An End-of-Year Look at the State of VA: Senate Hearing 117-567, December 1, 2021
Summary
Transcript of S. Hrg. 117-567, "An End-of-Year Look at the State of VA," a December 1, 2021 hearing of the Committee on Veterans' Affairs, chaired by Jon Tester with Jerry Moran as Ranking Member. The sole witness was The Honorable Denis McDonough, Secretary of Veterans Affairs, and senators including Margaret Wood Hassan, Thom Tillis, Mazie K. Hirono and Marsha Blackburn questioned the Secretary. The appendix holds the Secretary's prepared statement, Department of Veterans Affairs responses to questions for the record, and submissions for the record. The record was to stay open for a week, and the Committee adjourned at 5:07 p.m.
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“An End-of-Year Look at the State of VA: Senate Hearing 117-567, December 1, 2021.”
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[Senate Hearing 117-567]
[From the U.S. Government Publishing Office]
S. Hrg. 117-567
AN END-OF-YEAR LOOK AT THE STATE OF VA
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
----------
DECEMBER 1, 2021
----------
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.govinfo.gov
AN END-OF-YEAR LOOK AT THE STATE OF VA
S. Hrg. 117-567
AN END-OF-YEAR LOOK AT THE STATE OF VA
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
__________
DECEMBER 1, 2021
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
50-550 WASHINGTON : 2024
SENATE COMMITTEE ON VETERANS' AFFAIRS
Jon Tester, Montana, Chairman
Patty Murray, Washington Jerry Moran, Kansas, Ranking
Bernard Sanders, Vermont Member
Sherrod Brown, Ohio John Boozman, Arkansas
Richard Blumenthal, Connecticut Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii Mike Rounds, South Dakota
Joe Manchin III, West Virginia Thom Tillis, North Carolina
Kyrsten Sinema, Arizona Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire Marsha Blackburn, Tennessee
Kevin Cramer, North Dakota
Tommy Tuberville, Alabama
Tony McClain, Staff Director
Jon Towers, Republican Staff Director
C O N T E N T S
----------
December 1, 2021
SENATORS
Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............ 1
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas...... 2
Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire...... 10
Tillis, Hon. Thom, U.S. Senator from North Carolina.............. 12
Hirono, Hon. Mazie K., U.S. Senator from Hawaii.................. 14
Blackburn, Hon. Marsha, U.S. Senator from Tennessee.............. 16
Brown, Hon. Sherrod, U.S. Senator from Ohio...................... 18
Tuberville, Hon. Tommy, U.S. Senator from Alabama................ 20
Murray, Hon. Patty, U.S. Senator from Washington................. 22
Rounds, Hon. Mike, U.S. Senator from South Dakota................ 24
Blumenthal, Hon. Richard, U.S. Senator from Connecticut.......... 26
Sullivan, Hon. Dan, U.S. Senator from Alaska..................... 28
Manchin III, Hon. Joe, U.S. Senator from West Virginia........... 30
Cramer, Hon. Kevin, U.S. Senator from North Dakota............... 33
Sinema, Hon. Kyrsten, U.S. Senator from Arizona.................. 36
WITNESS
The Honorable Denis McDonough, Secretary of Veterans Affairs..... 3
APPENDIX
Prepared Statement
The Honorable Denis McDonough, Secretary of Veterans Affairs..... 45
Questions for the Record
Department of Veterans Affairs response to questions submitted
by:
Hon. Sherrod Brown............................................. 59
Hon. Richard Blumenthal........................................ 61
Hon. Mazie K. Hirono........................................... 68
Hon. Jerry Moran............................................... 75
Hon. Marsha Blackburn.......................................... 92
Hon. Tommy Tuberville.......................................... 93
Submissions for the Record
Labat-Anderson Incorporated, Palomares Nuclear Weapons Accident,
Revised Dose Evaluation Report, April 2001..................... 97
U.S. Air Force Safety Center, 2020 Topical Issues for Assessment
of Dose to Palomares Accident Recovery Workers (1966).......... 234
AN END-OF-YEAR LOOK AT THE STATE OF VA
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WEDNESDAY, DECEMBER 1, 2021
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 3 p.m., via Webex
and in Room SR-418, Russell Senate Office Building, Hon. Jon
Tester, Chairman of the Committee, presiding.
Present: Tester, Murray, Brown, Blumenthal, Hirono,
Manchin, Sinema, Hassan, Moran, Boozman, Cassidy, Rounds,
Tillis, Sullivan, Blackburn, Cramer, and Tuberville.
OPENING STATEMENT OF CHAIRMAN JON TESTER
Chairman Tester. I want to call this Senate Veterans'
Affairs Committee meeting together. Today we are here to take
stock on how the VA is doing and where it is headed in 2022. I
want to welcome our only witness today, the Honorable Secretary
Denis McDonough, for today's discussion.
Mr. Secretary, you have been a great partner and I
appreciate your leadership and your transparency and your
candor. You initially assumed your role in the middle of a
pandemic, and we all commend your team's efforts to care for
and vaccinate as many veterans as possible in the fight against
COVID-19. Today more than 3.7 million veterans have been fully
vaccinated by the VA and more than 105,000 veteran spouses and
caregivers have been vaccinated by the VA through our
bipartisan Saves Lives Act, which was enacted earlier this
year.
Running VA is a challenge, not just because it is the
Nation's largest integrated health care system but because of
the unique role it plays in all of our communities. VA provides
veterans with wraparound services and coordinated care, makes
huge investments in training our Nation's health workforce. It
also serves as a national backstop to overwhelmed hospitals and
health systems through its Fourth Mission.
And unlike the private sector, the VA has the benefit of
watchdogs organizations like the Office of Inspector General
and Government Accountability Office that point out
deficiencies and opportunities in VA care and programs. This
helps us, the Senate, ensure that the VA is doing all it can to
provide veterans with holistic, high quality, and timely care,
something that we are not fully ensured when veterans go into
the community for their care.
As we look to the year ahead, I know that there is a shared
commitment, of this Committee and of yours, on toxic exposure.
Veterans cannot afford to wait any longer for the care and
benefits that they have earned and deserve. I look forward to
working with you and Ranking Member Moran and other members to
ensure that these veterans are not left behind.
Another issue I want to highlight here today is the
caregiver program. The MISSION Act required VA to expand the
program to veterans of all areas by October 2021. The VA has
delayed full implementation until October of next year. By
missing this deadline, veterans and their caregivers have to
wait even longer for the support and resources that they are
due. I would like to get your assurance that the VA will work
to expedite this timeline while also ensuring veterans are not
unfairly denied. I know you share this commitment to do right
by our veterans because you always have.
I look forward to hearing more about your nearly first year
on the job and where the VA is headed.
And now I want to hand it over to my friend and Ranking
Member, Senator Jerry Moran.
OPENING STATEMENT OF SENATOR JERRY MORAN
Senator Moran. Mr. Chairman, thank you, and Mr. Secretary,
thank you for your service. Thank you for your service
specifically as the Secretary of the Department of Veterans
Affairs. The Kansan in me has to give you a compliment. I
appreciate the way you have conducted yourself before I provide
some criticism here momentarily. And while we are smiling about
that criticism, it is sincerely offered. I do not want to make
light of it.
Congress determined that the most effective way for
veterans to receive health care is to provide them with a
choice of where they receive that care, in the VA or from a
provider that is in their community. Under the MISSION Act the
law is clear. Through the access standards or through a
veteran's own consultation with his or her clinician, VA must
provide that choice.
Despite what the law says, I continue to hear, my staff
continues to hear about veterans, through the press, through
disclosures to my office, of those people who have not been
able to fully exercise their choice because the VA
administrators are discouraging the use of community care and
even overruling clinicians who seek community care for their
patients.
I had planned to comment on your inability, the
Department's inability to provide me with answers to what
should be a routine oversight request as we investigate these
reports and these disclosures. However, the Department provided
us with your responses to a request that stretches back to
October 4th yesterday afternoon. Should I have been provided
this information in a more timely manner we could have had a
more robust conversation today. I might have been better able
to analyze your answers to my concerns on a topic that is
critical to me, and, in my view, critical to the health of our
business.
Unfortunately, requests related to community care are not
the only outstanding oversight request. We still have not
received a response to our letter from October 27th, seeking
information and data related to the coronavirus vaccine
mandate. Although the vaccination deadline has passed for all
VA employees, the Committee has had very little information on
what impact the mandate has had on the workforce.
This is the positive point. I appreciate the views we
received from the Department on the Cost of War Act. These
views and cost estimates will help determine how best to
provide health care and benefits to veterans who were exposed
to toxic substances. I applaud the VA's recent efforts to
establish presumptive decisions related to toxic exposure.
However, we have yet to be briefed on the findings of the VA's
end-to-end internal review that resulted in the VA's
presumptive decision-making pilot program. The result of that
review is important from an oversight perspective. It also can
help us better understand the mechanics of the VA's process as
we draft legislation on this important topic.
I expect us to continue working closely together to
identify the remaining gaps in the VA's authority, refine
operational impacts on estimates, and develop legislation to
address veterans sickened by exposure to toxic substances.
Mr. Secretary, I look forward to your testimony and I thank
you for your service.
Mr. Chairman, I yield.
Senator Tester. Thank you, Senator Moran.
I would like to welcome our first and only panelist of the
day, the Honorable Denis McDonough, Secretary of Veterans
Affairs.
Secretary McDonough, the floor is yours.
STATEMENT OF THE HON. DENIS MCDONOUGH
Secretary McDonough. Chairman, thank you very much, Ranking
Member Moran, distinguished members of the Committee, thank you
for your support of veterans and for the opportunity to testify
before you today.
Our mission at VA is very simple and it goes back to what I
first said when I testified before you back in January. We must
serve veterans, their families, caregivers, and survivors as
well as they have served us. That is the promise we make at VA,
and between the pandemic and everything else that has happened
this year, keeping that promise to vets has never been more
important than it is right now.
Fortunately, throughout the past year, VA employees, many
of whom are vets themselves, have stepped up across the country
to fulfill that obligation. Employees like Bobie Smith in
Tennessee, who helped a veteran who had been struggling with
alcohol and substance use find a purpose again through our
compensated work program. Like Lindsay Daly, a call center
supervisor in Arizona who spoke at length with a veteran in
need, found out that he was teetering on the brink of
homelessness and got him housing assistance before it was too
late. Or like Herman Watkins, Michael Foster, and Brian Hudson
of the Alabama National Cemetery, who saw a surviving spouse
grieving at her husband's gravesite, discovered that she was
struggling with suicidal thoughts, got her the help she needed,
and, as she describes it, saved her life that day.
I tell those stories because those public servants are not
the exception at VA. They are the rule. And the work they have
done during the pandemic has not only helped us respond to
COVID but forged us into a stronger, better Department for our
Nation's veterans.
We have seen more patients via direct and, I underscore,
community care, processed more claims, and held more benefits
hearings than in any previous year in VA's history. We have
massively ramped up telehealth and tele-appeals, allowing us to
meet vets where they want, when they want, in unprecedented
ways. Our outpatient trust scores among vets rose to 90
percent, above 90 percent, the highest in years, and we
vaccinated, as you said, more than 4 million vets and others,
and led the charge in Federal Government on the employee
vaccine requirements.
We have cared for non-vets as part of our Fourth Mission,
deploying staff to hotspots and providing beds for hundreds of
COVID patients in need. And our cemeteries have not only stayed
open during the pandemic but expanded to six new locations.
So the state of VA is that we are now providing more care,
more services, and more benefits to more veterans than ever
before, and we are doing it by driving toward four fundamental
principles: advocacy, access, outcomes, and excellence.
Advocacy. Advocating for vets is a team effort, from the
White House to VA to Congress to vet service organizations, and
this year that team effort has resulted in lifesaving
legislation like the American Rescue Plan and the Save Lives
Act. It also resulted in a fiscal year 2022 budget that
delivers for veterans and for which I ask Congress to
appropriate funds as soon as possible to avoid a year-long
continuing resolution that would directly harm our Nation's
vets. And it has resulted in real progress and new presumptives
on environmental exposures, making President Biden the first
President to proactively provide benefits to vets who have
fought our wars in the Middle East and South Asia for the past
30 years, and, more importantly, ensuring that thousands of
those vets are finally getting the benefits they deserve.
