    [Senate Hearing 118-301]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 118-301

                    FRONTIER HEALTH CARE: ENSURING VETERANS'
                        ACCESS NO MATTER WHERE THEY LIVE

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED EIGHTEENTH CONGRESS

                                 SECOND SESSION
                                   __________

                                  MAY 15, 2024
                                   __________

           Printed for the use of the Committee on Veterans' Affairs

                   [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov
                                    ______

                       U.S. GOVERNMENT PUBLISHING OFFICE

    55-729 PDF                 WASHINGTON : 2025

                     SENATE COMMITTEE ON VETERANS' AFFAIRS

                         Jon Tester, Montana, Chairman
    Patty Murray, Washington             Jerry Moran, Kansas, Ranking
    Bernard Sanders, Vermont               Member
    Sherrod Brown, Ohio                  John Boozman, Arkansas
    Richard Blumenthal, Connecticut      Bill Cassidy, Louisiana
    Mazie K. Hirono, Hawaii              Mike Rounds, South Dakota
    Joe Manchin III, West Virginia       Thom Tillis, North Carolina
    Kyrsten Sinema, Arizona              Dan Sullivan, Alaska
    Margaret Wood Hassan, New Hampshire  Marsha Blackburn, Tennessee
    Angus S. King, Jr., Maine            Kevin Cramer, North Dakota
                                         Tommy Tuberville, Alabama

                          Tony McClain, Staff Director
                   David Shearman, Republican Staff Director

                                C O N T E N T S

                                  ----------

                                  May 15, 2024

                                    SENATORS

                                                                       Page
    Hon. Jon Tester, Chairman, U.S. Senator from Montana.............     1
    Hon. Mike Rounds, U.S. Senator from South Dakota.................     7
    Hon. Patty Murray, U.S. Senator from Washington..................     9
    Hon. Thom Tillis, U.S. Senator from North Carolina...............    11
    Hon. Angus S. King, Jr., U.S. Senator from Maine.................    13
    Hon. Dan Sullivan, U.S. Senator from Alaska......................    15
    Hon. Margaret Wood Hassan, U.S. Senator from New Hampshire.......    17
    Hon. Jerry Moran, Ranking Member, U.S. Senator from Kansas.......    19
    Hon. Richard Blumenthal, U.S. Senator from Connecticut...........    22

                                   WITNESSES

                                    Panel I

    Peter Kaboli, MD, MS, Executive Director, Office of Rural Health,
      Veterans Health Administration, Department of Veterans Affairs;
      accompanied by Ryan Heiman, MHSA, CPTA, Deputy Executive
      Director, VHA Member Services; Leonie Heyworth, MD, MPH, Deputy
      Director for Clinical Services, Office of Connected Care; and
      Wade Vlosich, Director, VA Oklahoma City Health Care System....     3

                                    Panel II

    Chauncey Parker, Executive Director, Great Plains Veterans
      Services Center................................................    23

    Alyssa M. Hundrup, Director, Health Care, Government
      Accountability Office..........................................    25

    Jon Retzer, Assistant National Legislative Director, Disabled
      American Veterans..............................................    27

                                   APPENDIX

                               Opening Statement

    Senator Jerry Moran..............................................    39

                              Prepared Statements

    Peter Kaboli, MD, MS, Executive Director, Office of Rural Health,
      Veterans Health Administration, Department of Veterans Affairs.    45

    Chauncey Parker, Executive Director, Great Plains Veterans
      Services Center................................................    59

    Alyssa M. Hundrup, Director, Health Care, Government
      Accountability Office..........................................    62

      Attachment--``Government Accountability Office (GAO)
        Highlights''.................................................    75

    Jon Retzer, Assistant National Legislative Director, Disabled
      American Veterans..............................................    76

                            Questions for the Record

    Department of Veterans Affairs responses to questions asked
      during the hearing by:

      Hon. Thom Tillis...............................................    87

    Department of Veterans Affairs responses to questions submitted
      by:

      Hon. Mike Rounds...............................................    89
      Hon. Tommy Tuberville..........................................    92
      Hon. Angus S. King, Jr.........................................    94

    Great Plains Veterans Services Center responses to questions
      submitted by:

      Hon. Angus S. King, Jr.........................................    95

    Disabled American Veterans responses to questions submitted by:

      Hon. Angus S. King, Jr.........................................    96

                           Statements for the Record

    Air Methods Corporation, Jaelynn Williams, CEO...................   101

    American Association of Nurse Anesthesiology (AANA), Dru Riddle,
      PhD, DNP, CRNA, FAAN, President................................   104

                         FRONTIER HEALTH CARE: ENSURING
                           VETERANS' ACCESS NO MATTER
                                WHERE THEY LIVE

                                  ----------

                            WEDNESDAY, MAY 15, 2024

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 3:30 p.m., in
    Room SR-418, Russell Senate Office Building, Hon. Jon Tester,
    Chairman of the Committee, presiding.

        Present: Senators Tester, Murray, Brown, Blumenthal,
    Hassan, King, Moran, Boozman, Rounds, Tillis, Sullivan, and
    Blackburn.

                 OPENING STATEMENT OF HON. JON TESTER,
                  CHAIRMAN, U.S. SENATOR FROM MONTANA

        Chairman Tester. Good afternoon. I want to welcome
    everybody to today's hearing on access to health care for rural
    veterans. We are going to take a closer look at whether VA is
    meeting the needs of rural veterans and what needs to be done
    better.
        On our second panel we have a gentleman by the name of
    Chauncey Parker, who is going to join us. Good to have you
    here, Chauncey. He is a native veteran from Montana, just down
    the road from where I live, as a matter of fact. Chauncey and
    his team at the Great Plains Veterans Services Center--Rocky
    Boy, do an incredibly good job for rural and native veterans,
    and I believe his insight, albeit on the second panel, to the
    challenges we have today is going to be key.
        I want to also thank Wade Vlosich. Wade, thank you for
    being here. He has done important work in Montana gathering
    feedback from veterans and staff and making recommendations to
    improve health care and services for veterans across our state.
    This included traveling to every facility in Montana to meet
    with folks, learn about the difficulties of accessing health
    care across long distances and challenging geography.
        If you want to understand the barriers that rural veterans
    face, you need to walk a mile in their shoes. More than 2.7
    million veterans enrolled in VA health care live in rural or
    frontier areas--that is code for ``remote''--and the VA must
    deliver quality health care and benefits to them, regardless of
    where they live. Key to that effort, and particularly difficult
    in rural America, is recruiting and retaining providers and
    support staff. That starts with ensuring the VA continues to
    aggressively recruit and retain high-demand clinicians in rural
    areas. It also includes access to transportation benefits and
    services, including beneficiary travel reimbursement. Last
    fall, with the help of Senator Moran, we introduced the Road to
    Access Act, which would improve the beneficiary travel claims
    process by reducing the burden on our veterans.
        And we need to make sure rural veterans can access
    lifesaving emergency air and ground ambulance transportation.
    We have got a bill called the VA Emergency Transportation
    Access Act that is going to ensure changes to the VA's
    reimbursement rates, will not reduce access to this special
    mode of transportation that is so critically important for
    rural America.
        And finally, any effort to expand access to rural veterans
    must include outreach to ensure that rural veterans know what
    benefits and services are out there for them. That includes
    expanding access and outreach to our Native American veterans
    who, by the way, serve the Nation at a higher rate than any
    other minority in this country. Yet, access to VA is at some of
    the lowest rates.
        And programs and strategies for health care staffing and
    services must be suitable for rural communities. Some of them
    may work well for urban veterans but not so much for rural
    veterans. And that is why I required the Department to develop
    and institute a rural-specific recruitment and retention
    strategy as part of the PACT Act, which was rolled out earlier
    this year. This kind of targeted planning and programming needs
    to spread across the VA to include research, direct care
    offering, grant programming, and much more. And I look forward
    to hearing more from our witnesses about these topics, and
    more.
        I think I will get right into the panel. I want to make
    some introductions here. First of all, good afternoon.
        On our first panel we have Dr. Peter Kaboli. He is
    accompanied by Ryan Heiman from VHA Member Services; Leonie
    Heyworth, from the Office of Connected Care, Telehealth
    Services; and the other guy that has got a tough name for me to
    pronounce, Wade Vlosich. How is that? Is that okay?
        Mr. Vlosich. It is Vlosich, like sausage.
        Chairman Tester. Oh. Vlosich. Why didn't you say so?
        He is the Director of the VA Oklahoma City Health Care
    System.
        Dr. Kaboli--by the way, why don't you guys just have a name
    like Tester or Rounds or something like that, okay?
        [Laughter.]
        Chairman Tester. That is for good reason you don't.
        But your entire written statement, Dr. Kaboli, will be
    entered into the record. I would ask that you try to keep it
    around 5 minutes. And with that the floor is yours.

                                 PANEL I

                               ----------

        STATEMENT OF PETER KABOLI, MD, MS, EXECUTIVE DIREC-
         TOR,  OFFICE OF RURAL HEALTH,  VETERANS HEALTH AD-
         MINISTRATION, DEPARTMENT OF VETERANS AFFAIRS;  AC-
         COMPANIED BY RYAN HEIMAN, MHSA, CPTA, DEPUTY EXEC-
         UTIVE  DIRECTOR,  VHA  MEMBER   SERVICES;   LEONIE
         HEYWORTH, MD, MPH, DEPUTY  DIRECTOR  FOR  CLINICAL
         SERVICES,  OFFICE  OF  CONNECTED  CARE;  AND  WADE
         VLOSICH, DIRECTOR, VA  OKLAHOMA  CITY  HEALTH CARE
         SYSTEM

