    [House Hearing, 119 Congress]
    [From the U.S. Government Publishing Office]

                          DELIVERING FOR VETERANS AND
                      CAREGIVERS: YEAR ONE OF THE DOLE ACT
    =======================================================================

                                    HEARING

                                   BEFORE THE

                           SUBCOMMITTEE ON OVERSIGHT AND
                                  INVESTIGATIONS

                                     OF THE

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED NINETEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                            WEDNESDAY, MARCH 4, 2026

                                   __________

                               Serial No. 119-49

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                        Available via http://govinfo.gov

                                  __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    63-836                     WASHINGTON : 2026
    =======================================================================

                         COMMITTEE ON VETERANS' AFFAIRS

                         MIKE BOST, Illinois, Chairman

    AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking
        American Samoa, Vice-Chairwoman      Member
    JACK BERGMAN, Michigan               JULIA BROWNLEY, California
    NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire
    MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,
    GREGORY F. MURPHY, North Carolina        Florida
    DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky
    MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois
    JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois
    KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York
    JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon
    ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey
    KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota
        Mariana Islands
    TOM BARRETT, Michigan

                           Jon Clark, Staff Director
                      Matt Reel, Democratic Staff Director

                  SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                       JEN KIGGANS, Virginia, Chairwoman

    AUMUA AMATA COLEMAN RADEWAGEN,       DELIA RAMIREZ, Illinois, Ranking
        American Samoa                       Member
    JUAN CISCOMANI, Arizona              TIMOTHY M. KENNEDY, New York
    KEITH SELF, Texas                    HERB CONAWAY, New Jersey

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

                                  ----------

                            WEDNESDAY, MARCH 4, 2026

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Jen Kiggans, Chairwoman............................     1
    The Honorable Delia Ramirez, Ranking Member......................     3

                                   WITNESSES
                                    Panel I

    Dr. Thomas O'Toole, Acting Assistant Under Secretary for Health
      for Clinical Services, Veterans Health Administration, U.S.
      Department of Veterans Affairs.................................     5

            Accompanied by:

        Dr. Mark Koeniger, Acting Assistant Under Secretary for
            Health for Patient Care Services, Veterans Health
            Administration, U.S. Department of Veterans Affairs

        Mr. Kenneth Smith, Executive Director of Education Service,
            Veterans Benefits Administration, U.S. Department of
            Veterans Affairs

    Ms. Sharon Silas, Director, Health Care, U.S. Government
      Accountability Office..........................................     7

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Dr. Thomas O'Toole Prepared Statement............................    25
    Ms. Sharon Silas Prepared Statement..............................    28

                           Statements For The Record

    Elizabeth Dole Foundation Prepared Statement.....................    49

                          DELIVERING FOR VETERANS AND
                      CAREGIVERS: YEAR ONE OF THE DOLE ACT

                                  ----------

                            WEDNESDAY, MARCH 4, 2026

                 Subcommittee on Oversight and
                                Investigations,
                        Committee on Veterans' Affairs,
                                 U.S. House of Representatives,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 2:45 p.m., in
    room 360, Cannon House Office Building, Hon. Jen Kiggans
    [chairwoman of the subcommittee] presiding.
        Present: Representatives Kiggans, Radewagen, Ciscomani,
    Self, Ramirez, and Kennedy.

              OPENING STATEMENT OF JEN KIGGANS, CHAIRWOMAN

        Ms. Kiggans. Good afternoon, everyone. This subcommittee
    will come to order.
        I would like to welcome everyone to this subcommittee
    hearing to discuss the implementation of the Senator Elizabeth
    Dole 21st Century Veterans Healthcare and Benefits Improvement
    Act. This landmark bill, led by House Republicans and my friend
    Representative Ciscomani from Arizona, made a slew of changes
    at the U.S. Department of Veterans Affairs (VA) to modernize
    healthcare delivery, especially for aging veterans.
        First, I would like to take a pause and ask that everyone
    joining us that we keep the servicemembers deployed to the
    Middle East and in harm's way in our thoughts and in our
    prayers, as well as the families of the six servicemembers who
    recently gave their lives.
        Today's hearing is about oversight, accountability,
    ensuring that the promises Congress made to veterans,
    caregivers, and their families are fully realized. While
    veterans and their caregivers are beginning to feel the
    benefits of this legislation, VA and Congress' work is not
    done. Last year Congress passed with bipartisan support the
    Dole Act with the goal of improving veterans' access to
    education, healthcare, and programs designed to prevent and
    reduce veteran homelessness. This was a sweeping, bipartisan,
    bicameral package negotiated and supported by members in both
    the House and the Senate, Democrats and Republicans alike,
    united by a shared commitment to those who served.
        The Dole Act represented one of the most comprehensive
    veterans reform package in recent years and I was proud to
    support it. This legislation moves the needle to modernize VA
    healthcare delivery, strengthen support for caregivers, expand
    access to education and job training, improve long-term care,
    address rural health disparities, and reduce veteran
    homelessness. It was designed to make systemic improvements,
    not incremental tweaks across the continuum of care for
    veterans and their families.
        The Dole Act included my Caregiver Outreach and Program
    Enhancement Act, or COPE Act, which intended to establish a
    grant program to provide mental healthcare to family caregivers
    supporting their veteran family members. The COPE Act was meant
    to recognize that when we care for veterans, we must also
    support those who care for them. Family caregivers are the
    backbone of our long-term care system, often sacrificing
    careers, financial stability, and their own health to support
    their loved ones.
        As a veteran, the daughter of a veteran, the wife of a
    veteran, and the mom to a future veteran and a healthcare
    provider, I understand the importance of investing in our
    veteran communities to improve health outcomes. I understand
    firsthand the sacrifices military families make and the strain
    that caregiving can place on spouses and loved ones. That
    perspective makes oversight of this law not just a policy
    responsibility for me, but a personal one.
        To my dismay, it appears the VA has not followed the
    congressional intent of the COPE Act yet and, to my knowledge,
    has not followed many other provisions within the Dole Act. Now
    I am asking the VA to follow congressional intent and fulfill
    all statutory promises in the Dole Act, and today we will
    hopefully get a follow-up and hear about the progress that is
    being made.
        Failure to carry out the will of Congress is unacceptable
    and I hope my colleagues will be united in demanding
    accountability from the VA. Passing a bill and having it signed
    into law is only one part of our job, sometimes the easiest
    part. The most important part of our responsibility is ensuring
    that the law is faithfully and efficiently implemented in full
    alignment with congressional intent on behalf of the veterans
    and families it seeks to benefit. Oversight is not optional. It
    Is a constitutional obligation. Today's hearing is about making
    sure this landmark law does not fall short in execution.
        Over a year after enactment, 55 out of 72 sections are
    currently in progress. The VA says it is on track to implement
    most sections within the timeframes required, but two on track
    sections are set to expire in less than a year. Section 106,
    which would increase access to dental care, is set to end
    January 2027, and it is my understanding that only one phase of
    the pilot program has been rolled out. Section 143, which
    covers ambulance costs for veterans in rural areas, is set to
    sunset in September of this year. The VA has not fully
    implemented this provision.
        These are not minor provisions. These are real benefits
    affecting real veterans: access to dental care, emergency
    transportation in rural communities, and essential services
    that directly impact health outcomes. When implementation lags
    and sunset dates approach, veterans are the ones who pay the
    price.
        Another eight sections have been marked as at risk or
    behind schedule. For example, the Veteran Employment Through
    Technology Education Courses (VET TEC) Pilot Program to improve
    short-term training and employment opportunities in specialized
    high-tech fields is behind schedule, putting implementation at
    risk.
        Congress and this committee are delivering on the promises
    we have made to the veteran community. The VA needs to mobilize
    and fully implement the Dole Act. This bipartisan, bicameral
    package was meant to drive sweeping improvements, not sit in
    prolonged implementation. Veterans, caregivers, and their
    families upheld their end of the bargain through service and
    sacrifice. Congress upheld its end by passing comprehensive
    reform. Now the VA must uphold its end by executing the law
    with urgency, transparency, and accountability.
        Today, we are not here to relitigate the merits of the Dole
    Act. We are here to ensure that it succeeds because the true
    measure of this legislation will not be the vote tally that
    passed it, but whether veterans on the ground feel the
    difference in their daily lives. I look forward to hearing from
    our witnesses about concrete timelines, measurable benchmarks,
    and the specific steps the VA is taking to ensure that every
    section of this law is implemented as Congress intended.
        I now recognize Ranking Member Ramirez for her opening
    comments.