Second, access. We are making sure that veterans have
access to the best care and services, at home, in the
community, and at VA. That means supporting caregivers. It
means finding the right balance between direct care and
community care, because veterans deserve a thriving and
sustainable direct care system, one that ensures that future
generations of veterans will enjoy the same great VA health
care that past generations have.
I underscore here in the letter, Senator Moran, I was
responding to a letter of November 12, so it may be that I
missed an earlier letter. But in any case I wanted to get that
in the briefing we gave to your staff to you, so we could have
that kind of conversation today and continue what I have
considered a very rich conversation in private as well.
It means reaching out to every vet who deferred care during
the pandemic, which we are doing through VHA's Moving Forward
Together campaign, to let vets know that we are here for them,
ready to offer timely, face-to-face, world-class care. And it
means deploying an electronic health record system that
improves access outcomes for vets wherever they get the care.
Third, on outcomes, which drive everything we do because
vets, not us, are the ultimately judges of our success. Two
important outcomes are addressing veteran suicide and veteran
homelessness, two phrases that simply should not exist in the
English language.
On preventing veteran suicide, we have held more telehealth
sessions than ever before, massively ramped up our lethal means
safety efforts, and reached out to every single veteran in our
network to let them know that they are not alone, especially in
the aftermath of Afghanistan.
And on ending veteran homelessness, we are making progress
in Los Angeles, where there are more homeless vets than
anywhere else in America, therefore building momentum toward
housing every one of the more than 40,000 homeless vets in the
country. Addressing these issues is a top priority because one
veteran who dies by suicide or who is homeless is one too many.
Finally, on excellence, I can just underscore one more time
that in this Administration nobody is going to have to fight to
get the quality care, benefits, and services they have earned,
no matter who they are, where they come from, or who they love.
So that the VA right now, delivering more care, more
benefits, more services to more vets than ever before. But the
state of VA is not just where we are now. It is about looking
around the corner to where we are going. Let's be honest--there
are some real challenges.
Looking ahead to this winter, we are going to be releasing
the AIR Commission recommendations, and I again encourage each
of you and your staffs to get the briefings from our teams now
on the market assessments in your States. Because we are on the
verge of some very big decisions here, and you should
understand the analytic basis for those decisions.
At the same time, we may be facing an increase in COVID,
which is already brewing across the country with the Delta
variant, even as we seek greater clarity on Omicron.
But I promise you this. We will learn from everything we
have done over the past 20 months to meet this moment. We are
already doing that in a place like Michigan, where we have more
than 35 beds at the ready for vets and non-vets alike, and in
places like Nebraska and Washington, where we have deployed
staff to State veteran homes to make sure they have the
capacity and training they need to help keep vets through this
coming surge.
The bottom line is that we will learn from last year to
prepare for next year. We will see veterans through this surge
and all of those coming challenges. We will work with this
Committee and keep you informed every step of the way as we do
it, because vets, their families, caregivers, and survivors
deserve our very best. And with your continued help and
partnership we will never settle for anything less.
Thanks for the opportunity to be here today. I look very
much forward to the conversation and your questions.
[The prepared statement of Secretary McDonough appears on
page 45 of the Appendix.]
Senator Tester. Mr. Secretary, thank you for your
statement. You have been on the job for almost a year. I do not
need to tell you how important the job that you are doing is
for our veterans, vitally important. So what has been the
biggest challenge and what has been the biggest success for the
Department during your tenure?
Secretary McDonough. The biggest challenge is most
definitely the pandemic. It has colored everything we do. It
impacts our vets and it impacts our workforce. And so I, as I
said in my opening remarks, take great pride in the fact that
we have led the Nation on vaccination, both as it relates to
veterans, and thanks to you all, veteran spouses and family
members, as well as our workforce.
I am equally proud of our work on toxic exposure.
The biggest complication that we face is the flip side of
the pandemic, which is our workforce is now 20 months into
extraordinary efforts. And there is no mobile work options for
clinicians in hospitals and clinics. They are working under
constant challenge associated with contracting COVID. They are
working in scenarios where their kids are, you know, over the
course of the last year, at homeschooling.
So I worry a great deal about ensuring that we keep that
workforce supported and its morale is where it should be, given
its high performance.
Senator Tester. So if you could, quickly if you could, tell
me what your top three priorities are going in for next year.
Secretary McDonough. One is getting vets timely access to
world-class health care. Two is getting vets timely access to
world-class benefits. I consider those two things to be core
course requirements. Anything else we do is extra credit,
meaning if we do not perform on getting timely access to care,
in the direct care system and in the community, and we do not
get timely access to benefits, anything else we do will not
matter.
The third priority is what you hit at the end of your
remarks. We are out of the gate, I would argue, strong on toxic
exposure, but we are nowhere near where we need to be, and I am
looking very much forward to continuing that progress,
including working with you all.
Senator Tester. I appreciate that. So right now it appears
that we are going to be working on a continuing resolution at
least until the end of January, maybe longer. I hope not but
maybe--maybe for the full year, actually. Included in the
Senate Appropriations Committee's passed 2022 is mandatory
funding needed to pay veterans' benefits resulting from the
Agent Orange presumptive, the new Agent Orange presumptive.
There is also discretionary funding to hire hundreds of claims
processors, additional processors.
Can you discuss how the VA is going to pay these veterans
their earned benefits and reduce the claim backlog if new
funding is not made available?
Secretary McDonough. Well I am very concerned about a year-
long continuing resolution. I think you just hit one of the big
detriments, which would be a $259 million decrement from what
we anticipated having to invest for toxic exposure at VBA,
staffing, and advancements in, for example, the digital GI
Bill. But there also would be a decrement of $941 million, for
example, in Community Care. That is a substantial hit.
Our challenge would be making do with a smaller allotment
for people. You know, we are out in the market right now,
hiring 2,000 people. We have about 900 already on board. They
have begun training. Under that scenario, we could get those
900 under a continuing resolution. We could get some of those
900 in seats. So we could continue to process some claims, but
it would inevitably lead to a longer backlog.
Senator Tester. So my daughter is CEO of a hospital in the
private sector. She has had a very difficult time getting
nurses. There are not enough to begin with, and now with the
traveling nurses getting paid big bucks, she is having a lot of
the nurses leave.
Could you just give me a quick update where the VA is as
far as workforce and what you see as the challenges, and if
there is anything we do to help you meet the challenges of a
fully staffed VA? And I can do the same for docs if you want.
Secretary McDonough. Yes. Look, first and foremost I just
want to underscore one more time how proud I am of that
workforce. Notwithstanding the huge challenges that they have
confronted they are performing extraordinarily well, first and
foremost.
Second--and I talked with Senator Boozman in Arkansas about
this last week--we have a series of OPM waivers that allow us,
for example, to hire people in as quick as three days during
the pandemic. Those are about five or six provisions that are
tied to the national emergency associated with the pandemic. If
that national emergency goes away we want to work with you to
incorporate those hiring authorities into authorization, into
statute. That is one place where we can work together. That
includes finding nurses.
Point three, we are asking the appropriators to give us
some flexibility on what we call the Three R's--relocation,
retention, and retraining--which would allow us, within the
existing budget envelope, to compete more aggressively to keep
our nurses, and to keep our docs, including our specialists.
We will, as we finish a review of other authorities, come
back to you with some requests--and this is basket four--where
we might work together, with your forbearance, to see about
doing away, for example, with the discrepancy between Title 5
employees at VHA and Title 38 employees at VHA, because the
multiple systems binds us up in unfortunate ways. But also
Title 5 is a lot less workable, frankly, for us than Title 38,
in a highly competitive market.
So I appreciate the question. That is the start of what we
are thinking. We will come back to you near the start of next
year with some additional ideas of how we are thinking about
nurse pay, doctor pay, importantly medical center director pay,
which is one of the big challenges between Title 5 and Title
38.
Senator Tester. I appreciate that. Senator Moran.
Senator Moran. Mr. Chairman, thank you.
Chairman, first of all on the idea of a continuing
resolution, there is absolutely no reason Congress cannot get
its work done. A continuing resolution is damaging, as you
described, to the Department of Veterans Affairs and most
importantly the veterans it serves, and there is no legitimate
reason that this Congress cannot resolve its differences on the
appropriations process. And I pledge to you and to Senator
Boozman, the Ranking Members of the Veteran Appropriations
Subcommittee, MILCON VA, and all my colleagues that we ought to
be all in on this, and we ought not let anybody have an
explanation, an excuse for why this cannot be done.
Senator Tester. Senator Moran, let's get 'er done.
Senator Moran. Let's get 'er done.
Let me start, Mr. Secretary, recently you were interviewed
on a number of news programs, and you indicated that if a
veteran is in need of urgent mental health services the VA will
provide that veteran with a same-day mental health appointment.
Is that correct, and could you walk me, the Committee through
how that process works. That is a great development, and it is
one of the things I worry about in rural America, where if you
need mental health services, if you are suicidal, you need that
attention immediately, and the VA, in some instances, is far
removed.
Secretary McDonough. Yep. So I want to distinguish between
emergency care and urgent care. So if we have a veteran who is
in emergency circumstances, a mental health requirement, for
example, manifests, at an emergency department or manifests on
the Veteran Crisis Line, we can get that veteran seen that day,
telehealth or in person, depending on distance. But if you come
to us through the Veteran Crisis Line, you come to us through
an emergency department, or you happen to manifest somewhere
else in a CBOC, community-based outpatient clinic, or in one of
our hospitals, we can get you there.
Urgent care, the word you used was ``urgent.'' Urgent care
is a degree less emergent, and we have looked back and done an
assessment over the course of the pandemic, and somebody
manifesting urgent care needs, mental health or physical
health, we are seeing an average of less than two days.
Senator Moran. I think I used the word ``urgent''----
Secretary McDonough. You did.
Senator Moran [continuing]. In the more----
Secretary McDonough. Well, that is why--I am not trying to
parse here, but I want to make sure you understand what I mean.
Senator Moran. I appreciate that distinction.
Secretary McDonough. And emergency would mean suicidal
ideation, for example, and this is why we have, and you guys
have given us as many resources as you have given us, for the
Veteran Crisis Line, for example.
Senator Moran. Is this a new development?
Secretary McDonough. Meaning the timeline?
Senator Moran. The capability to timely provide that
immediate care, that that-day care, is that something that is
new?
Secretary McDonough. It has always been our goal,
obviously. That is the definition of an emergency. But the
advancements at the Veteran Crisis Line, for example, allow us
to do that. So what happens is a veteran calls in to the
Veteran Crisis Line with suicidal ideation, we can locate where
he is, and during the time of that communication can then be in
touch with the emergency department where he closest to, to get
him then linked up to the emergency department. So the
technology has advanced to such a degree that it helps us to do
that. When precisely it happened, I do not know.
Senator Moran. Seven days a week, 365 days a year?
Secretary McDonough. Correct.
Senator Moran. Secretary, throughout the pandemic the
Department has maintained that ATLAS telehealth sites have been
a critical component to deliver care. I no longer remember--I
think it was your predecessor who was always talking about the
value of that ATLAS pod. I have been working with the VA and
the American Legion for more than a year to secure ATLAS sites
in Kansas, and you and I were in Emporia, where we discovered--
we did not discover but we knew that that was a site in which
an ATLAS pod was being placed.
My staff informed me today, as I came into this hearing,
that they were informed, not by the VA but by the American
Legion, that the Department's Office of Connected Care has
decided to begin a strategic assessment of the ATLAS program
which has paused delivery and planned clinical operations of
the Emporia site. That was not communicated to me. And
incidentally, the pod is developed. It has been made. And it is
now sitting in a warehouse unable to be used.
That ATLAS pod, again going back to suicide and mental
health issues, is one of the ways that we can deliver that kind
of care and meet those needs rapidly and in geographical
locations in which it is a challenge. Something has happened.
Your reactions suggest to me that you do not know what--I did
not mean it the way that it sounds, but that you are unaware of
this. I need your help in figuring out why this happened, and
if it does not make sense, which it does not to me, why we
would not complete this process.
Secretary McDonough. You have my commitment to get to the
bottom of it. In candor, I have heard--I have been in close
touch with the Legion as well. I have heard indications of
mixed success with some of the ATLAS pods. And we have been
looking at it as a general matter. I was not aware of the
decision on the Emporia pod, which you and I saw together, and
I regret both that it happened and I also regret that it was
not me who told you. So let me get to the bottom of it.