        Dr. Kaboli. Thank you, Chairman Tester and Ranking Member
    Moran and the Members of the Committee. Thank you for this
    opportunity to appear before you to discuss the Veterans
    Affairs efforts to enhance the well-being of rural veterans by
    addressing their unique challenges.
        I am joined by Mr. Ryan Heiman, Deputy Executive Director
    of Member Services; Dr. Leonie Heyworth, Deputy Director for
    Clinical Services for Telehealth; and Mr. Wade Vlosich,
    Director of the VA Oklahoma City Health Care System.
        Growing up in rural Lee County, Iowa, I experienced rural
    health firsthand. I attended medical school at the University
    of Iowa, and have since served rural veterans as a hospitalist,
    including as a tele-hospitalist filling gaps in rural sites.
        VA strives to bridge the gaps between veterans in rural
    areas and resources. Much of that work has been led by our five
    Rural Health Resource Centers in Portland, Oregon; Salt Lake
    City, Utah; Gainesville, Florida; White River Junction,
    Vermont; and Iowa City, Iowa, where I have practiced hospital
    medicine for 26 years.
        We serve all 4.4 million veterans who reside in rural
    communities, making up a quarter of all veterans. Most choose
    to live in these communities and appreciate the benefits of
    rural life. However, long travel distances and broadband
    limitations can make accessing care difficult. Rural veterans
    have a higher rate of enrollment in VA care, at 61 percent,
    compared to enrollment rates of only 41 percent for urban
    veterans.
        This higher enrollment rate and dependence on VA
    underscores the need to focus on four key challenges for rural
    populations. The first is geographic distance, second is
    telehealth and the digital divide, third is social determinants
    of health, and the fourth is workforce.
        For geographic distances, there are two ways to overcome
    this for rural and frontier veterans--either bring the veterans
    to us through transportation or bring the care to them through
    telehealth and home services. VA supports the Veterans
    Transportation Service, which fielded requests for over 900,000
    rides in 2023, including 105,000 rural trips. ORH also supports
    the Highly Rural Transportation Grants program that provided
    19,000 trips, averaging 74 miles each way, serving rural
    counties in 26 States and 58 Tribal communities. VA also
    manages and continues to streamline the Beneficiary Travel
    Self-Service System to reimburse travel costs and improve
    access.
        The second key challenge is the digital divide and the use
    of telehealth. VA has significantly expanded telehealth
    services with a 347 percent increase in use and a 3,100 percent
    increase in home video services over 5 years. In fiscal year
    2023 alone, VA delivered over 2.9 million telehealth episodes
    to 770,000 rural veterans. One current challenge is the state
    level variability, regulating controlled substance prescribing
    in telemedicine, and VA has requested clarified authority to
    standardize these services.
        The third challenge for rural populations involves social
    determinants of health, including special populations like
    American Indian and Alaska Native veterans, who serve at high
    rates and disproportionately live in rural areas. Key
    initiatives include exempting or reimbursing $3.2 million for
    180,000 copayments for over 4,000 eligible veterans; providing
    supportive housing for homeless veterans, with 29 Tribes
    participating in a joint VA-Housing and Urban Development
    program; and the third is enhanced efforts to reduce the high
    suicide rate among American Indian, Alaska Native veterans,
    including $52 million in grants and collaborations with tribal
    communities.
        The fourth key challenge is workforce. Although we all know
    we have a national shortage of health care providers, the
    shortage impacts rural communities more acutely. In rural
    locations they lack a deep bench of staff, so when one position
    is vacant it disproportionately impacts that site of care. So,
    to address this need, Office of Rural Health and Workforce
    Management developed the Rural Recruitment and Hiring Plan, and
    we disseminated that in 2023.
        So let me end with three examples that illustrate how we
    address the unique health care needs of rural and frontier
    veterans.
        The first is we developed a novel tele-HIV program to
    remote and insular islands, like Guam and American Samoa, that
    ensures highly specialized care.
        A second example is we have expanded home pulmonary
    rehabilitation services to 35 sites, which supports the PACT
    Act and veterans with toxic exposure and lung disease.
        And we are launching a new program called SCOUTS that hires
    former military medics to be trained as intermediate care
    technicians in emergency rooms, to engage with older veterans
    and provide close follow up through telehealth and home visits.
        So, Chairman Tester and Ranking Member Moran, thank you
    again for the invitation to join this important discussion. We
    value our ongoing engagement as we embrace our shared
    responsibility to better serve those who have served, and we
    look forward to answering your questions.

        [The prepared statement of Dr. Kaboli appears on page 45 of
    the Appendix.]

        Chairman Tester. I appreciate your testimony, and I assume
    the other three are there to support you in the Q&A.
        Before we get to the important questions about rural
    veterans' health care, you were an Iowa practicing doctor for
    26 years?
        Dr. Kaboli. Yes. I am still there. I have got to see
    patients on Monday.
        Chairman Tester. Did you deliver Caitlin Clark?
        Dr. Kaboli. No.
        [Laughter.]
        Chairman Tester. Just curious.
        Dr. Kaboli. But it is Iowa, so we all know each other.
        Chairman Tester. Okay. Well, that is good. That is good.
        Mr. Heiman, the most common complaints and casework
    requests I get from veterans in Montana are related to the
    Beneficiary Travel Self-Service System. That is your bailiwick.
    The system is getting better, but there is still room for
    improvement, from a user-friendly standpoint.
        Can you give me an update on your work with veterans to
    improve that claims submission process?
        Mr. Heiman. First of all, thank you, Chairman Tester. I
    appreciate your interest and your staff's interest over the
    years, quite frankly, on this topic.
        Last year we implemented a veteran survey. It was in
    partnership with the Veteran Experience Office. And so far, we
    have had over 11,000 veterans that have taken that survey. From
    the period of October 2023 to April 2024 we have seen an
    improvement. We have seen a 16 percent improvement in ease and
    simplicity associated with the BT app, and we have seen a 17
    percent overall increase in satisfaction.
        Another important note that we found interesting that I
    would share with you, because some of our concerns we get are
    from some of our more seasoned veterans, we will call them, but
    this population of veterans, of the 11,000, 80 percent are over
    the age of 50, that are responding to our survey.
        So, I would attribute it to a few things. There have been
    several enhancements to the Beneficiary Travel Self-Service
    System (BTSSS) application, specifically some integrations that
    we have completed is with the patient check-in application. So,
    it is really a seamless experience for veterans, as they are
    using that patient check-in application, as well as an
    important one with My HealtheVet, where when they log into My
    HealtheVet they are not having to log in again to get to the
    BTSSS portal. Login issues were some of the early on concerns
    that we heard.
        Chairman Tester. I can attest to that.
        Mr. Heiman. Yes. The second portion of this, I think, that
    is important is that we launched, in late 2022, a centralized
    team, or claims processing team, within our Veterans
    Transportation Program. We have helped, since then, 57 VA
    Medical Centers, specifically, to help them with their claims
    inventories and get them back to solid ground. And that is
    something that we have seen that has helped, and it improves
    the overall turnaround time for those claims.
        Chairman Tester. So, as has already been pointed out by
    you, Mr. Kaboli, 61 percent of rural veterans are enrolled in
    VA, 41 percent urban. This is for you, Dr. Kaboli, and Mr.
    Vlosich. How is VA using the new hiring authorities in the PACT
    Act to ensure that there is sufficient staff at rural
    facilities to accommodate newly eligible veterans?
        Dr. Kaboli. Yes. Thank you for that question, Chairman.
    What is nice about the new authorities with the PACT Act is it
    adds to the already large array of things that we can do. And
    as you mentioned, the work that we did with workforce
    management to develop a Rural Recruitment and Retention Plan,
    that came out in the end of 2023. One of the things that we
    have been doing is really disseminating that, which includes
    all the tools that are available, whether it is things that
    already existed, like the Education Debt Reduction Program--
    that is a program that one of my colleagues took advantage of
    to come to the Iowa City VA Medical Center, and is still
    there--and the other educational repayment programs.
        One of the specific things in the PACT Act is the buyout
    provision. I know so far there have been 15--I think 10 have
    already started, and there is a total of 15. I am familiar with
    3 of them at the Tomah, Wisconsin VA Medical Center, where I
    see patients from time to time. So, I think there are tools
    that we can use, and we appreciate that.
        Chairman Tester. Okay. Mental health is a big issue. It is
    something we hear about a lot in this Committee. It is
    something that is a problem in Montana. We lead the Nation in
    suicides, us and Alaska, one and two or two and one.
        The VA, what are they doing about getting providers into
    rural areas? I am talking about mental health providers. And
    specifically, what guidance have you received, either one of
    you, Mr. Kaboli or Mr. Vlosich, what guidance have you received
    from VA regarding recruitment and retention of mental health
    folks in 2024? And might I be specific, in the last 6 weeks.
        Dr. Kaboli. Thank you for that, and I will go first, and
    then you can fill in. I would say a couple of things. First of
    all, I have been in my position for 4 months but acting for
    about 20 months. Everything that I have heard over the last few
    years has really been for mental health, it is continue
    forward. And I have not heard anything change for that, even in
    the last 6 weeks?
        Chairman Tester. So, you have not heard, there has been
    nothing coming down saying you need to cease hiring for mental
    health?
        Dr. Kaboli. Not for mental health, no. That is one of those
    that I was told those are exempt and that we should continue to
    move forward on those, even as part of, you know, the strategic
    approach to looking at hiring, that mental health we should be
    moving forward.
        I would like to add one more thing about it.
        Chairman Tester. What would your advice to the VA be if
    they came down with a directive that said, ``We are going to
    freeze all hiring, including mental health''?
        Dr. Kaboli. Oh, I think that would be a terrible idea. My
    advice would be to rethink it pretty quickly. You know, the
    thing about mental health especially is one thing that we can
    do with mental health is the use of telemedicine, and you know
    that. But I think we can fill gaps very quickly using the
    clinical resource hubs and other resources to ensure that there
    are providers so there are not wait times, especially for
    urgent needs.
        Chairman Tester. Mr. Vlosich, do you have anything you
    would like to add?
        Mr. Vlosich. Yes, and we are continuing to recruit for
    mental health providers. One of the things we have noticed in a
    rural setting where we have kind of, as we have gone out and
    talked to veterans, what we are doing is focusing our efforts
    into hiring staff that are boots on the ground. A lot of our
    older rural veterans are saying, ``Hey, I like the virtual
    option every once in a while, but I really want a doctor face-
    to-face.''
        So to go to your PACT Act incentives, we have been able to
    start to recruit mental health providers, boots on the ground,
    due to the incentives that we have been able to provide through
    the PACT Act.
        Chairman Tester. You know, before I get to Senator Rounds,
    I just want to say this. I could not have answered my question
    any better than you guys answered my question. You need to
    ensure the VA is doing what you guys are saying, because quite
    frankly, mental health continues to be a crisis in this
    country, both in the civilian world and especially in the
    veteran world. And it is incumbent upon us to make sure that we
    have the providers there, we have the help there, we have what
    the veteran needs, especially if they are in crisis.
        Senator Rounds.