           OPENING STATEMENT OF DELIA RAMIREZ, RANKING MEMBER

        Ms. Ramirez. Thank you, Chair Kiggans.
        It has been 225 days since our last Oversight and
    Investigations Subcommittee hearing, so it is critical that we
    are back finally at dais. A lot has happened since our last
    subcommittee hearing. Secretary Collins has continued to
    attack, erode, and disrespect the VA workforce. He has tried to
    strip away veterans' earned benefits through a cruel Interim
    Final Rule (IFR), only to be swiftly met with so much
    opposition from veterans in Congress that he was forced to
    retreat. We witnessed U.S. Department of Homeland Security
    (DHS) and U.S. Immigration and Customs Enforcement (ICE)
    terrorize our communities, including our veterans, and execute
    one of our neighbors, including Alex Pretti, a VA nurse.
        Now the President has started an illegal war with Iran to
    consolidate power, enrich himself and his donors. He is sending
    servicemembers into harm's way. I am concerned that because of
    Secretary Collins' leadership, what is left of VA will not be
    adequate to meet servicemember needs when they return.
        Why am I concerned? Let me tell you why, because Secretary
    Collins' legacy thus far has been dismantling VA and eroding
    veteran benefits instead of improving the lives of the veterans
    we are supposed to be serving. That much is clear from the fact
    that the VA has not made much progress in implementing the
    bipartisan Dole Act since it was signed into law over 14 months
    ago. In defiance of Congress' authority, the vast majority of
    the law has not been, in fact, implemented, leaving the most
    vulnerable veterans without the resources that Congress
    approved for them.
        Let us start, for example, veteran homelessness. In the
    Dole Act, we included bills from my Democratic colleagues that
    gave VA crucial authorities that communities need to address
    and end veteran homelessness. We actually increased the Grant
    Per Diem (GPD) rate and authorized the VA to purchase basic
    necessities for homeless veterans. Having been the executive
    director of a homeless service agency myself, I understand that
    oftentimes organizations have to do more with less. I know that
    every resource and every dollar matters when you are trying to
    provide the best service possible with very limited means.
        VA worked with committee staff for over a year to refine
    the homeless sections of the Dole Act before it was signed into
    law. The VA assured us that providing these increased resources
    to community providers and to homeless veterans would be simple
    as a, quote, ``turning on a light switch'' once the bill would
    pass. Under the Biden administration, VA was prepared. Yet
    under Collins' disappointing, dysfunctional, and delinquent
    leadership, it has taken over a year to implement the most
    critical parts of the Dole Act.
        Homeless service providers are left receiving a paltry $85
    a day to provide transitional housing services to veterans
    instead of the $128 a day we had actually authorized in the
    law. Community providers are left with the GPD program--
    community providers have left the GPD Program in droves while
    they waited for the relief promised by Congress. Those exits
    create service gaps that are impacting our veterans every
    single day.
        Communities view VA Undersecretary Collins as an unreliable
    partner in the fight to end veteran homelessness and, frankly,
    I agree with them. Due to his delays, homeless veterans are
    also left without access to their basic needs, another critical
    resource Congress authorized in the Dole Act. We gave VA the
    authority to use funds to be able to pay for food, for shelter,
    for clothing, for transportation for homeless veterans to get
    to and from job interviews or for medical appointments. Every
    single day that passes, and Doug Collins fails to implement
    approved provisions of the Dole Act, he is defying
    congressional authority. Every day that passes that a veteran
    experiences homelessness on the streets of our country, they
    are left without the resources that they need to become stably
    housed. That, to me, is shameful, it is irresponsible, and it
    is a harmful failure of the Secretary.
        Let me talk to you about another shameful note. I want to
    discuss the staffing provisions of the Dole Act that have yet
    to be implemented. You see, section 146 required VA to develop
    and implement staffing models to ensure VA has the workforce it
    needs to provide care and benefits to the veterans. Staffing
    models are essential for aligning personal resources so they
    can be used efficiently, so that the workers with the right
    skills are in the right place at the right time.
        Folks listening may recall that the Veterans Health
    Administration (VHA) is currently undergoing a massive
    reorganization, which we discussed at a full committee hearing
    just last month. One would think that a reorganization of this
    magnitude of the largest integrated health system in the
    country would incorporate staffing models. By VA's own
    admission, they have not complied with the Dole Act and lack
    staffing models for the vast majority of the medical facilities
    service lines.
        Which begs the question, what is the evidence that the VHA
    reorganization is, in fact, needed? How can we be sure that the
    VA is making the correct changes if its leadership does not
    even know how many staff it needs and where they need them?
    Even worse, let me ask you this question. Why is VA cutting
    vacant positions if they do not have staffing models developed?
        VA provided data to my staff a couple weeks ago and over
    26,000 positions that were cut from the books. The details of
    those cuts are alarming. For months, VA has told us that these
    are quote, ``old COVID era vacancies for positions that are no
    longer needed at the agency.'' Let me tell you that the data,
    it paints an entirely different picture about the same nature
    of these cuts. You see over 18,000, not hundred, 18,000 of the
    positions VA cut had a person in that job in 2025 or even 2026.
    This included positions for nearly 3,000 nurses, 800 social
    workers, 300 psychologists, and over a thousand physicians who
    were on the job in 2025. These VA positions were discarded at
    the hands of the Secretary's reckless leadership and they are
    not going to be backfilled.
        Chair Kiggans, the medical center that serves your
    constituents had the most cuts of any VA facility in the
    country; 733 of the positions VA cut were at the Hampton VA
    Medical Center. At the facilities that serve my constituents in
    Chicago, Jesse Brown and Hines, 717 positions were cut. In
    addition to those 26,000 positions that were wiped from VA's
    books since Secretary Collins was sworn in the VA, he has
    showed a net 30,000 employees representing centuries' worth of
    experiences. Those losses included over 1,100 doctors, 2,300
    registered nurses, 700 more social workers, and nearly 300
    psychologists.
        All of these cuts and losses were made with no staffing
    models in place as required by the law. Cut after cut after
    cut, with no analysis of how veteran care and benefits would be
    affected. It is the definition of negligence.
        The Secretary and his political appointees intentionally
    misled and lied to Congress about the nature of these cuts.
    Secretary Collins is failing at the most fundamental part of
    his job, ensuring that veterans have access to world class care
    at the VA. It is why this hearing is so important. It is why we
    have to hold them accountable. I look forward to the
    conversation that we have in this hearing today.
        With that, Chair, I yield back.
        Ms. Kiggans. Thank you, Ranking Member Ramirez.
        I will now recognize our witnesses on our first panel.
    Testifying before us today, we have Dr. Thomas O'Toole, acting
    assistant undersecretary for Health for Clinical Services at
    the Veterans Health Administration. Dr. Mark Koeniger, acting
    assistant under secretary for Health and Patient Services of
    the Veterans Health Administration. Mr. Kenneth Smith,
    executive director, Education Services at the Veterans Benefit
    Administration. We also have Ms. Sharon Silas, director of
    health for the U.S. Government Accountability Office (GAO).
        Will the witnesses please stand and raise their right hand?
        [Witnesses sworn.]
        Ms. Kiggans. Thank you and you may be seated. Let the
    record reflect that the witnesses answered in the affirmative.
        Dr. O'Toole, you are now recognized for 5 minutes to
    provide the VA's testimony.

                      STATEMENT OF THOMAS O'TOOLE

        Dr. O'Toole. Good afternoon, Chairwoman Kiggans, Ranking
    Member Ramirez, and distinguished members of the committee.
    Joining me today are Dr. Mark Koeniger, acting assistant under
    secretary for Health and Patient Care Services, and Mr. Ken
    Smith, executive director of Education Services at Veterans
    Benefits Administration (VBA). It is an honor to be here to
    discuss progress implementing the Senator Elizabeth Dole 21st
    Century Healthcare and Benefits Improvement Act.
        First, thank you for this legislation and what it will
    accomplish. Within VA alone, the Dole Act mandates implementing
    more than 40 enhancements, new guidelines, or new programs;
    executing six new pilot programs; conducting outreach and
    releasing new online tools for veterans, patients, and coroner/
    medical examiners; and completing 50 new congressional mandated
    reports. Given the scope and breadth of the legislation, VA
    moved oversight of Dole Act implementation to the Office of the
    Secretary, ensuring senior most oversight. As of December 2025,
    the new Office of Strategic Initiatives is the responsible
    office.
        The lack of funding has been a hurdle, requiring us to
    change priorities and in some instances use funding from
    multiple areas to deliver on some of the sections. That said,
    we have made significant progress implementing this important
    legislation. Of the 72 sections, VA has fully implemented 25
    and we are diligently working on the remaining sections with
    significant progress being made. I would like to briefly
    highlight key accomplishments within VHA, VBA, and National
    Cemetery Administration (NCA), which are leading to
    transformative changes for veterans and their families.
        Section 101 of the Dole Act eliminated an unnecessary layer
    of approval, allowing veterans to access community care when in
    their best medical interest.
        Section 120 increased coverage for noninstitutional care
    alternatives from 65 percent to 100 percent of nursing home
    costs and the authority to exceed that cap for veterans with
    Amyotrophic Lateral Sclerosis (ALS), spinal cord injuries, and
    similar conditions. This enables more veterans to receive care
    at home, preserving independence and dignity.
        Section 402 expanded per diem payments for homeless
    veterans to 133 percent of the State home domiciliary rate and
    up to 200 percent for sites identifying--meeting identified
    criteria. To date, 150 sites have availed of the 133 percent
    increase and 40 sites have applied for the 200 percent rate.
        Section 149 requires an independent assessment of the
    National Veterans Suicide Prevention Annual Report and
    development of a public toolkit for coroners and medical
    examiners to improve reporting accuracy. The independent
    assessment was completed in January 2026.
        VA has experienced some challenges with the implementation
    of 143 and to a much lesser extent 129, and we welcome the
    opportunity to work with the subcommittee to ensure that VA can
    provide the benefits and services intended.
        The Dole Act expanded the VA's Native American Direct Loan
    Program, giving Native American veterans more opportunities to
    purchase, build, improve, or refinance homes on trust land. VA
    is also hiring additional coordinators to support these
    veterans and their families.
        Section 212 reestablished the Veterans Technology Education
    Courses program. VA has scheduled implementation of the managed
    service claims processing capability for the end of third
    quarter 2026 and published the student application in the
    Federal Register in December 2025.
        VA has also made progress implementing section 215, linking
    the GI Bill comparison tool to the Department of Education's
    College Navigator and is working to incorporate additional
    data.
        Of note, VA's conversion from the benefits delivery network
    to the Digital GI Bill has impacted full implementation of
    sections 208, 210, and 212, as well as recent court decisions.
    We will continue to provide updates to Congress in our calls
    and briefings.
        Section 301 expands burial allowances for veterans who die
    at home while receiving VA hospice care, ensuring families
    receive timely support.
        Section 302 improves outreach to States and Tribal
    governments to ensure veterans and their families are aware of
    burial and memorial benefits they have earned.
        Chairwoman Kiggans and Ranking Member Ramirez, this
    concludes my statement. We appreciate the opportunity to speak
    before you today and welcome any questions you or other members
    of the subcommittee may have. Thank you for your continued
    support of veterans, their families, caregivers, and survivors,
    and the many VA programs that serve them.

        [The Prepared Statement Of Thomas O'Toole Appears In The
    Appendix]

        Ms. Kiggans. Thank you, Dr. O'Toole.
        Ms. Silas, you are now recognized for 5 minutes to provide
    your testimony.