Senator Moran. And I do not know whether this is an
isolated instance or whether this is circumstances that are
occurring across the country in other of my colleagues' States.
My last question, for this round at least, Mr. Secretary.
Your written statement notes that veterans made over 33 million
visits to community care and over 78 million visits to VHA
facilities last year. Community care represents, then, about a
third of the total visits.
Looking at fiscal year 2021 appropriation levels, roughly
$18 billion was appropriated for community care and $76 billion
for VA medical care. These are not apples to apples, I
understand, but it would suggest that the cost of community
care is less than the cost of care within the VHA. Tell me what
I need to know about that.
Secretary McDonough. Yes. I mean, I guess I want to say a
series of things. One, I took to heart what you said. The last
time I appeared before you, you were unimpressed with the speed
with which we responded to one of your questions, one of your
letters. So I got this letter on November 12, and I said if
this is not signed out by the time I appear up there, somebody
is going to get chewed out.
Senator Moran. You know, before I leave here I am going to
be apologizing to you. Now stop.
[Laughter.]
Secretary McDonough. So that is one. Two, I understand kind
of the algebra that you are doing there, and on a certain level
I would say community care does provide absolutely important
opportunities and does so very competitively. For example, the
average urgent care appointment in the community, $164. When
you compare that to potential cost of an emergency room visit
or potential elapsed time before you can get to see a primary
care physician, even if we beat the 20-day target, that is an
absolutely great deal.
So if part of your question is, is community care a good
deal for us, it is. Community care is also the law of the land,
and we live by the law of the land. And the suggestion that
anybody who works for me is willingly breaking the law is
something I take really seriously.
And so every one of those newspaper stories that have
appeared I have been on the top of. Every one of the television
ads which made the assertions, we get to the bottom of. We will
continue to do it. But it is absolutely a critical tool for us.
Last point is because we invest so heavily in education,
training, research, and the coordination of care, it is really
incumbent on us, if we are going to continue to make best use
of care in the community that we get much better at
coordinating that care. Part of that is the electronic health
record, but part of that is our partners in the community and
the third-party administrator getting more serious about
running a professional network. And we are better now at paying
our bills on time. They have got to be better at providing
quality care on time, the way they promised, and at a cost that
is competitive.
And so that is what I would say to that. But again, A, it
is the law; B, it is really good for our vets; and C, at the
end of the day, it does not really matter what I think. It
matters what the vet chooses.
Senator Tester. Okay. Thank you. So I went over. Moran went
over. We both apologize. Let's try to keep it as close to five
as we can.
Senator Moran. I do not apologize. I just did what you did.
Senator Tester. I just did for you. Senator Hassan.
SENATOR MARGARET WOOD HASSAN
Senator Hassan. Thank you, Mr. Chair and Ranking Member for
this hearing, and Mr. Secretary, thank you for being here today
and it was good to see you yesterday.
Just to the point of needing more personnel trained up fast
I hope that the bill that the President signed into law
yesterday, that Senator Braun and I did, will really get the VA
much more proactive in recruiting health care workers from
active-duty members who are in their last year of service who
are already trained up by the United States military.
Look, I want to talk a little bit about what is going on in
New Hampshire. Obviously, support for our veterans is important
in all of our States. In my State of New Hampshire, veterans
make up more than 10 percent of our adult population, and the
VA projects that the number of VA enrollees in New Hampshire
will grow in the coming years.
In previous testimony you noted the need to modernize VA
health care facilities. It is especially true in underserved
areas like New Hampshire, one of the only States that lacks a
full-service VA hospital. As a VA New Hampshire Task Force
found in 2018, we need to improve specialty care services and
facilities, establish an ambulatory surgical center, build a
community living center, and improve parking to access these
facilities.
So, Mr. Secretary, I understand that the VA has internal
decision-making processes and you cannot get out ahead of that
in terms of making final decisions. But will you commit to
working with my office on finding a path forward for these
kinds of critical projects at VA facilities in New Hampshire?
Secretary McDonough. Yes, I will, and one, it was really
good to see you yesterday too. I have to say I much prefer
visiting the White House rather than working there. And it was
also nice to be there for the signing into law of those bills,
including yours, which is going to make a big difference for
us. So that is one.
Two, I make that commitment to you. Our teams have been
working together on this, as we discussed yesterday.
Importantly, if Build Back Better is enacted, there is $4.5
billion extra dollars for infrastructure there. That will be
managed through our internal processes, as you just talked
about.
I am also mindful of the fact that in the context of that,
New Hampshire projects will be, obviously, considered. There
are two projects currently in early stages of planning, both in
the areas you talked about, ambulatory surgery and a parking
garage. Analysis necessary to develop those projects is
underway.
The remaining two active minor constructions projects are
further ahead. That is ones at the Manchester VAMC. It is
currently developing a minor construction project for a
dedicated women's health clinic. And this project is moving
forward toward an early fiscal year 2023 construction contract
award. Additionally, a specialty care building is currently in
design, and is scheduled to be completed in the third quarter
of 2022, and considered then in 2023 construction funding.
So, we will stay on top of that. We will keep an open door
with you on that, as we do with everybody here, of course. But
it will be pursuant to our internal processes, but bottom line
is we work with you. My commitment on this is as rock-solid as
anything else on transparency and openness.
Senator Hassan. I appreciate that, and for our veterans who
do not have a full-service VA hospital in their State this is
just really, really critical.
Let me turn to another issue that I hear a lot about from
New Hampshire veterans and particularly New Hampshire National
Guardsmen and Reservists who swear to defend the Constitution
and this country, just like their active-duty counterparts, and
deserve the same respect and recognition.
So I introduced bipartisan legislation with Senators
Shaheen, Cramer, and Hoeven to reform the Veterans Cemetery
Grants Program to ensure that all members of reserve components
and the National Guard are eligible to be buried in State
veteran cemeteries. Veterans in my State strongly support this
bill, as do national veteran service organizations. The last
time you testified before this Committee you committed to
working with my office on this legislation, and we have had
good conversations. We have worked extensively with the VA, and
in particular the National Cemetery Administration, and I
believe we have found a path forward.
So just given the National Cemetery Administration's
support for this legislation, will you commit to implementing
it quickly once Congress is able to pass it into law?
Secretary McDonough. Yes. I mean, you raised this issue
with me. I took it for action. You know, Matt Quinn, who is the
second-best Montanan I know, took this on board and he has
worked it through. And so I think we are in a position--we have
enunciated our support for the provision and we will make sure
that it gets done.
Senator Hassan. Okay. Thank you. And last thing, just
because I am just about out of time, I had questions on toxic
exposure legislation, the TEAM Act that Senator Tillis and I
have introduced, and will follow up on the record. I will just
suggest that one of the provisions in there was just that the
VA could develop a questionnaire that would help them identify
veterans who have been exposed as part of the primary care
interaction. I think it could be something that the VA could
implement without us necessarily passing it into law, and I
think it would be a very important first step in really
identifying those veterans who have been exposed, just
integrating that into the quality care that you all are
striving to provide.
Secretary McDonough. A straightforward question. I think it
does sound like something we could do, and I will get you an
answer on that.
Senator Hassan. Okay. Thank you very much. Thank you, Mr.
Chairman.
Senator Tester. Thank you, Senator Hassan. Senator Tillis.
SENATOR THOM TILLIS
Senator Tillis. Thank you, Mr. Chair and Ranking Member,
and Senator Hassan, thank you for bringing up the TEAM Act, and
I look forward to us continuing to work on it.
I wanted to thank you for reaching out to me and talking
through the future governance structure and the management
structure for the VA. I do not know if the other members have
seen what I believe you announced formally today. The thing
that I like most about it is that we are really creating what I
would consider to be a classic program office for managing the
EHRM project, and I look forward to onboarding the person who
is going to lead that effort. It sounds like great experience
from the DoD.
I also hope that we can take what was a place on an org
chart that is not yet functional and that joint team with DoD,
because I do think that integration is going to be very
important. We have a lot to learn from there. So thank you for
sharing that information with me.
I did want to quickly, you touched on veteran suicide in
your opening comments, and I have introduced a bill called
Expanding the Families of Veterans Access to Mental Health
Services Act. It is a bill that I have introduced on my side.
We have a companion bill in the House. I do not know if the
Department has taken a position there but it is to recognize
that in the aftermath of a veteran suicide you have got a
family that could be in crisis, and we believe that having that
available to spouses and family members are very important.
Would you agree with that?
Secretary McDonough. Yes, very much so.
Senator Tillis. Thank you.
Secretary McDonough. And I will take a look at the bill. I
mean, among others, the assistance program for survivors, TAPS,
does great postvention work. This is something we are spending
a lot of time on through our Office of Mental Health and
Suicide Prevention. And so, I think what I hear from you about
the bill sounds like it is right on the same vector that we are
operating.
Senator Tillis. Yes, that would be really helpful as we
move forward, because we would like--if we have concurrence
from the Department it may be an expedient way to get that
done.
I do have a question about the integrated veteran care. I
think you all introduced this concept back in October, and I
have to say that when we are talking about trying to get timely
access to health care, either in a VA facility or in community
care, that we feel like we have hit some stumps or roadblocks.
I know the goal is to provide a seamless sort of access to
services and also working closely with the VSOs.
But maybe not for the purposes of this hearing--I have got
about two and a half minutes left--but I would really like to
get a better understanding of how that is going to compress
things, because it may just be the transition but we are
hearing that it may be causing some delays to get community
care or timely appointment.
Secretary McDonough. Well, the short answer is, in the
interest of time, we will stay close to you on this. Our whole
goal is to reduce kind of the overhead around the decision-
makers. Before we began to bring these two offices together--
the Office of Community Care and then the office of care in the
system; I forget what it is called precisely--we learned from
veterans that it created a lot of confusion, it probably added
to some of the time, but look, at the end of the day we own the
time. We own the clock. We have got to get shorter on this, as
a general matter.
I think it stands to reason that having one stop where the
vet does not have to make a choice which door he enters--he
just goes in there and works through his particular access
question and then ends up where he wants to end up, in the
community or in the direct care system--is the better way to do
this. I think it is unusual for us to start bringing down
overhead and reducing kind of people working on an issue. The
whole goal here is to make it a more streamlined process.
Senator Tillis. You also mentioned your priorities on
timely access to health care and timely access to VA benefits.
I think we have seen--and I am always looking for silver
linings in the COVID crisis--I think we saw that with
telehealth, and I am glad to hear that we are going to
institutionalize some of those things and move on. Of course,
if any of the things you are doing on the health side require
authority, we need to know that, whether or not it is within
your authority.
But I am also interested in whether or not you can apply
the same things that we did on the health care side to the
benefits side. Are you looking at how using a different
outreach, using tele-outreach, for example, what could we do to
expedite access to VA benefits?
Secretary McDonough. Yes. So one perfect example of that--
there is surely more for us to learn. Some of the hiring
authorities that have been so useful for VHA will be also
helpful to VBA, the Benefits Administration. But tele-appeals
have been extraordinarily effective at the Board of Veteran
Appeals.
Now, we are still pretty backlogged there, but to her great
good credit, the Chairman at the Board of Veterans Appeals has
gotten us in a position where we are doing many more tele-
appeals, meaning that it saves the vet a trip, it saves the
judge, you know, a trip, and we are looking for additional ways
to solidify that into practice.
On the regular benefits operation, I will be happy to come
back to you with some of our thoughts on that as well.
Senator Tillis. Okay. Thank you. Thank you, Mr. Chair.
Senator Tester. Thank you, Senator Tillis. Senator Hirono.
SENATOR MAZIE K. HIRONO
Senator Hirono. Thank you, Mr. Chairman. Mr. Secretary, I
know you are a can-do guy, and I really appreciate the fact
that you took the time after your confirmation hearing to
follow up with me regarding getting the ball rolling on a very
long-delayed clinic on Oahu, soon to be named the Akaka Clinic,
and we are actually going to be doing groundbreaking later this
month.
Secretary McDonough. I am really happy to hear that.
Senator Hirono. So I really thank you for that because that
is the kind of clinic that will provide community-based care
for our veterans. And you may or may not know that Tripler,
which is where part of their care occurs, there is no parking
and all kinds of issues there.
So at that time when we talked we had discussed making
changes to the leasing process to help other States avoid the
kind of delays that the ALOHA Project, which is the Akaka
Clinic, faced. Can you provide an update on any changes that
have been made?