                           HON. MIKE ROUNDS,
                     U.S. SENATOR FROM SOUTH DAKOTA

        Senator Rounds. Thank you, Mr. Chairman. First of all, I
    want to thank our guests for joining us here today, and for
    your service to our country.
        Dr. Kaboli, I would briefly like to talk about the need to
    appropriately resource VA facilities in rural America. I am
    encouraged that the Department is expanding facilities in Hot
    Springs, South Dakota, and allocating additional personnel to
    Fort Meade, which is near Sturgis, South Dakota.
        Can you talk about the importance of appropriately
    resourcing VA facilities in locations such as these in South
    Dakota?
        Dr. Kaboli. Yes. Thank you for that question, Senator
    Rounds. I would be happy to.
        So, I am also in the Veteran Integrated Network (VISN) 23
    in Iowa, so Hot Springs and Fort Meade are obviously in our
    VISN. And I know you were involved with the AIR Commission and
    the reports that came from that.
        I think we all are looking at better ways to provide
    services, and places like Hot Springs and Fort Meade, being 90
    miles apart, what are the things that need to be in one
    location, what can be shared, what needs to be in both
    locations.
        The other thing, in talking more broadly, even outside of
    South Dakota, is identifying where there are gaps in care, that
    we either use care in the community or that we establish new
    sites of care. We have been working with the USDA to try to
    identify locations that are ripe for adding either VA sites of
    care or partnering. We are looking at Craven County, North
    Carolina, which you are familiar with, Senator Tillis.
        Senator Tillis. You just saved me a question.
        Dr. Kaboli. Okay. Well, I can answer it again. But that is
    one that sort of fits all the needs for both distance of how
    far veterans would have to travel that already live there and
    what facilities are around there. It also allows us to partner
    with a local hospital--I cannot remember if it is a hospital or
    Federally Qualified Health Center (FQHC)--that has space, and
    that is something that we can either lease or, especially with
    some of the new abilities, but also whether we partner with an
    FQHC.
        There is another, in Polk County, Texas, that just sort of
    fits that perfect circle of where there is not care, that we
    could fill something in.
        Senator Rounds. Well, and just to your point, if we would
    have allowed the AIR Commission to move forward it would have
    been devastating to some of our rural hospitals. And, in fact,
    on a bipartisan basis, we were able to stop the recommendations
    that were found within that report. And now today we are
    talking about what we can do to actually improve rural health.
    The AIR Commission, in my opinion, would not have done that. In
    fact, it would have hurt it, shutting down emergency rooms in
    some places but severely restricting access for our rural
    veterans.
        In fact, Dr. Kaboli, as you know, a significant number of
    rural veterans receive acute care from critical access
    hospitals like Bennett County Hospital in Martin, South Dakota.
    It is the only non-Indian Health Service (IHS) emergency room
    for nearly 100 miles, and its emergency room remains busy
    caring for an average of 250 patients on a monthly basis.
        How important is it to make sure that critical access
    hospitals like Bennett County Hospital are appropriately
    resourced, and what would be the impact on care for veterans in
    rural areas if critical access hospitals in these areas were
    closed?
        Dr. Kaboli. Thank you for that question, Senator. That is a
    great example of why these critical access hospitals play an
    important role for not only their community but also for
    veterans that live in that community, because of the distance
    they would otherwise have to travel to be cared for by somebody
    like me who is a hospitalist.
        So, for hospital care, 80 percent of rural veterans get
    care for their hospitalizations outside the VA, and half of
    those are in rural hospitals and half are in urban hospitals,
    because a lot of rural residents live close to an urban center
    and they just come in for care. But those rural critical access
    hospitals are absolutely important for the community and for
    us.
        So, we need to partner with them. We have a couple of
    things that we are doing. One is we are starting a pilot
    program so that patients that are in those hospitals that are
    veterans, if they need to be transferred out that we can take
    them, and take them efficiently. But more importantly sometimes
    it is just keeping them there, that we can continue to pay for
    the care but keep them there in their hospital, they are in
    their community, and they are there where there is----
        Senator Rounds. And, in fact, I agree with you, and I do
    not mean to interrupt, but I have one more question I really
    want to ask because it is leading right down that line. I have
    heard from veterans in South Dakota who say that their care is
    disrupted when they have repeatedly received prior
    authorizations for their community care appointments. These
    requests can take weeks, and are sometimes seemingly denied
    with no apparent reason involved.
        What is the VA doing to make certain that veterans,
    especially those in rural communities, are not experiencing
    extra hurdles to receive the care in the community that they
    have chosen? And are you aware of the problem that they are
    having in literally having to go back through and get repeated
    authorizations for this care?
        Dr. Kaboli. Yes, thank you, Senator.
        Senator Rounds. I think the answer was yes, you are aware.
        Dr. Kaboli. Yes, I am aware.
        Senator Rounds. Okay.
        Dr. Kaboli. And then I am going to ask one of my colleagues
    to maybe help me out with it, too.
        I would say two things about it. The first is, you know, as
    a physician providing care in the VA, I take it very seriously
    that patients get the care, where they want it, where they are
    eligible for it, locally. That is totally fine, to make sure
    the authorizations go in and is managed through that office,
    the Community Care Office. There are times when authorizations
    do expire or if it is for a new condition, so they have to be
    renewed, and I think we need to get better at that.
        We have a Referral Coordination Initiative that has really
    done amazing things in some sites--I can say Ann Arbor,
    Michigan, is an example--to make sure that the office handles
    those and then gets them into VA care when we can provide it,
    and when they cannot, make sure they get care in the community.
        Mr. Vlosich. Yes, the other thing that we are doing, the
    Department is looking at what we call SEOCs, episodes of care.
    And so those standardized episodes of care, what we are doing
    is we are reevaluating them periodically to see how long those
    authorizations should last. So, you will see some adjusted,
    some linked in. So, we are really focusing in on how can we
    improve that experience for our veterans.
        So, for instance, in Oklahoma City, one of the initiatives
    that we have started is called VA Chat. So, if you have a phone
    or a computer and you need to get ahold of your provider or the
    Community Care Office about your community care provider, you
    can just put it in the chat and our staff will respond to them
    immediately to get them a turnaround, to get some of those
    authorizations back in place.
        We have experienced some of that due to the rules, but what
    we have done is we have allowed our staff locally to look at
    authorizations and how we can reenact some of those, to make it
    easier for veterans.
        Senator Rounds. Well, I am really glad you have got a
    workaround on it, but if you need a workaround the chances are
    the rule may not be right in the first place.
        But Mr. Chairman, I have used up my time. Thank you for
    allowing me the extra time.
        Chairman Tester. Well, it gave Senator Murray a chance to
    sit down. So, Senator Murray.

                           HON. PATTY MURRAY,
                      U.S. SENATOR FROM WASHINGTON

        Senator Murray. Thank you. Thank you to all of you for
    being here today.
        I know food insecurity continues to be a problem for our
    active duty servicemembers, but more needs to be done to
    address the fact that when servicemembers transition into the
    civilian world many of them continue to experience that food
    insecurity as veterans, especially those who are living in our
    rural areas. Rural veterans are more likely than other veterans
    to live in poverty, and almost half of them earn less than
    $35,000 a year. So, food-insecure veterans are also
    consistently less likely than their non-veteran peers to be
    enrolled in SNAP. So, it is really critical that we are able to
    fund those programs that veterans rely on outside of VA, but
    which compete each year with other programs under the tight
    spending caps we have.
        As Chair of the Appropriations Committee, I want to make
    sure we are meeting all the needs of our veterans, such as
    battling food insecurity, while still funding the VA medical
    care. VA medical care is a critically important, but it is a
    skyrocketing cost within NDD, which is why I have argued for
    making it its own separate third funding category so we can
    better avoid pitting its funding against the funding of other
    important programs for our veterans.
        Dr. Kaboli, I know VA has worked to implement a screening
    process to identify veterans at risk of food insecurity, but
    how can the VA improve its process to more accurately identify
    veterans who are experiencing that?
        Dr. Kaboli. Thank you, Senator Murray. I think you are
    referring to the Assessing Circumstances and Offering Resources
    for Needs (ACORN) screen?
        Senator Murray. Yes.
        Dr. Kaboli. Yes. That has just been rolled out in the past
    year, and I think we are all learning at how best to do that
    and how to act on positive findings from it. This is where our
    social workers are just an incredible asset, because they are
    the ones, once we can make the referral to them, to then
    connect them to resources in the community, or if they are
    eligible for SNAP or other programs.
        So that is one of the key things, I think, to say how we
    are going to do it is to use the screen, and then if people
    screen positive how do you act upon it.
        Senator Murray. Are you looking to expand any of your
    existing food insecurity programs?
        Dr. Kaboli. The one that I can comment on that is with the
    Office of Rural Health that we are working on, in partnership
    with USDA, is a food program that we piloted at the White River
    Junction, Vermont VA Medical Center, to essentially contract
    out food shares with local food producers and then veterans can
    sign up for them. We have done that for a couple of years and
    now we are expanding it to other sites. And our goal is to be
    able to come up with a mechanism to do this in partnership with
    USDA so that we can have this at any site that would like it.
        Senator Murray. Okay. Thank you very much.
        Let me talk about Native American veterans, because as you
    may know, they serve in the military five times in the national
    average, and in Washington State alone there are about 6,500
    Native American veterans. And as we also know, tribal lands
    tend to be more remote and isolated from medical services. For
    example, while 99 percent of urban households have access to
    broadband, only 65 percent of housing units on tribal lands
    have the same access. This is a huge issue for Native American
    veterans who rely on telehealth services to access care.
        I know the VA has made some progress in that area but more
    needs to be done. So, Dr. Kaboli, what are some of the ways VA
    is working to help more rural veterans access telehealth, and
    is VA looking to expand broadband internet access in tribal
    areas?
        Dr. Kaboli. Thank you, Senator Murray. I will take the
    first part and then I will have Dr. Heyworth answer.
        There are a couple of things I would say. First of all, we
    are to the point now with lower satellite internet and
    expansion of other broadband mechanisms that it is available
    almost anywhere, but it is whether you can afford it or not.
    You can sign up for some of these services at $100 a month, but
    if you do not have $100 a month it is hard to afford.
        So, a few things that we do. One is to ensure that there
    are other sites that they can get telehealth at, community-
    based clinics, or that they can log in from family members or
    other places. It is hard on tribal lands, and we are working
    with the Indian Health Service on programs that can potentially
    help with that. And I will let Dr. Heyworth answer.
        Dr. Heyworth. As part of the Bipartisan Infrastructure Act,
    we have been working very closely with the National
    Telecommunications Information Administration (NTIA), with the
    VA serving as a consultant to states as they roll that
    Broadband Equity Access and Deployment (BEAD) program and their
    digital equity proposals, with veterans as a covered population
    in that legislation. We want to ensure that we are very
    involved in the rollout and implementation as the funding goes
    out.
        In addition, we have been working as a member on the Rural
    Partners Network, which is led by USDA, again along the lines
    of involvement and making sure that veterans, as a covered
    population, are involved, as funding is rolled out for
    broadband expansion.
        I also had the honor of being on the Choctaw Nation in
    Oklahoma earlier this year, and had the opportunity to speak
    with tribal leaders there about broadband access, affordable
    access, and about the possibility of ATLAS sites, which stands
    for Accessing Telehealth through Local Area Stations--I would
    be happy to talk more about that--and the possibility of those
    sites as access to care mechanisms on tribal lands.
        In addition, we talked a lot about the opportunity for
    telehealth in the VA IHS MOU, which is an ongoing collaboration
    between VA and the Indian Health Service.
        Senator Murray. Okay. Thank you very much. And Mr.
    Chairman, I have gone over time. Thank you.
        Chairman Tester. Senator Tillis.

