Military Construction, Veterans Affairs, and Related Agencies Appropriations (May 4, 2022)

Summary

The transcript records the May 4, 2022 hearing on Military Construction, Veterans Affairs, and Related Agencies Appropriations for Fiscal Year 2023 before a Subcommittee of the Committee on Appropriations, with Hon. Martin Heinrich (chairman) presiding. The witness was Denis R. McDonough, Secretary of Veterans Affairs. Heinrich states that the hearing covers the Department of Veterans Affairs' fiscal years 2023 Budget and 2024 Advance Appropriations Request. According to the opening statement, the budget requests a mandatory appropriation of $161 billion and a discretionary appropriation of $135 billion, plus a $155 billion mandatory advance appropriation and a $128 billion discretionary advance appropriation for medical programs. The hearing was adjourned at 4:29 p.m.

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Full text

[Senate Hearing 117-]
[From the U.S. Government Publishing Office]

     MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES
                  APPROPRIATIONS FOR FISCAL YEAR 2023

                              ----------

                         WEDNESDAY, MAY 4, 2022

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 3:31 p.m. in room S-128, Capitol
Building, Hon. Martin Heinrich (chairman) presiding.
    Present: Senators Heinrich, Leahy, Tester, Murray, Reed,
Boozman, Murkowski, and Capito.

                     DEPARTMENT OF VETERANS AFFAIRS

STATEMENT OF HONORABLE DENIS R. McDONOUGH, SECRETARY

              OPENING STATEMENT OF SENATOR MARTIN HEINRICH

    Senator Heinrich. Good morning. This hearing of the
Subcommittee on Military Construction, Veterans Affairs, and
Related Agencies Appropriations Subcommittee is now called to
order.
    I'd like to begin by welcoming Denis McDonough, the
Secretary of Veterans Affairs. We appreciate the efforts of
VA's dedicated staff to provide care and support to veterans,
their families, and communities every single day, and
especially their efforts during the pandemic.
    It greatly expanded its telehealth capacity and adapted its
essential services, including housing, education, and training,
to better serve veterans, including those experiencing
homelessness.
    Today we will discuss the Department of Veterans Affairs'
fiscal years 2023 Budget and 2024 Advance Appropriations
Request.
    Veterans deserve the quality care and benefits that they
earned. This budget strives to do that and requests a mandatory
appropriation of $161 billion and a discretionary appropriation
of $135 billion, which reflects a higher reliance on VA care
and greater utilization of benefits and services than prior
years.
    It also requests a $155 billion mandatory advance
appropriation as well as a $128 billion discretionary advance
appropriation to support its medical programs in fiscal year
2024.
    The cost of medical care across private and public sectors
continues to rise. Although the pandemic is a factor, these
requests continue a trend of large increases in VA medical care
that reflect growing demand for both in-house and community
care.
    Veterans are relying on VA for more care today than ever
before, which highlights the improvements in VA's medical care
system.
    This year's budget request displays VA's medical care as a
separate and unique category from other non-Defense
discretionary spending in VA and across the government.
    Each year the Appropriations Committee must balance VA
medical care with non-Defense priorities across the government.
This display reflects that there has been significant growth in
VA medical care accounts over time under both Democratic and
Republican Administrations and that these costs, which are
supported across the political spectrum, should not come at the
expense of other critical programs.
    We hope to discuss the decision to change the budget
display as well as many other issues today. There are a few
areas of the budget I would like to highlight. The health
effects of military environmental exposures can take years, if
not decades, to manifest. The budget proposes to increase
efforts in this area, including provision of health care
research efforts, reviewing benefit claims, and implementing
new presumptions of exposure and service connection for certain
chronic conditions.
    The department has published new regulations expanding
presumption of eligibility for nine new diseases, but as the
Senate considers new legislation to further support veterans
who experience military environmental exposures, there will be
more to do.
    The budget before us did not anticipate enactment of this
legislation, which will require significant resources, and I
look forward to fully understanding your estimates for this
legislation.
    In March you released your recommendations to alter VA's
medical care infrastructure to the Asset and Infrastructure
Review or AIR Commission for review. Although they include many
opportunities to modernize care, recommendations to close
facilities will take away much-needed resources from already
underserved communities.
    We've already spoken about the impact of those proposals on
New Mexico's veterans in particular and I hope to discuss that
a bit more today.
    Beyond the Asset and Infrastructure Review, the budget
reflects VA's needs to invest in physical infrastructure.
Veterans deserve to be treated in facilities that are up to
date, modernized, and have the most cutting edge technology.
    In addition to proposed increased investments in all
construction and maintenance accounts, the budget included a
legislative proposal to allow VA to move forward on 31 pending
leases as well as to simplify the process for entering into
future leases. These efforts will not only improve existing
physical infrastructure but expand much-needed capacity to
serve veterans. I fully support authorizing action on this
effort.
    The budget continues robust funding for its Telehealth
Program with an estimated $4.8 billion for fiscal year 2023.
However, even with expanded hiring and telehealth capacity,
veterans in rural areas often struggle to access health care,
including due to challenges with transportation and lack of
Internet access.
    As more than one-third of veterans enrolled in VA health
care live in rural or highly-rural areas, I continue to
encourage VA to do more to close these access gaps.
    During the pandemic, VA used base and supplemental funding
to undertake tremendous investments to protect veterans who
were homeless or in danger of becoming homeless. This included
strategies, including temporary housing, rental assistance,
improved access to care, and employment services. Based on the
most recent PIT or Point-in-Time count numbers, these efforts
seem to have been quite successful.
    The budget requests $2.7 billion to continue and build upon
these efforts.
    Last year you undertook a strategic review of the
Electronic Health Record Modernization Program. Following that
review, a new leadership team took over and VA has now deployed
to two additional sites.
    VA also expects the independent life cycle cost assessment
to be completed in the coming months.
    We look forward to working with the department and with
Cerner as this must be a joint effort to make sure this
investment stays on track moving forward and that the full
costs of the initiative are well understood.
    It is clear that much is expected from the department.
Providing health care requires facilities, technology, and
clinicians, and quickly providing benefits requires staff and
more technology.
    For the department to succeed in these efforts, you must be
resourced appropriately, and I look forward to working together
to provide veterans with the services and the benefits that
they have earned and deserve.
    And with that, I will recognize Ranking Member Boozman for
his opening comments.