Secretary McDonough. Yes. Importantly, in the House-passed
version of Build Back Better, there is a fix to the
Congressional Budget Office procedure on scoring leases. So
this will be not only important for Hawaii and for other very
high-cost localities but, frankly, for every member on the
Committee, given the slowness that we have had in fulfilling
leases because of what I would argue is the antiquated way we
score them for budget purposes. So, this would be another
benefit of enactment of the BBB, if we can get that done.
Senator Hirono. Yet another reason to pass BBB.
Oh, hi, Joe. I am kidding.
Mr. Manchin. No, you were not.
[Laughter.]
Senator Hirono. Of course not.
You know, you cited in your testimony the ten key
challenges areas, and it covers the gamut from suicide
prevention, homelessness, et cetera. So as you are completing a
year or so of your tenure, do you have any ongoing frustration
with regard to meeting the challenges of these programmatic
areas that you cited? Is there something overriding that we can
help you with?
Secretary McDonough. You know, I think there are two
things. I am very focused on the fact that we have asked the
workforce to do a lot in a relatively short time, and they have
done it under extraordinarily demanding situations and
pressures. And so that means I think it is time for us--that
and the very tight health care labor market--means that I think
it is time for us to take a step back to look at hiring
authorities, training authorities. And I have committed to all
of you on this Committee that we get back to you early in the
new year with a stepped-back look at each of those things.
That is our biggest challenge, frankly, is managing this
workforce of 420,000 people, and doing it in a way that, as the
market around them gets tighter, and therefore wages get much
more competitive, how do we stay competitive there? The fact is
we are pretty sticky with our health care professionals, in
particular. Turnover in our system is somewhere around 9
percent annually. It is a little less than that the two years
of the pandemic, meaning that people are staying longer, people
coming out of retirement to work in the context of the
pandemic.
So we have to figure out how we can amplify that so we can
keep these people on board.
Senator Hirono. I think we had already made some changes to
help with filling some vacancies, because the VA had a pretty
convoluted, kind of a lengthy process. So if there are other
things that we ought to do to enable you to recruit and keep
your staff, that would be good because they are providing the
kind of direct services to our veterans.
Just about every VA Secretary that I have worked with, and
it has been quite a number, have put homelessness as a major
priority, and I am wondering whether you are doing something
different to reduce the number of homeless veterans that we
have. Because at one point there was an effort to work with
mayors, for example, all across the country, and the mayor of
City and County of Honolulu was engaged. I mean, that is really
getting down to it. But yet we have homeless veterans.
So are you doing something different, unique, something to
make a difference?
Secretary McDonough. Yes. Well thank you very much. We have
prioritized, in the first instance here, closing what was
called Veterans Row in Los Angeles, which is what I thought a
shameful scenario where between 40 or 50 of our vets every
night were living homeless, just outside of our facility in
West LA. Everybody who was on that facility is now in either
transitional or sustainable housing. We also have a goal now
where we are about 400 people into a 500-person goal of getting
500 veterans between basically October 10th and the end of the
year in LA County into housing for the holidays. We are at
about 400. We set the goal of 500, and we are going to get to
and through that 500.
But we have also made a series of changes under the broad
rubric of what we call Housing First, which is the most
important thing is to get a vet into a house and then to take
care of all the issues that led to homelessness in the first
instance--joblessness, association with the justice system,
substance use disorder, mental health challenges. We have made
some changes there as well. For example, under some of our
programming we have increased the amount of the subsidy that
can be dedicated to rental assistance. We have extended the
period during which somebody can stay in emergency housing.
All of this is made possible by the fact that under the
American Rescue Plan and the CARES Act, you all have made an
unprecedented amount of assistance available for homelessness
programming, which brings me to your last point. We have the
resources from you all. We have established procedures that are
proven to get vets into houses and keep them there. All that is
missing now is will and execution, and we are going to bring
that part of it, and our goal is to get the more than 40,000
homeless veterans into houses.
Senator Hirono. Thank you.
Senator Tester. Thanks, Senator Hirono. Senator Blackburn.
SENATOR MARSHA BLACKBURN
Senator Blackburn. Thank you, Mr. Chairman, and Mr.
Secretary, thank you for your time.
Secretary McDonough. Nice to see you, Senator.
Senator Blackburn. It is good to see you. Let's talk about
the VBA backlog.
Secretary McDonough. Sure.
Senator Blackburn. As you know, we hear a lot about the
backlog.
Secretary McDonough. I bet you do.
Senator Blackburn. We hear a lot about wait times, and I do
want to touch base with you on those. So talk to me about where
you are, because right now my understanding is there is about
250,000.
Secretary McDonough. Yes.
Senator Blackburn. So what is your timeline for bringing
that up?
Secretary McDonough. Yes. So I will just give you a quick
snapshot of where we have been and where we are going.
Senator Blackburn. That is great.
Secretary McDonough. So when we came in we were at about
215,000--220,000 cases in the backlog. That number had tripled
in the context of the pandemic, importantly because early in
the pandemic we stopped doing, for example, some exams because
of concerns about safety for the veteran.
So that led to a big spike up.
We got that down to about 170,000. That bumped up again
when Blue Water Navy cases, last August, came along. We worked
that down to about 190,000. It then bumped back up to this
roughly 250,000-260,000 case mark in October, when the three
presumptives in last year's NDAA that you all were so critical
in getting us access to, as those came due.
So we are at about 260,000. Our plan is through the use of
funding made available and the American Rescue Plan, through
the hiring of 2,000 additional claims----
Senator Blackburn. Adjudicators.
Secretary McDonough [continuing]. Adjudicators, and
through, ideally, increased automation of these processes,
which I do not have news on yet but I hope we will----
Senator Blackburn. Right. If I can jump in right there, I
think that having staff willing--VA staff willing to do that
training and using that technology is going to be crucial to
this. If not, we are going to have the same problems we have
had with the EHRs, and I think we want to be able to move past.
Secretary McDonough. I am with you.
Senator Blackburn. Okay.
Secretary McDonough. Let me complete a thought, just so I
do not miss answering your question. So under that process,
which right now includes mandatory overtime, for example, by
April 2024 we will have under 100,000 cases in the backlog.
The last point is, just to your point about the team, we
are hiring 2,000 people right now. We have already hired 900.
Some portion of them--I do not have the exact number at the
moment--are in training at the moment. We think we will have
those, provided we get the funding through a regular
appropriations bill, we will have those people in chairs, those
2,000 in chairs, trained, at the end of the spring.
Senator Blackburn. Okay. All right. And let me ask you
about using community care, because what we are hearing, our
caseworkers here, from veterans who call and complain about
wait times, and then they will say, well, the option of
community care was not offered to them on the front end. So I
think this also speaks to training.
So why is that not being offered at the outset, because
that is a way to get that veteran to care more quickly?
Secretary McDonough. Definitely.
Senator Blackburn. And I think this is a missed
opportunity. So the VA staff members need to be able to
immediately offer that to them, to speed this process up. And
the other part of that is that it looks like the way wait times
are calculated, whether you are using the date that it is
requested or, you know, the patient indicated date, so that we
get a truer picture of what that wait time really is.
Secretary McDonough. Yes. So two questions which is--let me
work back.
Senator Blackburn. Okay.
Secretary McDonough. This question on calculation of the
wait time, I am only now getting smart on this. I think we have
been reporting it to you--I am under the impression that we
have been reporting it to you all from the point that the
referral is made, which is, as you say, the patient indicated.
Senator Blackburn. And not requested?
Secretary McDonough. No. Well, let me make sure that I
understand it on my end. In any case, I guess what I am trying
to do is to agree with you that if we need to rectify our
reporting through, you know, public documents we will make sure
we do.
I think that what I understand, from our team and from
their interactions with you all and your staffs, that we have
been reporting it to you pretty straightforwardly on a regular
basis now for many months--in fact, years. But let me get to
the bottom of that and make sure that we are on the same page
on that.
On whether veterans are being made aware of their options,
I guess what I would ask, Senator, is if there is something
like that where one of your veterans finds that he or she has
not been made aware of what their options are, please let us
know. Our person who runs that office is up here on a monthly
basis with your all's staff, going through every kind of comma,
period, and semicolon of our reporting on this. I am not saying
that the reporting is perfect, but I am saying that we are up
here pretty regularly to try to get to the bottom of these
cases.
Senator Blackburn. We will communicate with you further on
that because we have veterans on our staff who work with
veterans, and it seems like this is a far-too-common
occurrence, and we would like to help solve that problem.
Secretary McDonough. Good. That is what we would like to
do.
Senator Blackburn. Thank you. Thank you, Mr. Chairman.
Senator Tester. Thank you, Senator Blackburn. Senator
Brown.
SENATOR SHERROD BROWN
Senator Brown. Thank you, Mr. Chairman. And Mr. Secretary,
nice to see you.
Secretary McDonough. Nice to see you.
Senator Brown. Thank you for your exemplary service in two
administrations.
A few months ago you were in this Committee about the
electronic health record implementation. As you remember, your
strategic review of that program, the OIG's report, new patient
scheduling system needs improvement as VA expands its
implementation. You remember all that? It was designed by
Cerner.
Secretary McDonough. I do.
Senator Brown. Part of the broader HR. It is currently at
the facility in Columbus, and the report outlined some pretty
big issues that slowly timely care for veterans. The scheduling
system left some clinics and appointments, their term, out, and
lacked the tools to measure wait times, another serious area of
concern.
The new EHR will come to Columbus as soon as March, four
months from now. My office talks to their staff regularly and
will follow up with them as they prepare for the new system.
You know how hard these VA workers are working everywhere
in our States, and we have got to set them up for success with
this new EHR. I am not sure we are doing that. I would like to
ask your health record team, you and your health record team,
to brief me and my staff soon so we can understand----
Secretary McDonough. Absolutely.
Senator Brown [continuing]. How the concerns raised will
affect those workers and that implementation.
Secretary McDonough. Absolutely.
Senator Brown. Thank you for that.
On Veterans Day I held a roundtable. I typically do not do
big town halls. I do roundtables because it reminds me of
Lincoln. Lincoln used to say, ``Go out and get your public
opinion baths,'' and it is how you really learn from people,
and it was a Zoom roundtable in this case. But a vet named
Daniel shared a story and outlined his health complications. He
said--and it was painful to watch. He is wheelchair-bound. He
was very healthy when he entered the service. He was exposed to
burn pits. He has immense pain, oxygen full-time from a rare
lung disease. He shared that story, then he said he and his
wife had been denied the higher tier for the caregivers
program.
What do you say to somebody like Daniel and his wife, who
puts her whole heart into caregiving, other veterans like that
who have been denied the expanded veteran caregivers benefits,
or put into a lower tier? What do you say to them?
Secretary McDonough. Well, look. It is obviously
heartbreaking, one. Two, I have been talking to many of you all
about the caregivers program, and my sense is that you did not
pass the caregivers program so that 80 percent of applicants
would be denied. And so I have given guidance to our team that
that has got to change. So we are looking at regulation to
figure out how we do that.
And so what I would say to Daniel is I would say thank you,
and I would say the same to his wife. And I would also say that
we are looking, by virtue of our toxic exposure work, at rare
respiratory cancers and rare lung diseases for our next round
of presumptives. And then on the caregiver program, you know, I
cannot say it better than some of your colleagues have said it,
which you did not pass that program so that 80 percent of
people would be denied.
Senator Brown. And my understanding, from Ann, on my staff,
who is really knowledgeable about this, is that an estimated
6,700 legacy caregiver participants will be discharged from the
program due to the new criteria. Does VA have the authority to
make the necessary changes that they can remain in the program,
or do we need to act?
Secretary McDonough. So let's take a step back maybe on
three things about the caregiver program, just real quick. On
the legacy program, that expired basically at the end of last
September, on October 1, because we are now expanding into the
new program. So we are going back and we are looking at
everybody who was eligible under the legacy program. That is
19,000 people. We have communicated with about 2,000 of those
people and begun the reassessments of their cases.
I have seen the same estimation, which is that 6,700 people
may not qualify for the new program. That is an estimation. We
do not have hard data on that yet. In many ways, I hope that
some of those people who do not qualify, do not qualify because
they no longer need it, which would be a good-news story.
Senator Brown. But you do not know that for sure.