                           HON. THOM TILLIS,
                    U.S. SENATOR FROM NORTH CAROLINA

        Senator Tillis. Mr. Chair, you know, Senator Sullivan and I
    have a history of comparing populations, but in the interest of
    our relationship, I am not even going to mention that there are
    seven states with smaller populations than the million veterans
    that I have in North Carolina. But I am not going to say that,
    in the interest of----
        Chairman Tester. I am glad you did not make that big----
        [Laughter.]
        Senator Tillis. Thank you. I did have a question. I want to
    go back to what Senator Murray talked about. Right now, with
    telehealth, we have got to crack the nut on broadband access.
    But are there authorities right now that are only temporary, or
    have we permanently authorized the use of telehealth for any
    sort of provisioning of health care in the VA?
        Dr. Heyworth. Thank you, Senator Tillis, for that question.
    I would first like to take a moment to briefly reflect on the
    tremendous growth of telehealth----
        Senator Tillis. No, 100 percent. I am sorry to cut you off,
    but if the answer is yes, there are some temporary, not
    permanent authorizations, I for one think that they need to be
    permanent. Now, a temporary authorization for telehealth would
    be tantamount to a temporary authorization for using Tylenol to
    treat a headache or a pain.
        Look, if we want to address the problems of broadband
    access, we have got to provide certainty to the markets that
    this is standard operating procedure. The minute we do that in
    the whole of government, you are going to see capabilities in
    telehealth we cannot even imagine right now. But if we do this
    year to year, every 2-year authorization, you are not sending
    the signal to market and innovators that it is here to stay.
        So, I would really appreciate if you could report back to
    the Committee which specific temporary authorities should be
    permanent, and please, have anyone in the VA contact my office
    if they think this telehealth thing is not here to stay. It is
    kind of like the internet. I think it is going to stick.
        So, on telehealth, I think we just need to move forward on
    that.
        I did want to get parochial. I try not to in these
    hearings. But I have got about a 31,000 number backlog--gives
    you an idea of how big our veterans population is--for expense
    reimbursement for travel. Tell me how I can make them feel
    better about getting timely reimbursement for travel to VA
    facilities?
        Mr. Heiman. Yes, thank you, Senator Tillis. I did speak
    just a little bit earlier. Something that we have put together
    is a team that is called a claims processing team. I will be
    happy to look into that for you, for some of your state----
        Senator Tillis. It seems like a big number. I mean, even
    though we are working with a big base of folks that use the VA,
    that is a big number. One of the reasons I love my state is in
    the last census it went from a majority rural state to a
    majority urban state, but it is basically 49/51. So, I get to
    observe all the challenges of an urban setting and all the
    challenges of a rural setting. In this case, the vast majority
    of these reimbursements are for people in rural area. So, if
    you could just report back for the purposes of the Committee.
        Mr. Heiman. Absolutely.
        Senator Tillis. Thank you. And the last question I had, you
    mentioned Craven County and a project there. You were talking
    about, to Senator Rounds, the USDA collaboration. You know, I,
    for one, think, we have done some work at Womack, and I have
    talked with Director Crews about this. Tell us what
    authorities, tell us what the impediments are. Are there
    authorities that you need? Are there constraints on being even
    more creative, beyond the USDA? Or is it money, or is it both?
    In other words, how can I crack the nut on getting really
    creative, with DoD facilities, USDA facilities, public-private
    partnerships? What more do we need to be able to have more of a
    physical presence of the VA in more places, in all our states,
    not just in North Carolina?
        Dr. Kaboli. Thank you for that question. For the sake of
    time, I will try to be brief. You know, I do not think I can
    answer all the things that we would need, but, you know, money
    always helps, but it is not always the thing that you need.
    Sometimes it is just taking down barriers to creating the
    relationship.
        And what we have found, at least in the work we have done
    in the Office of Rural Health, is it is the relationship that
    really matters. So, me being down in Texas a couple of weeks
    ago and meeting with people from Polk County, I really got a
    sense of what their need is and what the towns are. Same thing
    in North Carolina. I was in Fayetteville two weeks ago and
    getting to meet people there and the State Director for the
    USDA, and saying, ``Hey, we can do this.''
        So, I think it is getting the right people together to make
    it happen. Because we can identify the locations, and we have
    done that already, and now it is a matter of figuring out
    whether we can get lease space from existing facilities, like
    FQHCs or rural hospitals, or if we just buy services there.
        Senator Tillis. Yes, well thank you. I think that is very
    important. But you should, to the extent it requires authority
    or it requires gentle nudges from other agencies to come to the
    table, to please inform the Members of the Committee. I am sure
    they are all interested in the same outcome. Thank you.

        [Department of Veterans Affairs responses to Senator Tillis
    appear on page 87 of the Appendix.]

        Chairman Tester. Senator King.

                        HON. ANGUS S. KING, JR.,
                        U.S. SENATOR FROM MAINE

        Senator King. Thank you, Mr. Chair. Before beginning my
    questions, it has now been, let's see, 3 \1/2\ years since the
    Johnny Isakson and David Roe Veterans Health Care Bill passed,
    and in that bill was a requirement for the VA to provide back
    payments for domiciliary care in veteran homes. We still do not
    have the final rule, 2 \1/2\ years. Eisenhower retook Europe in
    11 months. Do you think we can get this rule out sometime?
    Would you take that message back? Thank you.
        Dr. Kaboli. Yes, thank you, Senator King. I will take that
    message back.
        Senator King. Just send an email that says ``Eisenhower!''
    with an exclamation point.
        [Laughter.]
        Dr. Kaboli. Okay. And I am sure they are watching it, so
    thanks for saying that.
        Senator King. Thank you. I want to associate myself with
    Senator Tillis' context on telehealth. I think it is one of the
    most important things that we are doing. We ought to be
    knocking down all barriers. It is better for the patients. It
    is better for the providers. We have found in Maine that people
    with telehealth appointments tend to make the appointment more
    frequently, and then for people with behavioral health, mental
    health issues, you do not have to sit around in a waiting room
    and feel uncomfortable about who else is there.
        So again, if there are any authorities that you need, any
    extensions--and I do not think those should be extensions. They
    ought to be made permanent. I think that is one of the most
    important things that we can do, particularly for rural
    veterans. And, of course, internet is important, but then if
    you can also make telehealth facilities available in Community-
    Based Outpatient Clinics (CBOCs).
        And how about this? How about setting up telehealth kiosks
    in American Legion posts, VFW posts? We have got places where
    veterans go in virtually every town in America. And let's think
    about that as a possibility for expanding access, particularly
    in communities where broadband access is difficult.
        Now, I am confused about personnel. We have seen a report
    that over the next 5 years you are going to have to hire 21,000
    new people to keep up with expected growth. One of the
    facilities, coincidentally, that is anticipating the most
    growth is Togus, the veterans hospital in Augusta, Maine. They
    need to hire nearly 800 new staff. But then Secretary McDonough
    is talking about zero growth, and also your budget calls for
    cutting 10,000 FTEs.
        I am confused. Are we going to hire the people we need, or
    not?
        Dr. Kaboli. Okay. Thank you, Senator King. I will take a
    first shot, and then I am going to ask my colleague here to
    help me out.
        I would say we had a lot of discussions over the last
    couple of days specifically about this, and the word
    ``strategic'' came up a lot, you know, how we are doing
    strategic hiring, and making sure that we are using the FTE and
    the budget that we have in the right places.
        So, over the next, I think, I am guessing, weeks and
    months, we will be looking at this very carefully to decide
    where we need to put the resources and where we need to put the
    people. Because you are right, it does not really compute when
    you say you need more people but then we are at a keeping FTE
    even.
        I am going to let Mr. Vlosich answer too.
        Mr. Vlosich. At the local level we are working with our
    VISNs and National Office. For those areas that are growing
    they are allowing us to move around our FTE. So, we are
    recruiting FTE, and we are still doing that.
        Senator King. Well, if you are sort of rationalizing the
    organization, I have no problem with that, as long as we do not
    end up with less service.
        Mr. Vlosich. No, and I think the services will not be
    impacted at all. We have got the staff we need in order to
    accomplish the mission. But what we are doing is we are looking
    at all of our FTE right now and trying to see where is the best
    place to put them into.
        Senator King. Okay. Thank you. Mr. Heiman, rural State
    Maine access, transportation is a huge issue. And a little
    homely example. The town of Caribou, which is way up in
    northern Maine, you had a contract deal with a contract to
    bring one veteran down for dialysis. They put somebody on the
    staff to do that kind of driving. It saved $7,000 in a month,
    saved the Veterans Administration. So I hope you will think
    about where and when additional staff to provide this kind of
    transportation can really make a difference.
        Mr. Heiman. Yes, I appreciate that, Senator King. We do
    have that program that you are referencing at 128 VA Medical
    Centers. There are over 1,000 vehicles in the fleet that are
    providing similar type services. I would also reference that
    this was included in the President's budget submission for
    fiscal year 2024 in relation to the Highly Rural Transportation
    Grant Program. This program is something that is critical to
    highly rural areas. Our proposed change is to increase and
    expand currently available to 25 States for the county level,
    to expand it to 50 States, so they would have access to this.
        The other expansion is that the eligibility criteria would
    include tribal and county VSOs.
        Senator King. We will be talking with them at the next
    panel.
        Mr. Heiman. Thank you.
        Senator King. But transportation is really important. We
    are in a large state duel here. I see two of my colleagues. To
    give you an idea of how tall Maine is, Caribou, which I
    mentioned, to Portland, Maine, our principal city, Portland,
    Maine, is halfway between Caribou and New York City. It is a
    long distance to get to the help.
        Chairman Tester. I do not know if you want to start talking
    distances.
        Senator King. I know. I know.
        [Laughter.]
        Senator King. That is why I prefaced it. I do not want to
    get into large state duels. He is in a state that you have to
    fly to get places.
        But anyway, the point is transportation is really important
    for our rural veterans, and I hope that is going to be an
    important focus. Thank you. Thank you, Mr. Chairman.
        Chairman Tester. Senator Sullivan. King has put it on the
    tee. You can hit the ball now.
        [Laughter.]

                           HON. DAN SULLIVAN,
                        U.S. SENATOR FROM ALASKA

        Senator Sullivan. Thank you, Mr. Chairman, and I do want to
    mention, the panel, look, a number of us--I think Senator
    Blackburn is leading the effort--we have some concerns, very
    serious concerns, about these bonuses that were paid out
    recently. It made a lot of news. I think it is important for
    the Committee to focus on this.
        I do want to mention, though, to the witnesses, we all know
    the vast majority of the VA, particularly in our states, does
    really excellent work, so I want to thank you all for that. You
    are seeing a lot of bipartisan focus on issues that matter to
    all of us--Alaska Natives, Native Americans, telehealth--and a
    lot of our veterans live in the big rural states like ours. I
    will not talk about how big Alaska is, but I think it is six
    times bigger than Montana.
        [Laughter.]
        Chairman Tester. You can do better than that.
        Senator Sullivan. And there is no Texas here so I will not
    do that one either.
        But I do want to follow up with what Senator King just
    mentioned, the staffing issue. You know, we are building out VA
    facilities in Alaska. We do not have enough VA staff in our
    state, and we just get nervous when you guys are talking about
    this dramatic cut that is going to be coming to the states that
    do not need cuts. We need more. So I just want to reiterate
    what he said. Hopefully you are going to do it strategically
    and look at the places where veterans are growing. They are
    certainly growing in my state, the population. So don't do it
    in those states.
        Can I just get your commitment to make sure you are doing
    it strategically?
        Dr. Kaboli. Yes, sir.
        Senator Sullivan. Good. Next, I want to talk about, again,
    related to all of our rural states, the Highly Rural
    Transportation Program. It is a really important program, I
    think, for literally every Senator here. In my state we have
    over 230 communities that are not connected by roads. No roads.
    So, you have either got to fly there or take a boat in the
    summer or a snow machine in the winter.
        So, this is a really important program. But as you can
    imagine, the more rural your state is, the more quickly you use
    up those funds. You know, they are dedicated borough by
    borough. I have been working on legislation. We are reaching
    out to the VA, to make the Highly Rural Transportation Grant
    funding per borough more reflective of the states like
    represented here--Montana is certainly one--that are so rural
    that you are blowing through the money really quickly as
    opposed to a more urban state. We kind of get penalized because
    it is a one-size-fits-all approach. We have actually been
    thinking about legislation to up that per-borough grant, so
    states like ours, represented here, with the exception of
    Senator Blumenthal, benefit. Do you see what I am saying, how
    it kind of--you just run out of money way quicker.
        Dr. Kaboli. Yes, sir. Thank you, Senator Sullivan. I did a
    month of my residency in Alaska at the Alaska Native Medical
    Center (ANMC), in the old ANMC, and then I was just back at the
    new ANMC last year for an advisory committee meeting, and it is
    really impressive what they have done there.
        Senator Sullivan. Yes, they have done a great job.
        Dr. Kaboli. Yes. I was so impressed.
        Senator Sullivan. The VA and the Native Health Care in
    Alaska have a really good partnership that matters,
    tremendously, to everybody.
        Dr. Kaboli. Yes. And we were at JB and got to see all of
    the things that were going on there, as well.
        To answer your question, I do want to say one thing, and I
    am going to have Mr. Heiman answer also. The Highly Rural
    Transportation Grant Program, like you said, there is only
    eligibility in 26 States right now--Sorry, Senator King, but
    Maine is not in that list--because of the way that it was
    written initially, at a county level. I know there is some
    legislation pending about changing it to a new definition that
    basically every state would have some areas that would be
    eligible.
        Senator Sullivan. Okay. That might be going in the opposite
    direction that I am talking about, but maybe we can work with
    your team. I just want to make sure that if you are a really
    big rural state and you have run through the money so fast, and
    then--again, I have 230 communities of people have to take an
    airplane just to get to the VA, so that money gets burned up
    really quickly.
        So, if there is a way to try to address that. I know that
    some of my other colleagues have similar concerns. It is just
    kind of a fairness issue.
        Let me just ask one final question. Senator Hassan and I
    are working on the Link VA Bill, that we have introduced. And
    the whole point on that is to enable the VA to partner with
    other entities--I use the example of the Alaska Warrior
    Partnership, a group we call Battle Dogs, a group we call
    Connect Vets in Alaska--that have been able to help with
    integration on issues that might not be a VA issue but a
    veteran might need help in some other element.
        We had a recent example of the Alaska Warrior Partnership
    was helping with veterans, believe it or not, get sources of
    fuel to keep their homes warm in the winter in Fairbanks when
    it is 40 below zero. This really works well. You guys kind of
    already do it. You have been talking about the USDA. But I know
    the VA has been supportive of our Link VA Bill. But what are
    you doing? Is legislation needed? What are you guys doing to
    kind of integrate those kinds of services? They may not
    directly be to the VA's relevant mission, but a veteran needs
    help, with somebody else. How are you making sure they just do
    not get told, ``Hey, that is not our department. Good luck with
    someone else''?
        Dr. Kaboli. Thank you, Senator Sullivan. The Link VA one, I
    am going to have to look that one up because that is not one
    that I am familiar with, but I hear what you are saying. And I
    am sure we have programs that would link to that, so to speak,
    but without knowing more about it, I am going to not say much
    because I do not want to say something dumb.
        Senator Sullivan. Okay. We will get back to you on that,
    our offices, but we think it is a good bill. I think most of
    your building is supportive of it, and it is trying to
    streamline, not create more bureaucracy, to help our veterans.
    But we can have our teams work together.
        Thank you. Thank you, Mr. Chairman.
        Chairman Tester. Segue to Senator Hassan.

