[Senate Hearing 117-218]
[From the U.S. Government Publishing Office]
S. Hrg. 117-218
REVIEW OF THE FISCAL YEAR 2022
BUDGET AND 2023 ADVANCE
APPROPRIATIONS REQUEST FOR
THE DEPARTMENT OF VETERANS AFFAIRS
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, JUNE 16, 2021
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Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
47-108 PDF WASHINGTON : 2022
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COMMITTEE ON VETERANS' AFFAIRS
Jon Tester, Montana, Chairman
Patty Murray, Washington Jerry Moran, Kansas, Ranking
Bernard Sanders, Vermont Member
Sherrod Brown, Ohio John Boozman, Arkansas
Richard Blumenthal, Connecticut Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii Mike Rounds, South Dakota
Joe Manchin III, West Virginia Thom Tillis, North Carolina
Kyrsten Sinema, Arizona Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire Marsha Blackburn, Tennessee
Kevin Cramer, North Dakota
Tommy Tuberville, Alabama
Tony McClain, Staff Director
Jon Towers, Republican Staff Director
C O N T E N T S
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JUNE 16, 2021
SENATORS
Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............ 1
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas...... 3
Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire...... 9
Boozman, Hon. John, U.S. Senator from Arkansas................... 11
Tillis, Hon. Thom, U.S. Senator from North Carolina.............. 12
Murray, Hon. Patty, U.S. Senator from Washington................. 13
Rounds, Hon. Mike, U.S. Senator from South Dakota................ 15
Brown, Hon. Sherrod, U.S. Senator from Ohio...................... 16
Hirono, Hon. Mazie, U.S. Senator from Hawaii..................... 24
Sullivan, Hon. Dan, U.S. Senator from Alaska..................... 26
WITNESSES
Panel One
The Hon. Denis McDonough, Secretary of Veterans Affairs
Accompanied By: The Hon. Jon Rychalski, Assistant Secretary for
Management and Chief Financial Officer......................... 4
Panel Two
Mr. Shane Liermann, Deputy National Legislative Director,
Disabled American Veterans, Mr. Patrick Murray, Director,
National Legislative Service, Veterans of Foreign Wars and Mr.
Roscoe Butler, Associate Legislative Director, Government
Relations, Paralyzed Veterans of America....................... 19
APPENDIX
Prepared statements
The Hon. Denis McDonough, Secretary of Veterans Affairs.......... 30
Joint Testimony of The Independent Budget Veterans Service
Organizations, Disabled American Veterans, Paralyzed Veterans
of America and Veterans of Foreign Wars........................ 47
Questions for the Record
Prehearing Questions submitted by:
Hon. Moran..................................................... 56
Post-hearing Questions submitted by:
Hon. Moran..................................................... 80
Hon. Blumenthal................................................ 108
Hon. Sinema.................................................... 111
Hon. Tillis.................................................... 118
Hon. Blackburn................................................. 119
Hon. Tuberville................................................ 122
Additional Documentation for the Record
The Independent Budget FY 2022 and FY 2023 for the Department of
Veterans Affairs............................................... 125
REVIEW OF THE FISCAL YEAR 2022
BUDGET AND 2023 ADVANCE
APPROPRIATIONS REQUESTS FOR
THE DEPARTMENT OF VETERANS AFFAIRS
----------
WEDNESDAY, JUNE 16, 2021
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The committee met, pursuant to notice, at 3 p.m., in room
418, Russell Senate Office Building, Hon. Jon Tester, Chairman
of the committee, presiding.
Present: Tester, Murray, Brown, Hirono, Hassan, Moran,
Boozman, Cassidy, Rounds, Tillis, Sullivan, and Blackburn.
OPENING STATEMENT OF CHAIRMAN TESTER
Chairman Tester. I call this hearing to order. Good
afternoon. I want to thank Secretary McDonough and my favorite
Montanan, Jon Rychalski, for being here today. I appreciate you
guys taking the time to take a closer look at the President's
Fiscal Year 2022 budget for the Department of Veterans Affairs.
Most everyone would agree that the VA handled the COVID-19
pandemic incredibly well. We also know that the ripple effects
of this pandemic is going to be felt for years to come. The
VA's budget needs to account for this, and we have to do
everything possible to ensure that no veteran is left behind or
negatively impacted because of COVID-19.
The current proposal in front of us is the largest request
we have ever seen from the VA. I am pleased to see increases in
funding for suicide prevention, including the implementation of
the Scott Hannon Act, and funding to help VA speed up claims
decisions for veterans with one of three Agent Orange-related
conditions added by Congress just last year. It is a step in
the right direction.
I am also glad to see a renewed effort to address veteran
homelessness in this budget request. However, the VA still has
a ways to go to address deficiencies in other areas.
Just last week, VA released its quarterly staffing numbers.
The Veterans Health Administration has 30,000 vacant positions,
with the majority of these being medical care providers. Look,
we cannot deliver on its promises to veterans if we do not have
the work force to do so. This is particularly concerning given
the rate the department is sending veterans into the community
for care. We need to talk about the balance between in-house
care and community care, and VA staffing is critical in that
conversation.
Though we talk a lot about health care, we need to ensure
VA's other missions are not left on the back burner. As I said
during our May hearing on VA compensation and pension, I am
concerned about the hundreds of thousands of backlogged VBA
claims. The pandemic threw a wrench in the claims processing
and the VA needs to address this backlog with the proper
balance of speed and quality.
This committee, as evidenced by our unanimous passage of a
framework for comprehensive toxic exposure reform will continue
to work to ensure that exposed veterans have access to earned
care and benefits. We need the VA's cooperation in this
endeavor, and I appreciate the Secretary's efforts to provide
official views on that legislation.
Finally, as we discussed in our hearing last week, VA has
almost $70 billion in unmet infrastructure needs. Simply put, I
do not see how the VA achieves any of its missions without the
foundation of a modern, efficient, infrastructure. At the end
of the day, these are all bipartisan issues, and this committee
is going to address them in that fashion.
Mr. Secretary, I know that having more of your leadership
team in place will help ensure VA is better delivering for
veterans across the board. So hopefully folks up here will stop
playing games so we can get the four pending VA nominees
confirmed and on the job, working for veterans. Because, quite
frankly, the last thing I want to do is bring you up here in 6
months and wring you up for something that we are the problem,
not yours.
I look forward to hearing from everyone today, especially
the veteran groups here representing the Independent Budget,
and how we can support our nation's veterans and their families
in next year's budget.
Senator Moran is not here, so I will turn to his right-hand
man and say, can we go to the testimony of the good Secretary
or do you want me to idle?
Senator Rounds. He is en route. Could you idle for 2
minutes?
Chairman Tester. We are going to idle for 2 minutes.
Rounds, you have got to have better control of Moran, I am just
telling you.
[Laughter.]
[Pause.]
Chairman Tester. So just so you guys know, we have got
three votes starting at 3:15. Is that correct? Three votes
starting at 3:15, so people are going to be shuffling in and
out, and it is no disrespect to the VA. Schumer scheduled votes
at the wrong damn time.
So that is what we will be doing, and we have got a couple
of panels today. We have not only got Secretary McDonough and
Jon Rychalski, Assistant Secretary for Management and Chief
Financial Officer, we have another panel too, which is equally
important, with the Deputy National Legislative Director of the
Disabled American Veterans, that would be Shane Liermann; with
the Director of National Legislative Services of Veterans of
Foreign Wars, that is Patrick Murray; and with the Associate
Legislative Director of Government Relations of the Paralyzed
Veterans of America, that would be Roscoe Butler.
So we have got a lot of stuff to do, and here is the
challenge that we have, so that everybody else knows. At 4:30
the Ranking Member has a hard stop, and quite frankly, I am
supposed to have a hard stop at 4, but that is probably not
going to happen. So we are where we are.
Man, I am glad we do not have to do push-ups for this 2
minutes, I am telling you.
We are going to recess briefly.
[Recess.]
Chairman Tester. All right. We will call the meeting back
to order, and we will hear from the illustrious Ranking Member,
the great Senator from Kansas, Senator Jerry Moran.
OPENING STATEMENT OF SENATOR MORAN
Senator Moran. Chairman Tester, thank you for that kind
introduction, and I will be expecting something that you want
from me once again, as a result. Mr. Secretary, nice to see
you. I apologize. I assume that your opening statement would
have been given in my absence, and I was hoping not to miss
that.
Chairman Tester. We did not do that. He is yet to go, so
you are good.
Senator Moran. Very good. Secretary McDonough, and to our
VSO witnesses that will join us in our second panel, I am
pleased that you are here. I am eager to hear from all of you
your thoughts regarding the VA's proposed budget for the Fiscal
Year 2022. These hearings, while sometimes tedious, are very
important. We need, in my view, particularly at this point in
time, greater transparency and an understanding of the VA's, in
this case, funding sources. There have been so many things
related to COVID-19 and the infrastructure plan, there are just
a lot of things now that are out there for us to figure out, in
my view, how it all fits together. And, of course, it is always
important for this process to be as transparent as we can make
it.
Mr. Secretary, you have helped in the cause today by
responding to our April inquiries. I would shorten my paragraph
here again to encourage you to insist the VA respond more
quickly to this committee. I think that even the pre-hearing
questions for today's hearing have only been answered in a
small portion. And so in this effort for transparency we still
need a better, quicker, more thorough response from your team.