Secretary McDonough. I do not, but where we are then headed
is--so that is what we are doing. We are working through those
cases. In any case, if somebody is found to no longer qualify
for the legacy program, the soonest their participation in the
program, the enhanced program, would end would be 90 days after
October 1, 2022. Okay? So more than a year from today. If they
are found today to no longer qualify for the legacy program, it
would be another year-plus before the support of the program
would end. So that is the legacy program.
Then the question is, are we ready for the new program? So
we have hired about 1,900 people. We are going to hire another
400 people for that program. We will be focused on consistency
of decision-making for participation and authorization into the
program, and we will be focused on making sure that the program
is as Congress intended, and 8 in 10 people being denied is not
as you intended. Right?
But that brings me, third, to this question which is
related to caregivers and is related to this question of the
Beaudette case, where several people who have been denied
access have asked for the right and have been granted it under
an initial ruling to appeal that case in our Board of Veterans
Appeals.
We are contacting everybody who has been denied and making
sure they know of their right to appeal. We are not seeking an
injunction on that ruling. We will carry out those appeals. but
we are also going to appeal the ruling itself to a higher
court, or at least we have petitioned the solicitor general to
allow us to appeal. I hope to hear from them soon about that,
but I want to level with you, on this question of the Beaudette
ruling, which will be meaningful to you and your team and to
the caregivers. We will appeal that decision.
Bottom line, though, is we are better positioned to carry
out the expanded program. We are staffed up. We will carry out
consistently and consistent with your intent.
Senator Brown. Thank you, Mr. Chairman. A real quick
comment. I appreciate your question about claims processing. I
want to follow up on that. And also I will want to send you a
letter on a question about the 90/10 loophole in the American
Rescue Plan and what we are doing to prevent for-profit
colleges from predatory behavior.
Secretary McDonough. I look forward to that conversation.
Senator Tester. Thank you, Senator Brown. Senator
Tuberville.
SENATOR TOMMY TUBERVILLE
Senator Tuberville. Thank you, Mr. Chairman. Thanks for the
early Christmas present, this new desk you gave me. It took
you, what, 11 months, but it is good. I am able to sit up at
your level now.
Senator Tester. That is very quick for the Senate to act, I
just wanted you to know.
Senator Tuberville. Thank you, Mr. Secretary. Good to see
you.
Secretary McDonough. Good to see you.
Senator Tuberville. Thanks for your hard work.
Secretary McDonough. Thank you.
Senator Tuberville. Do you have a count, or who would we
get a number from of how many vets we have lost to COVID this
past year?
Secretary McDonough. I could get you that number. I do not
have it at my fingertips. I wish I did, but I do not.
Senator Tuberville. I would not think you would. I think
all of us would like to know of this year, how many we have
lost.
I am going to go back to my HBOT question, hyperbaric. I
had success with them, being a lowly football coach, but we saw
success using that with concussions over the years. Why can we
not get some kind of feedback from people that have used it on
their own, paying for it themselves? Does it actually help? You
know, we are pumping drugs into these veterans every day, and
we need to find some way to slow this suicide rate down.
Secretary McDonough. Yes. So thanks very much. I would say
a couple of things about this. One is we are under requirements
because of statute to make sure that we are going through a
series of processes. We are implementing those processes. We
submitted a series of reports to you guys over the course of
the last couple of months, and I think just yesterday or
earlier this week, or maybe it was last week, sat down with
your team and some of the other staff members about this
question about what we are encountering at the moment, which is
certain ethical limits on how we assess impact on individuals
in the context not of a pilot, but in the context of actual
treatment.
And so I do not know the ins and outs of it, Coach, but
what I gather is our ethics team, and then our team has come up
and briefed your team about their concerns about precisely your
question, which is how do we go and do some kind of valid
testing while still maintaining fidelity of these ethical
standards.
And so the bottom line is, in answer to your question, is
we are trying to work through these ethical limitations and we
are in close touch with your team about it.
Senator Tuberville. Thank you. Are you familiar with
Operation Deep Dive, carried out by the University of Alabama,
about looking into studies of veterans that have committed
suicide? Are you familiar with that?
Secretary McDonough. I do not think I am.
Senator Tuberville. We need to find some way--you know, to
me suicide is--of course it is very important to all of us, and
we are losing, what, 17, 20 a day.
Secretary McDonough. Yes.
Senator Tuberville. And it is not getting any better. We
need to find some way of, after the fact, of following up what
happened at the VA, what were they on. We need to get some kind
of structure, some kind of graph of how we get to the bottom of
why. And I think that is where we all want to get to. But, I
mean, it is not getting any better. And, you know, I have lost
friends, and you think they are getting better. And they go to
the VA, but something happens to them, and we have got to get
to the bottom of that.
But there is a group, like I said, at the University of
Alabama, that does Operation Deep Dive. They look into why,
what happened, put all the information together. I wish we
would kind of do that from the VA ourselves instead of waiting
on some other group to do it.
Secretary McDonough. Yes. So we were just talking about
this with Senator Tillis as well. He has got a bill on this. We
do some work, we call postvention, rather than pre-
intervention, postvention, to make sure that we are working
with families and understanding as best we can.
I have an answer to your other question too, but the one
thing I would add here, Coach, is importantly we did see
improvements in 2018 to 2019, which is our most recently
released numbers, and it is all backward-looking because of the
way we aggregate the data. But we are making progress, by no
means enough progress, but we are making progress. And we do
believe that we know the steps that we need to take to continue
that progress. It begins with the assistance and the resources
that you are making available to us, but I would be more than
happy to dig into Operation Deep Dive at University of Alabama.
Senator Tuberville. Well they are telling me that they
cannot get information from the VA of whether this person that
committed suicide was actually connected with the VA. I mean,
if we could get somebody in contact with us to where we can
connect--all they are looking for is just as much information
as possible, and again, I think it would be beneficial.
Secretary McDonough. I will follow up with your team and we
will get a name of somebody and we will make sure that our
Office of Mental Health and Suicide Prevention is in touch with
them.
Senator Tuberville. Thank you. Thank you, Mr. Chairman.
Senator Tester. Thank you, Senator Tuberville.
Secretary McDonough. The number of veterans who have died
from COVID last year--this is as of November 29th, the last
time we reported it to the Committee--16,543.
Senator Tester. Senator Murray.
SENATOR PATTY MURRAY
Senator Murray. Thank you, Mr. Chairman, Secretary, good to
see you again.
Secretary McDonough. Nice to see you, Senator.
Senator Murray. Thanks for being here.
As you well know, this summer the VA completed its
strategic review of the Electronic Health Record Modernization
Program, and Deputy Secretary Remy made a virtual visit to
Mann-Grandstaff VA Medical Center in Spokane last month, in
November. I appreciate the senior leadership's continued
engagement on this issue, but we really do need to see
corrective actions to put this important program back on track
and to get it right for veterans, families, and staff who are
counting on it.
For Spokane VA Medical Center and its clinics, what are
VA's next steps for remedying the existing issues?
Secretary McDonough. Yes. So the next steps are that we
are--I last talked to Donald about this last night, Donald
Remy--we are pressing on Cerner to enhance the presence on the
ground in Spokane so that people can get more timely reaction.
Senator Murray. What do you mean, pressing them? Saying you
would like them to or telling them they have to?
Secretary McDonough. Yes. We are telling them that they
have to. And Donald reported to me last night he was in touch
with Rob Fischer, who is the medical center director there in
Spokane, and what Rob said to him is that as of last night, the
kind of presence that Cerner was manifesting was not what he
had been anticipating. And so Donald was going to tell Cerner
today that is not good enough.
Senator Murray. When do you expect to see that?
Secretary McDonough. I do not know the answer to that
question because he had that discussion today, but I will get
you the answer. I have not talked to him since he had that
discussion.
Senator Murray. Any other steps that you are taking?
Secretary McDonough. Well, we have regular engagement with,
through our Office of Electronic Health Record Modernization,
with the team in Spokane so that we, as an institution, are
making sure that we are taking whatever corrective answer we
need to take as well. And then we have obviously restructured
the management and governance of the implementation of the
project going forward.
Senator Murray. Okay. Well in your testimony you mentioned
that the VA plans to continue deployments to gain more
experience while increasing future site readiness. That is a
quote.
Almost two years ago I cautioned the previous
administration against deploying this new EHR until
infrastructure and staffing issues were addressed. I do not
want to see the new EHR deployed at other sites in Washington
State until it is fixed and it is ready to go. So to avoid any
confusion for future sites what indicators is the VA looking
for to know when a site is ready and that the deployment will
not disrupt a veteran's care or staff productivity or the
morale that we have seen?
Secretary McDonough. Yes, that is a fair question and maybe
the way to answer this, Senator, is that inasmuch as Walla
Walla would be the next site in Washington, why don't we come
to you with our dashboard on what we intend to measure as it
relates to Walla Walla, and then you can see our decision-
making on that.
Senator Murray. Are you, at this time, moving forward on
any other sites in Washington State?
Secretary McDonough. What we have indicated is that as soon
as March we will go to Columbus, and then shortly after that to
Walla Walla.
Senator Murray. Okay. And you will bring to me what your
indicators are before you proceed on that?
Secretary McDonough. Yes.
Senator Murray. Great. I expect to see that. All right.
You were asked about caregivers by Senator Brown. You know
that is a passion of mine too.
Secretary McDonough. Yes, and we have the program because
of you.
Senator Murray. Well, as you know, the previous
administration finalized a rule for the caregivers program that
restricted the eligibility criteria for veterans. I heard your
answer to Senator Brown and I know what you are doing about
those that have been denied, but he stated 88 percent of the
applications were denied.
So my question to you is a little different. How is the VA
going to fix that unnecessarily restrictive eligibility
criteria so we do not continue to see these denials?
Secretary McDonough. Yes. I think there are two big movers
in the decision. One is a statutory provision which says the
condition the veteran suffers has to have been incurred in the
line of duty. Our proxy for that is a 70 percent disability
rating, and we cannot get around that. That is statutory.
Right? We may, after looking at this, come back to you and say,
hey, can we look at the statutory language.
As I have discussed with several of you, the other mover is
a determination of the percentage of activities of daily living
that a veteran has to manifest problems with to qualify, having
gotten over that first hurdle to the 70 percent disability. We
do have some regulatory flexibility on that question of the
percentage of activities of daily living that would be required
once over that 70 percent hump. That is what we are looking at
now.
Senator Murray. So you are looking at changing some of that
criteria?
Secretary McDonough. We are.
Senator Murray. All right. And what is your timeline on
that?
Secretary McDonough. ASAP.
Senator Murray. Okay. All right.
Secretary McDonough. We may have to do it through
rulemaking. We may be able to do it through a clarification.
That is a question really for general counsel. But I am working
very closely with the caregiver office, with general counsel,
to make sure that we do whatever we can, as quickly as we can,
and surely in anticipation of the October 1 date.
Senator Murray. Okay. Thank you very much.
Secretary McDonough. You are welcome.
Senator Tester. Thank you, Senator Murray. Senator Rounds.
SENATOR MIKE ROUNDS
Senator Rounds. Thank you, Mr. Chairman. Secretary
McDonough, it is good to see you, and I think this is a great
opportunity to sit down and talk about what is going on in the
VA and to learn from you, from your perspective, what is
happening.
I would like to talk about specifically the implementation
of the MISSION Act, and about kind of what is going on with
regard to referrals outside of the VA facilities themselves. I
think the clarification that you could provide on the Referral
Coordination Initiative, particularly how this initiative
affects veterans' access to the community care. I think that is
the area that I really want to focus on.
You may have seen the results of the investigation
conducted by USA Today that was released earlier this month.
This report points out examples of VA actively denying access
to community care. I presume you are familiar with the article.
Secretary McDonough. I am, and we dug very deeply into each
of the instance and obviously cannot talk about a lot of that.
In fact, I am not even privy myself to each of those cases. But
our team was up here yesterday talking about this. We dig into
each of those cases to make sure that we understand what
happened.
Senator Rounds. Well, I think we have got a real problem
and I think it goes back down to dollars and cents. I have
concerns that these examples are not isolated and that they
could be the result of the implementation of the RCI in a way
that diminishes veterans' choice.
Secretary McDonough. Yes, I do not agree with that,
Senator.
Senator Rounds. Well, let me share with you the reason why
I am concerned. When a VA primary care provider refers a
veteran to community care because they believe it is the
veteran's best medical interest, does the referral coordination
team have the power to override that decision?