                   STATEMENT OF SENATOR JOHN BOOZMAN

    Senator Boozman. Well, thank you, Mr. Chairman, and I want
to take a second on behalf of you and I to recognize George
Castro, Clint Trocchio, Drew Platt, and Maddy Dunn. I
understand they did heroic work to get this set up here in a
very, very short timeframe.
    So as always, it's great to see you here, Mr. Secretary,
and we appreciate your coming and appreciate all of your hard
work.
    The budget requests $301 billion in fiscal year 2023 for
the Department of Veterans Affairs, including medical care
collections and the Transformation Fund, representing an 11.3
percent increase over fiscal year 2022-enacted levels.
    This includes a $135.2 billion in discretionary funds, a
$22.1 billion or 19 and a half percent increase over fiscal
year 2022.
    The budget also requests a total of $287.5 billion in
advance appropriations for Fiscal Year 2024.
    The large fiscal year 2023 increase highlights the
continued importance of programs for veterans. It also reflects
the continued growth in popularity of the Veterans Community
Care Program.
    Members of this subcommittee remain committed to providing
VA with the resources needed to care for our veterans.
    However, the growth of the department's budget at this rate
is unsustainable.
    Since 2018 VA's budget has grown by 52 percent or a $103
billion and that figure does not include the emergency dollars
from the CARES Act and the American Rescue Plan.
    With the current state of the economy, the historically
high rate of inflation, the ever-growing cost of health care,
it's more important than ever that we work together to ensure
we are getting the most out of the dollars that we appropriate
and I know that you're working very hard to do that.
    Furthermore, we need to cooperate to make sure Congress
doesn't mandate costly initiatives without thoroughly
considering the associated cost implications.
    This year's request includes a $118.7 billion for the core
medical care accounts. It also requests $1.75 billion for
electronic health record modernization.
    I look forward to hearing your thoughts on the state of the
program, the new leadership in place, and the path forward for
deployment.
    It also includes $2.7 billion for the Homeless Programs,
including $730 million for the supportive services for
veterans' families.
    In addition to updates on those programs, we look forward
to hearing details about the department's request for mental
health services, including efforts to combat opioid use
disorder and prevent veteran suicide, initiatives to prevent
veterans' homelessness and efforts to improve care for our
rural veterans, including through the greatly-expanded
Telehealth Program, which I might add the VA has always been a
leader in.
    Mr. Secretary, I want to thank you for your work to
expedite the publishing of the rules that will allow the SSG
Fox Suicide Prevention Grants to begin. Your budget includes
$56 million to support this effort. I think it's going to be an
important part of the broader suicide prevention effort.
    We look forward to discussing these and other issues this
afternoon, and with that, Mr. Chairman, I yield back.
    Senator Heinrich. Thank you.
    Secretary, would you like to give an opening statement?

               SUMMARY STATEMENT OF HON. DENIS MCDONOUGH

    Secretary McDonough. No, Mr. Chairman. I recognize the
pressure you're under with the votes on the Floor. So with your
permission, I'd be happy to make my opening statement part of
the record and just get right into your questions.
    Senator Heinrich. Fantastic.
    [The statement follows:]
               Summary Statement of Hon. Denis Mcdonough
    Chairman Heinrich, Ranking Member Boozman, and distinguished
Members of the subcommittee: thank you for the opportunity to testify
today.
    I'd like to begin with a story about two of VBA's great employees:
Judith Dawson and Candace Thorpe.
    A couple weeks ago, they heard from the family of a Veteran who was
really struggling. This Veteran served our country honorably for
decades, including in the Vietnam War, and the cost of his service
stays with him to this day. Specifically, he was exposed to Agent
Orange in Vietnam-and he's now struggling with multiple types of
cancer, among other conditions, associated with his service.
    He was, according to his family, losing hope. So, when Judith and
Candace heard about his claim, they sprang into action. They got right
to work, helped this Veteran, and-in less than two weeks-got him the
100 percent rating he'd earned and the benefits he so rightly deserves.
    According to this Veteran's niece, when he heard about the rating,
he ``immediately smiled and looked as if a tremendous burden had been
lifted off his shoulders.'' He appeared to be ``a changed man,'' and
looked ``alive"-truly alive-"for the first time in quite a while.'' For
that, his niece added, ``we are forever grateful.''
    That's what fighting like hell for Vets looks like, and that's what
VA employees like Judith and Candace do every day-and have done
throughout the pandemic. Their great work has led VBA to process more
than 960,000 Veteran claims already this year-the fastest pace in
history. It's led NCA to a point where we're approaching our goal of
providing 95 percent of Vets with access to burial sites within 75
miles of their homes. And it's led VHA to a point where outpatient
trust scores have reached 90 percent, and where studies show that we're
delivering better outcomes than the private sector.
    All told, since President Biden took office, we've provided more
care and more benefits to more Veterans than ever before. But make no
mistake: employees like Judith and Candace can't do that great work
unless they have the resources they need to do it. That's why this
budget is so important. It'll not only help us continue down this path,
but empower us to do even better for Vets, families, caregivers, and
survivors.
    Specifically, this budget will help us get 38,000 homeless Veterans
into permanent housing by the end of this year. It will help us deliver
the toxic exposure benefits that Veterans deserve-as fast as possible-
by researching military exposures, hiring claims processors, and
investing in claims automation. It will help us save Veterans from
suicide by expanding the Veterans Crisis Line, investing in lethal
means safety, and funding local intervention programs. It will help us
deliver for all Veterans-including women Veterans, our fastest growing
demographic-by investing the highest amount ever in our women's health
program, which delivers tailored, world-class health care to women
Vets.
    It will improve access and outcomes for Tribal Veterans by helping
us invest in resources to launch the Tribal Health Office-which will
make health care more equitable and accessible-and the Tribal
Representative Expansion Program-which will establish Tribal Veteran
Service Officers to help these Vets get the benefits they deserve.
    It will help us save lives by investing nearly a billion dollars in
VA's ground-breaking research, including Long-COVID and cancer
research. And it'll help us continue to save Veterans from COVID-19,
which is very much still here and very much still a threat for Veterans
across America.
    I could go on and on, but the bottom line is this: The number you
see when you look at this budget request is $301.4 billion, but what
this budget really means is health care for an estimated 9.2 million
Vets, disability and survivor benefits for an estimated 6 million Vets
and their families, and lasting resting places for an estimated 135,000
heroes and family members. What this budget really means is Veterans'
lives saved, or improved, by the work this funding makes possible.
    You know, President Biden often repeats a quote from his dad,
saying, ``show me your budget and I'll tell you what you value.'' Well,
this budget shows how deeply this President-and our country-values
Veterans, their families, caregivers, and survivors.
    They are the backbone of America. They deserve our very best. And
with this budget, that's exactly what we'll give them. Thank you for
the opportunity to testify, and for your support of Veterans and VA.
    I look forward to your questions.