The rest of that page is about criticizing you, and I saw
you nod with me so I will assume that means that things will
get better.
Turning to the budget request, the VA is seeking another
record budget that has grown from roughly $200 billion in 2019,
to a proposed $300 billion in 2022, when combined with the
American Rescue Plan spending and proposed Jobs Plan spending.
Congress has worked hard to deliver VA the funding and
resources it needs, and sometimes there is a suggestion that
the VA needs resources and I am for that when demonstrated. But
I need to make certain that what we are providing is being
responsibly spent and that you have the capability of doing so
effectively and efficiently.
That budget of the Department of Veterans Affairs has grown
significantly, while most budgets in the federal government,
our agencies and departments, have remained pretty flat, and
some have seen reductions. That is a testament to the priority
that veterans have within the larger debate on spending
deficits and debt, a priority that spans administrations and
whichever party happens to have the majority. But that does not
alleviate our responsibility to taxpayers and veterans to make
sure that every dollar requested is adequately justified.
Here is where I think I mostly need answers. The VA is
asking for a 15 percent increase in medical care spending this
year--15 percent increase in medical spending--which is a 63
percent increase since 2018. VHA staffing is projected to be up
17 percent since 2018 to nearly 370,000 employees, but
outpatient visits are only up 5.9 percent since 2018. The
average daily inpatient census is down 4.5 percent since 2018,
and the number of unique veteran patients seen is only up 2.4
percent since that year.
In short, how do these many sources of funding--the base
budget request, CARES, the American Rescue Plan--how do they
marry up with actual caseload, actual patient care at the
department?
Secretary McDonough, I am hopeful that your testimony will
untangle some of these questions so we have a clear
understanding of how the VA expects its workload to change and
why, and I believe that if we have the full picture, based upon
data and sound modeling, then together we can make certain that
the VA has the tools it needs to deliver good outcomes for
veterans.
Mr. Chairman, thank you for pausing to allow me to make my
opening statement, and I welcome the Secretary and look forward
to his testimony.
Chairman Tester. Thank you for your words, Senator Moran.
Now we will go to our first panel. Be as concise as possible,
Secretary McDonough. Your entire written document will be a
part of the record. You may proceed.
STATEMENT OF THE HONORABLE DENIS McDONOUGH, ACCOMPANIED BY THE
HONORABLE JON RYCHALSKI, ASSISTANT SECRETARY FOR MANAGEMENT AND
CHIEF FINANCIAL OFFICER
Secretary McDonough. Chairman, thanks very much. It is an
honor to be here, and Ranking Member Moran, thank you very
much. Let me just also acknowledge the veteran service
organizations who will appear after us and our union partners,
who I believe make VA stronger.
I am going to take one sentence from my prepared remarks
and then just ask that the rest of them be added to the record,
and then straight to questions, out of deference to your time
and deference to the second panel.
Chairman Tester. Okay.
Secretary McDonough. The most important sentence is this
one. I commit to using these appropriated resources
responsibly, being fully transparent with you, and getting the
greatest value out of every dollar.
I will submit the rest of the statement for the record, and
I look forward to your questions.
[The prepared statement of Secretary McDonough follows:]
Chairman Tester, Ranking Member Moran, distinguished Members of the
committee-thank you for the opportunity to testify today in support of
the President's Fiscal Year 2022 Budget Request and fiscal year Advance
Appropriation Request for VA, and for your steadfast support of
Veterans. I'm accompanied today by Jon Rychalski, our Assistant
Secretary for Management and Chief Financial Officer.
Let me also acknowledge the Veterans service organizations and our
Union partners who make VA better and stronger.
We have some great news. First, our goal is, by the end of July, to
provide more care than we did before the pandemic. I don't want to call
this ``reopening,'' because VA never closed-but I do want to make sure
that we're offering in-person programs like residential mental health
and substance abuse programs that are currently operating at 50 percent
capacity.
We will learn and improve from our pandemic experience-to ensure
we're establishing a new, improved version of what VA looks like, a VA
that doesn't just go back to how we operated before COVID, but one that
we've forged into a stronger department as a result of pandemic
challenges.
Second, we've taken steps to reduce the backlog of claims caused by
the pandemic. We ramped up scanning efforts to digitize federal records
for claims processing, and temporarily assigned VA employees to the
National Personnel Records Center to pull records necessary for claims
processing. Now, most of VA's requests for records are answered in 2 to
3 days, and the number of pending VA-related records requests dropped
by 90 percent to pre-pandemic levels.
Third, VBA rated our one millionth Veterans disability claim last
week, hitting this important milestone faster than in all but 1 year in
VA history-despite the challenges of COVID.
Fourth, VA has now vaccinated 3.3 million people with at least one
dose-Veterans, family members, caregivers, employees, and members of
other federal agencies.
Last, and most importantly, on May 24, just 3 weeks ago, there were
no COVID-related deaths in any VA facility for the first time in 441
days-since March 18, 2020.
These positive outcomes are a direct result of two factors:
resources, and caring, compassionate people. And as always, our efforts
will ultimately be judged by the outcomes we produce for Veterans and
their families. Let me tell you about one such outcome and the feedback
we received from the Veteran's family.
Last month, I received an e-mail from a Veteran's daughter, Dr.
Jennifer Bendiske [BEN-disc]. Jennifer's father, a Navy Veteran of
Vietnam, is receiving care at the VA Medical Center in Charleston, SC.,
for both Parkinson's disease and stage IV non-small cell lung cancer.
She wrote:
``Everyone who my parents or I have encountered at the Medical
Center, from those who work in the canteen to those who provide medical
care seem to genuinely care . . . the care that has been directed
toward my parents is a comfort to them, my sister, [me], and our
families. In addition to the genuine concern shown by the medical
staff, the treatments that have been proposed are in line with current
best practices for this type and stage of disease . . . I know this
because I am in clinical drug development, working toward new treatment
for non-small cell lung cancer . . . I suspect that much of the
feedback that you receive relates to that which is not working; I
wanted to provide an example of care that meets the expectations of the
Veteran and his family.''
That's the kind of experience every Veteran and every family member
deserves to experience at VA. And let's remember who makes that happen:
VA clinicians and staff.
They are the ones who are caring for Jennifer's father.
They are the ones who have spent the pandemic risking their lives
to serve the Veterans who served us.
And they are the ones who made zero COVID deaths on May 24th
possible.
But those employees will also be the first to tell you that their
life-saving work isn't possible without the resources they need.
That's why this budget is so important. The fiscal year budget
request will ensure VA can provide care and services for Veterans,
their families, caregivers, and survivors-and to other Americans, such
as the 488 non-Veterans treated at VA facilities as pandemic related
humanitarian admissions-including citizens from Arkansas, Arizona, and
Texas, among others.
These resources will be put to good use, empowering our department
to fulfill the mission that President Biden charged me with when he
nominated me to lead VA: to fight like hell for our Veterans.
This budget ensures we can continue the growth and success of our
Caregiver Support Program by fully integrating families and caregivers
into the care plans of the Veterans they love, continuing to implement
MISSION Act expansion of our Program of Comprehensive Assistance to all
generations of eligible Veterans. And this budget supports the training
of over 1,900 field-based staff to improve consistency across the
country and increase support of all family caregivers.
The budget provides needed funding for Women Veterans, at a time
when the number of women using VA health care has more than tripled
since 2001, by funding recruiting and hiring for women's health
providers, improved access to reproductive health services, and
emergency services.
The budget allows us to continue our success in reducing Veteran
homelessness-building on the good work of the last decade, during which
we decreased Veteran homelessness by 50 percent.
This budget allows us to provide strong, sustainable, and high-
quality direct care to our Veterans at a time when they need it most.
Community care and direct care are both important, and care in both
contexts is rising, as we knew it would-Veterans are returning to care
as we manage the pandemic. And while both are growing, care in the
community is rising at a faster rate than direct care.
Veterans need and deserve a thriving direct care system that they
can depend upon for generations to come, because it provides higher
quality, evidence-based, integrated care-and is tailored for Veterans
and their unique needs. Beyond that, our nation depends on the
research, innovation, and medical education components of VA direct
care-as well as an effective backstop to our country's health care
system, VA's 4th mission, that has been critically important during the
COVID pandemic.
And that's not all these budget resources will do. They will also
fund mental health and suicide prevention initiatives, address major
deficits in construction, physical and information technology (IT)
infrastructure, continue our electronic health record (EHR)
modernization, address issues of environmental exposures among
generations of Veterans, and continue to ensure VA is always a place
where diversity, equity, and inclusion are valued and sought.
In short, this proposed budget allows us to deliver high quality
whole health care and benefits to our Veterans at a time when they need
it the most. And it does so, in large part, by enabling the heroic work
of great people like those who care for Jennifer Bendiske's father.
I commit to using these appropriated resources responsibly, being
fully transparent with you, and getting the greatest value out of every
dollar.
Mr. Chairman, Ranking Member Moran, thank you for the opportunity
to appear today.
I look forward to your questions.
Chairman Tester. Thank you, Secretary McDonough. That may
be the quickest opening statement on a budget that I have ever
heard in my life, but that is fine. That is good, because we
will get down to the meat of it.
Secretary McDonough. I anticipate that.