Secretary McDonough. No, and, in fact, it is not even the
primary care provider's decision. It is the veteran's decision.
And so our job is to make sure that the veteran is aware of his
options and that we move with dispatch to execute his options,
and that it is, in fact, best medical interest that determines
that question.
Senator Rounds. I think this may be where the problem is,
because I think if the veteran actually makes the decision
himself, that is one of the reasons why I challenged the
MISSION Act in the first place was I did not read the law that
way, and I am not sure that a lot of the folks that are
implementing it read it that way either. And I will just give
you an example.
The Department's guidebook on the Referral Coordination
Initiative features a call script, a framework, that members of
the referral coordination team can use when speaking to a
veteran who is eligible for community care. The call script
framework recommends RCT members remind these veterans, and I
quote, ``You should know, by choosing the VA we can better
coordinate your overall care because we have the results of any
services or tests in your health record.''
It just seems to me that it--I am not sure it is
appropriate for the RCT members to be suggesting, you know,
that the VA might be a better option for a veteran, even after
a veteran's primary care physician has determined community
care is in the best medical interest. And I do not think that
is the way it was sold to a lot of folks here, and I am not
sure that is the way you would see it either.
Secretary McDonough. Yes. Look, I mean, I do not. I mean,
in effect--well, let me put it this way. GAO released a study
last month wherein they found that care in the community is
more difficult to coordinate. It is more difficult to get lab
results, it is more difficult to get test results, and,
therefore, more difficult, at the end of the day, to coordinate
that care for that veteran. That is not my finding. That is not
the Referral Coordination Initiative's finding. That is the
GAO's finding.
Senator Rounds. But either it is the----
Secretary McDonough. At the end of the day, then----
Senator Rounds [continuing]. Either it is veteran's choice
or somebody else is making the final decision, and see, I
really do think it should be the veteran's choice.
Secretary McDonough. It is the veteran's choice. That is
what the law says.
Senator Rounds. And yet I think a lot of veterans feel that
is not the way it is. And, in fact, within this article, there
is one article that really was, I think, pointing to the fact,
and the concern that I think Senator Blackburn had tried to
address a little bit, and what I really feel strongly about.
Part of the article says Dr. Kathleen Kim, who is the San Diego
VA Chief of Staff, said physicians sometimes incorrectly try to
relocate patients for treatments her hospital can offer, which
would be internal, and administrators are regularly educating
them to help keep veterans at the VA. And then the direct
quote, ``Because of the nature of the MISSION Act, the VA is
sending a lot of care in the community, and frankly, we are
worried that we are not going to be able to pay the bills,''
end of quote.
See, Mr. Secretary, I really think there is more of a
driver here with regards to dollars and cents than what there
is to making sure that the primary responsibility is to get
that veteran the care that they want. And I would really like
to explore this a bit more. My time has expired, but I think we
have got a serious problem here that is not going to go away.
Secretary McDonough. Yes, well, look. I mean, I am just
looking at the month-by-month obligations for care in the
community. So September, $2,067,412,193. So we had basically
four months above $2 billion a month. That is a significant
investment in the community.
At the same time--so this is, by definition, outpatient
care; correct--satisfaction ratings for outpatient care, north
of 90 percent. That does not mean we are at 100, and I did not
deal a lot in the 90 percentile myself, but 90 percentile is
good. I am like a 70-percentile guy.
But that is not to say that there are not problems. There
are. It is a big system. You know, when I find a problem I
snuff it out. But to suggest that, by design, we are breaking
the law is an overstatement. That is what the article suggests.
We took it very seriously, including with the team in San
Diego, to get to the bottom of it, as you, I think, would
expect us to do.
What I believe is that we are giving best available care to
our veterans, including historically high levels of care in the
community. I think that ultimately reflects the veteran's
interest. I want us to compete for access to that veteran.
Senator Rounds. And I like the idea of competing, but I
want it to be on a field that says we can provide equal or
better care and the veteran makes the decision.
Secretary McDonough. And we do, and that is what the GAO
concluded.
Senator Rounds. And I appreciate your thoughts on it, and I
would like to pursue it further.
Secretary McDonough. I look forward to that very much.
Senator Rounds. Thank you. Thank you, Mr. Chairman.
Senator Tester. Thank you, Senator Rounds. Senator
Blumenthal.
SENATOR RICHARD BLUMENTHAL
Senator Blumenthal. Thanks, Mr. Chairman. Thank you for
your service, Mr. Secretary----
Secretary McDonough. Thank you very much.
Senator Blumenthal [continuing]. And your excellent work
for the Administration. I want to talk a little bit about
infrastructure. I hear you are planning a trip in 2022 to
Connecticut. We will welcome you, and I will be delighted to
show you the West Haven Hospital, which is in desperate need of
rebuilding, as you and I have talked frequently, probably more
often than you care to remember.
Secretary McDonough. Oh, I remember every one.
Senator Blumenthal. This stuff is pretty serious to all of
us in the Congress and to the American people and I know to
you.
I am, frankly, disappointed that the Build Back Better
program does not have more money for VA health care
infrastructure. The way I read the Build Back Better program it
has about $4.1 billion allocated to infrastructure-related
expenditures in the VA, which is down from $18 billion--that is
less than a quarter--which is a fraction of the $60 to $70
billion that the VA has estimated that it needs, over a ten
year horizon. So everybody on this dais, on both sides, should
be aware we are shortchanging our VA, in my opinion. That may
not be the way you view it, but this is literally bricks and
mortar, and you say, in your testimony, that you are
reassessing the pre-pandemic market assessment because, quote,
``it may not have been expansive enough to identify emerging
health care demands.'' In other words, it is bigger, not
smaller.
Secretary McDonough. Yes.
Senator Blumenthal. I am not a good numbers guy. I am just
a country lawyer from Connecticut. But what I take away from
this assessment is in Connecticut, where we need a new hospital
facility in at least ten other places, and probably the
majority of VA health care facilities we have aging plans and
we have great professionals performing yeoman first class
medical work--we do in Connecticut--taking nothing away from
the great people working in the VA health care. In fact, it is
to their credit they are able to provide the gold standard of
medical care, even under these difficult circumstances.
What are we going to do?
Secretary McDonough. That is an excellent question. I mean,
the first thing is I do think that the investments in the Build
Back Better Act will be meaningful. Second is we do have--you
know, our average infrastructure, our average hospital is 59
years old. You know, you have an example of this, but there is
an example of a facility that is dated in everybody's State or
an example of States like Alaska or New Hampshire where there
is not a full-service hospital available. So that is definitely
a major challenge.
So we will do three things. One is we are looking at what
we call an Asset and Infrastructure Review Commission, to take
a kind of top-to-bottom look at our physical plant, what needs
to be upgraded, what can we do without. The second thing we are
doing is we have to get better at how we implement the projects
that we do get funding for. Denver was an embarrassment.
Senator Blumenthal. And I apologize for interrupting. I
visited Aurora, and I am very familiar with the cost overruns,
the delays, and I accept your point about doing it better. But
there is no free lunch here.
Secretary McDonough. No, which brings me to the third
point, which is we will need increased investment in
infrastructure. And so if it is not now it is going to have to
be soon. And look, I want to underscore that we have to be good
stewards of the taxpayer's dollars, and so we have to make
better use of the money that we do get and then make better
decisions around non-recurring maintenance, modernization, and
making hard decisions when something is no longer needed.
Senator Blumenthal. Well, I would love to explore this
topic at greater length and greater depth, and it may be the
topic for further conversation or maybe a roundtable we can do,
depending on what the Chairman would like to do. But VA
infrastructure, I think we are going to approach a crisis
point.
And I have run out of time but there are two other areas
that I will pursue in writing. One of them is, you know, you
were asked by Senator Brown what you would say to Daniel's
caregiver. My question is, what would you say to Daniel about
the burn pit exposure? What would you say to the other folks,
Palomares and others who have--the Palomares veterans who have
been exposed, whether it is to radiation or something else,
about how we can cut through the time that it takes, as it did
on Agent Orange, and the bureaucratic morass? And since it
predates you I can say the bureaucratic resistance to doing
fairly by our veterans.
And that is one of the reasons why we have submitted the
Cost of War Act. I hope you will support it, but it really is
an urgent need.
Secretary McDonough. I hear you. I could not agree more.
Senator Tester. Thanks, Senator Blumenthal. Senator
Sullivan.
SENATOR DAN SULLIVAN
Senator Sullivan. Thank you, Mr. Chairman. Mr. Secretary,
good to see you.
Secretary McDonough. You too, Senator.
Senator Sullivan. We are looking forward to having you in
Alaska here soon.
Secretary McDonough. There will be no sunlight.
Senator Sullivan. What is that?
Secretary McDonough. There is not going to be any sunlight.
Senator Sullivan. It is cold right now in Alaska. It is
cold. Twenty below in Fairbanks, so it is getting cold.
Although you are from hardy----
Secretary McDonough. I am from Minnesota. I get it, yes.
Senator Sullivan. As I remind Senator Klobuchar, you guys
are from the Land of 10,000. I think we have 4 million lakes
but I never brag about that in front of her.
Anyways, it is cold, though. You are tough.
Let me follow on a couple of topics that seem to be a bit
of a theme here. One is, you know, on talking about in--house
versus community care, one of the topics we have had with a
number of VA witnesses over the last couple months is the topic
of VA-DoD integration, which you and I have talked about
extensively. It is currently authorization in the NDAA that we
are debating right now to do that, and we are trying to kind of
reinforce that here in the Veterans' Affairs Committee. I think
your agency is fully supportive of my legislation that is
dealing with that.
Can you talk to those issues? We just think it is a better
way, efficiently, cost effectively, training with our docs, and
cross kind of pollenization between our military and our VA
members, both active-duty veterans but also the doctors on both
sides.
Secretary McDonough. Yes. Look, I mean, I will start where
you ended, which is what I keep hearing from our providers and
from vets is that vets like getting their care with active-
duty, and active-duty like getting their care with vets. And so
I start there. It seems like it would be a big satisfaction
increase.
But then I think there are kind of standard economies of
scale, training opportunities, affinity of maintaining cultural
competence for care for active-duty and care for veterans. And,
you know, I think this is one of the benefits of the EHR
itself, the electronic health record, which is that we are
going to have clinicians in both systems using the same
backbone. So their closer clinical practice cannot help but, I
think, improve outcomes for vets, which, at the end of the
day--I have assured you all that I will make every decision
based on whether it increases access for vets and whether it
improves outcomes, and I think us making better use of shared
infrastructure is an obvious step to take.
Senator Sullivan. Good. Let me ask, one issue that I want
to make sure we are able to do when you are up in Alaska is
reaching out to the provider community as well. And one of the
things that I unfortunately I am starting to see, just being
back home last weekend, is that particularly in a community
like ours where the VA footprint is very limited, the reliance
on our community providers is an imperative.
And as the MISSION Act is being rolled out, as we are
undertaking the work with the local representatives from
TriWest, I am hoping that we can make sure you are able to meet
with a number of the community providers, and these are both
community providers that are in the network, or have not yet
joined the network, or--and I am starting to see more of this,
and I do not know if it is happening around the country but it
is happening in Alaska--have decided no longer to serve
veterans under the MISSION Act. And I really want you to be
able to meet with them to hear their concerns.
Are you seeing this nationally? Anecdotally, I am seeing it
back home. But what is your take on this right now, in terms of
providers, they worry about rates, they worry about timely
payments. What we do not want to do, in Alaska or anywhere
else, is drive them out of the system.
Secretary McDonough. Yes. I hear you. So, one, I would look
forward to an opportunity to see whatever providers you think
make sense, and so I would be happy to do that.
Senator Sullivan. Great.
Secretary McDonough. Two is, we have gotten much better as
a partner, and I think the best way we can be a good partner,
aside from the issues I was just talking with Senator Rounds
about, is being a timely payer.
Senator Sullivan. Yes. Really important.
Secretary McDonough. Yes. And right now, on clean claims we
rival Medicare on payment times. Okay? So on payment time we
are beating industry standard, on clean claims.
Senator Sullivan. What is a clean claim versus a non-clean?
Secretary McDonough. That is a fair question. I think it
has to do with kind of the complexity of the number of
referrals and so forth.
Senator Sullivan. Okay.
Secretary McDonough. But on the apple to that apple, we are
beating industry standard.