    Senator Leahy. That's the best opening statement ever.
    Secretary McDonough. That hurt my feelings.
    [Laughter.]
    [The statement follows:]
               Prepared Statement of Hon. Denis McDonough
    Chairman Heinrich, Ranking Member Boozman, and distinguished
Members of the subcommittee. Thank you for the opportunity to testify
today in support of the President's Fiscal Year 2023 Budget and fiscal
Year 2024 Advance Appropriations Request for the Department of Veterans
Affairs (VA), and for your longstanding support of Veterans and their
families.
    President Biden describes our country's most sacred obligation as
preparing and equipping the troops we send into harm's way and then
caring for them and their families when they return. The President's
fiscal Year 2023 Budget reflects this commitment and honors this sacred
obligation to the Nation's 19.2 million Veterans by investing in:
world-class health care, including mental health care, and enhancing
Veterans general well-being; benefits delivery, including disability
claims processing; education; employment training; and insurance,
burial, and other benefits to enhance Veterans' prosperity.
    This Budget will ensure VA is moving swiftly and smartly into the
future as we serve our two core requirements: timely access to world-
class care, and timely access to earned benefits. This Budget ensures
all Veterans, including women Veterans, Veterans of color and LGBTQ+
Veterans, receive the care and benefits they have earned and
prioritizes Veteran homelessness, suicide prevention outreach and
caregiver support.
       fy 2023 budget and fiscal year 2024 advance appropriations
    The President's fiscal Year2023 Budget includes $301.4 billion
(with medical collections and Recurring Expenses Transformational
Fund), $30.7 billion (11.3 percent) above the President's fiscal Year
2022 Budget. The discretionary request is $139.1 billion (with
collections), $21.9 billion (18.7 percent) above the 2022 Budget. The
request includes $122.7 billion (with collections) for VA medical care,
$21.6 billion (21.5 percent) above 2022. The 2023 mandatory funding
request totals $161 billion, $8.6 billion (5.7 percent) above 2022.
This funding is in addition to the substantial resources provided in
the American Rescue Plan act of 2021 (Public Law 117-2).
    The 2024 Medical Care Advance Appropriations request includes a
discretionary funding request of $132.1 billion (with medical care
collections). The 2024 mandatory Advance Appropriations request is
$155.4 billion for Veterans benefits programs (Compensation and
Pensions, Readjustment Benefits, and Veterans Insurance and
Indemnities).
                     delivers benefits for veterans
Investing in our Workforce
    Serving as Secretary of VA along with the dedicated, highly skilled
professionals who constitute the VA workforce -many of them Veterans
themselves--is the honor of my lifetime. VA employees are committed to
serving Veterans, their families, caregivers and survivors. Over the
course of the COVID-19 pandemic, VA employees have ensured that VA did
not weaken or slow down. VA got stronger and took care of Veterans when
they needed it most. The 2023 Budget supports 435,840 Full Time
Equivalent (FTE), an increase of 28,963 from the 2022 estimated level.
This Budget will allow us to take care of the great people who have
diligently balanced the challenges of life during the pandemic, and
during unprecedented demand for frontline workers, have continued to
serve Veterans. As we have seen during this period, we need to do more
to invest in our employees, because VA's employees are the foundation
that make all the Services VA provides possible.
    In order to attract and recruit qualified diverse talent, VA has
submitted several legislative proposals. VA needs relief from limits on
hiring housekeeping aides, an occupation identified by the Office of
Inspector General as a recurring shortage occupation. VA is also
seeking funding for a critical investment in talent teams, which will
be instrumental in improving the hiring experience for applicants and
hiring managers, and implementing data-driven assessment strategies to
improve selection outcomes. Talent teams will be instrumental in
conducting outreach and recruitment for interns and early career
positions and designing and deploying assessments that can be used to
reduce time to hire and improve identification of qualified candidates.
    In order to recruit and retain employees in mission critical
occupations, particularly in a competitive market, VA is seeking
legislative relief from certain limits on pay. VA is deeply
appreciative of Congress's passage of the RAISE Act which will assist
in recruiting and retaining Physician Assistants, Registered Nurses,
and Advanced Practice Registered Nurses. VA is seeking legislative
relief to modify the compensation system for healthcare leaders to more
successfully compete with the levels private industry offers.
Recognizing employee contributions to the mission through special
contribution awards increases engagement and morale. Current agency
limits do not adequately allow VA to recognize the groundbreaking work
our talented employees are performing. VA strongly supports the
legislative proposal put forward by the Office of Personnel Management
to increase the incentive awards authority for agency heads.
    Another tool to invest in our workforce is through student loan
repayment programs, education debt reduction programs, and
scholarships. Continuous development in leadership and technical skills
enhances employees' service and performance. Limits on current programs
have not kept up with the increasing costs of education and have a
greater impact on underserved and unrepresented groups. Our proposals
expand access to these programs and ensure we are reaching more groups.
    Finally, our Budget reflects an investment in people and technology
to:

  --Support surge hiring in VBA to handle military environmental
        exposure (MEE) claims;

  --Develop and implement staffing models throughout the VA;

  --Promote strong labor relations with our National unions;

  --Lead our post-pandemic occupational safety and health planning and
        programs; and

  --Improve the hiring experience for applicants, managers, and HR
        professionals.

    Three personnel systems have created a complex set of rules.
Automating these processes has been challenging. There is wide
agreement that we need to do better, and we will. Stakeholders are
working to identify and implement changes and resources are needed to
support improved outcomes.
Veterans Benefits Administration (VBA)
    The 2023 Budget includes $3.9 billion in discretionary funding for
the General Operating Expenses, VBA account, a $440 million increase
over the 2022 Budget. This includes funds to hire 379 additional claims
processors to support growing demands and the increased scope of
disability compensation claims as well as to advance claims automation
and modernization efforts. It also supports 795 FTE employees for
processing claims related to the three new Gulf War presumptive
conditions VA implemented in 2021.
    The Budget provides disability compensation and survivor benefits
to 6 million Veterans and their families; education and job training
benefits to 921,000 Veterans and qualified dependents; guarantees
nearly 995,000 home loans and funds 5.8 million total lives insured for
Veterans, Service members and qualified dependents.
    The Budget provides $120 million for VA to support automating the
disability compensation claims process from submission to
authorization. VBA is leading a comprehensive modernization of the
claims process through the utilization of data and automation and
leveraging technology. VBA will use datasets specific to a Veteran's
military service, claims history, and medical encounters to feed
automation models. Historically, manual administrative tasks and
workflows are being automated to enable more effective claim decisions.
Investments in automation will increase VA's ability to deliver faster
and more accurate claims decisions for Veterans.
National Cemetery Administration (NCA)
    The 2023 Budget includes $430 million for the NCA operations and
maintenance account, an increase of $36 million (9.1 percent) over the
2022 Budget, to ensure Veterans and their families have access to
exceptional burial and memorial benefits including expansion of
existing cemeteries, as well as new and replacement cemeteries. With
this Budget, NCA will provide for an estimated 135,100 interments, the
perpetual care of almost 4.2 million gravesites, and the operations and
maintenance of 158 national cemeteries and 34 other cemeterial
installations in a manner befitting national shrines. This request will
fund 2,281 FTE needed to meet NCA's increasing workload and expansion
of services, while maintaining our reputation as a world-class service
provider. NCA field employees (85 percent of the total NCA workforce)
provide direct support to Veterans and their families and ensure that
the service they receive is dignified, respectful and courteous.
    NCA is nearing its goal of providing 95 percent of Veterans with
access to a burial option in a national, State, territorial or Tribal
Veterans' cemetery within 75 miles of their homes. To achieve this
goal, NCA will establish the remaining planned new national cemeteries
and expand existing national cemeteries to meet projected demand,
including the development of columbaria and the acquisition of
additional land. Construction projects to develop new national
cemeteries will enhance burial services and provide new burial options
to Veterans and their families. Construction projects also keep
existing national cemeteries open by developing additional gravesites
and columbaria or by acquiring and developing additional land. The 2023
Budget includes $140 million in major construction funds for a
replacement cemetery in Albuquerque, New Mexico, a gravesite expansion
at Jefferson Barracks, Missouri, and completion of a new national
cemetery in Western New York. The Budget also includes $157.3 million
in minor construction funds for gravesite expansion and columbaria
projects to keep existing national cemeteries open and for projects
that address infrastructure deficiencies and other requirements
necessary to support national cemetery operations. The 2023 Budget also
includes $50 million for the Veterans Cemetery Grants Program to
continue important partnerships with States and Tribal organizations.
This Grants Program plays a crucial role in achieving NCA's strategic
target of providing 95 percent of Veterans with reasonable access to a
burial option.
    continues timely access to high quality health care and support
                                services
    The 2023 Budget includes $122.7 billion (with collections) for VA
medical care, $21.5 billion or 21 percent above the 2022 Budget. The
2024 Medical Care Advance Appropriations Request includes a
discretionary funding request of $132.1 billion (with medical care
collections). I acknowledge that these requests, and their annual rates
of increase, are significant. However, the challenges VHA has faced
these past two pandemic years, and will continue to face, are just as
significant, and the requested resources are essential to ensuring the
9.2 million enrolled Veterans will continue to receive the high
quality, timely health care they need and have earned.
    VHA successfully met the challenge posed by COVID-19, delivering
improved health outcomes for Veterans while successfully supporting the
broader American health care system as part of its ``fourth mission.''
And while we are optimistic that the world has turned the tide against
this horrific disease, much of this Budget's substantial requested
increase is evidence of the continuing pandemic impacts being felt
today. We anticipate higher health care costs in fiscal Year 2023 in
part due to the returning wave of health care that was delayed over the
past 2 years, and that care is more complex and expensive due to the
effects of that delay or the confounding impacts of long COVID-19
disease or other pandemic-related exacerbation. We also need to
continue to be prepared for additional waves and new variants of the
COVID-19 disease. While the Biden Administration has largely rebuilt
the Nation's economy, VHA continues to struggle with lingering supply
chain complications, inflationary pressures and national health care
workforce staffing challenges.
    VA researchers are generating real-world evidence of COVID-19
vaccines' effectiveness over time across the country. Through
collaborations with the Food and Drug Administration, Centers for
Disease Control, and National Institutes for Health, this knowledge
helps to inform decisions on significant issues such as the need for
boosters and new vaccine targets.
                   addresses veterans' specific needs
Improves Support for Veterans Impacted by Military Environmental
        Exposure (MEE) During Service
    To deliver benefits more quickly to Veterans who developed
disabling conditions due to exposure to environmental hazards and to
reduce the evidentiary burden on such Veterans, VA is piloting a new
model to accelerate and improve the decision-making process for
considering whether to add new presumptive conditions through
rulemaking. The new model is evidence-based, transparent, and allows VA
to make faster policy decisions on crucial MEE issues. This new
approach considers all available data, listens to and learns from
Veterans' experience, and is guided by one core principle: getting
Veterans the benefits and health care they've earned and therefore
deserve. Recognizing that incomplete and inconclusive research often
hampers VA's ability to take timely action, the new model fills this
void with other evidence-based data to reach a recommendation,
including VA claims data analysis and trends. It also incorporates
other mitigating factors that may otherwise impact the scientific and
claims data findings. This new model will fundamentally change how VA
makes decisions on environmental exposures. Key components of the
proposed presumptive decision-making model framework include:

1. Review of relevant medical and scientific literature, including but
    not limited to reports from the National Academies of Science,
    Engineering, and Medicine (NASEM).

2. Review of benefits claims data to identify trends in claims to help
    inform which reviews of conditions are needed.

3. Review of relevant other data, including but not limited to
    manifestation periods and life expectancy prognoses.

    VA is fully committed to this deliberate forward-leaning approach
to deliver benefits and health care services more quickly to Veterans
who develop conditions related to military environmental hazards. In
addition to modernizing the presumptive decision-making process, VA is
also proactively taking the following direct steps to respond to
Veterans' concerns in this area:

1. Expanding training for health care providers,

2. Improving science, surveillance, epidemiology, and research, and

3. Increasing Veteran outreach and employing an integrative approach
    leveraging internal and external partnerships.

    VA has developed policy and research regarding the health outcomes
of MEE to Veterans deployed or in garrison at Camp Lejeune (includes
family members). VA conducts epidemiological research, education, risk
communication, and consultation with clinicians in the field and
translational clinical research for care of MEE though the War-Related
Illness and Injury Study Center (at 3 sites; in New Jersey, Washington,
D.C., and California).
    VA conducts research that improves health care through the
development of best practices and improves policy decisions related to
support of benefits for Veterans. VA subject latter experts review
current scientific literature and provide surveillance to develop
policy recommendations grounded in science. The Cancer Moonshot
reignited initiative includes two projects focused on MEE: an
interagency effort will develop a cohort of Veteran tumor samples from
various registries to conduct sequencing and identify genomic
signatures that may be associated with carcinogens from military and
environmental exposures, and VA will develop a centralized and
accessible data compilation to better understand the unique exposures
of Veterans and ensure 2-way data exchange. With this data made
accessible in this way, VA, as well as other agencies and institutions,
will have the ability to learn from more patients and reduce the cost
and time of data curation.
    To define adverse health outcomes as well as emerging environmental
threats, VA:

  --Improves scientific understanding of health effects of military
        (toxic and other hazards) environmental exposures,

  --Translates the MEE science into care and treatment for Veterans,
        and

  --Provides access to health services for individuals who were
        exposed.