Chairman Tester. Yep. Look, we are coming out of a global
pandemic, as I said in my opening statement, in which more than
600,000 Americans have lost their lives, including 12,000
veterans in the VA health care system, and likely a whole lot
more than that outside the system. VA facilities were filled to
the brim, forcing VA leadership to bring mobile medical units
and pop-up hospitals to care for sick veterans. VA clinicians
worked day-in, day-out, risking exposure to the virus, to take
care of every veteran in need, as well as hundreds of non-
veterans, because civilian hospitals were stretched to their
breaking point.
We know the statistics related to the claims backlogs and
wait times at VA facilities were negatively impacted. It was a
global pandemic, after all, so that does not come as a
surprised to anyone, or at least it should not.
So, Mr. Secretary, as the VA emerges out of this pandemic,
can you highlight some of your efforts to address the claims
backlog and VA wait times?
Secretary McDonough. Yes. Thank you very much, Chairman,
and this is obviously an issue that has come up in discussions
with many of you since I have come into this job. And I think
it is important to highlight some collaborative efforts that we
have undertaken to reduce the backlog of claims.
We have revved up significantly scanning efforts to
digitize federal records for claims processing. We have
temporarily assigned VBA personnel to the National Personnel
Records Center in St. Louis to pull records necessary for
claims processing.
Now, most of VA's requests for records are answered in two
to 3 days, and the number of pending VA-related record requests
at that facility have dropped by 90 percent, getting back to
pre-pandemic levels.
Importantly, that is happening as we are bringing the debt
backlog down. It was about 220,000 cases when I got there. It
is about 180,000 cases now. The staffing enhancements that are
envisioned in the President's budget request will allow us to
bring it down further still, so that we get it entirely
accounted for by the end of next fiscal year.
Importantly, this is all happening while we are managing
existing claims, and last week VBA rated our one-millionth
veteran benefit claim this year at record pace. There has only
been one other year that we have rated that many cases, a
million, that quickly, and by the way, we did that during the
pandemic.
So we have significant investments here, Mr. Chairman, to
allow us to continue that performance, and we have anticipated
increases in the backlog from, for example, Blue Water Navy,
coming in August. But we have a plan to account for that, and
more.
Chairman Tester. Also, can you speak to the urgency of
having more of your leadership team on the job and confirmed,
and what would it mean for veterans, particularly distressed
veterans?
Secretary McDonough. Well, I thank you very much, Chairman,
on that. We have an unbelievable team, a very effective,
capable team at VA. I am very proud to be--in fact, honored to
be associated with the team. That millionth claim rated as of
last week is a perfect example of that. I have just had an
opportunity to talk with one of your committee members. I
appreciate it very much that she made time for me in that
conversation.
The main thing we need is a Deputy Secretary confirmed with
your imprimatur, responsive to your concerns, but also in a
position to help me staff the commission to find an Under
Secretary for Claims. That is supposed to meet next Monday and
Tuesday. We really need him in the seat for that job, because
we really need a confirmed Under Secretary for the first time
in several years on this important thing, including on issues
related to the backlog.
Chairman Tester. Thank you. I will turn it over to Senator
Moran.
Senator Moran. Chairman, thank you. Mr. Secretary, I noted
in my opening statement that--incidentally, your opening
statement was more popular than mine--I noted in my opening
statement VA spending on medical care and staffing for VHA is
increasing at a much faster rate than patient visits. Some
measures of VHA workload, such as the number of inpatients
treated and the average daily count of inpatients is actually
dropping.
If less than 5 percent of the cost increases are due to
health care trends, like inflation and costlier care, then what
is driving the rest of the sharp increases we are seeing?
Secretary McDonough. Yes, very fair question. I appreciate
it. I want to focus on two things. One is something that we
have been anticipating and we are now experiencing, which is a
significant increase in the demand for care coming out of
foregone care during the pandemic, something that we are
seeing, incidentally, across the care, for veterans and non-
veterans alike.
As an example of that, I will just tell you that from March
to May of this year, in the direct care system, we had 16.5
million appointments. In the community care system we had 1.25
million appointments. Compared to the same period last year we
had 9 million appointments in the direct care system, less than
700,000 in the community care system. So that is about an 80
percent increase in each--81 in the first, 79 in the second.
Part of our staffing request for this year recognizes that
bow wave of care will continue into next year. So that is
obviously very important.
Now next--and we have been working with your teams on
this--how we calculate care is in virtual care units rather
than in FTEs or rather than in people, clinicians to provide
the care. And what we know about virtual care units is that our
vets generally are bigger consumers of health care, have more
complex cases. So individual appointments may be not the best,
most comprehensive way, especially as you are thinking about
cost, to calculate what we are delivering in terms of value.
And so this is something that obviously we have developed
over time, through several Secretaries, in a model, by the way,
that has held up pretty well, when you look back at it.
So big bow wave of care, generally more demanding patients,
relatively sicker, and so that means more complex cases, which
means greater cost.
Senator Moran. Let me see--is there anything that you said
that answers this question. What portion of the 2022-2023
medical care request funds are a result of increasing costs due
to deferred care during the pandemic? You may have said that.
Secretary McDonough. Yes. Rather than Jon whispering it to
me, why doesn't he----
Mr. Rychalski. It is really a health care projection model.
Due to COVID, it was about 7.9 percent is the estimate.
Senator Moran. 7.9 percent of the increase?
Mr. Rychalski. Yes. And to your point about 5 percent, 4.9
percent is attributable to intensity, inflation, reliance, and
then there is another 2 percent for demographic changes,
population changes.
Senator Moran. OK. Thank you for that. Let me ask a
question about community care. Your budget submission notes the
department's desire to place veterans at the center of their
own care. It also prioritizes a rebalance of direct and
community care. I do not know if the department told us in
detail what a rebalance would entail in this budget submission.
What specific factors and data is the department taking into
consideration for a rebalance, and how does this influence your
budget and advanced appropriation request?
Secretary McDonough. Great. Thanks very much for that. I
think the numbers are roughly about--we anticipate about $25 to
$26 billion in community care in this coming year, and in the
advanced appropriation we are asking for, it is slightly over
$24 billion. The first and most important thing is we are
trying to understand precisely what the vets want, right. If we
are going to put them at the center of their care, the way we
do that is we ask them. So the Veterans Experience Office is
out in the field with a very aggressive effort to understand
from them what it is that they want, specifically what have we
learned from the experience of the pandemic, where vets have
demonstrated a much greater intensity and interest in, for
example, video and telehealth than I would have anticipated,
and then any conventional model had been anticipated
heretofore.
The second thing relates to making sure that we recognize
vets in our care do better in terms of outcomes. And I have
committed to you that everything I decide here will be decided
on access and outcomes. And so one of the things we know about
outcomes is the fact that we have integrated care with the full
range of specialties that vets have come to rely on,
particularly given their particular challenges of care. One of
the things I will be looking at very closely, Senator, is our
ability over time, understanding that we will be under budget
pressure and we will not see these kinds of record budgets, is
maintaining the system and its integrated nature with the full
range of specialties that our veterans demand.
And so one of the indicators that you see in our budget is
making sure that we can recruit and keep specialists in the
system, so we can address those in-house, rather than being at
the risk of weakening that if we become over-reliant on the
community.
Senator Moran. I will have a couple of followup questions
if I have the chance later. Otherwise, I will submit them to
you in writing and we can have a conversation.
I am going to go vote, so Senator Tester can go vote.
SENATOR MARGARET WOOD HASSAN
Chairman Tester. Senator Hassan?
Senator Hassan. Well, thank you, Mr. Chair and Ranking
Member Moran, and thank you Secretary McDonough and all of our
other witnesses for testifying today. Mr. Secretary, I was not
on the committee yet when you were confirmed so this is my
first hearing where you are appearing. I am really looking
forward to working with you to help veterans across the country
and in New Hampshire get the benefits they earned and deserve.
New Hampshire is one of three states, along with Alaska and
Hawaii, that lacks a full-service VA hospital, something am
working to change. As my colleagues have pointed out, the VA's
budget is insufficient to meet the agency's dire infrastructure
needs.
In your prepared testimony you noted that the President's
proposed funding in the American Jobs Plan for VA
infrastructure--and that is something I strongly support as
well--but we need to make sure that VA funding that goes toward
infrastructure adequately addressed the need of Granite state
veterans.
So does the agency take into account the lack of full-
service VA hospitals in certain states when developing your
budget plan and priorities?
Secretary McDonough. We do.
Senator Hassan. That is helpful to know, and I would love
to continue to work with you to make sure that, especially as
we deal with the needs for community care and improved
infrastructure at the resources we do have in New Hampshire,
that they are attended to.
Secretary McDonough. You can count on that.
Senator Hassan. Thank you. The National Cemetery
Administration has made increased access to burial benefits a
strategic goal. This includes providing additional grant
funding to state and tribal organizations. Unfortunately, as a
condition of receiving VA money for improvements, state veteran
cemeteries are barred from interring many National Guard
members and reservists. Today I joined Senator Shaheen, Cramer,
and Hoeven in introducing a bipartisan, bicameral bill that
addresses this issue.
So Secretary, will you and your team consider this bill and
provide us with feedback, and will you work with my office to
increase access to burial benefits, including for National
Guard members and reservists? It is a matter just incredibly
important to Granite state veterans.