                       STATEMENT OF SHARON SILAS

        Ms. Silas. Chairwoman Kiggans, Ranking Member Ramirez, and
    members of the subcommittee, thank you for the opportunity to
    be here today to discuss VA's progress implementing
    requirements in the Elizabeth Dole Act.
        The Dole Act authorized significant expansions to
    healthcare programs and support for veterans. Today I would
    like to highlight GAO's work in two areas that are addressed in
    the law: the Veterans Community Care Program and the Caregiver
    Support Program.
        First, the Dole Act contains a number of provisions for VA
    that are intended to improve the agency's healthcare
    operations, including community care. Relatedly, GAO has a long
    history of review reviewing the Community Care Program,
    including some of the more recent changes to how referrals are
    processed and appointments are scheduled. In a little more than
    10 years, the Community Care Program has tripled in size and
    represents nearly 42 percent of all VA healthcare appointments.
    With that expansion, the administrative processes at VA
    facilities have become more complex and continue to be labor
    intensive.
        Through this growth, the Veterans Health Administration has
    made new, numerous changes to how the program is administered
    in order to gain efficiencies and ensure that veterans
    understand their healthcare options. In 2020, we issued a
    report on VA's implementation of the Veterans Community Care
    Program. In that review, we described the timeliness of
    processing referrals and scheduling appointments. We made three
    recommendations to VA in that report, two that remain open,
    including that VHA assess the staffing and resource needed to
    process community care referrals and schedule appointments. We
    also recommended the agency set standards for monitoring the
    appointment scheduling process, including the receipt of care
    with a community care provider.
        We also issued two reports in 2025 addressing two key VHA
    efforts: the establishment of the VHA's Integrated Veteran Care
    Office, or IVC; and the Implementation of the Referral
    Coordination Initiative.
        The creation of the IVC was an organizational reform to
    address VHA's progressively complex processes to manage
    healthcare delivery at facilities and through the Community
    Care Program. It consolidated the management of VA healthcare
    delivered in the facilities and through community care with the
    intent of improving coordination and ensuring veterans receive
    seamless access to care.
        The Referral Coordination Initiative was created to ensure
    veterans understood their care options and to also create
    efficiencies for facilities in processing referrals and
    scheduling appointments. In both reports, we highlight
    deficiencies in the implementation of these efforts that
    ultimately can impact veterans access to care. Recommendations
    from both of those reviews remain open.
        As VHA prepares to go through additional changes, including
    restructuring and the next generation of community care
    contracts, it is critical that the agency ensure it has the
    effective management structures in place to ensure veterans'
    timely access to care. Addressing GAO's outstanding
    recommendations and addressing the mandates in the Dole Act
    will help VA to ensure veterans receive consistent, high-
    quality healthcare.
        The second program that I would like to highlight is VA's
    Caregiver Support Program. The Caregiver Support Program plays
    a critical role in supporting caregivers who assist veterans
    who have suffered serious injuries with essential tasks of
    everyday living. There are currently about 98,000 caregivers
    participating in the program. Given the toll that daily
    caregiving can take on caregivers' mental health, ensuring VHA
    effectively spreads awareness about the mental health support
    it offers to caregivers is essential to ensuring that
    interested caregivers participate in the program and they
    receive the help that they need. The Dole Act includes a number
    of provisions to bolster the supports for caregivers caring for
    veterans, including a mandate for GAO to review mental health
    support for caregivers.
        Our work is ongoing, however, I will preview some
    preliminary findings. In our report, we describe a variety of
    services to support caregivers' mental health and well being,
    such as individual therapy, support groups, respite care, among
    others. We also identified some challenges caregivers
    experience in accessing the services, including the limited
    ability to travel to receive support in person. In our report,
    we describe some steps VHA has taken to address these
    challenges, such as creating a virtual psychotherapy program
    for caregivers.
        However, our preliminary findings also show that VHA has
    not fully implemented performance management practices for
    ensuring veterans and their caregivers are aware of the
    program. Effective implementation of performance management
    practices is not just a bureaucratic exercise. Following the
    practice of setting program goals with targets and timeframes,
    collecting data to measure progress toward those goals, and
    then using that information to assess results and informed
    decisions on any adjustments to those efforts can help to
    ensure the program is meeting its intended results: getting
    caregivers the support they need.
        The requirements for VA in the Elizabeth Dole Act align
    with many of the findings and recommendations from GAO's
    reviews. VA's adoptions of those recommendations would aid the
    Department's progress toward implementing the Dole Act's
    provisions.
        That concludes my prepared statement. Thank you.

        [The Prepared Statement Of Sharon Silas Appears In The
    Appendix]