    VA administers Congressionally mandated programs related to
environmental, occupational and garrison exposures that may have
affected U.S. Veterans and some family members during military service,
including six exposure registries. VA is developing Veterans Exposure
Team--Health Outcomes of Military Exposures (VET-HOME), a tele-health
pathway for Veterans and providers to access resources and services
related to MEE. VET-HOME will consist of two interconnected parts: a
call center for Veterans and providers, and a nationwide network of
specialists. Veterans with questions about MEE will call into a central
location and be guided through the registry exam or environmental
exposure process. They would then be referred to one of 40
environmental health providers across the United States who would use a
telemedicine platform to assess and, if necessary, refer the Veteran to
a VA facility to complete any specialty testing, like a pulmonary
function test or other lab work. Providers with questions on MEE would
be referred to one of the 40 military environmental heath SMEs. The
results of the consultation would be shared with the Veteran's primary
care doctor, helping to deliver better care to the Veteran.
    The Budget increases resources for these efforts, including $111
million for processing new presumptive disability compensation claims
related to environmental exposures from military service, as well as
$63 million within the VA medical care program for Health Outcomes of
Military Exposures (HOME) to increase scientific understanding of and
clinical support for Veterans and health care providers regarding the
potential adverse impacts resulting from environmental exposures during
military service.
    The Budget also invests $51 million in funding to support medical
research related to MEE, an increase of $20 million over the 2022
Budget. VA is expanding its military exposures research efforts.
Funding supports the VHA Office of Research and Development (ORD)
Military Exposures Research Program, established in 2022 with an
emphasis on advancing military exposure assessments and understanding
the effects of military exposures on Veterans' health outcomes to
inform care and policy. In a phased approach, ORD will build upon
ongoing research on health outcomes resulting from exposure to burn
pits, Gulf War Illness, Vietnam Veterans' health and precision oncology
to develop new work in areas such as constrictive bronchiolitis,
genomics and other emerging technologies. We will ensure collaborations
across the Department with academic institutions and with other Federal
agencies and our prospective efforts will include close partnerships
with exposed Veterans.
    From a benefits perspective, VBA will establish a new Military
Exposures Team (MET) that will provide resources and a dedicated focus
to issues related to MEE. This initiative supports my commitment to
Veterans and stakeholders to expedite review and analysis of the types
of conditions potentially warranting initiation of rulemaking to
establish a presumption of service connection under part 3 of title 38
of the U.S. Code of Federal Regulations. MET is part of my aggressive
MEE strategy, fortified by a new model for considering additional
presumptive conditions and the elevation and expansion of VHA's new
HOME Office.
    MET will have program oversight and management responsibility to
address all disability benefit claim related program research and
supporting data analysis for making recommendations for service-
connected conditions deemed presumptive due to military exposure, as
well as supporting claims research and data analysis necessary to
address evidence-based policy determinations for compensation benefits
under the VA directives and framework that govern such decisions.
    Through these efforts, VA will accelerate Veterans' ability to
access the health care and services they have earned and deserve.
Bolsters Inclusion for Caregiver Support
    Family caregivers of Veterans are force multipliers for VA.
Supporting caregivers provides those family and friends who care for
Veterans with the support, services and tools they need to successfully
support Veterans, resulting in better health and well-being outcomes
for both the Veteran and the caregiver. VA has long supported
caregivers through the delivery of a host of supports and services, as
well as home and community-based services. Our Caregiver Support
Program (CSP) is designed to promote the health and wellbeing of family
caregivers who care for our Nation's Veterans, through education,
resources, support, and services. CSP administers two programs: the
Program of General Caregiver Support Services (PGCSS) and the Program
of Comprehensive Assistance for Family Caregivers (PCAFC). Both
programs provide services to support and engage caregivers of Veterans
as partners in care, integrating caregivers as members of the Veteran's
health care team. The Budget recognizes the important role of these
family caregivers in supporting the health and wellness of Veterans.
The $1.8 billion included in this Budget provides funding for both
PCAFC and PGCSS, including staffing, stipend payments and many other
supports and services to help empower family caregivers of eligible
Veterans. In addition, this funding allows for further improvements and
enhancements to both PCAFC and PGCSS, allowing VA to reach and support
more caregivers than before.
    In 2011, PCAFC was implemented for caregivers of eligible Veterans
who incurred or aggravated a serious injury in the line of duty on or
after September 11, 2001. The VA MISSION ACT of 2018 (Public Law 115-
182) expanded eligibility to Veterans of all eras in a phased approach,
among other changes. The first phase of this expansion occurred on
October 1, 2020, expanding eligibility to Veterans who incurred or
aggravated a serious injury in the line of duty on or before May 7,
1975. On October 1, 2022, eligibility will be further expanded to
Veterans who incurred or aggravated a serious injury in the line of
duty in all service eras.
    VA is currently reviewing all aspects of eligibility for PCAFC.
While this review is underway, VA will not discharge any caregivers or
Veterans who were participating before the first phase of expansion on
October 1, 2020, referred to as Legacy Participants. This review will
result in an improved and expanded PCAFC with a focus on providing
accurate, consistent and transparent decisions. CSP strives to make the
right decision the first time, but if a Veteran or caregiver believes
we've gotten in wrong, Veterans and caregivers have more options to
seek further review of PCAFC decisions than ever before. The VHA
Clinical Appeals process, also known as the VHA Clinical Review
process, is one option for seeking further review of decisions. In
April 2021, the U.S. Court of Appeals for Veterans Claims ruled that
PCAFC decisions are now appealable to the Board of Veterans' Appeals.
As a result of this ruling, the CSP and the Board are diligently
working to develop the necessary infrastructure and processes to offer
the full spectrum of options available under the Veteran Appeals
Improvement and Modernization Act of 2017 (AMA) (Public Law 115-55),
including additional AMA options for Supplemental Claims and Higher-
Level Reviews. The implementations of these processes require the
development of new workflows, procedures, training, information, and
technology.
    At the same time, VA has significantly strengthened and enhanced
PGCSS. CSP increased PGCSS staff to enhance program capabilities that
offer caregivers access to standard and consistent assistance such as
psychosocial support, coaching, and skills training inclusive of the
evidence-based suicide prevention training, termed VA S.A.V.E.
Training, which is offered at every VA Medical Center (VAMC). In
addition, PGCSS staff are responsible for coordinating and facilitating
an annual resource fair at every VAMC. These required events provide
opportunities for caregivers and families to learn about the supports
and services available to them through VA as well as through community
resources.
    VA continues to expedite the hiring of key staff to standardize
application processing and adjudication, ensuring consistent
eligibility decision-making, ensuring Veterans and caregivers receive
timely, accurate assessments and an improved customer experience.
Invests in Access to Mental Health, Suicide Prevention, and Substance
        Use Disorder Treatment
    VA has made suicide prevention a top clinical priority and is
implementing a comprehensive public health approach to reach all
Veterans. This approach is in full alignment with the President's new
National Strategy for Reducing Military and Veteran Suicide, advancing
a comprehensive, cross-sector, evidence-informed public health approach
with focal areas in lethal means safety, crisis care and care
transition enhancements, increased access to effective care, addressing
upstream risk and protective factors, and enhanced research
coordination, data sharing and program evaluation efforts. The 2023
Budget includes $497 million to support suicide prevention initiatives
and programs. Funding for mental health in total grows to $13.9 billion
in 2023, up from $12.3 billion in 2022. This funding will support our
system of comprehensive treatments and services to meet the needs of
each Veteran and the family members involved in the Veteran's care. Our
commitment to a proactive, Veteran-centered Whole Health approach is
integral to our mental health care efforts and includes online and
telehealth access strategies. Whole Health can help Veterans reconnect
with their mission and purpose in life as part of our comprehensive
approach to reducing risk. Suicide is a complex issue with no single
cause. Maintaining the integrity of VA's mental health care system is
vitally important, but it is not enough. We know some Veterans may not
receive any health care services from VA, which highlights VA alone
cannot end Veteran suicide. This requires a nationwide effort.
    The new Staff Sergeant Parker Gordon Fox Suicide Prevention Grant
Program (SSG Fox SPGP) will enable VA to provide resources toward
community-based suicide prevention efforts to meet the needs of
Veterans and their families through outreach, suicide prevention
services, and connection to VA and community resources. In alignment
with VA's National Strategy for Preventing Veteran Suicide,\1\ this
grant program will assist in further implementing a public health
approach that blends community-based prevention with evidence-based
clinical strategies through community efforts.
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs (2018). National Strategy for
Preventing Veteran Suicide. Washington, DC. Available at https://
www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-
Health-and-Suicide-Prevention-National-Strategy-for-Preventing-
Veterans-Suicide.pdf.
---------------------------------------------------------------------------
    The Budget includes $663 million toward opioid use disorder
prevention and treatment programs, including programs included in the
Jason Simcakoski Memorial and Promise Act (Public Law 114-198). Among
the risk factors for suicide, substance use disorder is strongly
implicated. In addition, drug overdose fatalities inclusive of suicide
have escalated dramatically in the Nation. Therefore, the need for
effective interventions to address substance use cannot be overstated.
Supported by the President's Budget, VA is expanding evidence-based
substance use disorder treatment and harm reduction initiatives
consistent with the Biden-Harris Statement of Drug Policy Priorities.
The fiscal Year 2023 request includes a projected budget of $181
million for the following staffing initiatives: 1) Supported Employment
Specialists to expand access to employment opportunities for Veterans
in treatment and recovery; 2) Peer Specialists to work with Veterans
with substance use disorder to increase their engagement and retention
in substance use disorder evidence-based treatment; 3) Substance use
disorder staff on Behavioral Health Interdisciplinary Program and
Primary Care Mental Health Integration teams to support evidence-based
treatment outside of specialty care, including medications for opioid
use disorder and treatment of alcohol use disorder; 4) VA case managers
to work with Supportive Services for Veteran Families (SSVF) grantees
and homeless program staff assisting Veterans experiencing housing
instability and substance use disorder; and 5) Staff to improve access
to residential substance use disorder treatment programs. Furthermore,
VA's Budget will support expansion of its Psychotropic Drug Safety
Initiative to address the growing crisis of stimulant use overdose
fatalities. This initiative will ensure the safe and appropriate
prescribing of stimulant medications as well as expanding Veterans'
access to evidence-based treatments for stimulant use disorder
including cognitive-behavioral therapy and contingency management, both
of which are recommended by the VA-Department of Defense Clinical
Practice Guidelines for the Management of Substance Use Disorders.