Secretary McDonough. Yes, I will say three things about
this. I do not want to eat up your time. One is the budget
request in the President's budget for this year continues a
strategic expansion of our cemetery footprint to ensure that
everybody has access. I am very proud of that service. I think
this is really an important investment.
Second is it came to my attention very early in my tenure
here that we have a discrepancy whereby New Hampshire has asked
for one way to use its state grant from us for its cemetery. It
is inconsistent with current reg.
Senator Hassan. Right.
Chairman Tester. But there is North Dakota, who is
currently using VA-provided funding in that same way.
We have gone out with a Request for Information to the
field, to all 50 states, to say hey, how should we do this.
Senator Hassan. Okay.
Secretary McDonough. Then we will have a conversation with
you about it. In all cases, I will look at your bill.
Senator Hassan. Well, I appreciate that very much and I
know Granite state veterans would too.
Last question. In this year's budget, the Veterans Benefits
Administration lists two organizational priorities: benefits
delivery and suicide prevention. The veteran suicide rate is
highest among those 18 to 34 years old. This age group also
accounts for 75 percent of transitioning servicemembers.
You and I have discussed the Solid Start program, an
initiative that aims to contact every veteran multiple times by
phone in the first year after they leave active duty, to check
in and help connect them to VA programs and benefits. I have a
bipartisan bill with Senators Cramer and Cassidy to strengthen
and make permanent this important program, which the committee
will consider further, I hope during our legislative hearing
next week.
Secretary McDonough, can you please speak to how the Solid
Start program aligns with the Veterans Benefits
Administration's priorities, and will you work with us to
support and build on this program?
Secretary McDonough. So often the benefits package is the
introduction to VA service for our vets, and we want to make
sure that the introduction is not only professional,
transparent, based on the customer service, and a positive
experience, but that it also opens the door to the full range
of services we have. So being in touch with our vets, including
about introducing them to all of our services, including, when
necessary, mental health services, is really important, and it
is consistent with what we are doing through our program called
REACH VET, which is a fundamental tenet of our suicide
prevention programming.
Senator Hassan. Well, thank you. I would love to continue
to work on this and the Solid Start program with you. What I am
hearing from veterans is just there is so much transition going
on in that first period after they leave active service that
they could really use that kind of steady outreach, and it may
take multiple attempts. And I think it really benefits all our
veterans and the country. So thank you.
Secretary McDonough. Might be a good way for us to get more
enrollees too.
Senator Hassan. Yes. Yes. Thank you. Thank you, Mr. Chair.
Chairman Tester. Senator Boozman?
SENATOR JOHN BOOZMAN
Senator Boozman. Thank you, Mr. Chairman, and thank you,
Mr. Secretary, for being here. I want to be quick because
Senator Tillis and I have to go vote. That is the only thing we
have got to do around here.
But I appreciate your transparency and I appreciate your
willingness to work with us. We had a good talk about Chairman
Tester's Cost of War Act, again going further so we can get
good information. We are all really interested in doing that
and get some really good legislation passed.
The Senator mentioned suicide, and I am pleased that the
John Scott Hannon bill, you know, we got that done and we are
starting to implement that. Can you briefly discuss how the
program is progressing? Do you have any more updates,
particularly about the effort with the grant program?
Everything tells us once they get in the VA they are going to
do better than being on the outside.
Secretary McDonough. Yes, we have had an extended
conversation, now going back a couple of months, on this.
Obviously the Hannon Act, as a general matter, offers us a lot
of new, additional, very helpful authorities. One in particular
is the Sergeant Fox--I think the Sergeant Fox Grant Act. We
have been in the field now, seeking public comment on that. We
want ideas from the actual service providers we want to fund.
We are aggregating that. We are now in a position that we
will be able to invite competition for grants come next spring,
and we believe that will be in the field with the funding by
next fall. I am thinking October-ish. The President's budget
anticipates that. The funding for that program is in the
President's budget. It is part of the increase in funding for
suicide prevention that the Chairman talked about in his
opening comments, and we think it is really important.
Senator Boozman. Good. I have got an additional question I
will put in the record concerning the medical records, you
know, the process there.
Thank you, Mr. Chairman.
Chairman Tester. Thank you, Senator Boozman. Senator
Tillis?
SENATOR THOM TILLIS
Senator Tillis. Thank you, Mr. Chairman, and thank you,
Senator Boozman. Secretary McDonough, it is good to see you.
I want to go back. You know, we had the recent addition of
three new diseases for the Agent Orange presumptive list, and
that could be another potential bow wave if you have seen how
the VA has dealt with this in the past. I do not think they
were quite prepared for the influx of claims, not under your
watch but under a prior administration. Now we have the TEAM
Act, and the Cost of War Act, which is far more expansive than
that, potentially.
To this point we have not received from the department a
position on either the Cost of War Act or the TEAM Act. The
puzzle pieces that we have had, had them refer to the
legislation that came together under the Cost of War Act.
At some point we are going to need definitive stance on
whether or not the legislation is workable and whether or not a
budget request would take into account something that is
likely, I believe, going to pass out of the Senate and
potentially enjoy support on the House side.
So I think I can make an assumption that your current
budget request does not in any way account for that additional
influx of claims?
Secretary McDonough. That is correct. So we have several
lines of effort going at the moment. You mentioned the three
Agent Orange claims. We have just started those presumptive
claims. We announced, ourselves, the initiation of rulemaking
on three conditions that may be included, related to service in
Iraq, Afghanistan, and Uzbekistan. We are continuing to work
that.
Our budget anticipates the Agent Orange pieces. Anything
beyond that it does not yet anticipate, because I think those
would be outside this fiscal year. But you have my commitment,
as I have given the Chairman, as I have given Senator
Blackburn, as I have given Senator Moran, and I have testified
in the House, that we owe you--entirely fair question--we owe
you what our estimates are for cost, discretionary, mandatory,
what we believe will be required in terms of people, and what
we believe will happen as it relates to the backlog.
We are trying to get that accurately, you know, under the
theory, you want it bad, you get it bad. I want it good, and I
want to be able to stand by it. So I have said we can get that
to you while you are still in session, in this summer. If I
give it to you now it just would not be accurate, and I do not
want to give you something I cannot stand by.
Senator Tillis. Yes, we need that as quickly as possible,
and I think some of your internal reviews on how you may be
able to provide a solution to the problem under the current
authorities.
I also wanted to talk about your $2.7 billion for the VA
health record account and $4.8 billion in total services for
the Office of Information Technology. This represents about, I
think, a $100 million cut under the 2021 appropriation for
OI&T. So I am trying to understand, as you grow, as you add
resources there is typically an operational tell for
information technology and support. What assumptions did you
make to justify the $100 million reduction?
Secretary McDonough. Yes, so I am going to let Jon do that,
but the first thing I want to say is just on EHRM, generally.
We have really appreciated your scratching in on that with us.
I will be in a position before the end of this month to submit
a series of reports to you all. We will talk with our VSO
partners, with our staff about that, with our agency staff
about that, and with you all. But we know we are on the hook to
provide that, and I think we are going to be in a good position
to do it. But in terms of the OI&T budget, Jon can talk about
the assumptions.
Mr. Rychalski. Sir, that $4.8 billion is part of our budget
request, but we also have access to the transformational fund
starting in 2022, which is access to our expiring
appropriations that we can use for two purposes. One is for IT
and one is for physical infrastructure. And so we are going to
use about, I think, $600-and-some million of that
transformation fund for IT, and that will bring the total
funding to about $5.3, $5.4, which is about a 13 percent
increase.
Senator Tillis. So it is only a category cut----
Mr. Rychalski. Source of funding. You do not see that in
the budget, or in that table, yes.
Senator Tillis. Very good. I am going to submit a question
for the record about dental health services down in the VA
facility. We are building it. We are standing up additional
facilities, but I think there is a need down there, with the
growing population, that may easily tap the additional facility
that you all have in mind, but I will submit a question for the
record on that. And I look forward to getting with you all on
the progress of the program office for the HR. Thank you, Mr.
Chair.
Chairman Tester. Thank you, Senator Tillis. Senator Murray?
SENATOR PATTY MURRAY
Senator Murray. Thank you so much, Secretary McDonough.
Good to see you here. Thank you for being with us today. You
know, since the implementation of the expanded Caregiver
Program last October, VA has reported receiving more than
81,000 applications for the Caregiver Program, and
unfortunately VA denied many of these applications because of
the activities of daily living requirement and the 70 percent
service connection requirement.
Chairman Tester and I actually wrote to you in May about
our concerns about how the program is being implemented. It is
so critical for so many of our families. It is essential that
veterans receive accurate decisions and do not experience
delays in approval determinations.
So I wanted to ask you today, what is the VA doing to
implement the Caregiver Program, as Congress intended,
including addressing these restrictive regulations? And also,
what is the VA doing to respond to the Beaudette court
decision?
Secretary McDonough. Yes. Thanks so much. Let me talk about
the Beaudette case first. We have submitted paperwork for an
appeal of that to the next level court inside the Vet's Court
of Appeals. We are working that. We are in direct touch with
the litigants on the other side, to make sure that if there is
something that we can do to work this out toward shared
objectives that we do this, that we do not necessarily need to
take an adversarial posture on this.