Third, and I will take this for action, but I have not
heard--I have spent a lot of time on community care--I have not
heard dissatisfaction with providers driving network vitality.
Fourth, I, to be honest with you, and I am really excited
about the fact that we got the TriWest thing worked out for
Alaska. It took some doing, but I am really glad we got there.
I think we should be leaning on the third-party administrators
now to help us get more vigorous about building those networks.
So that is how I think about it.
Senator Sullivan. All right.
Secretary McDonough. And look, I am ready to be rebutted on
this idea that there are providers, not providers walking from
the system. I just have not heard it.
Senator Sullivan. Okay. Good. Well, I appreciate your
openness on this. It is an important topic, I think, for all of
us, and I think it is going to be really a critical issue on
the implementation of the MISSION Act.
Secretary McDonough. Thank you.
Senator Sullivan. Thank you, Mr. Chairman.
Senator Tester. Thank you, Senator Sullivan.
Secretary McDonough. I am sorry, Chairman. Can I just say
one quick thing? What we are not seeing, by the way, is a lot
of slack in the community system, meaning wait times in the
community. Now we are really digging into this, by virtue of
this requirement to come to you all with a report in June. We
are trying to find out precisely what is the apple to the wait
time in the direct care system to the wait time in the
community.
And the community system is really pressed. The pandemic
really squeezed the community system, and so there is no slack.
And a lot of times what we are seeing is that the apple to the
apple, we are faster. And this, again, I think, should be a
third-party administrator role, which is, hey, let's keep these
networks vibrant for the care that our vets need. I saw this
acutely in Montana and Kansas. I think that we have got to be a
better partner, pay on time, most importantly. We need the
third-party administrators to step up.
Senator Sullivan. Good. Thank you, Mr. Chairman.
Senator Tester. Senator Manchin.
SENATOR JOE MANCHIN
Senator Manchin. Oh, thank you, Mr. Chairman. Secretary,
good to have you here.
Secretary McDonough. Thank you for having me.
Senator Manchin. I had to go down and get a little
assistance in the medical and come back and I lost my turn, but
I am glad you wrote me back in.
Secretary McDonough. Are you okay?
Senator Manchin. I am good. I got a couple of shots.
Secretary McDonough. Okay.
Senator Manchin. Anyway, Secretary, you and I talked a lot
about the Clarksburg situation. It is horrific. And I know both
the Senator and the Ranking Member have heard me talk about
this before. But, you know, still the glaring thing that
happened in our VA is that they were getting passing grades.
They were Joint Commission which accredits the VA facilities
were saying that everything was good, consistently passing, as
you remember. And then we found out the OIG report was
completely different.
Give me a little update on what you have been able to do to
change that from the Joint Commission versus the OIG, to see if
they are in sync.
Secretary McDonough. Well, so, you know, obviously we
continue to be subject to that regular Joint Commission
investigation, but we have also had, obviously, very aggressive
IG participation on the ground in Clarksburg, including most
recently, as you and I have discussed. And, importantly, we
also have our Office of Accountability and Whistleblower
Protection is taking a hard look at Clarksburg. So that is from
the accountability side.
Senator Manchin. Have you all look at some of the other VAs
too? Is this inherently problematic throughout the VA system?
Secretary McDonough. You know, you and I have talked at
length about what are the lessons that we can apply from
Clarksburg. Among the things we did, after I went up there and
visited with you and then after the trial and everything, is
VHA did a system-wide stand down on patient safety and
accountability. So the entire enterprise dedicated time
expressly to these questions raised by virtue of the experience
in Clarksburg.
So what I can tell you now is that we have looked across
the system. We do not see this as endemic to the system. I
think this was a particular challenge with this nurse and some
of the oversight of performance in Clarksburg. But we are
continuing to stay on top of it and we will apply whatever
lessons we need to there.
The last point. We also continue to apply new blood to the
system, and I just got an update on Clarksburg last night. What
I heard last night is that the contract teams that we have,
including on the wards in question that you and I have
discussed, report increased morale, improved performance, and
improved outcomes.
Senator Manchin. Have we been able to do anything--and I
think we all talked about this--the people that basically would
be under suspicion for allowing these types of egregious acts
to happen, they retired and they are getting full pensions,
full benefits, full everything, I understand. Were we able to
reach back at all and find any of them negligent?
Secretary McDonough. Not yet.
Senator Manchin. Cannot do it. Okay.
The assets cost of maintaining and updated critical
infrastructure at the VA, you know a lot of money being talked
about and how we are going to spend it. You have a Strategic
Capital Investment Planning program from 2010.
Secretary McDonough. The SCIP.
Senator Manchin. SCIP, yep. And then you have the AIR,
which is the Asset Infrastructure Review.
Secretary McDonough. Yes.
Senator Manchin. Are those two going to conflict with each
other? Are they overlapping? Does one slow one down?
Secretary McDonough. Yes. So they are completely different.
The Asset Infrastructure Review Commission was enacted by
statute, by you all. I have been saying, and I think our teams
have talked, I have urged you all and your teams to look
closely at what we call the market assessments.
There have been market assessments going on since 2019, in
96 markets around the country, where we are making some
assessments about what are the care needs today and what will
the care needs be for veterans in the future. And we will make
then some recommendations. We will give those to the AIR
Commission itself, which is an independent commission. The
President appoints some members of that commission. Senator
Schumer, Senator McConnell, Mr. McCarthy, and Speaker Pelosi
make some recommendations to that commission. Right now we have
seven commissioners ready to go. Two are still not done. So we
do not even have a commission yet, and they still have to come
before you to be confirmed. So you will be able to ask them
some of these questions.
So that is an aspirational look at our entire footprint,
what is going to be needed, what, therefore, is not needed over
the next two and a half decades.
The SCIP process is the process through which we make
decisions based on the resources we get from you all, on a
year-to-year basis, and then where do we allocate those
resources. So the SCIP process should surely inform what we are
thinking about on AIR over time, and then AIR informs SCIP over
time, but the SCIP is a much more nuts and bolts, dollars and
cents. AIR Commission much more aspirational. And, by the way,
right now I am kind of concerned, since we do not have the two
remaining commissioners, we cannot even submit them for your
consideration.
Senator Manchin. Okay. Can I ask one more question? Senator
Cramer would you mind if I--Mr. Chairman, would you indulge me?
Senator Tester. We have only got a couple more to go so go
ahead, Senator Manchin. Then I have got a question for you.
Senator Manchin. Real quickly, the VA seems to do the best
job as far as when it comes to pharmaceutical pricing.
Secretary McDonough. Yes.
Senator Manchin. Okay. Give me a little breakdown on that.
Why can't we--why can't Medicare--why can't we copy yours? You
are a single payer, right?
Secretary McDonough. We are.
Senator Manchin. Is there any way that we can integrate
that into what we are trying to do with Medicare?
Secretary McDonough. You know, so I would say a couple of
different things. One is our ability to negotiate drug prices
saves taxpayers billions of dollars and saves veterans----
Senator Manchin. You are the lowest cost, basically, of any
of the providers we have in the Federal Government. Medicaid is
next, and then Medicare is just balls to the wall and get
whatever they can.
Secretary McDonough. And we are very proud of our
pharmaceutical formulary. And I would be more than happy to
have our team come up and brief you.
Senator Manchin. Has anybody ever approached you from
Medicare or Medicaid or any of our other agencies?
Secretary McDonough. We have provided technical assistance
to members of the Senate, of the House, over time, including in
the context of the negotiations----
Senator Manchin. I am talking about with the Medicare--you
know, the Federal Government, Medicare.
Secretary McDonough. Correct. And so what I understand----
Senator Manchin. Is it possible--is it possible for us to
integrate with your----
Secretary McDonough. We think it is--we have demonstrated
that it is sound medical and fiscal policy to negotiate drug
prices, and we do it well. The question of should you use our
formulary is more complicated. The way the House has done it is
the House has said, as I read the bill, HHS should negotiate
based off average international market price, and if there is
not an average international market price--I would have to
imagine that for every known pharmaceutical there is an
international price--then you can look at VA and others.
My view on that is the average international market price
is the right way to go, and it gives you the leverage that you
need to do the negotiation.
We are very proud of the way we do it. I think we have
demonstrated that negotiation actually saves dollars, and I
think that is consistent with what the House has in its Build
Back Better.
Senator Manchin. Sounds like a winner to me.
Senator Tester. I am with you.
Senator Manchin. Thank you, Secretary. I appreciate it very
much.
Secretary McDonough. Thank you, Senator.
Senator Tester. Senator Manchin, just because the Ranking
Member and I are so concerned, did you get these medicinal
shots delivered by needle or by some other method?
Senator Manchin. Needle.
Senator Tester. Okay. All right. Senator Cramer.
SENATOR KEVIN CRAMER
Senator Cramer. I could not have done so well with those
three minutes so I will let him keep----
Do you know what the score of the Concordia-St. John's
football game was this fall?
Secretary McDonough. I do.
Senator Cramer. I was hoping you would say no.
Secretary McDonough. I am also aware of the way the
Johnnies lost on Saturday to Linfield, Oregon, and so I am kind
of bummed out.
Senator Moran. Senator Cramer, I do not----
Senator Cramer. Never mind. If he is not going to tell you
I am sure as heck not going to tell you.
Secretary McDonough. I know who sits where.
Senator Cramer. By the way, I know that Senator Hassan
expressed appreciation, and I want to join her in appreciation
for the VA supporting our legislation to get these burial
rights straightened out for our Guard members. Thanks for that.
And General Quinn, as you probably know, was out in North
Dakota last week and talked to some folks. So anyway, but thank
you.
Secretary McDonough. He told me it was really windy and
cold.
Senator Cramer. That hardly ever happens there. I do not
know what he is talking about. He is from Montana, for crying
out loud. How big a deal could it be?
Secretary McDonough. I will just say, on that bill, Senator
Cramer, I think that worked really well. You all raised this to
my attention, we dug into it, and I think very transparently,
straightforwardly, our staffs, our teams working together we
came to a good outcome. I am really proud of that work.
Senator Cramer. We just have to pass it.
Secretary McDonough. Yes.
Senator Cramer. We have a way of complicating simple things
around here, however. You might have noticed.
You might recall that one of my main focuses on the
Committee, particularly last Congress but also this Congress,
of course, is use of HBOT. And we were able to get some
language into a bill last year, S. 785, that is now a law, of
course. And I am just going to read a couple of lines from the
bill so that we can then talk about it. You know it well.
Secretary McDonough. Yep.
Senator Cramer. The law will ``authorize the Secretary of
the VA to enter into public-private partnerships to research
the effectiveness of hyperbaric oxygen therapy; will require
the VA to use an objective test to measure the effectiveness of
hyperbaric oxygen therapy.'' ``It will commission a
comprehensive review and study of HBOT, both within the VA and
in outside organizations.'' ``The study would be completed with
a recommendation from the VA about the effectiveness of
hyperbaric oxygen therapy.''
All right. So that was last Congress. You and I talked
about it at the beginning of the year. You know, I know some
days you may feel like you have been there for years and some
days it may seem like last week. I do not know, but it has
been----
Secretary McDonough. Most days it feels like a long time.
Senator Cramer. Yes, I bet it does, and time does fly. But
maybe if you just give me a little bit of an update on where we
might be on that.
Secretary McDonough. So I am really glad you asked about
this, and I knew you would. So we submitted our first report to
you all in October. We have two remaining issues on the
language that you just read, and so I want to read these two
issues to make sure I get them right.
Senator Cramer. Thank you.
Secretary McDonough. Issue one, Section 702, subsection D,
requires us to commence a study on, quote, ``all individuals
receiving HBOT through the current pilot program,'' which you
just read, to provide HBOT to veterans to, quote, ``determine
the efficacy and effectiveness of HBOT for the treatment of PTS
and TBI.''
The program evaluation, i.e., the pilot program, is not
considered a research study, and therefore commencing research
activities with veterans who have agreed to participate in the
program evaluation, i.e., the pilot program, poses an ethical
risk, because they entered into the program, under a different
pretense, according to our team.
Issue number two, 702(D) requires VA to commence a study--
sorry. Outcomes related to the efficacy and effectiveness of
HBOT are not assessed as part of the pilot program, and there
is some necessary components of human subject clinical trials
that are not included in the pilot program. So the point is we
did the pilot program but it is not a sufficient or ethical
basis on which to make the research conclusions. Do you see
what I am saying?