        Ms. Kiggans. Thank you, Ms. Silas.
        We will now move to questions and I yield myself 5 minutes.
        I want to ask a quick question to Mr. Smith. Can you talk,
    I know you guys all kind of overviewed some of the work that
    the VA has done to implement the Dole Act, and can you just
    briefly describe what the education outreach has been, that has
    been done to educate veterans, their families, and community
    care partners, too, just about these new resources that are
    available to veterans? Are we putting pamphlets in waiting
    areas or are we sending email? What does that outreach look
    like?
        I know as a primary care provider we often had a large
    group of veteran patients. It was challenging to understand the
    resources the VA has out there and we have put so many good
    things in place and a lot of good changes in motion. I just
    want to know how we are communicating with veterans and their
    families that these things are now available.
        Mr. Smith. Thank you for the question. For our education
    programs, our outreach is predominantly through our website. We
    have published a number of--information on our website, as well
    as provide marketing to our students directly through email
    campaigns. Last, our Veterans Service Organization (VSO)
    community, they are a great partner in disseminating
    information.
        Ms. Kiggans. The VSOs are a good source, and I get the VA
    emails as a veteran, married to a veteran. I do not think I
    ever visited the VA website before my current job, so I do not
    do a lot of visit--I do not know how many veterans out there
    actively--maybe if they are Google searching. I just--that
    outreach piece, there is a lot of primary caregivers out there,
    and there is probably a lot of patients sitting in waiting
    rooms. A poster, I am thinking of even the technology
    integration we see in waiting rooms, you know, just letting
    people know. I think that is one of our hardest parts. We have
    great benefits, but what are those benefits, and communicating
    that, so.
        Keep in mind our primary care, our civilian counterparts as
    well, we all take care of veterans. I have a large veteran
    community in Hampton Roads, so it was just always a challenge,
    you know. I had a great office manager who would do that
    research and try to connect with the VA. Even as a veteran
    provider, I did not even know all the resources that were out
    there, so I think that is half our battle. I am just throwing
    that out there.
        Then going to Dr. O'Toole, the Dole Act has reoriented VA
    healthcare to put the best medical interests first in each
    veteran. I applaud the VA for enacting this provision. It saves
    lives. However, the VA was marked section 122 complete, and
    that is the operative section of my bill, the COPE Act. It has
    come to my attention that VA decided not to issue any grants
    specifically under this program.
        Just wondering, Dr. O'Toole, why that law has not been
    fully acted about the grants? There was 10 million--
    specifically, there was $10 million appropriated for the
    program in Fiscal Year 2025 and another 10 million appropriated
    in Fiscal Year 2026. Just wondering where that money went.
        Dr. O'Toole. Thank you, Congresswoman. I appreciate that.
    That is the awards contract for mental healthcare for family
    caregiver support. My colleague, Dr. Koeniger, I believe, is
    better situated to comment on that.
        Dr. Koeniger. The caregiver support, particularly in the
    mental health realm, we have implemented the Virtual Caregiver
    Support Program. With that program, we have seen, let me see,
    actually almost 29,000 encounters. That is a virtual--most of
    those encounters are the virtual program, but caregivers can
    also be seen face to face as well. Again, those almost 29,000
    encounters, there are over 4,300 unique caregivers tied to
    those encounters.
        Ms. Kiggans. That is good news. Thank you for that.
        Let us see, back to Dr. O'Toole. Section 142, it waived the
    pay cap for highly skilled medical staff. Dr. O'Toole, can you
    tell us how many waivers the Secretary has made for that? I
    know that was a complaint we heard frequently, especially with
    our surgeons, anesthesiologists, we have trouble recruiting,
    retaining physicians, specialty care physicians who could make
    so much more on the outside. We need those people at the VA. I
    am just wondering if you update for that.
        Dr. O'Toole. Yes, thank you, Congresswoman. First, this is
    really important legislation for us, as you know, and the wage
    gap between what these highly trained specialists would make in
    the private sector versus the VA is only growing.
        The challenge and issue for us, quite honestly, is that
    many, many more specialty groups and specialists among the
    25,000 physicians, for instance, that we have in the VA far
    exceed the 300 people. We run the risk of second and third
    order consequences if we do not do this right. In particular,
    if we are picking out certain groups where, you know, one
    provider is afforded the expansion or the cap extension and
    others are not, what that may do to the practice.
        The other dynamic that we are looking at is how can this be
    considered from an enterprise perspective? That if a telecare
    service, such as teleradiology, can be used in a rural
    community, it is probably going to be a lot more efficient and
    effective than trying to extend that cap to a radiologist in a
    rural community.
        We are actively moving forward on this. I meet with the
    under secretary and others to review the parameters for data.
    We anticipate having a criteria put forward within the next 1
    to 2 months, I am hopeful for, to be able to start awarding
    that cap. I do want to pay notice to the fact that, you know,
    this is critical because it is going to have to extend beyond
    these 300 individuals that are ultimately selected in this
    first pass.
        Mr. Kiggans. Keep us posted. I know that is an important
    part of the program, but thank you.
        My time has expired. I will save some for maybe a second
    round.
        I now recognize the ranking member for 5 minutes of
    questioning.
        Ms. Ramirez. Thank you, Chairwoman.
        Dr. O'Toole, I just want to go ahead and follow up on that.
    First, thank you for being here. As you know, a few weeks ago
    the Secretary testified before the full committee and in a
    back-and-forth with our ranking member, he asked Ranking Member
    Takano if he would commit to introducing a bill to raise the
    cap on physician pay so that he can compete in the market to
    hire more doctors. I want to double down a little bit more on
    this conversation, because I know you just started a moment
    ago.
        In that committee hearing, the Secretary claimed that he
    cannot recruit physicians because he does not have the
    authority to pay physicians more. I am hearing you talk a
    little bit about the 300, but here is the thing. Section 142 of
    the Dole Act does authorize the VA to use waivers to increase
    pay for 300 physicians. The VA does have the authority to pay
    its physicians more already, which actually contradicts the
    Secretary's testimony when he said he did not have the
    resources or the authority to be able to raise those wages.
        It sounds like Secretary Collins apparently does not think
    it is important to learn the laws that govern his agency, much
    just enact those laws to improve the VA and veteran care. That
    gets to my next point. I think you have answered this, but I
    just want to make sure that I put this on the record. How many
    pay waivers has the VHA requested for physicians under the Dole
    Act? It sounds like it is zero. The answer is zero. Correct?
        Look, in a request for information provided to my staff on
    February 12, the VHA indicated they had not requested or
    approved any pay waivers for physicians. I just really need to
    reiterate what I said to the Secretary at our hearing last
    month. He cannot come to our committee and state that he cannot
    hire doctors because he cannot compete in the market when he
    will not even use the authorities he already has, that we,
    Congress, have given him to make more competitive offers to
    attract physicians.
        Secretary Collins waited until January 9th of 2026, a year
    after the Dole Act was signed into law, to publish the
    implementation plan for the authority to make it easier to hire
    doctors. It did not seem like there was any real urgency there.
        You have to understand why I am concerned here. The
    Secretary comes before the committee, and he claims that he
    cannot hire doctors, but he will not even use the tools that we
    have already given him, authorized them, to make some
    competitive offers for a number of these physicians. Instead,
    he lost 1,000 doctors and then he wiped 1,500 more physicians
    positions from the VA books. It makes no sense, if our goal is
    to strengthen the services veterans receive, it makes no sense
    to continue to claim, as Doug Collins does, that veteran care
    and benefits are not affected when we are hearing from our
    constituents on a regular basis, veterans, that they cannot get
    appointments at the VA. However, his actions make perfect sense
    if Secretary Collins does not want to hire, let me say this
    again, does not want to hire doctors because his goal is to
    ensure that the VA fails so that he can further dismantle and
    maybe even privatize it.
        I want to follow up on another piece, and this is more
    specifically to Ms. Silas. Ms. Silas, GAO has recommended that
    VA assess its community care staffing and resource needs to
    ensure timely appointment scheduling for veterans seeking care
    and community. My question to you, Ms. Silas, is why is such a
    staffing assessment important? How does this recommendation
    align with the requirement in the Dole Act for VA to implement
    a staffing model in the IVC, Veterans Integrated Service
    Networks (VISN), and the local medical facilities?
        Ms. Silas. Thank you for that question. An agency's
    workforce is really central to an agency transitioning into a
    high-performance organization. In GAO's high-risk work, we have
    worked with the Veterans Health Administration to try to get
    them to be better in terms of clarifying their resource needs.
    The staffing model and performance metrics that are provisioned
    in the Dole Act are incredibly important because it helps to
    align your resources and staff needs with your program needs.
    It also is important for being able to plan ahead and to manage
    any risks.
        As you all know, each VA facility is unique in terms of the
    veteran population that they serve and then also in the
    communities that they reside in. I know that one thing that we
    have heard consistently for as long as I have been doing this
    work is that when we meet with staff in these facilities, they
    say there is not enough staff to process referrals in a timely
    manner and to do timely appointment scheduling. We always hear
    about challenges with workload.
        In our 2020 report where we recommended that VA assess
    their staffing resources, they had told us that they have the
    staffing tool and that they were in the process of updating
    that, and they have been continually updating that staffing
    tool as the processes have evolved over the last 5 years. That
    recommendation, as you know, remains open.
        For the staffing model and performance metrics that have
    been required in the Dole Act, the staffing tool, at the least,
    can provide information or input into the staffing models they
    are delivering now.
        Ms. Ramirez. That makes sense.
        Ms. Silas. It is kind of unclear how these both fit in
    together. Regardless, GAO does have a mandate in the Dole Act
    to do a review of the VA's development of the staffing model
    and performance metrics. Once they complete the effort and
    issue some reports we will be doing our own review.
        Ms. Ramirez. Thank you, Ms. Silas. My time is up. If we
    have a second round, I will do a follow-up. Thank you, Chair.
        Ms. Kiggans. Thank you, Ranking Member.
        The chair now recognizes Mrs. Radewagen for 5 minutes.
        Ms. Radewagen. Thank you, Chairwoman Kiggans. Talofa lava.
    I thank the panel for being here today. It is an important
    hearing today, so thank you to the witnesses as well.
        Mr. Smith, what has been the greatest barrier for
    implementation of section 302 of the legislation?
        Mr. Smith. Thank you for the question, ma'am. Right now, VA
    is working to publish a rule for that grant program so that we
    can perform or issue grants to perform the veteran outreach as
    required by 302.
        Ms. Radewagen. How has section 302 helped VA better partner
    with State and Tribal entities?
        Mr. Smith. I believe that once implemented, we will be able
    to provide, or at least provide grants, you know, to those
    organizations so that they can perform outreach on VA's behalf
    and ensure that they are communicating with their members in a
    culturally responsive way.
        Ms. Radewagen. Ms. Silas, in GAO's review of the Dole Act
    implementation, what has been your greatest concern?
        Ms. Silas. The GAO has a number of mandates to review
    implementation of various provisions within the Dole Act. Much
    of our work that we need to do is either waiting on VA to
    complete their enactment of their provision so we can oversee
    that or we are waiting for some reports to be released in order
    for us to do the review. We have not looked directly at the
    implementation of any of the specific provisions that VA is
    responsible for.
        We do have ongoing work for our own mandates around the
    dental services. We are looking at VA's oral health program. We
    are also looking at the Veterans Community Care Dentistry
    Program. We are making progress on those reviews. Otherwise, we
    are waiting for VA to complete their efforts before we look at
    them.
        Ms. Radewagen. Do you believe that VA will be able to
    implement the act in its entirety in the allotted timeframe?
        Ms. Silas. I do not think I could state for sure. It would