Second, I do think it is a fair critique that perhaps some
of these regulations have been overly restrictive and some of
the decisions to date have been insufficiently explained to our
applicants. That is why you see what you see in the President's
budget request for the year going forward, to allow us not only
to be prepared to implement the full expansion of the program
at the end of next Fiscal Year but that we are in a position to
also adequately staff across the country with 1,900 additional
staff offices to address these concerns forthrightly with our
vets and their caregivers.
So this is a major priority for the President, as you know.
I cannot tell you that we will resolve every question exactly,
precisely, but I can tell you that it is a major priority, and
the budget gives us some additional resources to make that the
case.
Senator Murray. Okay. I look forward to working with you to
get that. This is just a huge priority for me. It has been for
a long time. These families have been waiting, and it is just
absolutely critical to them.
Secretary McDonough. Absolutely.
Senator Murray. You know, as VA has transitioned to the
Community Care Network, my office has helped a lot of veterans
as they adjust to this new system, and as clinics close in some
locations and open in new ones across the state. In addition,
the President's budget request includes funding for the Asset
and Infrastructure Review Commission to review VA's
recommendations in realigning the VHA facilities.
How will VA take into account the challenges veterans face
in navigating the new Community Care Network as well as
existing geographical challenges that rural veterans face when
making recommendations about the realignment?
Secretary McDonough. You know, Access for our rural vets is
a fundamental priority of the President. It also happens to be
a fundamental priority of this committee, and I have been able
to spend some time in your state and Senator Tester's state and
Senator Moran's state, exploring exactly these questions.
We do believe that Community Care is a key portion of that,
but we also, as I said in response to Senator Moran's
questions, want to make sure that we sustain the integrated and
full-service nature of the VA system itself. If you look at now
as that relates to the AIR Commission, if you look at the
criteria on which we will make our decisions about
infrastructure in that commission, we published it in the
federal register about two and a half weeks ago, we put at the
heart of that these questions of the integrated care system and
the multiple roles that the VA plays, from education to
training to research and to the provision of service across the
entire country, to inform those decisionmaking opportunities
that we will have in that commission.
So my commitment to this committee is that we will handle
all these decisions very publicly, very transparently,
including, if necessary, an open session with you, to make sure
that you understand the basis for our decisions and that we are
able to get your feedback on them. It does not make any sense
to me for us to conduct this review on such a critical issue
behind closed doors. So that is my commitment to you, and I
think you should be able to see that becoming evident in the
next months on this.
Senator Murray. Okay. Thank you very much. I appreciate it.
Senator Brown. [Presiding.] Senator Rounds is recognized.
SENATOR MIKE ROUNDS
Senator Rounds. Thank you, Mr. Chairman. Gentlemen, first
of all, thank you for your service and thanks for appearing
here before the committee today.
Mr. Secretary, thank you for the phone call a couple of
weeks ago with regard to housing, veterans' housing. I think it
is something that we can work on together----
Secretary McDonough. I agree.
Senator Rounds [continuing]. and make some substantial
improvements on. So I appreciate your attention to that.
In addition, I will just share with you that I recognize
that we have got veterans and we are making more veterans, and
we have needed to. And as we do that, we owe them the
commitment that we are going to honor our pledge to them with
regard to the benefits that they have earned. And I know that
there is a cost involved in that.
I appreciate the comments that you made with regard to
where the increases have been going and why they are there
today. I look forward to working with you in the future. I just
want to make sure that the resources that we put in, whatever
they may need to do the appropriate job, that they are doing it
in as efficient a way as possible but also one which clearly
has that veteran first at heart. And I think you feel the same
way that I do on that.
I would also like to come back in on an item that is of
real interest to me on a personal note, is the Hot Springs VA
campus.
Secretary McDonough. Yes.
Senator Rounds. As you know, that particular campus,
located in Hot Springs, South Dakota, is a critical part of the
department's Black Hills Health Care System. Last October,
former Secretary Wilkie rescinded a record of decision on the
future of the campus, which provides vital health care
services, not only to South Dakotans but residents of four
other states. That record of decision would have significantly
reduced the Hot Springs campus, and I am very happy that he
worked with us to have it rescinded.
In your confirmation hearing you recommitted to working
closely on addressing the needs of the Hot Springs VA Medical
Center. Has the department developed a long-term plan to
modernize and expand this facility?
Secretary McDonough. If the department has, Senator,
candidly, I am not aware of it, but we are in the process, in
the context of our infrastructure review and the context of the
AIR Commission, and in the context of the annual budget
process, continually looking at those questions. Included in
this, and this is probably something I think you or your team
would want to dig into, we have been conducting what we call
market assessments pursuant to the Asset and Infrastructure
Review Commission. My guess is that those market assessments
speak a little bit to demand in that region in South Dakota,
obviously, including, as you said, Nebraska and the other
bordering states.
So no specific plans that I am aware of, but my commitment
to you remains, which is that as we do that, my commitment is
to work with you closely on it.
Senator Rounds. I understand that you are just getting on
the ground and rowing through it, and that is what I would ask
of you, sir, is that as you move forward in this that we not
lose sight of the fact that you have got an absolutely
beautiful facility, and you have got one that serves the needs
of a large number of vets in a very rural area, and you have a
community that clearly wants to continue to provide that
service. So I would just ask that you keep us in the loop, and
we will make contact and arrange for direct contact continuing
in the future.
Secretary McDonough. You can count on that.
Senator Rounds. Thank you.
Secretary McDonough. Thank you, Senator.
Senator Rounds. Thank you, Mr. Chairman.
Senator Moran. [Presiding.] Senator Rounds, thank you.
Senator Brown?
SENATOR SHERROD BROWN
Senator Brown. Thanks, Ranking Member Moran, and Secretary,
nice to see you again. Our committee has made great strides
getting veterans and their families vaccinated, making sure
that homeless vets and veterans at risk of becoming homeless
have additional resources through the ARP. Thank you for your
efforts there. The $18 billion in VA funding to improve and
modernize VA infrastructure, all of that is really important
and it will help improve veterans' access to care, as you point
out, and as I know Chairman Tester mentions over and over,
getting the care where they want to receive it, that is at the
VA, where most veterans want to go.
When Senators Tester, Reed, and I raised concerns about the
proposed rule for military borrowers, coming out of the last
days of the last administration, you took action to ensure that
veterans and servicemembers who struggled had the opportunity
to get back on track with their payments and remain in their
homes. Thank you for doing that. That was essential.
I also encourage you to keep working with the CFPB's Office
of Servicemember Affairs, which plays a critical role
advocating for military customers, consumers, if you would be
willing to continue to do that.
Secretary McDonough. You can count on that.
Senator Brown. Thank you. At last week's hearing, Senator
Murray raised whether VA has a comprehensive plan to assess
long-term care needs for veterans, whether it be at CLCs or
state veterans homes or through home-based care options.
Senator Murray and I will be following up with you on that
topic, because investing in veterans' care is so important. I
hope you will work with us to make sure VA has the right
strategy and resources.
Secretary McDonough. We will.
Senator Brown. I know you are thinking about that. Thank
you.
Secretary McDonough. Yes.
Senator Brown. We recently received a troubling OIG report
about Chillicothe in southern Ohio, its facility. It lacks
specific physical infrastructure to ensure veterans' physical
well-being. That veteran should not have been admitted because,
as the report stated, the patient's overall needs did not align
with the services and capabilities available in the CLC. The
veteran later died, as I think you know. You are aware of that
report?
Secretary McDonough. I am.
Senator Brown. Okay. Thank you. I hope that VHA leaders
review and implement OIG recommendations uniformly across VA's
health system to ensure that all veterans at VA remain safe. My
question, Mr. Secretary, has VA looked at its CLC facilities to
see whether additional security features, like sure outdoor
areas, two-door entry systems, might be appropriate to maintain
patient safety? If so, could the American Jobs Plan
infrastructure funding go toward those projects?
Secretary McDonough. We are constantly reviewing the CLCs
and, in particular, we have taken a deep look at performance in
the CLCs during the pandemic, and have been able to apply those
lessons learned in privately held facilities and state-run
facilities, so I am proud of that.
I will be very candid with you. I do not know whether we
have looked at the specific security upgrades you have talked
about, but I will find that out.
Then as it relates to the infrastructure money anticipated
in the Jobs Plan, of the $18 billion, $3 billion would be set
aside for immediate needs. We have a list of those now. I will
make sure that we have anticipated any specific security needs
for that, and will come back to you on that. The other $15
billion would be dedicated to the kinds of investments that,
you know, are pretty evident across the system, and we would be
more than happy to talk to you about that in additional detail.
But on the specific questions around security upgrades, I do
not have that with me. I have not looked into that, and I will.
Senator Brown. Okay, if you would. Thank you.
Mr. Secretary, last, we know the VA has a huge compensation
and pension claims backlog, and exam backlog too. You have
publicly discussed the VA using a mix of telehealth and in-
person exams at the VA and with contract and medical examiners.
Secretary McDonough. Yes.
Senator Brown. I know that you raised this when Senator
Tester asked. Please keep us updated, because Ohio veterans
raise that issue frequently with me.
Secretary McDonough. And they are right to, and they are
right to expect a fair call on that, and we are trying to turn
up the volume on each of those channels, and we want to do it
in a way where vets feel like they get a fair shake, and that
is what we will intend to do. And, by the way, we have cranked
up, thanks to interventions from many of you on this committee,
the provision of C&P exams in the VHA system itself, from our
providers. Now that comes at a cost to other services we
provide, but we think it important, and Dr. Stone has been a
great partner on this.