                       HON. MARGARET WOOD HASSAN,
                    U.S. SENATOR FROM NEW HAMPSHIRE

        Senator Hassan. Thank you very much, Mr. Chair, and thanks
    to all of you and the entire VA team for everything you do.
        I will just add my support for comments you have heard from
    all of the Senators, I think, about the importance of bridging
    that digital divide, making sure that we are doing everything
    we can to make permanent telehealth, and then to make sure that
    our veterans in the most rural areas of the country have the
    connections they need, and the devices they need, to access
    that.
        And I will add my voice to the chorus. Let us know what
    authorities you need, what barriers there are to make that
    happen, because the veterans we are hearing from in New
    Hampshire are very, very appreciative of the service, and
    especially as we do not have a full-service hospital in New
    Hampshire it is a really important link to both Boston and
    White River Junction.
        I want to talk a little bit more about transportation,
    another thing that all of us who have rural communities have
    talked about. Obviously, many rural veterans live very far away
    from a VA facility. The DAV Transportation Network is
    particularly important and vital in New Hampshire. This is a
    network of volunteer drivers who provide veterans free
    transportation to appointments.
        But what the DAV continues to struggle with is getting
    their volunteer drivers approved through the VA. In fact, when
    DAV representatives testified before a Joint Committee hearing
    in March, they told me that the VA needs to standardize and
    streamline the onboarding process for volunteer drivers. And I
    will let you know, the volunteers will kind of say to us,
    ``Well, I wanted to do this but it is taking VA so long, I am
    doing something else to volunteer right now, because I don't
    want to sit at home idly, not helping people.''
        So, what can the VA do to help improve this process so that
    we can get drivers screened and onboarded in the most efficient
    manner possible?
        Dr. Kaboli. Thank you, Senator Hassan. I did not know that
    was a big problem until 2 weeks ago. I am with the Office of
    Rural Health, and we have a Federal Advisory Committee. And a
    gentleman named Joe Parsetich from Montana is on that
    committee, and he brought that up at our meeting just 2 weeks
    ago and said this is a big problem. And I said, ``Joe, we will
    look into it.'' Because now that I know it is a problem, I will
    bring it to the right people.
        Senator Hassan. We made some improvements in New Hampshire,
    but literally there are people who would love to be helping
    make a difference here in getting veterans to their
    appointments, and they just cannot get cleared.
        I also want to build on something that Senator Sullivan was
    just talking about. When people serve in the military, they
    often feel that sense of purpose and connection, both to the
    work they are doing and to the people they serve with. When
    they leave the military and reenter civilian life, one of the
    most difficult parts of that transition can be feeling a loss
    of community. The VA is one of the places where veterans can
    reengage with one another and can feel a sense of connection to
    the military community that they have left.
        Rural veterans, though, are often more isolated from VA
    facilities and other community resources that can present these
    kinds of opportunities. Can you discuss what the VA is doing to
    engage with and help foster a sense of community and support
    among rural veterans?
        Dr. Kaboli. Senator Hassan, that is a really good question.
    You know, I think there are so many different things that we do
    in the VA that I am sort of struggling to figure out which are
    the ones that come together to really address that. You know,
    we do a lot of group visits. There are now group telehealth
    visits.
        One thing that we have learned over the years, though, is
    that when they do come in, that is part of their community, and
    they feel that, and that is why telehealth is really important,
    but sometimes it is important that they come in.
        We have also learned that through the Veteran
    Transportation Service, just that van ride in and talking to
    the driver. I mean, I know one of our drivers, Connie, and she
    knows everybody that is on the route, and they all know each
    other. So, I think that is a really important part, that if we
    do everything telehealth and have everybody remote, we lose
    that community.
        Senator Hassan. One of the other things that has been a
    strength in New Hampshire is a program that Northeast Passage,
    which is affiliated with the University of New Hampshire, does,
    bringing veterans to do outdoor activities together in a rural
    place, providing the equipment, providing the guidance, if you
    have never kayaked before, et cetera.
        But I just think, again, coming back to us with ideas if
    there are authorities you need but also just being creative
    about what life in rural America looks like and where are the
    natural places that people get together. We have put into place
    things like Buddy Check and Solid Start. But as we are
    grappling with the real difficulty of a lack of connection, of
    loneliness, and of veteran suicide, I just think we really need
    to be thinking about how to foster this community. Thank you.
        Chairman Tester. Senator Moran.

                          HON. JERRY MORAN,\*\
                RANKING MEMBER, U.S. SENATOR FROM KANSAS

        Senator Moran. Chairman, thank you. I do not know that I
    have questions, but I probably will end up asking a couple. I
    am, again, troubled, and this is not necessarily the topic of
    this hearing, but I am wanting to air my grievances, even
    though it is not Festivus.
        [Laughter.]
        What I know about veterans and the circumstances they are
    in is generally by conversations I have with veterans, with the
    Veterans Service Organizations. But so much of what I know or
    believe is going on is what we call casework, a veteran who
    calls, comes to the office, emails us, tells us a story about
    experiences at the VA. And again, many times those
    conversations are very complimentary of the VA.
        But I am concerned about what I have seen going on for the
    last 6 months, and only increasing, and it is the number of
    cases of veterans who call, write, email, or tell me, or my
    staff, that they want to utilize Community Care but the VA says
    it is not available to them. I think, by law, that is not a
    fair statement that the VA should be making. It is my view,
    based upon what conversations I have had with people who work
    at the VA, that there is a concerted effort to rein in
    Community Care and to increase care within the VA hospital. I
    do not know, Mr. Vlosich, I do not know whether that is
    something that you would care to comment on.
        But what has got me exercised today is this. Over the
    weekend I usually read my weekly case report from my,
    particularly, veteran staff caseworkers. Time and time again, I
    would guess in this report there were a dozen veterans who
    called to say, ``I have been getting chiropractic care in the
    community. The VA tells me it is no longer available to me.'' I
    do not understand why that is.
        But here is the one that stands out and has my ire today.
    This gentleman tells us, this veteran, tells us that he has
    been receiving cancer treatments in his hometown. He has two
    more cancer treatments to complete--and I do think there is
    something going on at the VA in regard to oncology. He has two
    treatments to complete his cancer treatment, and the VA says
    that he is no longer eligible for Community Care where those
    treatments have been occurring. He has 58 treatments completed
    and he needs 60, and they are saying, ``Come to Topeka.''
        Our research, talking with the VA about the circumstance,
    is that he was allowed Community Care because he lived 60
    minutes from the VA hospital. They have recalculated. He lives
    59 minutes now from the VA hospital. It changed his status, his
    eligibility for Community Care, and he was told to drive.
        Now I cannot imagine that you are not going to fix this. I
    cannot imagine I am telling you this story without it getting
    fixed. But there is something, a mindset, that this represents,
    along with all the other instances in which people tell me, ``I
    like my Community Care, but the VA tells me I now need to come
    to the hospital.''
        I mean, I have had this conversation with the Secretary and
    all the way down, and I am always assured that there is no bias
    against Community Care, there is an explanation that Community
    Care is costing us too much money. Most of that, in my view, is
    in the emergency room, of which I am waiting to see what the
    plan is to care for emergency care, which generally takes place
    in the community.
        So, what am I missing here, or what is going on that I
    ought to be aware of, that you are willing to tell me? Maybe
    that is you, Dr. Kaboli?
        Dr. Kaboli. I will take a first shot at that, and thank you
    for the airing of grievances, Senator Moran.
        Senator Moran. I wish I could say these things in a more
    angry manner, with less of a smile, because this is serious
    stuff in people's lives.
        Dr. Kaboli. It absolutely is. So, the case, in general, we
    will look back at that specifically. But I think the point
    about cancer care is really important. So, we have a Close To
    Home program to try to get care closer to the veteran's home,
    whether it is in their home or in the community, or bringing
    the drugs to the CBOC.
        There is always an exception that can be made for the best
    medical interest of the individual or hardship. So, going from
    61 minutes to 59 minutes makes zero sense to me, as a
    physician, that that was allowed to be changed.
        Senator Moran. It should not be, ``Oh, your mileage has
    changed.'' I do not know whether he moved a mile or it was
    recalculated. But the fallback would be, but it is in your best
    interest, and the law allows in your best interest. If you and
    your provider say it is in your best interest then we are going
    to continue. But that was not what the VA decided. That would
    just be the normal thing for someone to say. ``Oh, let's see if
    we can't find a way to make this work.'' And instead, it was,
    ``Come here.''
        Dr. Kaboli. Yes. And I know, as a physician, and I think my
    fellow oncologists who do this would say, ``We would never do
    that for a patient.'' So, whatever happened we will look into
    that example. But I think it serves as an important example of
    why we should be very careful and look at each individual case.
        Senator Moran. I appreciate that. Anything further?
        Mr. Vlosich. Thank you for the question. I would just echo
    that. But in these instances, a Medical Center Director has the
    authority to expand that authorization. So, in that case we
    would just allow them to continue their treatment, because that
    is the right thing to do for the veteran.
        Senator Moran. Is there something concerted going on in
    eliminating chiropractic care within the community?
        Mr. Vlosich. No, not that I know of. I think that there has
    been an effort to review some of the chiropractic care to where
    they reach functional stability, but in terms of eliminating
    chiropractic care, no.
        Senator Moran. I think in these instances it is you can
    have chiropractic care but only if you come to the hospital,
    come to Topeka, Wichita, or Leavenworth.
        Mr. Vlosich. In my home state we are not doing that, so I
    cannot speak to that. But we do provide chiropractic care.
        One of the things that we found is that some of our
    veterans want to continue chiropractic care for years and
    years, so we like to bring them back in to reevaluate them,
    because they are not going to get better by doing some of that.
    It requires surgery.
        Senator Moran. Thank you for allowing me to air my
    grievances on behalf of Kansas veterans. I do not know that I
    am asking you to do anything. This is more of a statement for
    those in the VA who are maybe making those decisions. But Dr.
    Kaboli if you have any role to play. We have raised this topic
    with the VA already, and I cannot imagine that cannot be fixed.
        But it just highlights what I think is a trend that is
    troublesome to me. In a state like ours, Kansas, where
    distances are so great, the error on the side always ought to
    be for the veteran, and he or she has a choice to make on this
    issue.
        Thank you.
        Chairman Tester. Senator Moran, I think they do need to do
    something in this particular position. I think, if you feel
    comfortable with it, get them the name to find out who made the
    decision, because if they made a bad decision with this
    veteran--which I think is a bad decision, by the way. People
    who have gone through cancer care have their own problems--then
    I think that there should be some follow-up and ask these
    people why that is going on.
        Senator Moran. Mr. Chairman, I can assure you, and I can
    assure the veterans at home that we are following up, have
    followed up with the VA. They are responding to us. They are
    looking into the facts. And if we do something further, I am
    happy to have a conversation with you and my colleagues on this
    Committee to see if we can't get serious attention.
        Chairman Tester. Any time Senator King winces you know you
    are on the right track. Senator Blumenthal.