    be up to VA to tell you what their progress is. Again, I can
    only speak to the programs that we have oversight of in terms
    of the mandate and provisions to review those programs. Most of
    that work is ongoing right now.
        Ms. Radewagen. Thank you, Chairwoman. I yield back the
    balance of my time.
        Ms. Kiggans. Thank you, Ms. Radewagen.
        The chair now recognizes Mr. Kennedy for 5 minutes.
        Mr. Kennedy. Thank you. I want to look back at what we were
    told about the VA staffing cuts versus what has actually
    happened. In February 2025, Secretary Collins eliminated 2,400
    VA jobs after publicly promising that 300,000 mission-critical
    positions would be protected to ensure uninterrupted services
    for our Nation's bravest. One month later, a leaked memo showed
    plans to cut more than 80,000 employees, a number the Secretary
    confirmed, then denied, then revised to 30,000.
        On May 15, Secretary Collins assured our veterans that
    mission-essential jobs, like doctors, nurses, and claims
    processors would be protected and that reforms would
    strengthen, not strain, veterans access to care. That promise
    was broken. In December, a leaked memo revealed plans to
    eliminate up to 35,000 healthcare positions in a single month,
    the doctors, nurses, and support staff that veterans count on
    for timely quality care.
        When a psychologist is cut, the veteran in crisis has fewer
    options and longer waits. When a community care scheduler is
    eliminated, the veteran waiting for a cancer consult or
    neurosurgery referral waits longer, sometimes dangerously
    longer. When nurses and physicians are cut, the people who
    catch conditions early and respond to emergencies are not there
    when they are needed most. These are not just workforce
    reductions. There are direct cuts to the care our veterans
    depend on, sometimes for their lives.
        That is why I requested detailed staffing data for the
    Western New York VA system to understand exactly how many
    positions were cut and how it is affecting veterans in my
    district. The VA refused and then days before this hearing, we
    received incomplete numbers. What we recently uncovered in my
    own district in Buffalo, New York, is demonstrative of what we
    are seeing in VA medical centers across the Nation.
        On December 14, roughly 100 healthcare positions were
    eliminated at the Buffalo VA, 23 active critical roles,
    including 2 psychologists, 2 social workers, 1 recreation
    assistant, 1 respiratory therapist, 3 physicians, 2 nurses, and
    11 Electrocardiogram (EKG) technicians, all cut. These are the
    people who treat Post-traumatic Stress Disorder (PTSD),
    diagnose heart conditions, coordinate the care that keeps
    veterans out of emergencies rooms, and so much more.
        We already know what happens when staffing falls short
    because we have seen it happen at the Buffalo VA. In 2024, an
    Office of Inspector General (OIG) investigation found that
    dangerous delays in scheduling community care consults put
    veterans at serious risk. This investigation identified
    staffing shortages as a key cause of this degradation of care.
    Community care schedulers in a follow-up conversation in
    response to the investigation told us directly that staff
    shortages led to countless untreated patients and devastating
    health outcomes, including at least one death.
        The Trump administration's response? Eliminate the staff
    who schedule the consults, the technicians who conduct exams,
    the personnel who ensure psychiatric care, and the
    professionals who ensure no veteran is left behind. We know
    what happens when those positions go unfilled: veterans care
    suffers and some veterans will die. This is not just
    mismanagement. It is life and death for the veterans who rely
    on the VA for timely care.
        Secretary Collins stood before this committee and promised
    that the doctors and nurses should who care for our veterans
    would not--would be protected. He promised that care for our
    veterans would not be cut. He was not telling the truth and our
    veterans are the ones paying the price.
        I have a very simple question for those here representing
    Secretary Collins' VA. When veterans in my district get sick
    because of a lack of resources, which of you will take
    responsibility and what are we to tell them?
        Dr. O'Toole. Well, thank you, Congressman, and I appreciate
    what you are bringing up and I fully acknowledge the challenges
    and the issues. If I can, I appreciate--I am hoping for a time
    extension to be able to respond to your question, if that is
    okay, Chairwoman.
        The issue of having enough providers for care is a
    significant one. It is one, however, that we share with the
    entire American healthcare system. Right now there is an
    estimated shortage of physicians, nurses, social workers,
    psychologists, psychiatrists, estimated to be at 90,000 over
    the next 10 years in the American healthcare system. What we
    are challenged by in the VA is what all of American healthcare
    is challenged by. I think that is an important consideration to
    make. It is why I also, you know, emphasize the importance of
    section 142 in really trying to help us be to be more
    competitive in attracting people to come in. It is absolutely
    important.
        I do need to emphasize, though, and clarify. When the
    Deferred Resignation Program (DRP) process went through, those
    clinicians who were involved in direct care with providers--
    with patients were not allowed to pursue the DRP. Those
    requests for DRP were denied by those direct clinicians. That
    does not mean that people are not going to retire. That does
    not mean that people--that positions are going to attrit or
    that people may leave the VA. We all have workforce challenges
    in healthcare, and I do not want to minimize that issue or
    point, nor the importance of Congress in helping us navigate
    those waters. It is a shared challenge for all of us that
    extends beyond this.
        The positions that were eliminated were vacant positions
    that had not been filled for quite some time. That does not
    mean that people were losing their jobs. I do think that is a
    really important clarifying point to the issues that I think
    are very valid that you are bringing up.
        Ms. Kiggans. Thank you, Dr. O'Toole.
        The chair now recognizes Mr. Self for 5 minutes.
        Mr. Self. Thank you. Thank you, Madam Chair.
        Dr. O'Toole, I do not question the President's authority to
    use impoundment. I just want to clarify. None of what we are
    hearing is an impoundment under the Dole Act, is it?
        Dr. O'Toole. I am sorry, Congressman, I am not sure I am
    following your question. Can you please----
        Mr. Self. Congress authorizes a certain level. The
    President decides to spend less than that level. Is that--is
    impoundment involved here? Just to clarify.
        Dr. O'Toole. Not that I am aware of at all, sir.
        Mr. Self. Very good. I want to go to your written versus
    your verbal testimony. I think I heard something that is not in
    your, excuse me, your written testimony. It is in the
    paragraph, I believe, where you talked about VA using funding
    from multiple accounts to deliver on some of the sections. Now,
    in your verbal testimony, you said lack of funding. Can you
    clarify what you said in that paragraph?
        Dr. O'Toole. Thank you, Congressman. You know, obviously,
    you know far better than I, you know, the dynamics of
    appropriations, and I am not trying to speak to that. Some of
    the provisions in the Dole Act did not involve appropriated
    funds. We have tried to implement within the capacities that we
    have to the best of our abilities or if funds were available
    through other accounts, use those and just trying to be
    fiscally prudent within that context. I want to defer to my
    colleagues who might be able to speak better to that.
        Mr. Smith. Thank you. For the Digital GI Bill program, we
    are required to make changes to that environment in order to
    implement----
        Mr. Self. No, I am not asking for specifics. Thank you. I
    just wanted to clarify your lack of funding. You did say that,
    I believe, and I am not sure you clarified it, but thank you.
        I want to move to accountability in the 3 minutes I have
    left because we talk a lot in this committee about inputs. We
    get VA employees coming and telling us about all the inputs.
    Who is going to be accountable for this?
        This bill was to improve ability to receive care at home.
    Correct? If you believe that changes in the fee schedule for
    reimbursement rates related to home health aid and homemaker
    services were to result in a reduction of up to 43 percent in
    rural Texas, some of which I represent, do you believe that
    that improves a veteran's ability to receive home healthcare?
    How is that balanced?
        Dr. Koeniger. Sir, thank you for the question. I cannot
    speak directly to veterans in Texas in terms of receiving home
    healthcare. I can say, though, that the home and community-
    based services, the VA has done actually a great job at
    expanding those services. The----
        Mr. Self. Do you think the 43 percent reduction is going to
    improve their ability to receive home healthcare?
        Dr. Koeniger. So the--again, I----
        Mr. Self. Okay.
        Dr. Koeniger [continuing]. cannot speak specifically to
    that, but I can say that, again, over--compared to Fiscal Year
    2024, over roughly 600,000 veterans have actually benefited
    from the home----
        Mr. Self. Okay.
        Dr. Koeniger [continuing]. and community-based services.
        Mr. Self. Very good, thank you.
        Dr. O'Toole, can you name the specific individuals who, in
    VA, who are going to be responsible for each of the at-risk
    sections?
        Dr. O'Toole. Thank you, Congressman. As I mentioned in my
    opening statement, we have a centralized office, Office of
    Strategic Initiatives, that is overseeing this process. All of
    our senior leadership are fully engaged in this and as the
    committee staff would know, meet with frequently. I am more
    than happy to forward to you the org chart that delineates
    specific----
        Mr. Self. No, I do not need the org chart. I am asking you
    if you are going to hold someone accountable because you are
    about one-third of the way through implementation. Is that
    about right? One-third of the way through in terms of sections?
        Dr. O'Toole. Sure.
        Mr. Self. What I am really asking is who is going to be
    held accountable?
        Dr. O'Toole. Our senior leaders----
        Mr. Self. We always talk about inputs. I want
    accountability for when you implement this.
        Dr. O'Toole. Our senior leadership throughout the agency
    are responsible, sir, including myself.
        Mr. Self. Okay. Very good. What is the critical milestone
    between now and full--oh, my time is up, Madam Chair. I will
    yield back. Thank you.
        Ms. Kiggans. Thank you, Mr. Self.
        The chair now recognizes Mr. Ciscomani for 5 minutes.
        Mr. Ciscomani. Thank you, Chair Kiggans, for convening this
    important oversight hearing. Thank you to the witnesses from
    the Department of Veteran Affairs and Government Accountability
    Office for being here today with us.
        I was proud to help introduce the Senator Elizabeth Dole
    21st Century Veterans Healthcare and Benefits Improvement Act
    last Congress and even more proud to see it passed and get into
    law, be signed into law, because I believe strongly that our
    veterans and their caregivers deserve a system that truly
    reflects the sacrifices they have made for our Nation.
        Far too often, veterans and their families face barriers
    when trying to access care, navigate benefits, and receive the
    superior that they have earned from the VA. This flagship VA
    legislation was designed to modernize the VA and create a
    system that works, that works better for veterans and their
    families and who stand beside them every single day. One year
    after enactment, it is important that we take a close look at
    how the Department is implementing these reforms.
        While progress has been made in several areas, some
    provisions remain behind schedule or at risk of not fully being
    implemented. For veterans and their families these timelines
    matter. Delays can mean waiting longer for care, missing out on
    an important support service, or facing unnecessary barriers to
    benefits they earned through their service. This is why I want
    to ask a couple of the follow-up questions here, and I will
    start with Dr. O'Toole.
        The Dole Act includes a wide range of reforms touching
    clinical care, caregiver support, and community-based services.
    How has the VHA prioritized implementation across these areas
    to ensure that the most immediate needs of veterans are
    addressed first?
        Dr. O'Toole. Thank you, Congressman. I want to defer to my
    colleague on the community care question, if that is okay.
        Dr. Koeniger. That is a great question. In terms of
    community care or even caregiver support, I mean, we recognize
    that taking care of veterans, no matter what their problems
    are, is very important. In terms of the community-based
    services, we have four programs that we have rolled out. Those
    programs have actually seen an increase, as I mentioned
    earlier, in terms of supporting caregivers as well.
        Mr. Ciscomani. How do you--I am sorry to interrupt because
    we are going to run out of time, but how do you prioritize? How
    do you make sure that those that have the most immediate need
    of veterans get seen first? What is the process like?
        Dr. Koeniger. Again, the veterans that have the highest
    needs in terms of medical issues, you know, those are the folks
    that we want to make sure that we take care of.
        Mr. Ciscomani. I agree. How do you get there? How do you
    identify that?
        Dr. Koeniger. The specific process I would have to get back
    to you on. I mean, certainly----
        Mr. Ciscomani. I want to make sure that that is actually
    happening. It is just that, you know, I think you get the sense
    from the committee here on both sides of the aisle, we are