Senator Brown. Thank you, Mr. Secretary.
Chairman Tester. [Presiding.] Senator Moran, you have an
important question.
Senator Moran. Mr. Secretary, or Secretary Rychalski, I
want to go back to what is driving increased requests for
funding. In the budget document it talks about health care
trends as the component that drives 5 percent of the increase,
and I assume that is increased demand and inflation. And yet we
are at a 15 percent increase. So what is the other 10 percent?
Am I missing something here?
Mr. Rychalski. So year to year, the greatest increase for
us in health care, and I think in the commercial and Medicare/
Medicaid is, it is not the number of appointments. It is the
inflation, but also intensity, and I guess the best way to
describe intensity is the replacement of one treatment modality
with a more expensive, like Hep C treatment or Alzheimer's
treatment. And then there is the demographic changes, the
population changes, more people come into the system. Their
reliance is a big thing for us, how much people rely on the
system. Historically, people have relied on the VA for about 30
percent of their health care. That is increasing. And then in
our 2022 budget, there is the COVID impact, which is about 7.9
percent, and if you look in our budget and brief book, it
breaks out those categories of the things that are major
contributors to the 2022 budget request.
Senator Moran. I think I understand that, and one of my
takeaways from that answer is that when I look at increasing
number of patients seen, that is an inadequate determiner of
the necessary funding for their care.
Mr. Rychalski. Right. The number of patients seen is not--
you know, our patients, our actuary had determined that our
patients are about 30 percent, I don't want to say sicker, but
have more serious conditions, about 30 percent, and that is
going to be exacerbated by COVID. And so they tend to cost
more. An emergency room visit costs more than, say, you know, a
nurse practitioner visit.
That is something else that we are seeing, is a lot of
patients, our emergency room visits are sort of off the charts,
so to speak. People are accessing emergency rooms at a rate
that we have just not seen before. So it is things like that.
Senator Moran. Did the urgent care clinics diminish
emergency----
Mr. Rychalski. No. They increased dramatically, and
emergency room visits increased, doubled, dramatically.
Senator Moran. OK. Thank you both.
Mr. Rychalski. It is hard to know yet whether that is a
fleeting thing, inasmuch as this is a tenet of the return to
care, but we are very focused on it. I am quite concerned about
it. The cost implications are significant. We have been talking
to your teams and the appropriators, just in full candor, about
whether we have the money to make it through this year, so we
would continue to talk to you about that in terms of Community
Care funding. So we will keep a very open line on that.
Senator Moran. I think absent COVID, Mr. Secretary, with
the increasing use of urgent care at the VA, I think I would
expect a reduction in emergency room.
Mr. Rychalski. You would think, and there are some of these
trends that, on one level, are illogical. But, you know, the
question is how much of the logic gets thrown out because of
the pandemic.
Senator Moran. Thank you very much. Thank you, Chairman.
Chairman Tester. Thank you, Senator Moran. Thanks to both
of you for being here today. I wish there could have been more
of a grilling, but the votes kind of screwed that up.
Secretary McDonough. We are not that disappointed.
Chairman Tester. I bet you are not. That is good, but thank
you, guys.
Secretary McDonough. We are comfortable with the level of
grilling.
Chairman Tester. It will come later, okay, so thank you
both for being here.
Now while we get the panel set up, we are going to hear
from three veteran service organizations who wrote this year's
Independent Budget. I have said many times, and I believe this,
that Congress needs to take its cues from veterans, and I am
looking forward to hearing the veteran service organizations'
views on this year's budget proposal.
I want to introduce three people I guess should be just
made part of the committee because they are here every
committee meeting: Shane Liermann, Deputy National Legislative
Director for DAV, the Disabled American Veterans; Patrick
Murray, Director of National Legislative Service at the
Veterans of Foreign Wars; and last but not least, Roscoe
Butler, Associate Legislative Director for Paralyzed Veterans
of America. These guys all know how important the VA is for
health care, housing, and others, and we look forward to your
words. Mr. Liermann, you may start.
STATEMENT OF SHANE LIERMANN, PATRICK MURRAY AND ROSCOE BUTLER
Mr. Liermann. Thank you. Chairman Tester, Ranking Member
Moran, and members of the committee, thank you for inviting the
Independent Budget veteran service organizations--DAV, PVA, and
VFW--to testify on VA's budget request.
For more than 30 years, the IBVSOs have presented
comprehensive budget and policy recommendations to ensure that
VA is properly funded. Earlier this year, in February, we
released the IB budget recommendations for Fiscal Year 2022 and
Fiscal Year 2023 advanced appropriations, which detailed our
best estimates at the time, and we ask that the full IB report
be made part of the record.
On behalf of my colleagues from PVA and the VFW, I am
pleased to offer our highlights of the main IB budget
recommendations and comment on the administration's request for
VA funding.
Mr. Chairman, overall the administration's proposed budget
for Fiscal Year 2022, when combined with appropriated funding
from the American Rescue Plan, available funding from VA's
transformational fund, and proposed funding from the American
Jobs Plan, would fully fund veterans' programs, benefits, and
services for the first time in a generation. We commend the
administration for this historic VA budget request, and now we
call on this committee and Congress to ensure VA and veterans
receive what they need and deserve.
Mr. Chairman, for VA medical care the IB recommended a
total of $81.5 billion for Fiscal Year 2022. By comparison, the
administration has requested $78.1 billion in new
appropriations. However, VA will also have an additional $12.5
billion for medical care from the American Rescue Plan that was
enacted in March.
The administration also requested a significant increase
for medical community care, plus $2 billion from the AARP. We
would note that the primary reason for community care increases
continues to be inadequate access to VA health care due to a
lack of treatment space and health care providers. For this
reason, the IBVSOs recommended filling at least 25 percent of
pending VHA vacancies, and we are very pleased that the VA's
budget request proposes 17,000 new FTEs for VHA.
With more than half the veterans population over age 65, we
recommended an additional $335 million to expand VA's long-term
care programs. We also recommend that VA be provided sufficient
funding to accelerate the Phase 2 expansion of VA's Caregiver
Program.
To ensure that VA has adequate IT capabilities, the IVBSOs
recommended $5.2 billion to sustain all of VA's critical IT
programs for VHA, VBA, and NCA. Within that IT budget, the
IBVSOs call on VA to fund some specific needs, to include $42
million to support VA research programs, $175 million to begin
funding a portion of VBA's most critical pending IT projects,
and $25 million for the Board to modernize its Case Flow
program and AI needs.
Mr. Chairman, the COVID-19 pandemic not only delayed VA
health care for millions of veterans, it also created backlogs
in the delivery of benefits by VBA and the Board. In February
2020, there were approximately 70,000 benefits claims at VBA
pending over 125 days. At the end of May of this year, there
were more than twice that, almost 190,000 backlogged claims.
There are also over 90,000 pending hearing requests with the
Board, an increase of 15,000 pending hearings from a year ago.
In order to address these backlogs, IBVSOs called for
significant budget and FTE increases. We note that the
administration proposed an additional 429 FTEs for VBA, whereas
the IBVSOs recommended more than twice that amount to address
the claims backlog, expand VA's call center capabilities, and
address a growing volume of FOIA requests. The IBVSOs also
recommended an additional 200 FTEs to address the hearing
backlog, whereas the administration has requested roughly
three-quarters that amount.
Mr. Chairman, VA could not provide timely, quality care to
enrolled veterans without having adequate and modern health
care facilities. For Fiscal Year 2022, the IBVSOs recommended a
total of $2.8 billion for major construction, which included $1
billion for seismic deficiencies. Although the administration
requested just $1.6 billion, it has also proposed that VA
receive $15 billion for VA hospital construction as part of its
infrastructure proposal in the American Jobs Plan. More
importantly, the IBVSOs recommend that VA significantly
increase its internal capacity to plan and manage
infrastructure and construction projects by hiring additional
personnel.
As we await the recommendations of the upcoming AIR
Commission, Congress and VA must not wait to conduct critical
maintenance upgrades and modernizations and new construction of
already necessary facilities. While the AIR process will inform
the future of VA's health care infrastructure, there is already
a $60-plus billion backlog that represents VA's needs right
now.
Finally, Mr. Chairman, the IBVSOs remain grateful for the
continued bipartisanship support of VA and veterans programs by
successive congresses and administrations of both parties. Like
all of you, we are committed to ensuring that precious federal
resources provided to VA for veterans care, benefits, and
services are effectively and efficiently used, and that waste,
fraud, and abuse are minimized. However, we must never forget
that providing those who served with the health care and
benefits they have earned is a part of the cost of our national
defense.
As Congress looks to expand benefits for veterans,
including those exposed to burn pits and toxic substances, we
must never ask veterans themselves to pay for these benefits by
cutting veterans programs and services. And for those who would
look at the size of VA's budget request and ask, ``When will VA
be adequately funded?'' our answer is clear: when all enrolled
veterans have timely access to quality care and all earned
benefits are delivered accurately and on time.
Mr. Chairman, we are confident that with the continued
bipartisan work of this committee and Congress, we can achieve
that goal for all the men and women who served.
This includes the IB testimony on VA's budget. My
colleagues and I look forward to any questions you and the
committee may have.
Chairman Tester. Thank you, Mr. Liermann. I have been
informed that you did most of the talking and the others will
answer all the questions. Is that true?