    President Biden's new strategy for addressing the National mental
health crisis recognizes that many people face challenges in accessing
mental health care. VA continues to evaluate staffing needs and
prioritizes mental health hiring and training. However, we recognize
that hiring additional mental health staff in VA will not resolve the
growing demand. To address President Biden's vision to build system
capacity, connect Veterans to care and create a full continuum of
support for Veterans, VA is committed to being the Nation's leader in
ongoing research enhancing current mental health treatment, identifying
new mental health interventions and developing effective prevention and
at-risk identification protocols. Ongoing Congressional support for VA
Mental Health Centers of Excellence (CoE), the Mental Illness Research,
Education, and Clinical Centers (MIRECCs), and mental health research
initiatives through the Health Services Research and Development
Service (HSR&D) will be essential as VA continues to address access,
mental health care, and suicide prevention.
Improves Support for Women Veterans
    This Budget requests $9.8 billion for all women Veterans' health
care, including an estimated $767 million to support women's gender-
specific care. The Budget also includes $134 million for women's health
program efforts. VA continues outreach to women Service members and
Veterans, to encourage them to enroll and use the services they have
earned. As a result, the number of women Veterans enrolling in VA
health care is rapidly increasing. More women are choosing VA for their
health care than ever before, with women accounting for over 30 percent
of the increase in Veterans served over the past 5 years. Investments
support comprehensive specialty medical and surgical services for women
Veterans at a VA facility or through referrals to the community. The
number of women Veterans using VA services has more than tripled since
2001, growing from 159,810 to more than 600,000 today. VA is committed
to providing high quality, equitable care to women Veterans at all
sites of care. To address the growing number of women Veterans who are
eligible for health care, VA is strategically improving services and
access.
    VA is enhancing services and access for women Veterans by
continuing to invest in hiring initiatives in 2022, providing funding
for a total of over 800 women's health personnel nationally: primary
care providers, gynecologists, mental health providers, and care
coordinators. VA has also addressed clinical equipment needs such as
those for mammography, exam tables designed for women with low
mobility, and breastfeeding pods. Funds are available for programs that
have traditionally not been offered by VA, such as pelvic floor
physical therapy, lactation support and maternity care coordination.
    The Budget fully funds women's health care provisions of the Johnny
Isakson and David P. Roe, M.D. Veterans Health Care and Benefits
Improvement Act of 2020 (Public Law 116-315), which improves access to
VA care for women Veterans. The Budget also supports implementation of
VA's zero tolerance policy for sexual harassment and assault.
    The Budget further supports all Veterans by including a legislative
proposal to enhance equity by expanding access to assisted reproductive
technology, including in vitro fertilization and adoption
reimbursement, and to eliminate cost sharing for contraception-related
health care and services.
Increases Effort to End Veteran Homelessness
    The 2023 Budget increases resources for Veterans' homelessness
programs to $2.7 billion, with the goal of ensuring every Veteran has
permanent, sustainable housing with access to high-quality health care
and other supportive services to end and prevent future Veteran
homelessness. This Budget includes funds to assist with the design and
development of project-based housing partnerships for aging Veterans, a
growing need and area of focus for the Department of Housing and Urban
Development (HUD)--VA Supportive Housing program. In addition, funds
will be used to provide additional grant funds for special needs grants
that provide transitional housing through the Grant and Per Diem
program. Funds will be used to support the following staffing
initiatives: 1) The Health Care for Homeless Veterans (program will
hire an additional 140 social workers to assist homeless Veterans in
enrolling in VA health care or community health care; 2) The Veterans
Justice Programs will support outreach and linkages to VA services for
justice-involved Veterans by providing funding to expand Veteran
Justice Outreach to approximately 440 staff; and 3) The SSVF program
will continue to maintain health care navigator positions to connect
Veterans to VA or community health care.
    Since 2010, VA and its Federal and nonprofit partners have helped
house or prevent from experiencing homelessness more than 938,000
Veterans and family members. These efforts have led to a 55 percent
reduction in sheltered Veteran homelessness since 2010. On a single
night in January 2021, there were 19,750 Veterans experiencing
sheltered homelessness in the U.S. Between 2020 and 2021, the number of
Veterans experiencing sheltered homelessness decreased by 10.4 percent
(2,298 fewer people). However, COVID-19 impacted the ability of
communities to do their counts in January 2021. The report is only able
to provide national estimates on sheltered homelessness. Therefore,
while it is an important snapshot of sheltered homelessness, the report
does not provide a complete picture of homelessness in the United
States.
    As of March 21, 2022, there were 86 areas (83 communities and 3
States: Delaware, Connecticut and Virginia) that met the criteria and
benchmarks established by the U.S. Interagency Council on Homelessness,
VA and HUD, for eliminating Veteran homelessness and those areas have
publicly announced an effective end to Veteran homelessness.
    VA's goal is to prevent and end Veteran homelessness by providing
support and services to homeless and at-risk Veterans that enable them
to lead independent lives in the community of their choosing. In
support of this, VA's homeless programs provide a comprehensive and
practical range of services, including outreach, prevention assistance,
housing solutions, employment assistance, health care, and justice and
re-entry services. Notably, VA has set goals to permanently house more
Veterans in calendar year 2022 and is actively collaborating with HUD,
the US Interagency Council, and a broad range of State and local
partners to achieve joint progress for Veterans and Americans.
          supports research critical to veterans' health needs
    The 2023 Budget requests $916 million in appropriations for VA's
Medical and Prosthetic Research account to continue the development of
VA's research enterprise, including research in support of American
Pandemic Preparedness plan goals. This request builds upon the historic
investment from the 2022 Budget to continue to increase funding to
advance the Department's research missions in MEE, traumatic brain
injury, cancer and precision oncology and mental health. These efforts
will be conducted under a recent enterprise strategy aimed at
optimizing a range of capabilities and expertise in clinical,
informatics/data science, genomics, and other biomedical research
strengths that actively partner with VA clinical and operations
partners to help bring real world impact to Veterans within the
Nation's largest integrated health care system. VA research has been a
leader in bringing many breakthrough advances for treatment and care to
Veterans the Nation. The Budget will help continue that leadership
while also expanding into newer areas of science for which VA is
uniquely positioned. These efforts have also enabled VA to be a partner
of choice with Federal, academic and industry groups to provide more
opportunities for Veterans through research and allowing them to
further service their country by participating in groundbreaking
science. Most recently, VA not only contributed to the Nation's
understanding of COVID-19 vaccines and treatments, but also to better
understanding of possible long-term outcomes related to COVID-19
infection. These efforts capitalized on the extensive data that VA
possesses to allow large-scale analyses that are not often possible in
other settings.
    The Budget is also poised to support activities in the Cancer
Moonshot initiative, with an investment of $81 million in research
programs. Funds will support research in molecular diagnostics,
accessing our diverse patient population. Through this population, we
can identify genomic signatures that may be associated with carcinogens
from MEE, identify druggable targets and pathways in rare and common
cancers based on understanding of their unique characteristics, and
apply precision oncology approaches to cancer screening and early
detection.
    As you know, VA has ownership interests in inventions and patents
that are licensed to commercial entities where the inventions were made
in whole or in part with the support of VA resources, including funds,
personnel, space, and equipment. The Department is taking important
steps to strengthen its oversight and audit of its intellectual
property rights and we are accelerating our efforts to ensure that VA
is able to recoup royalties from any invention that is licensed. This
will benefit not only Veterans, but also taxpayers. We are ensuring
that the hundreds of millions of dollars we spend on research not only
go to advance medical understanding that helps Veterans, but that those
expenditures also serve to produce a return on our investment to help
our mission.
   leverages technology to support service and medical care delivery
    VA is undergoing one of the most comprehensive information
technology (IT) infrastructure modernizations in the Federal
Government, which will support seamless transition of health care
information throughout an individual's journey from military service to
Veteran status. Additionally, with Congressional support, VA is moving
to significantly enhance filings, information collection and decisions
on Veterans' claims through automation and improved digital
interactions to include claimants, authorized agents or
representatives. The 2023 Budget includes $5.8 billion in
appropriations for the Office of Information and Technology (OIT) to
pilot application transformation efforts, support cloud modernization,
deliver efficient IT services and enhance the customer service
experience. The Budget prioritizes cybersecurity, Infrastructure
Readiness Program (IRP) and claims automation, with the mission to
ensure a seamless customer experience for Veterans. In particular, the
Budget includes $402 million for cybersecurity that will allow OIT to
deliver enterprise-wide cybersecurity strategies, policy, governance,
oversight, and network defenses to protect Veterans' information and
VA's information systems. Further, the fiscal Year 2023 Budget
strengthens platforms to support emerging business requirements and
accelerates adoption and rollout of VA-requested Software as a Service
products. This is necessary to respond to increased demand for new IT
capabilities, increased growth identified by our business partners
requesting new space and facility activations, as well as increased
modernization to enhance and optimize the infrastructure.
    Our main transformative projects are the implementation of the
Electronic Health Record Modernization (EHRM) program and the adoption
of a new financial and acquisition management system--our Financial
Management Business Transformation (FMBT).
Renewed Focus on EHRM
    VA has moved forward with the EHRM program following the strategic
review and has incorporated lessons learned from initial operating
capability deployment in Spokane, Washington. On March 26, 2022, VA
deployed the new EHR solution to our second initial operating
capability site, the Jonathan M. Wainwright Memorial VAMC in Walla
Walla, Washington. In addition, new EHR governance and management
structures have been established, and the strategy has been updated to
rebuild a core foundation to right size the organization with a focus
on people, processes, policy and systems. The program is aligned to a
revised schedule for the rollout of the EHR solution through early
fiscal Year 2024, with deployments at sites in Veterans Integrated
Service Networks (VISN) 10, 12 and 20.
    In support of this effort, VA requests $1.8 billion for fiscal Year
2023. This is in accordance with the new strategy, which re-baselined
the requirements to align with VA's updated deployment plans. This
funding is vital to support the 19 EHR deployments scheduled for fiscal
Year 2023, as well as the pre-deployment activities at future sites,
which are conducted 6 to 18 months in advance of go-live to ensure
sites are equipped to receive the new EHR system. In fiscal Year 2023,
VA plans to conduct EHR activities at 34 sites across four VISNs and
infrastructure readiness activities at 68 sites across seven VISNs. The
funding will provide for:

  --EHR Contract: Contracts for site assessments, site transitions,
        enterprise integration and site implementation, which include
        activities such as site activation, training and workflow
        development.

  --Infrastructure Readiness: Infrastructure upgrades to support the
        new EHR solution, which includes activities to update computers
        and network infrastructure, and efforts related to system
        interfaces and cybersecurity.

  --Program Management Office: EHRM Integration Office (EHRM IO) hiring
        and retention of staff with the necessary expertise to support
        effective change management and implementation of the EHR.

    Continuity of funding is integral to our ability to prepare sites
for the deployment of the new EHR and execute VA's rollout schedule. By
the end of fiscal Year 2022, EHRM IO will have invested infrastructure
readiness funding in 15 out of VHA's 18 VISNs. The vast majority of
infrastructure modernization work will be completed in VISNs 10 and 20,
with significant progress already made in eight additional VISNs, and
initial efforts already underway in five more VISNs. The 2023 Budget
supports security, server stack and Local Area Network work at the
final three VISNs, which represent the initial set of infrastructure
readiness items that the sites receive.
    In addition to the funding requested for the EHRM account, VHA's
Medical Facilities request includes $505 million in Non-Recurring
Maintenance (NRM) funding for infrastructure projects required to
support EHRM.
Financial Management Business Transformation
    The Financial Management Business Transformation (FMBT) program is
increasing the transparency, accuracy, timeliness and reliability of
financial and acquisition activities across the Department. The 2023
Budget includes $350 million (including General Administration,
Information and Technology, Supply Fund and Franchise Fund sources) for
FMBT, a program that is improving fiscal accountability to taxpayers
and enhancing mission outcomes for our employees who serve Veterans. We
completed three successful deployments of the new Integrated Financial
and Acquisition Management System (iFAMS) at NCA and VBA and identified
opportunities to improve our approach. We are learning from these early
deployments and adjusting our strategy to manage the complexities
inherent in a financial and acquisition system implementation of this
magnitude. Each implementation brings us one step closer to providing a
modern, standardized and secure integrated solution that enables VA to
meet its objectives and fully comply with financial management and
acquisition statuses and directives. The next system rollout is
Enterprise Acquisition for NCA in April 2022, followed by the Office of
Management and all Staff Offices it supports in October 2022. System
rollouts will then continue across the remaining Administrations and
Staff Offices until enterprise-wide implementation is complete.
                       prioritizes va facilities
    The 2023 Budget includes $3 billion for construction requirements
in 2023--$2.1 billion in major and minor construction appropriations in
addition to $968 million in estimated unobligated balances from the
Recurring Expenses Transformational Fund (RETF) planned for major and
minor construction requirements. Funding for four medical facility and
three national cemetery expansion projects are included in the request.
The RETF will provide funding for three additional medical facility
major construction projects, bringing the total to 10 major
construction projects funded in fiscal Year 2023. In addition, VHA's
Medical Facilities account includes $2.5 billion for non-recurring
maintenance (NRM).
    VA operates the largest integrated health care, member benefits and
cemetery system in the Nation, with more than 1,700 hospitals, clinics
and other health care facilities; a variety of benefits and service
locations; and national cemeteries. The VA infrastructure portfolio
consists of approximately 184 million owned and leased square feet--one
of the largest in the Federal Government.
    While the median age of U.S. private sector hospitals is 11 years,
the median age of VA's portfolio is 58 years, with 69 percent of VA
hospitals over the age of 50. With aging infrastructure comes
operational disruption, risk and cost. VA estimates between $58 billion
and $70 billion will be needed over the next 10 years to maintain and
enhance our infrastructure through our annual Strategic Capital
Investment Planning process. However, efforts to fully address the
aging infrastructure portfolio needs by recapitalization would exceed
those funding estimates and occur over a longer timeline.
    At current funding levels, some facility conditions will continue
to degrade, and the highest priority selected improvements will
continue to reflect short-term capital investments designed to meet
immediate business needs versus long-term plans that meet the optimal
service delivery objectives expected of modern health care delivery
infrastructure. The funding originally proposed in the American Jobs
Plan and the Build Back Better Bill would allow VA to begin structuring
a recapitalization effort designed to fully upgrade and modernize our
facilities, bringing them up to the standards Veterans deserve. This
need still exists and VA will continue to develop our strategy to fully
modernize or replace outdated medical centers with state-of-the-art
facilities.
    Transforming VA health care to achieve a safer, sustainable,
pollution-free, person-centered national health care model is a
priority for this Administration and we are committed to ensuring our
facilities represent the best for Veterans. We look forward to working
with Congress to achieve our shared goal of addressing VA's aging
infrastructure.
AIR Commission
    On March 14, 2022, VA published the Asset and Infrastructure Review
(AIR) Commission recommendations in the Federal Register as required by
the MISSION Act.
    The recommendations within this report are the result of years of
research and analysis studying the VA health care system and the
Veteran population. We solicited feedback from Veterans, collected and
poured over data, visited VA facilities, talked to VA employees across
the country, met with key partners and asked ourselves one question
above all else: what is best for the Veterans we serve?
    The result of asking that question over and over again, in markets
across the country, is a set of recommendations that will:

  --Cement VA as the primary, world-class provider, integrator and
        coordinator of Veterans' health care for generations to come.