    running a little impatient on the implementation of a lot of
    these programs. This was supposed to be a much more expedited
    process and seeing the benefits of this. We are not seeing
    that. This is coming from every angle and every State
    represented here, we are all seeing this in our district. We
    need to really zero in on this and we need to start seeing some
    results.
        I am going to move on here. Dr. O'Toole, again, one of
    Congress' goals in the Dole Act was to improve timely access to
    care. From your perspective, what measurable changes should
    veterans expect to see in appointment availability or service
    delivery as implementation continues?
        I keep hearing from our veterans the care they receive at
    the VA is excellent once they receive it. Receiving it and
    getting there is the main issue. Again, I am starting to see a
    trend here of what was passed not being enacted. I want to
    start seeing some results and so do our veterans. What way are
    you measuring this?
        Dr. O'Toole. Thank you, Congressman. This is very important
    and I think to follow up with your second question as well--or
    previous question as well.
        This is a massive piece of legislation, as you know, you
    know, 72 provisions that impact across the agency. I cannot--I
    have been a primary care provider in the VA for 20 years. This
    is one of the most significant pieces of legislation I have
    seen having impact across the vast entire agency. First, thank
    you for that.
        As your staff knows and meeting with them and having sat in
    on several of the calls, this is something where we have to be
    able to chew gum and walk at the same time and implement
    multiple efforts concurrently. We are. This has been a
    difficult year in both securing our most senior leadership, our
    Senate-confirmed leadership, going through the government
    shutdown, which created some undue slowdowns in terms of
    getting things through. We are on the cusp with several of
    these provisions within the next weeks to a month or two to
    having them posted in the Federal Register and being
    implemented.
        Very much I feel confident that we will be able to
    implement all of the provisions in the time allowed. They are
    priorities for us because they are priorities for our veterans
    across many different contexts.
        Mr. Ciscomani. I am out of time. I do look forward to
    seeing results. You know, I think we understand it. We know the
    significance, the size of the legislation. We worked on it. We
    passed it. It is big and it is going to take time, we know
    that. It has been over a year. We need to see some results
    here. You say weeks, months. I hope it is weeks and I hope we
    can get a report exactly on numbers and what this matters.
        Madam Chair.
        Dr. Koeniger. Madam Chair, I know we are over time. Could
    I--Congressman, you mentioned access to care and I would just
    like to say it is a very complicated process. As you know,
    there are just so many things that have to be taken into
    account to improve access.
        I can tell you that as of May of last year, the Veterans
    Health Administration stood up the Access Choices in Excellence
    Group of which I am the executive sponsor and we have been
    working diligently on all aspects of access to care to, again,
    objectively measure all of those things and to work on
    improving access.
        As a 36-year veteran of the United States Air Force myself,
    that sits--that is near and dear to me to make sure that
    veterans can get in when they need to get in.
        Mr. Ciscomani. Thank you.
        Ms. Kiggans. Thank you. I think we have a few minutes for a
    second round of questions. I just have two questions for Dr.
    O'Toole.
        As a former geriatric nurse practitioner one of my greatest
    concerns was ensuring our aging veterans are getting the care
    that they deserve. Can you provide the committee just with an
    update on the rollout of the pilot program, section 127, to
    fortify the assisted living services for veterans and what that
    looks like?
        Dr. O'Toole. Thank you, Congresswoman. I think--is that in
    your scope?
        Dr. Koeniger. Yes. Yes. Thank you for the question. As you
    know, our population is aging. Again, we have 49 percent of all
    our veterans are 65 and older. We are working in terms of the
    two pilots as section 127 states. The VA is--has been working
    on a purchasing authority and a fee schedule options are under
    development because we are--we need to get those things in
    place so we can ramp up those pilots. We are making progress
    and work in the details of getting the pilots going.
        Ms. Kiggans. Okay. We would love to see some movement in
    that, too. I think that is important. There are not enough
    options, especially housing options, for aging Americans.
    Perhaps the VA should hire more geriatricians, but that is just
    my two cents.
        Then, Dr. O'Toole, our stakeholders have highlighted that
    the best medical interest standard is coming into conflict with
    transportation benefits that usually accompany care for
    disabled veterans. Veterans should not have to sacrifice the
    best standard of care because the VA will not pay for
    transportation. How does the VA intend to harmonize this
    conflict to deliver patient-oriented care?
        Dr. O'Toole. Thank you. It is a huge issue and obviously
    providing care that somebody cannot get to sort of misses the
    mark. We are working specifically and having some challenges
    specifically on the transportation provision. I think I
    mentioned that in my opening statement, and it is something
    that we would like to be able to work with the committee
    further to be able to go through those provisions to address
    some of the challenges we are having with that implementation.
        Ms. Kiggans. That would be great. I think that should
    definitely be a priority for us moving forward.
        The chair now recognizes Ranking Member for any remaining
    questions.
        Ms. Ramirez. Thank you, Chair. Here you go.
        Dr. O'Toole, I just want to follow up on some of the
    conversations we had at the beginning of the hearing.
    Specifically I want to talk about my own district. Before the
    VA cut the 130 nurses at the Jesse Brown and Hines VA Medical
    Centers, did the VA have staffing models in place as required
    by the Dole Act to determine that those 130 nurses were no
    longer needed at those facilities in Chicago?
        Dr. O'Toole. Thank you, Congresswoman. It is important to
    keep in mind, particularly as I know a lot of questions about
    the staffing model come up in consideration of the Rise
    Initiative and the reorganization, there has been no change
    whatsoever in terms of direct care staffing modeling based upon
    the reorganization efforts under Rise.
        Ms. Ramirez. Doctor----
        Dr. O'Toole. The----
        Ms. Ramirez. Dr. O'Toole.
        Dr. O'Toole. The staffing models have--we continue to do.
    They are being refined in the context of the Dole Act.
        Ms. Ramirez. Did we have staffing models in place there to
    determine that we did not need those 130 nurses? It is more of
    a yes or no. Just trying to get clarity.
        Dr. O'Toole. Ma'am, those positions were not removed. Those
    were not active positions. Those were positions that had not
    been filled and not have been filled for quite some time.
        Ms. Ramirez. I am just looking here at some of the reports
    we got from all of you here. For example, there are 41 nurses
    positions filled in 2025 or 2026 that were no longer filled
    after. These were positions that were--they had bodies in them
    prior to the cut of these. Of these nurses, yes or no? Did you
    have people working there? Were there nurses working there?
        Dr. O'Toole. No.
        Ms. Ramirez. Okay. Well, the data says a different--the
    thing is that I am looking at the data that you provided for me
    for these centers, and so it is inconsistent with what I am
    getting from you. Let me just wrap up here because I know we
    only have a few minutes and we want to close this hearing.
        Dr. O'Toole. We can take that for the record for further
    clarification.
        Ms. Ramirez. Yes, I would appreciate that.
        I want to just come back to housing real quick. You heard
    me say I ran a homeless shelter for about 9 years, of which I
    had the honor and opportunity to serve many veterans who were
    experiencing homelessness. I just want to wrap up with sections
    402 and 403 of the Dole Act, which provided the crucial
    resources to the VA and community providers who serve homeless
    veterans. I want to make sure that it is clear that due to the
    delays in implementing these provisions, homeless veterans and
    community organizations are having to go without these
    resources.
        During the Biden administration, the homeless program's
    office staff told me and my team repeatedly that it would be
    ready to swiftly implement the Dole Act, that it would be like
    turning on a light switch. It is hard for me to know that we
    are 14 months in, and it sounds like for Secretary Collins it
    is going to take over a year to flip a light switch. You know,
    to me, it is a testament to poor leadership that homeless
    veterans still do not have the resources they need.
        Sadly, I know there is something nefarious going on that
    led to the delay in implementation of these homeless sections.
    Specifically, the administration, including Secretary Collins,
    has wielded attack after attack against veterans experiencing
    homelessness. They prioritize handcuffs and jail cells over
    getting these veterans help that they need in place of getting
    them a home. Look, I believe that the swift--and they are
    swifting away from interventions that we know have worked
    address homelessness, programs like Housing First models. This
    administration's focus on programs that have proven time and
    time again to actually make homelessness worse are leading the
    delay that we see here.
        You see, I see that Collins is actively pushing a strip
    down, in effect a for-profit model of homeless service delivery
    driven by special interest instead of leaving intervention to
    the experts in homeless program offices. We know that the VA,
    especially the political leadership, meddled in implementation
    of the Dole Act is getting in the way of these programs that we
    actually know work.
        Instead of relying on the expertise of an office that has
    housed over 50,000 homeless veterans last year, these political
    appointees substituted their poor profit-minded judgment for
    expertise. The consequence? Fourteen months of veterans not
    having access to the housing, transportation, clothing, and
    food that they need. I find that to be unacceptable. Frankly, I
    find it to be despicable.
        These same political appointees are pushing a dangerous
    proposal to destroy Housing and Urban Development-Veterans
    Affairs Supportive Housing (HUD-VASH), the most successful
    permanent supportive housing program in the history of this
    country and replacing it with a poorly conceived program that
    we know will fail called Bridging Rental Assistance for Veteran
    Empowerment (BRAVE).
        I want to make sure, on the record, in the last few seconds
    I have, that I am going to tell you I am going to continue to
    defend our homeless veterans. They should not be homeless to
    begin with. We cannot sit here idly watching this
    administration destroy these programs so that billionaire
    buddies can get enriched as a result of it
        I look forward to getting an update in the immediate future
    that the VA has fully implemented the homeless sections of the
    Dole Act and has abandoned the BRAVE proposal because anything
    less is a disgrace and a disservice to our most vulnerable
    veterans.
        With that Chairwoman, I yield back.
        Ms. Kiggans. Thank you. I just wanted to take a minute to
    thank the witnesses for coming today. I appreciate the candor
    in your testimony and your willingness to participate.
        Implementing the Dole Act remains a top priority of this
    committee. I look forward to continuing to ensure the VA
    remains committed to this goal. Thank you all for being here
    today.
        I ask unanimous consent that all members shall have 5
    legislative days in which to revise and extend their remarks.
    Did you have any concluding remarks, sorry, as well?
        Ms. Ramirez. I do, Chairwoman, thank you.
        As I reflect back on the hearing, our first one in over 200
    days, I am struck by some of the answers that were received
    here. First, Dr. O'Toole, you said that no doctors or nurses
    were allowed to take the Deferred Resignation Program. However,
    data the VA has provided themselves to Mr. Kennedy shows that
    two nurses from Buffalo were allowed to take the DRP last year.
        You also reiterated that the Secretary's talking point that
    many of these positions eliminated were not filled in a long
    time. However, again, the data that has been provided by you
    all says the opposite. Seventy-one percent of these 26,000
    positions were filled at some point since January 2025. If
    these were really COVID era positions, then why were these
    positions still there? Specifically, I am thinking about the
    Jesse Brown/Hines positions.
        Look, I am glad that we are here. I know that we are going
    to go ahead and follow up. I think that the work that we do in
    this committee is incredibly important because we have to
    implement every facet and every provision of the Dole Act.
    Twenty-five of the 72 is unacceptable. I look forward to
    following up with you to make sure that you take the urgency
    necessary to implement every single section so that our
    veterans have what they, in fact, need and they deserve.
        With that, I yield back.
        Ms. Kiggans. Thank you all again for being here today. I
    ask unanimous consent that all members shall have 5 legislative
    days in which to revise and extend their remarks and include
    any extraneous material. Hearing no objection, so ordered.
        The hearing is now adjourned.
        [Whereupon, at 3:55 p.m., the subcommittee was adjourned.]
    =======================================================================