Mr. Liermann. That is right.
Chairman Tester. Okay. All right. We will start then.
You spoke about this, Shane, in your remarks. Last week we
had a hearing on what the VA needs to ensure its infrastructure
is ready to support the veterans for years to come. One key
component of this is construction. As the Independent Budget
notes, VA has multiple sites that lack the funding to complete
projects that are underway. The administration is requesting
$1.6 billion for major construction. The Independent Budget
estimates the need at $2.8 billion. You already pointed out
that if we are able to get the infrastructure bill there is
another $15 billion there, which would be incredibly
significant.
Can you all speak to why you think this account needs more
funding, and what it means in terms of service that the VA
provides to your members? I would just say this. I am part of
the bipartisan team that is doing the negotiations on the $587
billion package. The VA is not in that, OK. So tell me, using
the potential infrastructure money, with and without, what the
challenges are.
Mr. Liermann. Mr. Chairman, thank you for bringing that up.
Last week in the hearing, Kaiser mentioned that they go off
about 3 percent operating costs. Three percent for VA would put
them somewhere, anywhere from last year, this year, the
upcoming year, anywhere from $6 to $8 billion. That would
probably take care of VA's infrastructure needs.
Currently they cannot do that work, though. They need more
people to do the work. We talk about vacancies in VHA, the
30,000 mostly doctors and nurses. That is also critical. But we
need the buildings to do that. We need to not only fill the
vacancies that are there for the construction jobs--the project
managers, the engineers--we need to expand that cap as well. So
we think that adding additional personnel to do that would
help.
Also a plan to actually knock down the backlog. The
Secretary mentioned there were records and claims backlogs that
are being addressed by adding VBA personnel, by adding staffing
to take care of that. There is no plan to even meet the current
backlog, never mind actually start to diminish it. So we think
a plan to knock that down, a 10-year projection, whatever it
might be, that is something critical in order to address
infrastructure.
Chairman Tester. Okay. So just to be clear, when you say if
they build the construction they do not have the manpower, that
is not necessary to build the physical infrastructure. That is
to actually man the physical infrastructure once it is built.
Mr. Liermann. No, it is to actually execute the contracts,
specifically like NRM contracts. There are billions of dollars,
about $22 billion worth of maintenance needed. If we gave them
$22 billion in a year, they would not be able to execute that
workload.
Chairman Tester. I got you.
Mr. Liermann. So that is the manpower that we need to
actually execute the contracts, and oversee them as well.
Chairman Tester. That is helpful because I read it a
different direction, so thank you.
Let's talk about mental health for a second. The
department's request fully funds the Hannon Act, as has been
pointed out by several on this panel today on this rostrum, to
the previous panel. This is an important step for getting high-
quality mental health out to all veterans who need it, and we
all know that COVID-19 has not helped the mental health status.
But we know that staffing plays a major role in ensuring
veterans have the mental health that they need, and make sure
their needs are met.
Are there any staffing-related challenges that your members
are facing, and how would you suggest that the VA addresses
them, or better yet, how would you suggest that we address the
challenges so the VA can address them?
Mr. Murray. Chairman, it is essential that VA implement the
authorities that you have given them, the John Hannon Act, and
so forth, and fully ensure that all the things that are in
place are implemented, and veterans can receive the mental
health services that they deserve. Right now, as you know, with
the staffing challenges, a lot of the staffing challenges are
clinical service-wise, and when you have those types of
challenges, it creates burnout amongst the staff that are there
doing the work.
So VA needs to ensure that they have a sufficient staffing
plan that they can share with you, to demonstrate how they are
going to decrease the staffing shortages, but also ensure that
the authorities that you have given them to help offset some of
the services being provided in-house can also be provided
through the other means made available to them.
Chairman Tester. Thank you. Senator Moran?
Senator Moran. Chairman, thank you. Gentlemen, thank you
very much.
The VA's budget for 2022 proposes spending from all sources
for medical care that is $17.5 billion more than the IB's
recommendation. That is a 17 percent difference. Where does
that come from?
Mr. Murray. Frankly, Senator, as the Secretary mentioned,
COVID. There are a lot of details that we do not have as
accurate information as the department does. But our
recommendations come off of trends, come off of what we have
seen, basically appointments, as was also discussed,
appointments is not the most accurate way when you are talking
about the complexity of the appointments. So that is some of
the difference there, that we are basing ours off of
appointments, which I am sure we would love to see more about
their information. But that is the difference.
Senator Moran. Okay. Thank you.
Mr. Butler. Let me also add, VA released their budget---I
mean, the IB released their budget in February. As Shane was
saying, or Patrick was saying, Mr. Murray was saying, is that,
you know, VA recently released their budget, and so additional
information was made available to them that we did not have at
the time that we released our budget. But our assessment was an
independent assessment of, at that time, what we felt was the
need.
Senator Moran. Thank you both. The Independent Budget's
estimate for community care assumes that the existing access
standards remain in place. I did not say it quite right. Is
that true? So you are estimating the need, the dollars
necessary for community care, we have community care standard
in place. I assume that your estimate would be based upon those
community care standards staying in place as they are.
Mr. Murray. Yes, sir, until the next period to review them
would be, yes.
Senator Moran. Okay. Thank you. You noted, in your
testimony, the importance of a couple of economic programs that
I consider important and have championed, such as the Veteran
Rapid Retraining Program and then the VET TEC Act. Do you have
any suggestion for how we make certain we have the right kind
of data for these programs that would tell us how we can
improve employability and mitigate loss of earnings,
particularly for disabled veterans, going forward?
Mr. Murray. Absolutely. Thank you for bringing those up.
The VET TEC Program, we have seen great successes in so far. It
is a newer program, and increasing the capacity, the number of
slots available we think is very important. It originally
started at about 15,000, doubled, now it is to 45,000. There is
a bill to increase it to about 125,000. The demand is there.
There are a lot of people looking to go back to work through
that program.
The Veteran Rapid Retraining Program, some of the last
numbers there were about a few thousand applicants so far, so
that is getting off the ground. We are very excited about that
program. It takes some of the existing employment along with
some of the BAH model payments that the GI Bill has, and kind
of a hybrid, to get folks back to work.
We are very encouraged by what we have seen so far, and I
think transparent, regular reporting about those programs would
really help, to let us know where we need to almost double
down. If we are going to invest in programs that are going to
put people back to work, you know, putting food on the table,
paying taxes back into the system, that is important for us to
know exactly how successful those are.
Senator Moran. You said it very well. Thank you, Mr.
Murray. Chairman, I will yield back my time.
Chairman Tester. Senator Hirono?
SENATOR MAZIE HIRONO
Senator Hirono. Thank you, Mr. Chairman. Thank you, all of
you on the panel, for your advocacy on behalf of veterans.
I want to get to the subject of reproductive health, so
this is for Mr. Butler and Mr. Liermann. Am I pronouncing your
name correctly? So increasing health services for women at VA
facilities necessarily includes reproductive care. Would you
agree?
So does this budget, in your opinion, support reproductive
care, especially as it relates to women veterans with service-
connected conditions that may impact their ability to have
children? Any of you can respond to that.
Mr. Butler. I think the Independent Budget recommendation
support the necessary increase for IVF, and that we fully
support that recommendation.
Senator Hirono. So the question was specifically whether it
is adequate to provide reproductive health services to women
veterans. Have you been in contact with advocacy groups for
women veterans on this point, whether they think it is enough
funding?
Mr. Butler. We have, and our contact at PVA has spoken with
many advocates of women veterans, and they support PVA's budget
recommendations.
Senator Hirono. Good, because we are making progress,
because at least now we are recognizing this is an important
aspect of what should be made available, services to women
veterans.
Not too long ago eliminating homelessness among the
veterans community was the No. 1 priority for the VA, and
Secretary McDonough's statement notes that it still is among
those, but it is no longer the top priority. Obviously with
COVID there are even more veterans who are homeless. Correct?
So are you satisfied that the VA is doing what is necessary
or doing all that it can to eliminate homelessness among
veterans, and if not, what should they be doing?
Mr. Butler. Well, this predates back to Secretary
Shinseki's statement about----
Senator Hirono. Yes, I know. I was here then.
Mr. Butler [continuing]. calling to eliminate homelessness
and the initiative that he put forth. So over the past
administration, since Secretary Shinseki left, there has been,
in our opinion, a lack of increasing in eliminating
homelessness. There are some examples of where they did not
spend all of the money that they should have spent toward that
initiative.
So we would like to see the VA renew its efforts in
eliminating homelessness across the nation.
Senator Hirono. Well, you are nodding your head. Did you
want to add something to this, Mr. Liermann?
Mr. Liermann. No, I agree with Mr. Butler's comments. If
you take a look at some of the legislation that has been
introduced lately, talking about increasing grants and
increasing more funding for other organizations that are able
to provide those, we absolutely agree.
Then when you try to think of what is the priority, right,
homelessness, absolutely. Suicide, absolutely. Mental health
services, providing women veterans with what they need. So we
believe, and we are all committed, as part of the DAV, to find
ways to eliminate and find the right balance of funding for all
of these programs.
I think trying to say that one should be a priority over
another is very difficult do when they are all just as
important as the other, but I do agree that we do need to
increase that commitment and renew it. Veterans should not be
homeless when there is a means to get them the help they need.