Senator Cramer. I do, but I think it is why we put in the
law both within the VA and outside organizations, you know, so
that we could put together a large enough sample.
Secretary McDonough. Yes. So it now makes sense to me, more
sense to me what Coach Tuberville was asking, because he made
this point about outside participants. So let me take these two
questions and make sure I understand and come back to you
again.
Senator Cramer. That would be great. I would appreciate
that. And I know it is complicated, but I also know, and you
and I have talked about this before you went into the job, and
General Quinn and I talked about it, when I warned him about
burial rights for Guard members I said, ``Because it sounds so
easy until you get there and you bump up against that giant
wall called bureaucracy.'' It is not mean-spirited. It is just
bureaucracy, and it gets in the way.
Secretary McDonough. Yes.
Senator Cramer. And people that do not want to do certain
things find it very easy to not do those things.
So that would be great if you get that for me, and maybe it
is a great opportunity just to renew the invitation to come out
to Fargo.
Secretary McDonough. I was saying to Quinn that I was
jealous that he went, and I look forward to coming. I will
come. I hope to come this year. I have just run out of real
estate, but I definitely look forward to coming.
Senator Cramer. You cannot be everywhere every week, for
sure. But sometime on your way to Stillwater, you know, it is
not that far. And as I know about you, February will not scare
you. I mean, in fact it sounds like you are going to Alaska, it
sounds like.
Secretary McDonough. I am going to Alaska in two weeks. I
do not know. I am actually going to have to get a new coat for
that.
Senator Cramer. Oh, good. Well, then you will be ready for
Fargo.
Secretary McDonough. Yes, definitely.
Senator Cramer. Well, we would love to have you, of course.
Secretary McDonough. Thank you so much.
Senator Cramer. Yes. Thanks for your service.
Secretary McDonough. Yes. Thank you.
Senator Tester. Senator Cramer, could I just make a quick
request? Could you tell us the score of the Concordia-St.
John's game?
Senator Cramer. No.
Senator Tester. You can't?
Senator Cramer. It was a lot to nothing.
Senator Tester. Okay. We can make the assumption.
Senator Cramer. You can assume from there.
Senator Tester. Senator Moran.
Senator Moran. Sinema.
Senator Tester. Oh, you are right. Thank you very much. We
have Senator Sinema online.
SENATOR KYRSTEN SINEMA
Senator Sinema. Thank you, Chairman Tester, and thank you,
Ranking Member Moran, for holding this hearing, and thank you,
Secretary McDonough, for appearing before the Committee today.
I appreciate the time you spent at the Phoenix VA Medical
Center in August, and as we discussed the Arizona VA medical
care system serves a large and growing population, and they
have a number of construction needs to better serve the
community. Among these projects is the need for a new bed tower
and long-term care facility at the Phoenix VA, which is
undergoing a feasibility study right now. The Tucson VA Medical
Center also needs a new bed tower, and these are both major
construction projects. I am looking forward to working with you
and the Committee to move these projects forward so Arizona
veterans can get the care that they have earned.
I am grateful for the partnership between the American
Legion, the VA, and Philips Healthcare that brought an ATLAS
pod to Wickenburg, Arizona, and I also appreciate that the VA
team is continuing to update my staff on this pilot. In these
conversations we have been concerned that the VA is seeing low
utilization of the pod, not just in Arizona but at other sites.
So we have connected Arizona State University with the VA to
explore how local community partnerships might help build
success for these pods.
Do you see these types of local collaborations beneficial
to the pilot, and if so, what steps could the VA take
nationally to build these kinds of collaborations?
Secretary McDonough. Yes, that is a fair question and
thanks very much, Senator. The bottom line is we have seen
uneven use of the pods in the ATLAS program, so I think the
kinds of things that we can do are the kinds of things that you
are exploring, including these local partnerships, including
with Arizona State, which has a significant veteran population.
And so we believe that local partnership are useful. We
also think that, you know, the ATLAS project, being in
partnership with the Legion itself, makes it very attractive
for further partnerships.
But all of this is to say, too, that I have noticed
underutilization of the pods in different places across the
country. That is not isolated to Arizona. So we are looking at
that to try to get to the bottom of it.
Senator Sinema. Great. You know, veterans in Arizona
consistently reach out to my office with questions and concerns
about accessing dental care. Dental care is a critical aspect
of whole health, and access to these services is important for
veterans. In Arizona we have some wonderful programs that
provide discount or free dental services to veterans, including
participation by local dental schools, but the demand far
outweighs the supply. And that is why I am particularly
interested in the VETSmile pilot program that was started in
New York and New Jersey in July, to help veterans access free
or discounted dental services.
Now I know it is early in the pilot launch, but are there
any updates you can share about its progress?
Secretary McDonough. No, but I have just taken note of it
and I will get back to you concretely with that, because I
agree with both kind of--I obviously agree with the thrust of
the question, and I am embarrassed to confess that I do not
know much about VETSmile pilot, so I will dig into it and I
will get back to you on it.
Senator Sinema. Great. As we get that information I would
ask you to consider working with my office. As the VA is
expanding the pilot program, we would like you to consider
launching a pilot in Arizona.
Secretary McDonough. Good. We will be happy to work with
you.
Senator Sinema. Great. You know, as we talk to our Arizona
VA medical center homeless program offices and all the
organizations that support veterans experiencing homelessness,
we encountered two recurring issues. VA Medical Center HUD-VASH
case managers are managing growing caseloads and their time is
divided with other responsibilities. There is also a lack of
housing that actually accept these vouchers. So while there are
vouchers available for veterans, there is no housing to place
them in.
So how is the VA assessing the staffing levels and support
for homelessness prevention efforts and what efforts are being
taken to address the lack of housing, particularly in crowded
urban areas like Phoenix, where landlords do not have an
incentive to participate in HUD-VASH, or in more rural areas
where there is just a lack of landlords and housing?
Secretary McDonough. Yes, that is a good question. The
bottom line is we have to get better about staffing up those
offices. We are now operating under new authority in the Roe-
Isakson Act that said if by October 1 of this year we were not
at full capacity with hired staff that we need to go out and
contract staff. So our homeless program office is filling those
vacant staff slots with contracted staff. So that the most
important thing we can do, Senator, is actually get people in
those chairs, because they should not be as pulled among
multiple assignments as they currently are, and when they are
not pulled among multiple assignments as they are currently,
they can actually make a better case to the landlords.
And so these two issues are related. We are seeing a lot of
good progress in Los Angeles, and throughout California,
frankly, by partnering with local nonprofit housing advocates,
and I think that that has got to be part of the solution, in
addition to these hiring contracted staff to the challenge in
Arizona. But let me take that one too and come back to you with
something more concrete on it.
Senator Sinema. I appreciate it.
Mr. Chairman, my time has expired. Thank you.
Senator Tester. Yes, thank you, Senator Sinema. Senator
Moran.
Senator Moran. Chairman, thank you. I will do my best to be
brief. You too, Mr. Secretary, be brief, for all of our
benefits.
You mentioned third-party administrators need to step up.
What do you have in mind?
Secretary McDonough. Well, I just think that they know
these markets well. I think they can help us understand the
full complexity of the market, range of providers in the
market, and help market us to those providers. So that is what
I mean. They are out in the market. We should empower them with
timely payments, we should empower them with professional
experience with us, and then we should expect of them that they
help build robust networks for us.
Does that make sense?
Senator Moran. It does, and I am happy to try to encourage
that as well. I would highlight for you a topic that I have had
with you and with third-party administrators. Currently the
third-party administrator contracts do not include the same
standards, access standards as the law does. It is particularly
true for one of the administrators because the contract was
entered into before, and we have been encouraging you to make
sure the standards that are in law are the standards they have
to comply with under their contract, and we have not been
successful in getting that accomplished.
Secretary McDonough. You and I have talked about this, and
I am smarter but not yet as smart as I need to be on this. But
this is one of the things that we are looking at as we do this
review in anticipation of the June report to you.
So I think it is a very fair critique/question, as I have
indicated to you before, and so let me try to make sure that we
get a better answer to you.
Senator Moran. I think we find that the networks are not as
robust as they were previously, and you have veterans who are
then accustomed to a provider that no longer can go to that
provider. Maybe that is just the nature of changing third-party
administrators, and it altered the network. At least the
standards ought to be the same and the veteran ought to be able
to rely upon those standards, day in and day out, year in and
year out.
Secretary McDonough. I mean, this is assessment, not hard
intel, but we have seen, because of the pressures on providers
in the community from the pandemic, a willingness to engage
with us in certain markets. I do know if that is not the case
in Kansas, but it would surprise me if it is not. But it ended
up being such an important source of revenue for them in the
context of the pandemic that it helped actually put us in a
position of a kind of a buyer's position, which I thought
would, therefore, translate into a more robust network. So I am
surprised to hear you saying that is not the case.
Senator Moran. Let me make clear, I think the challenge is
not that the providers are not interested. The circumstance is
the providers are interested but they are not being--they may
not meet the criteria----
Secretary McDonough. I see.
Senator Moran [continuing]. And brought in. So the
providers are interested, and so we share that same
circumstance.
I also would say that our third-party administrator, when
we bring a provider to their attention, they have been very
cooperative in trying to bring that provider in. But, I mean,
we are happy to do the ad hoc thing, but if nobody is knocking
at their door it does not happen.
Secretary McDonough. My instinct is that we are paying
these guys a lot to help us administer these networks, and I
think they can do a better job. We are also in a market that is
pretty thin so far. We really got opted in TriWest. We should
be able to leverage a more active market there. We are surely
spending enough.
Senator Moran. My only follow-up that is left is to
continue our back-and-forth, the letter--oh no, I have one more
before I go to the back-and-forth.
We had this conversation about trying to get folks to the
AIR Commission, and nominated.
Secretary McDonough. Yes.
Senator Moran. What I know about that is that Senator
McConnell made his nomination and Representative McCarthy did
as well, and the one I believe is the most recent is
Congressman McCarthy, and it was made four weeks ago. So I am
not sure what holds this up.
Secretary McDonough. I am happy to chat with you a little
bit off--if we can, off-mic on that.
Senator Moran. Not a problem.
Now, only to continue our banter on community care, but in
this case really about the responses from the VA, we only set
the letter on November 12th because there was no response to
the staff request on October 4th.
Secretary McDonough. Okay. Well, I take really seriously
what you said to me at the last hearing, which is like, ``Come
on, man. Just answer our questions.'' And so when I saw this I
was like, let's answer this darn thing. So I am sorry about the
October 4th thing. We will make sure that we do a better job of
it.
I really think that this question about, as we have
discussed, how we provide care, where we provide it, is one
that benefits from our debate, and I wanted to make sure that
we got you the information to inform this debate, so I
apologize that did not----
Senator Moran. No, I appreciate at least your statement and
perhaps your belief that our circumstances benefit the cause.
And I do not want to be the proverbial that you just decide to
write off, never satisfied.
Secretary McDonough. Well, actually, unfortunately I do not
really have that option.
Senator Moran. I do not like the way you say that.
Secretary McDonough. Even if it were my predisposition.
Senator Moran. Because it suggests you would like to do
that. We will continue to work closely together to see if we
cannot solve this circumstance.
Secretary McDonough. Good.
Senator Moran. Thank you, sir.
Secretary McDonough. Thank you.
Senator Tester. Thank you, Senator Moran. I would just say
what I have said before in this regard, and that is that we can
outsource the work, and we can, and we should when the veteran
wants it, but we can never outsource the responsibility of
taking care of our veterans.
Secretary McDonough. That is exactly right.
Senator Tester. And so I think that is very important.
Secretary McDonough, thank you for being here today. I
appreciate your service at the VA. I also want to express my
appreciation for professionalism on both sides of the dais
today. I think that the Committee members did well and I think
you did well, and I want to thank you for that, because, after
all, we are working for our Nation's veterans and their
families.
And so I know we have got a strong partner in you in making
sure we are doing right by our veterans, that they get what
they have earned, and I think that is really important. Thanks
for being here, and I think this was a good Committee hearing.
I will tell you that I think everybody showed up. There
were only two that did not ask questions, because they had
other conflicts. But I just want to say thank you to the
Committee members for being here and thank you for being here.
This record will be open for a week, and with that the
hearing is adjourned.
Secretary McDonough. Thank you very much.
[Whereupon, at 5:07 p.m., the Committee was adjourned.]
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