        \*\ The opening statement of Senator Jerry Moran appears on page 39
    of the Appendix.

                        HON. RICHARD BLUMENTHAL,
                     U.S. SENATOR FROM CONNECTICUT

        Senator Blumenthal. Thank you, Senator Tester and Senator
    Moran. Dr. Heyworth, you are currently an associate professor
    at the University of California. You are practicing I guess
    primary care or internal medicine at the VA Medical Center in
    San Diego, and you are a VA official. So, thank you for all
    your great work. I do not know how you do it all, but that is
    not my question.
        From what I can gather, you have helped to build the VA
    telehealth system, which is probably larger in scale than any
    other maybe in the world. What can hospitals or health care
    systems learn from the VA experience? It seems to me that the
    VA is leading the medical profession in this area, as it has
    done in some other areas, as well, over the years, because of
    its unique needs--artificial limbs and brain injury, and so
    forth.
        On telehealth, shouldn't our health care system be
    investing much more heavily in this system of delivering care,
    not just for rural areas but for others, as well?
        Dr. Heyworth. Thank you, Senator, for that question. While
    we are really excited that we are at the point of almost 40
    percent of our veterans last fiscal year doing some kind of
    their care through telehealth, and of all our encounters in
    telehealth last year, 28 percent were to rural veterans, and we
    are really proud that we are on our fourth consecutive year of
    increasing trust and satisfaction scores with telehealth, we
    still want to do more for all of our veterans.
        And part of that is critically making sure that every
    veteran who wishes to engage with telehealth has the
    opportunity to do so, which is why one of our key areas of
    focus is in our Digital Divide Initiatives, such as through our
    ATLAS program, Accessing Telehealth through Local Area
    Stations, where we have telehealth access points in rural
    communities. In the Chairman's State of Montana, we have an
    ATLAS site in Eureka, for example.
        We are also focused on key barriers to delivering care to
    urban and rural veterans, as you point out, and one key area of
    critical focus is on the clarification of authority in
    prescribing controlled substances by telemedicine. VA lacks a
    standardized approach, so frontline providers like myself are
    subject to laws in states that are varied, that change
    frequently, and often lead to a lot of confusion on the front
    lines about doing the right thing for the prescription of
    controlled substances, particularly for veterans who rely on
    these critical treatments for such conditions as opioid use
    disorder, Attention-Deficit/Hyperactivity Disorder (ADHD), and
    the like.
        So, we have a legislative proposal and would welcome
    further discussion on this topic. VA has put that together with
    input from DOJ.
        The other key thing I would say, back to talking about our
    Digital Divide Initiative, is the intra-agency partnerships
    that we have been engaged with. And I think this is a critical
    point because the opportunity for every veteran to engage in
    telehealth relies, again, on every veteran having the
    opportunity to access the technology needed and to afford the
    broadband needed.
        So, while, in 2020, we kicked our Digital Divide consult
    off, and so far we have completed over 166,000 of these
    consults, which involve social workers working with veterans to
    understand their eligibility for programs such as the Lifeline
    Program, or to offer a loaned device through VA, we have our
    Connected Devices Program. This has been a highly successful
    program, and our veterans who use these loaned devices in
    mental health, we have learned, in a recent study that was
    published in JAMA, actually, that they have improved engagement
    in mental health, they have reduced suicide behavior, and
    reduced visits, actually, to the emergency room for mental
    health.
        So, access to technology, access to the affordable and
    needed connectivity I think is a theme, not just at VA, but I
    think something that all health care organizations can learn
    from, and we are really proud to have led the way in that area.
        Senator Blumenthal. My time has just about expired, but I
    would like to follow up on these issues with you. And I assume
    you would believe that, I think you mentioned 28 percent, that
    is a number that could easily grow, and should grow, whether it
    is urban or rural.
        Dr. Heyworth. Absolutely.
        Senator Blumenthal. Thank you. Thanks.
        Chairman Tester. Thank you, Senator Blumenthal.
        We are going to move to our next panel now. I appreciate
    you guys' testimony. I appreciate your work. Thank you for
    being here today. And you are welcome to stay for the second
    panel, if you have got time.
        On our second panel, while we are making that transition,
    we have got Chauncey Parker, who I recognized in my opening
    statement. He is from Montana. He is the Executive Director of
    the Great Plains Veterans Services Center. He works with Native
    Americans and probably anybody else, too, in Montana, as far as
    that goes.
        We also have Alyssa Hundrup from the Government
    Accountability Office, otherwise known as the GAO.
        And then we have Jon Retzer from the Disabled American
    Veterans.
        And I want to thank you all for being here today.
        As per usual, your entire written statement will be part of
    the record. I would ask you to try to keep your oral statements
    to no more than 5 minutes, and then we will get into questions.
        Chauncey, you are up first.

                                PANEL II

                               ----------

           STATEMENT OF CHAUNCEY PARKER, EXECUTIVE DIRECTOR,
                GREAT PLAINS VETERANS SERVICES CENTER

        Mr. Parker. Thank you, Chairman Tester, Ranking Member
    Moran, and Members of the Committee. Thank you for the
    invitation to come here and speak on some of the boots on the
    ground that we are doing as veterans organization, specifically
    amongst the Native community as well as rural communities in
    Montana. So thank you.
        Just real quick, our organization, Great Plains Veterans
    Services Center, we are a nonprofit organization providing
    support to three Native reservations through our support
    services, and to 28 of 56 counties in Montana with our
    transportation.
        We primarily serve our Native population but we also serve
    a rural and frontier population. That frontier population is
    very remote, and I think a lot of the discussion on the
    transportation particularly concerns us as we provide those
    services to those veterans.
        But one of the big things, the reason we started our
    organization, is to help bridge that gap between VA and our
    veterans. And why do we need to bridge that gap? It is because
    when we first started the organization there was a lot of lack
    of services from the VA being provided, not just to Native
    veterans but rural veterans, as well. And as I mentioned,
    transportation is one of those big issues.
        We are a sub-grantee of the Highly Rural Transportation
    Grant. That is provided to our local American Legion post.
    Under that particular program, we are having a very difficult
    time in being able to manage that. One big thing, as I
    mentioned, we serve 28 of 56 counties in Montana, and we are
    currently working under a funding that is less than half of
    what we originally requested to do that. So we are providing
    transportation with five drivers, full-time and on-call
    drivers, to those 28 counties.
        It has been very difficult, but we have still been able to
    make it work. Thankfully, as a nonprofit organization, we have
    other means to be able to meet those goals. For example, last
    year our organization had driven over 160,000 miles, providing
    support to the veterans in Montana. Now that is a lot of
    mileage, and being able to continue to do that, despite the
    fiscal challenges, is part of our mission, the reason why we
    are there, again, to bridge that gap between the VA and our
    veterans.
        Within that transportation program, another issue, I think,
    we have been running into, as well, as while this is a rural
    program and available to rural veterans there are a few
    counties in Montana that do not, per the VA's rules, do not
    classify as rural. And because of that there are communities in
    those counties that we cannot provide that service to. We still
    get requests, and we still honor those requests under our
    different funding means. But those are one of the areas that
    this particular program, we have run into challenges in.
        Another area is our mental health and access to health care
    services. We are also a grantee of the Staff Sergeant Fox
    Suicide Prevention Grant Program. We are providing that service
    to three Native American reservations. An issue that we have
    run into in this particular area is that cultural barrier. As I
    mentioned, we are primarily serving a Native American
    population under that Staff Sergeant Fox program.
        One of the largest means that we have, amongst our Native
    communities, in order to be able to provide that outreach to
    those veterans is outreach events, getting them together in
    groups. But unfortunately one of the stipulations under this
    particular program is we are not able to provide meals to those
    veterans. So part of our Native culture is a lot to do with
    food, and having that ability to be able to bring that in
    around a meal is very difficult if we are not able to provide
    that. But again, part of our other methods, as a nonprofit
    organization, is we have other fiscal and funding options that
    we can use, again, to bridge that gap.
        Another issue that we have encountered----
        Chairman Tester. I need to get you to wrap, Chauncey. Go
    ahead.
        Mr. Parker. Another issue we have encountered is just the
    visibility from the VA. We are rural. We are frontier. There is
    not a lot of visibility from the VA. It has improved somewhat.
    You know, we have had a PACT Act event. These PACT Act events
    are definitely helpful. But being able to see that visibility
    from the VA, specifically in Montana, would definitely be
    helpful in trying to get the resources to our veterans.

        [The prepared statement of Mr. Parker appears on page 59 of
    the Appendix.]

        Chairman Tester. Thank you very much for your testimony.
        Next, from the GAO we have got Alyssa Hundrup. Alyssa?