Senator Hirono. I think we need to become a lot more
creative about our approaches, because homelessness among
veterans, it is not a monolithic issue. There is a lot that you
have to delve into to figure out, you know, how we can house
the veterans, how can we provide them with the training they
need, if they need training to get jobs, all of that. It is
interconnected. So when we talk about mental health needs, that
also relates to homelessness, I would say. Suicide also.
So there is an interconnectedness, and I do not know if the
VA has really embarked on much more of an interconnected
approach to eliminating homelessness among veterans, but what
could be--I can't say more important, I knowledge all these
things are important. This has been just a perennial issue, and
it is very troubling.
Cemetery maintenance. The National Memorial Center of the
Pacific, Punchbowl--have you all been there? It is quite the
facility, yes--anyway, currently has a number of deferred
maintenance projects, some of which have been on the books for
nearly 10 years. Now your testimony applauded VA's budget
request for the National Cemetery Administration. So knowing
that, for example, the Punchbowl facility has been waiting for
over 10 years for some needed improvements, do you still think
that the funding for the National Cemetery Administration is
adequate?
Mr. Murray. Ma'am, one of the things that we would really
like to see happen is to almost clear the deck of some of these
outstanding projects, much the same way that state veterans
homes recently, there was about $500 million given to kind of
take out that priority list. We think that especially projects
like Punchbowl, as you mentioned, and cemeteries around the
country that have very similar challenges--you know, space,
they need to actually just put in the right facilities in order
to place our nation's heroes. That facility mirrors other
challenges around the country, and we think that those are ways
that we can just clear that deck, by adding infrastructure
moneys to actually address some of these longstanding project
issues.
Senator Hirono. Well, that is the thing--and I am sorry,
Mr. Chairman--but I would love to clear the decks on all of
these things. You know that we are on the page with you all,
but obviously the need exceeds the funds available, not to
mention that there are communities of veterans still waiting
for, for example, CBOCs to be built. And, you know, we have had
situations on Oahu, for example, where the community has been
waiting for like 5, 6, 7, 8 years. So, you know, those need to
be cleared too.
So I would just like to see the VA, especially under
Secretary McDonough's leadership, have a sense of urgency, and
let's get on with all of these things. So I got that off my
chest, Mr. Chairman.
Chairman Tester. That's good. Senator Sullivan?
SENATOR DAN SULLIVAN
Senator Sullivan. Thank you, Mr. Chairman. Gentlemen,
thanks. Mr. Secretary, thanks. Sorry I missed the first panel.
Man, that went fast. We had a bunch of votes, but maybe I will
call you and give you kind of update on some of the issues I am
focused on, one of which I was going to ask the Secretary but I
want to ask our VSO leadership. It goes to this issue of VA-DoD
integration. You know, we have that in Chicago. It is a good
way to actually save money but expand services. You do not have
a lot of those opportunities throughout the country, really
throughout the federal government.
In Alaska, over 40 percent of our residents are federal
health care beneficiaries. That is VA or DoD kind of related,
which is really pretty big. I think it is one of the biggest
per capita, if not the biggest in the country. But we do not
even have a full-service VA hospital, in the whole state. More
vets per capita than any state in the country.
What is the general view, from you guys' perspective, on
those kind of opportunities--VA-DoD integration in terms of
hospitals and health care?
Mr. Murray. Senator, one of the things that we really think
is critical for VA is flexibility. Hopefully the AIR Commission
is going to provide a lot of answers. As you mentioned,
Chicago. There are other places where they can have
partnerships, the public-private partnerships.
Senator Sullivan. I am pushing this in the NDAA this year.
I think the VA is supportive. But Alaska, to me, I know Senator
Hassan mentioned it a little bit ago, but I think we are kind
of a pole position for that.
Mr. Murray. But shared facilities is another flexible one.
Reviewing the lease authority so that they can execute the
leases that are different than the 10-year moneys needed up
front. But also looking at areas like medical schools, so that
they could partner with places that need a place to train. VA
has been a training organization for years. Over 70 percent of
physicians have been trained at VA facilities at one point in
their career.
Partnering with folks like that, with organizations like
that, we think is important, and giving them the authority to
start those sharing facilities from the ground up, not going
into an existing one and trying to create an authority to share
it once there is already an existing facility in place, but
actually starting from, you know, digging the first shovel in
the dirt. They do not have that right now. I think that would
help add to the flexibility.
Senator Sullivan. Good. I am glad you mentioned medical
schools. We do not have a medical school in Alaska,
unfortunately, but we did have legislation a couple of years
ago that had VA residency programs with our Alaska Native
health organizations. It was very popular. We are implementing
it now, so that is another good example on flexibility. Shane,
anyone else, gentlemen, you have views on that first question I
asked?
Mr. Liermann. Absolutely. Thank you, Senator. Evidence
shows, and what we know is veterans do better with VA health
care. They thrive. They have better preventative maintenance
and they are just long term going to do better. So if we can
find ways to provide that with these partnerships and with
other facilities, other organizations, it is going to benefit
veterans in the long run. It is hard to believe there is not a
full hospital there, but providing that access is extremely
important.
I come from a very rural part of the country as well,
Nebraska, and the nearest VA facility was over 3 hours from
where I was living at the time. They have increased CBOCs in
those areas, but again, to the point, when you cannot have
access to the health care we need to find that flexibility, as
Pat mentioned, to get them, because we know they do better with
VA health care.
Senator Sullivan. Okay. Mr. Butler, do you have a view,
sir?
Mr. Butler. Well, the Chicago facility has demonstrated to
be a proven model. I have also been to Alaska and seen now the
integration between DoD and the Alaskan health care system
works together.
So I think that there is opportunities for improvement in
those areas, and expansion in those areas. So there should be
serious concerns, and hopefully this administration will look
to do more in those efforts.
Senator Sullivan. Good. Thank you. Let me go back, Mr.
Liermann, real quick, on the burn pit exposure. You know, my
legislation with Senator Manchin, you have been really strong
supporters of. You referenced in your opening statement
challenges with the current claims backlog.
What we are trying to do here, as you know, is get in front
of this, not having an Agent Orange-type of situation, but also
make sure the VA is getting the science right and making sure
that we can afford this, so there is a balance. One issue that
a lot of people forget, if you do massive amounts in this area
you start to crowd out people who are already in the system.
Can you kind of unpack a little bit more of the reference
you made in your opening statement on the claims backlog and
what you think, in addition to my legislation, needs to happen?
Mr. Liermann. Thank you, Senator. With over roughly 190,000
pending claims right now, and then we know that VA now has to
add the newer implications, Blue Water Navy, Agent Orange
cases, the three new presumptives that are starting, any new
additional presumptive diseases that would be added, or new
exposures, based on my experience in 2010, when VA added three
additional exposures at that time, it really did create a
significant amount of additional work, and it really did add to
the backlog of pending claims throughout the VA.
So going forward, we need to be mindful that if we are
going to add additional presumptive disease and exposures that
VA is very well prepared with the number of people in place,
and a plan in place before they start, so we do not add an
additional one-to 2-year wait on claims, as we have seen in the
past.
Senator Sullivan. Yes. It is a huge issue, and I think--I
am not sure this committee is thinking through that well
enough. We do not want to create a giant backlog by doing
something we all think--and trust me, I have been, you know, on
the front foot on this one for quite a while--what we think we
are doing right, but then there are consequences that we are
creating even more wait times for not just burn pit exposure
veterans but Blue Water Navy, I mean, just the list gets long.
Any thoughts on that?
Mr. Murray. Yes. We agree with you that we need to be
mindful of that. But this is not necessarily a new problem. The
scope of what we are talking about is new. This might be larger
than anything we have talked about, but in terms of an influx
of new claims, we have seen that. In terms of it creating a
backlog, we have seen that. So moving forward, when this
passes, we want to see that there are resources dedicated up
front, so we can do what we can to mitigate that, so we do not
run into that problem again. It is the same problem we have
seen. This will maybe be something a little bit more expansive,
but we should be able to get ahead of it.
Senator Sullivan. Yes. We have seen this movie before. The
committee and the VA need to be ready for it, right? We know it
is coming. We have just got to comprehensively look at how to
address it. Mr. Butler, do you have any views on that?
Mr. Butler. No.
Senator Sullivan. [Presiding.] Okay. All right. I think I
have been given the gavel here, and so I want to thank the
Secretary and the VSOs, the leadership here. We make a promise
to those who serve our country, and if the VA is going to
deliver on them they need the resources to do it. I am
supportive of that increase.
I am not sure if I should raise it, but I am going to raise
it anyways. This administration has put forward a budget that
actually cuts the Department of Defense, adjusted for
inflation. That is not good. That is not good. I know that is
not you guys' area, but you guys care about it. My veterans
back home in Alaska, they care about the VA budget. They care
about the DoD budget too. We should not be cutting the DoD
budget, but that's a whole other topic.
We will keep the record open for a week. Mr. Secretary, I
know there were a number of us who wanted to--I did not get
here in time for your testimony. It was not at all disrespect.
It was just the votes. So I am sure there are going to be
questions submitted for the record for you, sir.
Other than that, I want to thank the witnesses for their
service, particularly to our great veterans, and this hearing
is now adjourned.
[Whereupon, at 4:29 p.m., the Committee was adjourned.]
APPENDIX
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