 
have access to pain-management treatments that have demonstrated a 
lower risk of overdose and misuse, like buprenorphine, or other 
therapies with abuse deterrent formulations or qualities?
    Answer. Buprenorphine medication products that are approved for 
pain management by the Food and Drug Administration (FDA) are available 
at all VHA facilities and are part of the VA National Formulary. 
Buprenorphine medication can be prescribed by VHA clinicians who are 
also registered with the Drug Enforcement Administration to prescribe 
such medication products. VA already has multiple educational materials 
for providers and Veterans, and is developing additional training 
material to increase education regarding the use of buprenorphine for 
pain management. VA is also updating guidance documents to ensure 
access to buprenorphine by removing existing barriers to the use of 
buprenorphine products for the treatment of opioid use disorder. In 
addition, as part of VA's larger strategy to provide whole person pain 
care that is safe and effective, VA offers many evidence- based 
nonpharmacological approaches for pain management.
    Question. Is the Department evaluating and updating the VA National 
Formulary to ensure appropriate access to these drugs?
    Answer. Buprenorphine medication products that are FDA-approved for 
pain management are available at all VHA facilities and are part of the 
National Formulary. Due to increased demand for buprenorphine, 
education and prescribing guidance is being reviewed and updated in 
collaboration with VA National Formulary to improve access and remove 
barriers to prescribing for frontline providers.
    Question. Recently, the Department of Veterans Affairs issued a 
final rule that would reduce the reimbursement rate of emergency air 
medical services. Has the Department considered what the impact would 
be on the lives of rural veterans who would lose access to emergency 
medical care in life-threatening situations if rural air ambulance 
bases are closed because of the cuts of up to 80% in VA reimbursement 
rates?
    Answer. VA is committed to ensuring Veterans receive timely care, 
which is supported by meeting the transportation needs of its eligible 
beneficiaries. Emergency air medical services is an issue for many 
Americans. It is noted that VA payments for such services, even at the 
current billed charges, is dwarfed by other payors in the market such 
as Centers for Medicare and Medicaid Services (CMS) and other public or 
private entities. Anecdotal research indicates that in 2022, the total 
air ambulance transports in the continental United States numbered 
slightly more than 500,000, while the total number of air ambulance 
transports billed to VA was just above 9,000.
    To address the particular needs of rural Veterans, VA is pursuing 
one or more Air Ambulance Broker Contract(s), which will be able to 
subcontract with a large number of air ambulance providers, including 
those located in and serving rural areas, including outside the 
continental United States (Guam, Mariana Islands, American Samoa, 
Hawaii, Puerto Rico and U.S. Virgin Islands).
    Question. You stated in a recent correspondence that the rule was 
delayed to allow providers time to negotiate with VA to contract for 
payment rates that may reflect their costs more accurately than the CMS 
fee schedule. This seems to recognize that the CMS fee schedule is not 
an accurate reflection of costs. Would you consider delaying the 
implementation until the CMS data is released that shows what the 
appropriate costs are?
    Answer. This decision to delay implementation was not a reflection 
on the adequacy of the CMS ambulance fee schedule. VA delayed the rule 
to promote nationwide coordination and communication with vendors on 
the opportunity to enter into contracts as appropriate.
    Question. Can you provide more detail on how contracting works now 
or will work with emergency air providers? How many contracts currently 
exist with emergency air providers across the country and how do these 
contracts work? Are the rates based on a market rate or higher than 
CMS? How do contracts work if veterans are transported from a scene 
accident or non-VA facility and go to a non-VA hospital? Will the 
contracts be with facilities or regions or enterprise wide? Since most 
emergency air ambulances are not tied to a hospital and have no control 
over who they pick up (no self-dispatch) how would this work?
    Answer. As of September 30, 2023, there are eleven total contracts, 
which serve several VAMCs. One contract serves all facilities in VISN 
23, and one contract serves three Medical Centers in VISN 22. All 
contracts, or solicitations, are managed by VA Office of Procurement 
and Logistics (OP&L) and follow all the Federal Acquisition Regulation 
requirements. Currently, VA is preparing to publish a solicitation for 
an Air Ambulance Broker contracts, which would be enterprise wide. The 
Brokers that would be awarded the enterprise-wide contract would then 
be responsible for contracting with air ambulance providers to serve 
the continental United States, Alaska, Hawaii, American Samoa, Guam, 
Puerto Rico and the Manilla Community-Based Outpatient Clinic with air 
ambulance services. Additionally, VA provided direction in the 
solicitation Performance Work Statement, which would permit VA to 
reimburse, at the contracted rate, any emergent transports performed by 
any subcontractor to the Air Ambulance Broker contracts.
    Question. 263 of Public Law 112-56, which added subsection 
(b)(3)(C) to 38 U.S.C. ' 111 references that the VA may tie rates to 
the lower of billed charges or the Medicare rate for transports to and 
from VA facilities. Does this rule also cover non-VA transports 
considering most Veterans that are emergency airlifted are originating 
and ending at private commercial hospitals and facilities?
    Answer. As stated in response to Question 4b, with the enterprise-
wide Air Ambulance Broker contracts, if a Veteran is transported by an 
air ambulance provider who has a sub-contract with the Broker, the air 
ambulance provider will be reimbursed at the contracted rate negotiated 
with the Broker. This contracted rate may be below or above, depending 
on appropriate justification, the CMS rate. If the Veteran is 
transported by an air ambulance provider that does not have a contract 
with the Broker, they will be reimbursed at either 100% of the CMS 
rate, if they are Beneficiary Travel eligible, or as much as 70% of the 
CMS rate if the Veteran is not Beneficiary Travel eligible, is eligible 
under authority for VA to reimburse for emergency treatment pursuant to 
38 U.S.C. 1725, or is eligible for emergency suicide care under 38 
U.S.C. 1720J.

                          SUBCOMMITTEE RECESS

    Senator Murray. With that, we stand adjourned.
    [Whereupon, at 12:17 p.m., Wednesday, April 26, the 
subcommittee was recessed, to reconvene subject to the call of 
the chair.]