         STATEMENT OF ALYSSA HUNDRUP, DIRECTOR, HEALTH CARE,
                 GOVERNMENT ACCOUNTABILITY OFFICE

        Ms. Hundrup. Good afternoon, Chairman Tester, Ranking
    Member Moran, and Members of the Committee. Thank you for the
    opportunity to discuss our work on the Department of Veterans
    Affairs' efforts to improve access to health care for veterans
    living in rural areas. My testimony today covers findings and
    recommendations we have made related to rural health care
    issues.
        Rural veterans represent a significant proportion of our
    Nation's veterans, and VA projects this population will
    continue to grow. The definition of ``rural'' can mean
    different things. For example, it can mean driving 45 minutes
    or even more than 4 hours to reach the closest VA medical
    center, and in some cases, as we have talked about already,
    driving is not an option, such as in remote Alaska, and
    veterans may need to fly long distances to receive care. These
    long distances, along with limited access to broadband,
    internet, and staffing shortages affect rural veterans' access.
    The challenges can lead to disparities in accessing quality of
    health care for veterans in rural areas. For instance, VA
    research has shown rural veterans experience worse health
    outcomes such as higher rates of cardiovascular and suicide
    deaths than those who live in urban areas.
        Our past work has highlighted various approaches VA has
    taken to improve rural veterans' access to care. However, more
    work needs to be done to address this critical issue.
        For example, in our May 2023 report, we examined efforts
    made by VA's Office of Rural Health, whose mission is to
    improve the health and well-being of rural veterans. The office
    does this by funding specific initiatives that seek to expand
    existing health care services to rural veterans as well as by
    funding research. For example, VA researchers are studying
    various interventions, such as knee or cardiac rehabilitations,
    that could be done through telephone or video visits.
        However, we found that the office has only communicated
    this research funding availability informally, such as by word
    of mouth. As a result, many researchers may be unaware of
    funding, resulting in missed opportunities for relevant
    research. We recommended the office develop a policy to
    communicate available research funding opportunities across VA.
    VA agreed with this and anticipates developing a communication
    plan by this September.
        We also found the Office of Rural Health had not defined
    the level of performance the office aims to achieve. For
    example, the office collects data on the number of clinicians
    it trains through funded projects, but it has not defined how
    many it should train each year to help achieve its goal of
    reducing health care workforce disparities. We recommended that
    the office develop performance goals to help inform its
    decision-making, which will allow it to more clearly measure
    its progress toward meeting its mission. VA also agreed with
    this recommendation, and stated that the office is developing a
    new strategic plan that will include performance goals, and
    estimated it will finalize this plan by the end of the month.
        Additionally, in December we issued a report examining VA
    mobile medical units. This is one important tool VA can use to
    deliver care to veterans living in rural areas. These units
    help VA medical centers expand clinical services, such as by
    providing oncology, primary care, or audiology services.
    However, we found VA lacks accurate and complete information
    about mobile medical unit operations and performance,
    potentially resulting in missed opportunities to leverage these
    units to increase access to care for rural veterans.
        For example, VA reported there were 52 units nationwide,
    yet we found at least 9 that did not meet the definition of an
    active unit. Some of these units were no longer operable due to
    maintenance issues, faced staffing challenges, or had been
    repurposed for other non-clinical uses. We recommended VA
    assess the reliability of the data it reports on mobile medical
    units. More reliable information will give a more complete
    picture of their performance, which would then better position
    VA to understand the types of circumstances when using mobile
    units are most effective and help ensure they are fully
    leveraging this important tool to increase access to care and
    improve outcomes for veterans.
        We are monitoring steps VA is taking to implement our
    recommendations, and also continue to examine other VA efforts
    related to rural access to care. For example, we currently have
    work examining VA programs that are looking to help veterans
    access telehealth services, such as its Accessing Telehealth
    through Local Area Stations, or ATLAS program.
        In closing, in light of the unique challenges rural
    veterans face, it is essential that VA take a proactive, multi-
    pronged approach to ensure their access to care.
        This concludes my prepared statement. I would now be happy
    to answer any questions that you may have. Thank you.

        [The prepared statement of Ms. Hundrup appears on page 62
    of the Appendix.]

        Chairman Tester. There will be questions for all three of
    you. Jon Retzer from the DAV, you are up.

            STATEMENT OF JON RETZER, ASSISTANT NATIONAL
         LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS

        Mr. Retzer. Thank you, Chairman Tester, Ranking Member
    Moran, and Members of the Committee. DAV is pleased to offer
    our view on issues impacting rural veterans.
        Veterans living in rural communities face a number of
    unique health care challenges due to the scarcity of medical
    resources, a problem that is intensified for those with
    service-related injuries and illnesses. Of the 4.4 million
    veterans living in rural areas, 2.7 million are currently
    enrolled in the VA health care system. Approximately 58 percent
    have at least one service-connected condition, and 56 percent
    are 65 years or older.
        To meet the health care needs of all enrolled veterans, VA
    must ensure that its overall health care strategy has properly
    balanced the needs of rural veterans and addresses the special
    challenges they face.
        Mr. Chairman, the greatest and the most obvious obstacles
    to health care for many rural veterans is availability of
    transportation to access needed care. One major shortcoming of
    the VA Beneficiary Travel Program is that the mileage
    reimbursement rate of 41 cents per mile falls short of covering
    the actual expense, including gas and other associated costs,
    which can create a barrier to getting the care that they need
    and deserve. We recommend the Secretary exercise his full
    authority under the law to adjust the mileage rates to 67
    cents, in alignment with the current rate for government
    employees.
        In addition to VA transportation program, DAV continues to
    fill a gap in transportation needs. In fiscal year 2023, DAV
    Transportation Network, with 3,200 DAV volunteer drivers,
    provided no-cost transportation for ill and injured veterans
    across the country, logging nearly 9.3 million miles. With a
    total value of $96 million, DAV has donated over 3,700 vehicles
    to VA since 1987 to support this critical transportation
    program, and we appreciate that Senator Hassan brought up the
    issue with regard to our challenge with onboarding and
    screening issues with the VA to get our volunteer drivers into
    the much-needed program. And we ask that the Secretary create
    standardized screening processes and onboarding processes to
    help that in a timely manner.
        In addition to transportation nationwide, clinical staffing
    shortages impede timely health care delivery to rural veterans.
    According to the report by the Health Resources and Services
    Administration in 2023, 65 percent of rural areas were found to
    have a shortage of primary care physicians. Due to limited
    access to VA service in rural communities, rural veterans rely
    heavily on VA's Community Care Network. However, the medical
    care staffing shortages, basic services, and specialized care
    can be difficult to access in a timely manner.
        In addition, there are also concerns about quality and the
    cost of that care. A recently VA-commissioned report titled
    ``The Urgent Need to Address VHA Community Care Spending and
    Access Strategies'' has raised notable concerns about VA's
    Community Care Program. The ``Red Team'' report unanimously
    concluded that VA needs to take urgent action to protect both
    VA's health care system and its Community Care Program. The
    report noted that VHA has insufficient information to know
    whether referrals to community providers will result in the
    veterans receiving either the soonest or the best care.
        It also found that community providers are not required to
    demonstrate competency in diagnosing and treating the complex
    care needs of veterans, nor understanding military culture,
    which is often critical to providing quality care for veterans.
    Unfortunately, the Veteran Community Care Program referral
    process generally does not provide veterans with information
    about quality of care in the community or accessibility data
    that would allow them to make truly informed choices about
    where they receive care.
        Finally, the report found that the lack of care
    coordination between VA and community providers is a
    significant cause for concern for veterans who must rely on
    both avenues of care. DAV strongly believes that VHA should
    guide veterans to care based on quality and accessibility,
    whether to be in the VA or in the community. Neither VA nor
    Community Care can easily be accessible in every area of the
    country. Therefore, VA must optimize the use of mobile and
    virtual resources to provide care for those veterans who do not
    have better options.
        To ensure best outcomes for veterans, DAV continues to
    advocate to keep VA as a primary provider and the coordinator
    of veterans' health care, regardless of where veterans live or
    how they access their care.
        Mr. Chairman, we urge Congress and the VA to require
    community providers to meet the same training, certification,
    and quality of care standards as VA providers.
        In closing, to address the specific needs, geographic
    barriers, and unique challenges veterans face in accessing
    health care in rural communities, VA must implement targeted
    strategies and develop creative solutions to fill existing
    gaps.
        Chairman Tester, this concludes my testimony, and I am
    pleased to answer questions you or Members of the Committee may
    have.

        [The prepared statement of Mr. Retzer appears on page 76 of
    the Appendix.]