                             A  P  P  E  N  D  I  X

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

                        Prepared Statements of Witnesses

                                  ----------

                      Prepared Statement of Thomas O'Toole

        Good afternoon, Chairwoman Kiggans, Ranking Member Ramirez, and
    distinguished members of the Committee. Joining me today are Dr. Mark
    Koeniger, Acting Assistant Under Secretary for Health for Patient Care
    Services, VHA, and Mr. Ken Smith, Executive Director, Education
    Service, Veterans Benefits Administration (VBA). It is an honor to be
    here on behalf of VA to discuss our progress on implementing the
    Senator Elizabeth Dole 21st Century Veterans Healthcare and Benefits
    Improvement Act (the Dole Act; P.L. 118-210).
        Enacted on January 2, 2025, the Dole Act is a comprehensive law
    with more than 70 sections that require action from VA, the Department
    of Labor, educational institutions that serve Veterans and their
    families, and the Government Accountability Office. The Dole Act
    includes requirements for VA to:

          implement more than 40 enhancements, new guidelines, or
    new programs;

          execute six new pilot programs;

          conduct outreach and release new online tools for
    Veterans, patients, and coroners/medical examiners; and

          complete 50 new congressionally Mandated Reports.

        This variety of new requirements required VA to realign its
    priorities and establish an enterprise-wide approach to support Dole
    Act implementation. This approach has been updated several times as new
    VA leadership was sworn in and VA uses funding from multiple accounts
    to deliver on some of the sections.
        VA moved oversight of implementation of the Dole Act to the Office
    of the Secretary to ensure senior official oversight and involvement in
    these critical responsibilities. In December 2025, the new Office of
    Strategic Initiatives became the office responsible for VA-wide
    oversight, facilitation, and monitoring of implementation efforts, such
    as those required by the Dole Act.
        We are pleased to report that VA has made significant progress
    toward implementing the Dole Act. Of the 72 sections that required VA
    implementation efforts, VA has fully implemented 25 sections as of
    February 9, 2026. We are diligently working on the remaining sections.
        While implementation spans the Department, I will begin by
    highlighting key accomplishments within VHA, which has led to
    transformative changes in care delivery and support for Veterans and
    their families under the Dole Act.

    VHA

        In alignment with section 101 of the Dole Act, effective May 19,
    2025, VA eliminated an unnecessary layer of approval in the community
    care process, allowing Veterans to access care when it is in their best
    medical interest (BMI). Removing that unnecessary layer has made a real
    difference. Between June and December 2025, referrals to community care
    under the BMI criterion increased by over 66 percent compared to the
    same period in the previous year. Additionally, VA launched a
    nationwide outreach campaign, including updates to VA.gov and targeted
    communications through the Solid Start program, reaching over 83,000
    newly separated Veterans. These efforts help Veterans understand their
    options for care from day one, creating a more seamless and responsive
    health care experience.
        The Dole Act also delivered expanded options for Veterans needing
    long-term and home-based care. Using the authority granted by section
    120 of the Dole Act, VA increased coverage for noninstitutional care
    alternatives from 65 percent to 100 percent of nursing home costs, with
    authority to exceed that cap for Veterans with amyotrophic lateral
    sclerosis, spinal cord injuries, and similar conditions. This expansion
    enables more Veterans to receive care at home, preserving independence
    and dignity. These changes, combined with new pilot programs for
    assisted living and enhanced Homemaker and Home Health Aide programs,
    reflect VA's commitment to meeting Veterans where they are--with care
    that honors their service and supports their families.
        VA has also made critical strides in addressing homelessness and
    suicide prevention under the Dole Act. Section 402 of the Dole Act
    expanded per diem payments for homeless Veteran programs, increasing
    the maximum per diem rate from 115 percent to 133 percent of the State
    Home domiciliary rate and allows VA to waive the maximum rate for per
    diem payments to provide payments at a rate that does not exceed 200
    percent of the rates authorized for State Homes for domiciliary care
    under 38 U.S.C. Sec.  1741(a)(1)(A) for no more than 50 percent of all
    grant recipients and eligible entities for a Fiscal Year (FY), subject
    to the availability of funding.
        Section 403(a) of the Dole Act authorizes VA to provide to covered
    Veterans, as VA determines necessary, food, shelter, clothing,
    blankets, and hygiene items required for the safety and survival of the
    Veteran; transportation required to support the stability and health of
    the Veteran for appointments with service providers, the conduct of
    housing and employment searches, and the obtainment of food and
    supplies; and tablets, smartphones, disposable phones, and other
    technology and related service plans required to support the stability
    and health of the Veteran through the maintenance of contact with
    service providers, prospective landlords, and family members. Section
    403(b) authorized VA to collaborate with one or more organizations to
    manage the use of VA land for homeless Veterans for living and
    sleeping.
        Section 404 created a new 38 U.S.C. Sec.  2069, which requires VA,
    to the extent practicable, to ensure that Veterans participating in or
    receiving services from a program under chapter 20 have access to
    telehealth services to which the Veterans are eligible under the laws
    administered by VA.
        These changes, from implementing sections 402, 403 and 404,
    strengthen the safety net for Veterans at risk of homelessness and
    improve access to care. VA published a Federal Register Notice on
    February 6, 2026, notifying the public of subregulatory guidance to
    implement section 402 of the Dole Act, and we expect to publish very
    soon a Federal Register Notice to inform the public about VA's
    implementation of section 403 of the Dole Act.
        In addition, section 149 of the Dole Act strengthened
    accountability by requiring an independent assessment of the National
    Veteran Suicide Prevention Annual Report and development of a public
    toolkit for coroners and medical examiners to improve reporting
    accuracy. The independent assessment was completed in January 2026.
    VA's most recent Annual Suicide Prevention Report, published February
    5, 2026, shows 6,398 Veteran suicides in 2023--down from 6,442 in
    2022--with the average daily rate falling slightly to 17.5. However,
    suicide rates remain elevated among younger Veterans and those facing
    risk factors such as homelessness, health challenges, and chronic pain.
    To address these risks, VA has expanded outreach and care access. Since
    January 2026, VA has conducted a new outreach campaign that has led
    more than 33,000 unenrolled Veterans to sign up for VA care, and
    partnerships with civilian health systems have helped identify and
    contact 140,000 at-risk Veterans. VA has made good progress on the
    remaining requirements and anticipates meeting the statutory timelines.
        VHA has experienced some challenges with implementation of certain
    sections of the Dole Act, particularly section 143 (regarding
    reimbursement for transporting certain Veterans by ambulance from rural
    locations for care) and, to a lesser degree, section 129 (regarding
    recognition of organizations and individuals to assist Veterans, family
    members, and caregivers in navigating VHA programs and services). VA
    would greatly welcome the opportunity to work with the Subcommittee to
    modify these provisions to ensure VA can provide the benefits and
    services intended by these sections.

    VBA

        These efforts within VHA demonstrate our commitment to improving
    health care access and support for Veterans and caregivers. Equally
    important are the provisions under the Dole Act that strengthen
    Veterans' benefits and streamline claims processing.
        Native Americans have historically served in the U.S. military at a
    higher per capita rate than any other group. However, they face unique
    challenges in obtaining home loans on Federal trust land. To help VA
    address this challenge, the Dole Act expanded VA's Native American
    Direct Loan (NADL) program, thereby strengthening VA's authority to
    make, evaluate, and secure loans on trust land and giving Native
    American Veterans more opportunities to purchase, build, improve, or
    refinance homes on trust land. VA is also hiring additional NADL
    coordinators and collaborating with other Federal agencies to develop
    effective policies that support Native American Veterans and their
    families and developing new policies to support a Native Community
    Development Financial Institution relending program.
        VA continues to prioritize systems enhancements to support
    implementation of sections 208, 210, and 212 of the Dole Act. In 2025,
    after years of planning and coordination, VA had scheduled and
    committed to the decommissioning of the Benefits Delivery Network (BDN)
    system. The Fiscal Year 2025 decommissioning date could not be moved
    due to the ending of the BDN support contract in October 2025, and a
    requirement to close out Fiscal Year 2025 books in BDN.
        The largest provision of the Dole Act to be implemented by VBA is
    section 212, which reestablished the Veterans Technology Education
    Courses (VET TEC) program, or VET TEC 2.0. VA will implement the VET
    TEC 2.0 claims processing capability in Fiscal Year 2026 and has made
    other significant progress toward implementation. For example, on
    December 16, 2025, VA published the Student Application in the Federal
    Register, starting the 60-day public comment period. VA also
    successfully completed updates to the payment management systems that
    will enable Education Service to implement a claims adjudication and
    process capability by the end of the third quarter of Fiscal Year 2026.
    Finally, VA completed several other tasks to ensure a smooth rollout of
    VET TEC 2.0 as soon as the information technology solution is
    available. For example, VA completed:

          the Training Provider application,

          a draft Communications plan to notify the Training
    Providers and begin soliciting and accepting new Training Provider
    applications,

          a Training Provider and Expert Credentials checklist, and

          a training plan for the Training Providers and Education
    Liaison Representatives.

        VA has made progress toward implementing section 215 of the Dole
    Act. For example, VA has linked the GI Bill Comparison Tool to the
    Department of Education's (ED) College Navigator and recently met with
    ED to identify the appropriate points of contact to incorporate
    additional data.
        VA will also schedule and adopt additional updates following two
    recent court decisions - Rudisill v. McDonough and Perkins v. Collins.
    Specifically, by 2027, VA will aim to achieve 1-day completion of
    education claims and reinstitute VET TEC 2.0.
        VA has not yet scheduled:

          DGIB updates necessary to support the integration of the
    new monthly housing allowance requirements under section 208; and

          integration of electronic certificates of eligibility and
    award letter requirements under section 210.

        VA anticipates it will schedule these updates in 2026. To mitigate
    challenges until they are scheduled, VA conducts quarterly reviews of
    DGIB enhancements and continues to prioritize enhancements. VA will
    continue to provide updates to Congress in our calls about DGIB
    progress about sections 208 and 210.
        In addition to benefits focused on the Native American community
    and education services, the Dole Act strengthens memorial benefits
    administered by the National Cemetery Administration. For example,
    section 301 of the Dole Act expanded burial allowances for Veterans who
    die at home while receiving VA hospice care, ensuring families receive
    timely support during a difficult time.

    National Cemetery Administration

        VA is working under section 302 of the Dole Act to improve outreach
    to States and tribal governments, helping ensure that Veterans and
    their families are aware of burial and memorial benefits they have
    earned. These provisions reflect VA's commitment to honoring Veterans
    not only throughout their lives but also at life's end, with dignity
    and respect.