        Chairman Tester. I want to thank you all for your
    testimony. We will get going with questions right now. We are
    going to start with you, Ms. Hundrup. Are the VA current
    offerings sufficient to meet the transportation needs of rural
    and highly rural veterans?
        Ms. Hundrup. Thank you. I think the short answer is no, but
    there are multiple programs, which is good news. There is the
    Veterans Transportation Service, that we are aware of, the
    mileage reimbursement. And what I would mention also is that we
    do have a current engagement looking at the Veterans
    Transportation Network, so we will be able to talk much more of
    that soon. That is coming your way.
        But more broadly I think I would say we are very glad to
    see VA taking a multi-pronged approach, which was the right
    thing to do. There is not one solution to this. So I think
    looking more broadly, I think we have to look at VA bringing
    veterans to the brick-and-mortar facilities as well as
    transporting health care to them. I think it needs to be all of
    the above. So whether that is through telehealth or mobile
    medical units, getting that care to the veterans.
        So I think there are great efforts in all of those regards,
    and more work remains in that area.
        Chairman Tester. Chauncey, from your perspective, in
    Montana, your neck of the woods, what is Montana veterans'
    experience with accessing VA Transportation Services? What are
    their overall views on that? Is it positive, negative,
    otherwise?
        Mr. Parker. There have definitely been challenges, for
    sure. There is positive and there is also negative.
        Chairman Tester. What are those challenges?
        Mr. Parker. Challenges is getting in touch with the VA
    Transportation, requests for transportation specifically
    through the VA's programs. So when they do have those
    challenges, a lot of times they will end up turning to
    ourselves to provide those services. So being able to contact
    the VA itself is definitely a challenge.
        Chairman Tester. Do you have capacity to provide those
    services?
        Mr. Parker. Currently we do, but again there are challenges
    there. If this continues, being able to continue to provide
    those services will be a challenge.
        Chairman Tester. You are a secondary provider. In other
    words, you are looking for them to be the primary provider.
    Okay.
        Mr. Retzer, you talked in your opening remark about DAV
    drivers and volunteers. I want you to flesh this out a little
    bit more about what are the barriers that DAV faces in
    recruitment and maintaining volunteer drivers.
        Is Mr. Heiman still in the room here, by the way?
        Mr. Retzer. Thank you for that question, because this has
    been an ongoing issue.
        Chairman Tester. He is. Good. This is for you, by the way.
    Go ahead.
        Mr. Retzer. And I appreciate that. We are directing that to
    the people who need to hear this, most importantly, because we
    have many volunteer drivers in our fraternal organization, and
    in the community, who want to help veterans get to the care
    that they deserve and need. And they know, and we know, as an
    organization, since 1987, that transportation is a must to be
    able to get them there.
        And so what is happening is throughout the country, the
    standard in which they are being screened and onboarded is very
    inconsistent, and that is to the point of where Senator Hassan
    had brought up, that we are losing volunteers because of that.
    And just like we testified in our oral here is that 3,200 last
    year, drivers, volunteered to assist, and there are so many
    more that want to help, in very rural areas.
        Chairman Tester. So talk to me, if you can. If you cannot,
    that is fine. But tell me what the barriers are. Tell me, if I
    want to be a volunteer driver, what do I have to go through to
    get that ability to be a volunteer driver, which means you do
    not pay me a damn nickel.
        Mr. Retzer. Right. So thank you for that. The issue is for
    our volunteer drivers there is a screening process, a medical
    screening process that they have to go through, that is quite--
    --
        Chairman Tester. Is that medical screening process given by
    the VA or somebody else?
        Mr. Retzer. By the VA.
        Chairman Tester. Okay. At the closest VA?
        Mr. Retzer. Yes.
        Chairman Tester. Okay. Anything else, other than a medical
    screen that they have to go through?
        Mr. Retzer. And then also making sure the background checks
    are done adequately.
        Chairman Tester. And how quickly is that process done?
        Mr. Retzer. That is inconsistent throughout the areas that
    we have been told. We had a situation where we testified last
    year where it was over a year in the process for a veteran, so
    we had lost numerous veterans to that process.
        Chairman Tester. So the reason I bring this up is because
    you are not the first one to bring this up. I have had my local
    DAV say we have got people we can get driving, but by the time
    they jump through all the hoops they have run out of gas--no
    pun intended. And so I think that is really important. We need
    to make sure our veterans are safe. We need to make sure they
    are in a good rig, going to the appointments, and you do not
    have a ding-a-ling driving them around. Okay?
        But the bottom line is that this can be done much quicker,
    and it can be done much more efficiently. And we need to keep
    that in mind, because these folks are volunteers, and they
    might just say, ``You know what? I would love to be a good guy
    but I can't wait this long.''
        I will turn to you, Senator King.
        Senator King. To follow up, time is often the problem. When
    you talk about screening, I mean, that is something that I
    think the DAV has to work with the VA to accelerate that
    process. And it would be helpful if you could document it. In
    other words, how many people walked through the door and said,
    ``I would like to be a volunteer driver'' and how many people
    end up being a volunteer driver, and what the losses are.
        The other piece that you mentioned is the mileage, and I
    just want to be sure I have got this right. So a volunteer
    driver gets mileage reimbursement of 41 cents a mile. Is that
    right?
        Mr. Retzer. Yes, Senator, currently.
        Senator King. And a government employee gets a
    reimbursement of 57 cents a mile.
        Mr. Retzer. It is 67 cents, effective January 1st of this
    year.
        Senator King. It is 67.
        Mr. Retzer. That is for a POV, and----
        Senator King. What is wrong with that picture?
        Chairman Tester. The very first bill I carried was
    increasing the mileage reimbursement, and I do not think it has
    been moved up since 2007.
        Senator King. Well, let's get after it. I think that is
    something that, to me, that just makes common sense.
        Ms. Hundrup, I was very interested in your testimony when
    you talked about mobile vans, which it sounds like the GAO
    concluded are not being adequately used, are not being
    adequately deployed, you do not have the data. Is that correct?
        Ms. Hundrup. It was really hard to tell based on the poor
    data. Because of the inaccurate and incomplete data, we were
    not able to determine just how many there were or how many were
    performing for what types of services.
        Senator King. One of my favorite mottos is ``Does it work,
    and how do you know?''
        Ms. Hundrup. And in this instance we did not have the
    information to be able to know, and I do think this is an
    important tool that could be leveraged further. But it is
    almost as if each medical center is left to its own devices to
    run these and see how it works for them.
        I think there are great things happening out there. We
    talked to folks on the ground all across the Nation that had
    mobile medical units. They were using them effectively. It is
    just we do not know nationwide. So I think there is a missed
    opportunity.
        Senator King. Well, one nice thing would be if there was
    some kind of clearinghouse so that the ones that are being used
    effectively could become templates for others.
        Ms. Hundrup. Exactly. I think there are a lot of great
    things, and folks can learn from each other instead of having
    to reinvent the wheel--no pun intended here--but to learn best
    practices and put that into place.
        Senator King. That was better than running out of gas, for
    the record. Sorry. Yes, that was on short notice.
        This is a question for you but it is also for our VA folks
    who are here. The biggest challenge for seniors, including
    senior veterans, is falls. And I am working on legislation to
    set up a Falls Prevention Office in the VA. And by the way, if
    we can prevent them we would save a lot of money. Nationally,
    the medical system spends $38 billion a year on falls, and yet
    Medicare, for example, will not pay for a grab bar that costs
    $50, or a bathmat, a non-slip bath mat.
        So I would hope that the GAO could think about where could
    the VA beef up its prevention activities, and I am thinking
    these vans could be screening vans to develop prevention.
    Because often diseases are much easier to treat when they are
    caught early, particularly cancer.
        So I hope that is something you will look at, and I hope
    the VA will follow up on that, on the issue of prevention and
    falls.
        Mr. Retzer, I would appreciate it if you could synthesize
    your testimony and come back to us with five things we can do
    to improve the Community Care interface, because that strikes
    me. You mentioned it as a significant problem, and the report
    talks about staff in Togus, for example, in Maine, have come up
    with workarounds of the current system in order to make the
    interface between Community Care and the VA better. So I would
    appreciate it if, for the record, you could talk to your
    members, and based on the experience of the DAV, tell us how we
    can improve that system. Because that is going to be a bigger
    and bigger part of this, the whole VA medical system.
        And Mr. Parker, I appreciate your testimony, and again, I
    am going to ask you to do a little homework. To what extent,
    and how could the VA improve its service to Native American
    veterans, of whom there are many. And part of it is also
    employment services, so that when a Native American veteran
    comes back to the reservation they have employment
    opportunities outside of the military.
        So I hope you can supply the Committee, for the record,
    some thoughts about five ways the VA could improve its service
    to Native American veterans. It would be very important for us.
        Thank you. Thank you, Mr. Chairman.
        Chairman Tester. My staff reminded me that just for the
    record, Mr. Heiman, medical screening in Montana is done at two
    facilities, Fort Harrison, which is our hospital, and Billings,
    which is a super-clinic. Now, to put this in perspective for
    you, I live halfway between Plentywood and Helena, maybe not
    even halfway, actually, and it is a 3-hour drive for me to get
    to Helena. Helena is where Fort Harrison is.
        We have got some great CBOCs, and, in fact, we have got
    some great doctors. So we could use assessments from doctors.
    They CDL assessments are also accepted, and that is good too
    except a CDL is not what most people have if they are a
    volunteer driver. They are driving a semi if they have got a
    CDL, okay. So that is kind of where we are at.
        And I say that because DAV transportation is really, really
    important in rural states. It is really, really, really
    important. And if you could do some things to make it so that
    it is more user friendly to get drivers, and this program can
    continue. And it really is a program that helps our veterans
    and does not cost money. So if you could do that.
        I have got a couple more questions on telehealth. Ms.
    Hundrup, while looking at the VA's telehealth program will you
    review how ATLAS program has helped address the digital divide
    for rural veterans? Have you done that review, and if you have
    not, will you do that review?
        Ms. Hundrup. Yes, thank you. We are actually in the process
    of completing that review now, so that report will be coming to
    you this summer. But preliminarily I can tell you that we are
    looking at specifically at ATLAS and its efforts to address the
    digital divide. Right as of fiscal year 2023 there are about 24
    active sites. The use has been very low. I think 14 of those
    have had almost no use, and there is not much going on out
    there. I think the Office of Connected Care, when we have
    talked to them, they recognize that some veterans are really
    not aware of the availability of these sites, and that is
    contributing to the low use. So they are working on additional
    promotional materials.
        Where there has been use we have had very positive
    feedback. It has helped reduce travel time, especially in the
    winter. It has also helped where there is limited digital
    proficiency. But I think it is another theme that we are seeing
    in terms of missed opportunities here, where because of the
    lack of awareness it is not being utilized to the extent that
    it could be. So I think it is going to be really important for
    the VA to work on that promotional material. Otherwise, it is a
    great resource that is just being underutilized.
        We are also looking at changes to the ATLAS program. As I
    am sure you are aware, it started as a pilot program. And since
    it is now shifting over to a grant program that goes back to, I
    think the John Scott Hannon Act of 2019. And as you are acutely
    aware, I think you are also aware that it is not until fiscal
    year 2026 that they are planning to administer these grants. We
    are working on getting additional details about why there is
    the need for this information, so we appreciate your questions
    in this regard, as well.
        Chairman Tester. Absolutely. One of the things that Senator
    Tillis brought up was predictability in a program, and that is
    the VA's issue. Predictability is something that business looks
    at, and veterans look at. And so I want to reinforce his
    comments because I think they were good ones.
        Chauncey, the veterans you serve, do they utilize
    telehealth, number one. And number two, is that what they
    prefer?
        Mr. Parker. Yes, Senator Tester. We do have veterans that
    do utilize it but not to the extent that I think we are
    expecting. A lot of them are the younger veterans. We have a
    number of the older veterans who prefer that in-person talk
    with their providers. However, though, I still think having
    that ability--because we are going to be having a new
    generation coming up that will have that access, and getting
    that access in now will be very beneficial.
        Chairman Tester. Is internet connectivity an issue in
    Indian Country?
        Mr. Parker. It is. Yes, Senator.
        Chairman Tester. So hopefully the Bipartisan Infrastructure
    Bill, hopefully they are laying fiber right now, in Rocky Boy.
    Are they?
        Mr. Parker. They are.
        Chairman Tester. Okay, good. That is good.
        [Laughter.]
        I do not have any more questions. Do you? Senator King.
        Senator King. I am very interested in the potential of the
    vans as mini-CBOCs. You have got VA hospital, you have got
    CBOCs, but then there are a lot of territory where for people
    it is still a long drive.
        And my first job in Maine was with the National Legal
    Services Program in a very rural area. But we did not sit in
    our office and wait for people to find us. I used to go out,
    once a week or so, and go to three small towns. But it was
    predictable. Everybody knew the lawyer was going to be in Milo,
    in the town office, Thursday morning at 10, and then Dover-
    Foxcroft, and then Greenville. In Greenville it was the fire
    station.
        But I like the idea of thinking about using the vans on a
    predictable schedule to cover some of the really rural areas
    for screening but also for perhaps some kind of primary care
    treatment. It sort of fills out the system in a rural area. And
    I hope that is something you can take back and that the VA will
    think about it. I think the vans have tremendous, it sounds
    like, unmet potential if there are only 51 of them in the whole
    country. So I hope you all will think about that.
        Thank you, Mr. Chairman.
        Chairman Tester. Yes, I just want to add to that. I think
    the predictability is the issue here. If you show up in a town
    once, nobody is going to show up. If everybody knows what day
    you are coming, and you come that day, you are going to get
    more and more and more and more customers, to the point where
    it really could be a pain in the neck, but that is exactly what
    we want, okay. So it is good.
        I want to thank you guys for your testimony today. I
    appreciate it very, very much. I also want to thank the VA
    testifiers for sticking around. I appreciate that, guys and
    gals. I do know that your hearts are in the right place to
    improve access to care for our rural veterans, and I know that
    working together we can fix the problems that are there,
    truthfully. You listen to the folks that are on the ground, you
    take the inspector general's comments seriously, we can get to
    a point where every veteran--and by that I might add,
    regardless of what Tillis says, rural America, we have a lot of
    veterans living there. A very high percentage of the overall
    population are veterans. So this is no small issue.
        We will keep the record open for a week. If questions are
    headed your way by anybody on this Committee I would ask that
    you would answer them as efficiently and as quickly as
    possible.
        As of right now this hearing is adjourned.
        [Whereupon, at 5:11 p.m., the hearing was adjourned.]

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                                A P P E N D I X

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