    Conclusion

        Chairwoman Kiggans and Ranking Member Ramirez, this concludes my
    statement. We appreciate the opportunity to speak before you today and
    welcome any questions you or other Members of the Subcommittee may
    have. Thank you for your continued support of Veterans, their families,
    caregivers, and survivors as well as the many VA programs to support
    them.

                       Prepared Statement of Sharon Silas
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                           Statements for the Record

                                  ----------

                Prepared Statement of Elizabeth Dole Foundation

        Chairwoman Kiggans, Ranking Member Ramirez, and members of the
    subcommittee, the Elizabeth Dole Foundation would like to thank you for
    the opportunity to submit our views on the status of implementation of
    the Senator Elizabeth Dole 21st Century Veterans Healthcare and
    Benefits Improvement Act.
        The passage of this legislation during the 118th Congress marked
    one of the most significant Federal policy advancements secured on
    behalf of veterans, caregivers, and survivors in recent years, and
    Senator Dole remains both proud and humbled to have had it named in her
    honor.
        The Foundation worked tirelessly with caregivers and our veteran
    service organization partners to secure its passage not only because of
    the impact on family caregivers, but also because of the broad array of
    issues covered in the bill that impact veterans and families. While as
    an organization we focus on issues of direct impact to caregivers, we
    also address issues of significant interest to that population.
    Clearly, the quality of the care and services available to veterans is
    at the top of that list.
        Daily we hear from caregivers asking about the long-delayed
    finalization of the rule governing the Department of Veterans Affairs
    Program of Comprehensive Assistance for Family Caregivers (PCAFC). We
    are now entering year 4 of waiting for a new rule to expand eligibility
    and improve the program. Even more often, however, we hear from
    caregivers about their struggles navigating VA's programs and services
    including Veteran Directed Care, CHAMPVA, respite, home health, skilled
    care, benefits, home and vehicle modifications, etc.--all programs
    intended for the veteran but with real life impacts for the whole
    family.
        While there is still work to be done, the Dole Act was intended to
    address many of these challenges for the benefit of the entire veteran
    community. We are especially pleased that Section 120, which
    drastically increased the expenditure cap for non-institutional care,
    was implemented in September 2025. The enactment of this provision
    helps our most vulnerable veterans and their caregivers by removing a
    long-standing barrier to keeping loved ones at home. We encourage VA
    and the Office of Geriatric and Extended Care (GEC) to continue
    training clinical providers and social workers both inside and outside
    GEC on this opportunity to ensure those in need are aware of available
    services.
        However, the Elizabeth Dole Foundation has questions and concerns
    regarding multiple remaining provisions and their current status.

    Section 101:

        Section 101, also known as the ``Medical Best Interest'' provision,
    allows veterans to access care in the community if it is determined by
    the clinician that it is in the veteran's medical best interest to do
    so. We supported this provision because we recognize both the need to
    ensure VA is able to offer robust, high-quality care as well as provide
    access to necessary care in a timely manner, sometimes found in the
    community. We are familiar with cases where this provision was
    especially helpful in getting a veteran to appropriate specialty care.
    However, VA's regulations that govern necessary travel often associated
    with care in the community have not yet caught up to the intent of
    section 101.
        Under the current rules, VA can only authorize travel reimbursement
    to the closest medical facility that can provide the necessary care.
    Since the relevant provision does not comment on the facility's
    capability--only on the veteran's medical best interest--we are seeing
    travel authorizations denied even though the care itself is authorized.
    We encourage VA to reconcile this language to ensure that veterans and
    their family members are not unnecessarily and unintentionally caught
    in a bureaucratic trap that leads to either increased out-of-pocket
    expenses or an inability to access care.

    Section 122:

        Based on the Chairwoman's COPE Act, this provision authorizes the
    VA Secretary to award grants to community-based organizations to
    provide mental health services to family caregivers participating in
    PCAFC. According to a 2024 RAND study commissioned by the Elizabeth
    Dole Foundation, caregiving often places significant strain on
    caregivers and increases their risk for developing physical and mental
    health conditions, including depression and suicidal ideation.
    Relatedly, caregivers' mental well-being directly affects the quality
    of care provided, impacting outcomes for both caregivers and those they
    support. By prioritizing the mental health of caregivers, the overall
    effectiveness of care can be enhanced.
        Recognizing both the value and risks associated with caregiving, VA
    established a program through which PCAFC caregivers can receive mental
    health care from VA providers, with options available through both
    telehealth and in person. With approximately 29,000 encounters among
    4,374 patients in Fiscal Year 2025, the program is certainly beneficial
    and a significant step in the right direction. However, caregivers
    enrolled in PCAFC are often hesitant to seek mental health services
    directly from VA for fear their participation will impact their
    eligibility for the caregiver support program. In addition, they are
    hesitant to use another VA program, as it is perceived as an additional
    care coordination burden.
        While VA has not yet issued grants in accordance with section 122,
    as it was discretionary and not mandatory, the Elizabeth Dole
    Foundation strongly supports the establishment and issuance of these
    grants to increase opportunities for access to necessary mental health
    care for family caregivers. In addition, the Elizabeth Dole Foundation
    supports increasing the pool of eligible participants to those enrolled
    in the VA's Program of General Caregiver Support Services (PGCSS),
    rather than just PCAFC, to improve the health and well-being of a
    larger pool of caregivers as well as that of the veterans for whom they
    care.

    Section 123:

        Derived from the original Elizabeth Dole Home Care Act introduced
    by Representatives Brownley and Bergman, Section 123 codifies the Home
    and Community Based Services (HCBS) programs to ensure their long-term
    viability. Under this provision, the Veteran Directed Care (VDC)
    program, provided in partnership with the Administration on Community
    Living (ACL), is required to be provided at each VA medical center. VDC
    provides a flexible, monthly budget, allowing veterans to hire their
    own caregivers---- including family or friends--and purchase services
    to manage their care. This system offers more control and ownership of
    that care to the veteran and caregiver and, where utilized, has proven
    very effective.
        VA has stated that VDC is now technically available in all VA
    medical centers, but we have learned that access remains difficult due
    to a limited number of contracts in place, staffing VDC as a collateral
    duty, and a general lack of knowledge of program availability. In order
    to learn what steps may have been made to address some of these
    challenges, the Elizabeth Dole Foundation requests VA brief all
    interested veteran service organizations regarding the current status
    of VDC implementation including enrollment numbers and locations,
    current contract availability, and staffing models. This briefing will
    help VA identify ongoing challenges as they seek the full
    implementation of this valuable program.

    Sections 123 and 124:

        The Elizabeth Dole Foundation was pleased to participate in a
    recent roundtable hosted by the Senate Veterans Affairs Committee to
    discuss many of the improvements to PCAFC required under sections 123
    and 124. These include the enhanced use of automation to facilitate
    information gathering and eligibility determination processes as well
    as improvements to decision letters to better inform applicants. The
    Elizabeth Dole Foundation was also pleased to learn that steps are
    being taken to improve the coordination of care between the PCAFC
    program and services available to individuals under GEC.
        While we appreciate these positive steps, the Elizabeth Dole
    Foundation is gravely concerned that the final rule governing the PCAFC
    program has not been issued. As mentioned above, recognizing
    significant challenges and an excessive number of caregiver removals in
    March 2022, the VA suspended discharges from the program in an effort
    to pause, review, and discuss needed changes. Eventually, VA entered
    into a new rulemaking process and issued a proposed rule in December
    2024. Garnering over 800 comments, this proposed rule appears to be
    stalled; we are now well over a year after its issuance, leaving this
    highly vulnerable population of family caregivers in limbo as they wait
    to learn their fate. Worse, the very rule that was recognized as
    insufficient in 2022 and that resulted in the pause, is still being
    used today to determine eligibility for new applicants, leaving many
    out of the program whom Congress intended to cover. The Elizabeth Dole
    Foundation strongly urges Congress to use its oversight authority to
    impress upon VA the urgency of finalizing a rule quickly that supports
    family caregivers and aligns with congressional intent.

    Section 129:

        Commonly referred to the ``Pathway to Advocacy'' this provision
    requires the VA Secretary to establish a process by which organizations
    can become trained, certified and recognized to help a veteran,
    caregiver, or survivor to navigate the services of the Veterans Health
    Administration. Too often, this committee learns of situations where
    vulnerable individual veterans or their family members are unaware of
    or unable to access the programs intended to help them, even though VA
    has the services necessary to support them. Given the potential
    positive impacts of this initiative on connecting veterans, caregivers,
    and survivors with needed resources, the Elizabeth Dole Foundation
    again recommends that VA brief interested organizations on the status
    of this provision's enactment and solicit feedback to ensure any
    recommendations align with congressional intent.

    Section 130:

        Given veteran preference for care in the home, GEC provides an
    invaluable set of tools to both accommodate the veteran's wishes and
    support the family caregivers who are often thrust into this role.
    Among other things, section 130 requires that VA undergo an extensive
    review of these services to ensure consistency in program management,
    appropriate staffing levels, proper care coordination, and eliminate
    service gaps. While this provision was enacted prior to the current
    reorganization efforts underway at the agency, the Elizabeth Dole
    Foundation encourages VA to enact the provisions in the spirit in which
    they were intended to ensure that these vital programs are staffed
    appropriately to better serve veterans and caregivers.

    Conclusion:

        The passage of the Senator Elizabeth Dole 21st Century Veterans
    Healthcare and Benefits Improvement Act provided an opportunity for VA
    to implement bipartisan legislation that was carefully crafted with the
    support of many in the veteran community. As VA continues its work on
    the implementation of this law, we encourage the agency to update and
    solicit regular feedback of relevant veteran service and non-profit
    organizations to achieve our mutual goal of serving veterans,
    caregivers, and survivors.
        The Elizabeth Dole Foundation would once again like to thank the
    subcommittee for the opportunity to present our views today. We look
    forward to continuing to work with you on the full and prompt
    implementation of this law and would be happy to answer any questions.

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