  --Build a health care network with the right facilities, in the right
        places, to provide the right care for Veterans in every part of
        the country.

  --Ensure that the infrastructure that makes up VA in the decades
        ahead reflects the needs of 21st Century Veterans-not the needs
        and challenges of a health care system that was built, in many
        cases, 80 years ago; and

  --Strengthen VA's dual roles as the leading health care researcher in
        the U.S. and the leading health care training institution in
        America.

    In short, these recommendations represent a massive investment that
will make VA stronger-and fortify our ability to deliver the timely,
world-class health care that Veterans so rightly deserve.
                               conclusion
    Chairman Heinrich, Ranking Member Boozman, I look forward to
working with you and this subcommittee. Thank you for the opportunity
to appear before you today to discuss our progress at the Department
and how the President's fiscal Year 2023 and fiscal Year 2024 Advance
Appropriations Request will serve our Nation's Veterans.

    Senator Heinrich. Take it when you can get it around here.
    Well, thank you, Secretary. We'll proceed with questions
using the standard five-minute rounds. Senators will be
recognized in the order in which they arrive and I'll start by
recognizing myself for five minutes.
    A few weeks ago you released your recommendations for the
Asset and Infrastructure Review Commission to review once
installed. I think we can all agree that VA should provide
high-quality care in modern facilities.
    You've been clear that you believe VA is maintaining a
presence in every market. However, as you and I have discussed,
in New Mexico and some other states, recommendations were made
to close clinics in areas where there are not in my view
adequate community providers and broadband access can limit
telehealth options.
    I believe these closures would have a dire impact on
veterans in some of the areas that I'm most familiar with.
    What's VA doing to ensure that these historically
underserved veterans will continue to have access to care,
especially given the already significant barriers that these
recommendations may be exacerbating?
    Secretary McDonough. Yeah. Thanks, Mr. Chairman. Thanks for
the questions. You've been, shall we say, exceedingly clear
about your view on these and I appreciate your candor on them.
    You know, as I've said to you privately and I've made clear
publicly, this is the start of that process and we'll keep
working that. The import of data from New Mexicans, from local
VSOs and from veterans obviously most importantly will inform
the Commission going forward.
    Meanwhile, we are being as aggressive as we can in ensuring
that the infrastructure that we have today is adequately
staffed. That's a problem, as you and I have discussed, in at
least two of the CBOCs in your state. Some of the resources
that we seek in this year's budget are designed expressly for
that.
    So nowhere in the AIR Commission statute does it require us
to stop investing in any community. We will continue to do
that, including in infrastructure development, and, you know, I
hope to get a chance to spend time with you in New Mexico
looking at that directly.
    Senator Heinrich. Great. I want to follow up on that issue
of data because of how long this process took to get started.
Some of these assessments were based on pre-pandemic data.
    What's the VA doing to ensure that more current information
is considered by the Commission in cases where the fundamentals
of that data may have changed dramatically?
    Secretary McDonough. Yeah. I think it's a great question.
This is a principal concern I had about this process from the
day I arrived. Much, as you said, of this data dates to pre-
pandemic. I think we all understand that the pandemic had a big
impact.
    We took the extraordinary step of asking our Red Team to
look at the data. That Red Team said the data is dated. The GAO
subsequently said that data is dated. The IG has said that data
is dated.
    We have stood up a separate contract now to look at the
data, to update that concurrent with the Commission going
forward so that they can have that information to make some
judgments on our decisions, our recommendations, and I have no
pride of authorship here. If the data has moved in an
appreciable way, I think the Commission should update their
recommendations to reflect it.
    Senator Heinrich. Great. The fiscal year 2023 request
presents VA medical care as its own category of discretionary
funding separate from the rest of non-Defense discretionary
funding.
    The budget suggests funding for VA medical care should be
considered independently from other non-Defense needs without
one impacting the other.
    I agree that providing care for veterans should not come at
the expense of other critical domestic programs.
    Can you share more about this proposal, if implemented, how
it would specifically help veterans?
    Secretary McDonough. Yeah. Thanks very much. I mean, the
bottom line is I think now is as good a time as any to
underscore the fact that VA obviously is central to the
provision of care and support and benefits the veterans, but
veterans actually benefit from programming in every Federal
agency.
    That was particularly clear in the course of the pandemic
where HHS and we, for example, collaborated very closely on the
provision of care for veterans, but it's true in SBA where
basically one in 10 veterans own a small business themselves
and so we have 2.4 million vet-owned small businesses supported
by SBA.
    HHS supports veterans who may not have access either to
health insurance through us or through the market. 600,000 vets
are enrolled in Medicaid, 4.5 million vets in Medicare. So that
means HHS is critical.
    HUD supports 105,000 HUD-VASH beneficiaries. Those are vets
who would otherwise be homeless, and obviously we have 40,000
vets who are homeless every night.
    The Department of Education supports many vets and
dependents through student loan debt. About 27 percent of
undergraduate vets themselves take debt.
    USDA supports 1.2 million veterans on SNAP. I wish that
weren't the case. In fact, makes me extraordinarily mad that it
is the case but that is the case.
    IRS provides numerous benefits of vets and military
families, including free tax preparation services to eligible
vets and their families.
    Veterans have free access to national parks. Indian Health
Service helps up to a 150,000 American Indian vets, and USPS
helps us deliver 95 percent of our outpatient prescriptions, 95
percent of our outpatient prescriptions.
    So we can't continue to grow at the expense of our partners
who help us provide that critical care to veterans.
    Senator Heinrich. Gotcha. You know, we know that rural
veterans already face significant challenges to access care in
person or via telehealth in part due to the difficulty in
recruiting and retaining primary care and specialty providers
that you spoke about.
    Perhaps due to the timing of the budget formulation, the
budget requests $307.5 million to support rural health
initiatives which is $20 million less than enacted.
    Please confirm that the department will spend the full
amount allocated to this purpose by Congress in this fiscal
year and then describe what initiatives VA is undertaking to
serve veterans in rural areas better, including through the
Rural Partners Network and through the Highly Rural
Transportation Grant Program.
    Secretary McDonough. Yeah. So you have my commitment that
we will invest that money that you appropriate for us and have
appropriated for us, one.
    Two, on the Highly Rural Transportation Grant Program, we
will work closely with you and with the authorizers to make
sure that we continue and expand that program.
    We obviously have, as you have just discussed, our Rural
Network which we are aggressively working, and, you know, my
own view is in your state and my home state and states like
Kansas and Montana. That Community Care Network and the Rural
Care Network are critical to the timely provision of care.
    Working with the President, he has demanded that we
increase our access in rural communities. So we've just begun
finalizing the appointment of a Rural Desk Officer so we have
somebody who's running point in the department on ensuring that
we have access issues for our rural vets from the center.
    Rural vets disproportionately come from rural communities
and we want to make sure that we meet them where they are.
    Senator Heinrich. Great. Thank you, Secretary.
    Ranking Member Boozman.
    Senator Leahy. Mr. Chairman.
    Senator Heinrich. Mr. Chairman.
    Senator Leahy. Excuse me, I wanted to step out, I
apologize, for another appropriations matter, but I thank you
for coming to Vermont.
    Secretary McDonough. Thank you very much, Chairman. It was
a great trip.
    Senator Leahy. I'll send in my questions.
    Senator Heinrich. Fantastic. Without objection.
    Senator Boozman. Thank you, Mr. Chair.
    The VA's Fourth Mission played an essential role in the
interagency response to the COVID-19 pandemic and we are very
grateful for the efforts in that regard.
    I introduced a bill last week that prohibits the VA from
using any funds to allocate health care staff to care for non-
citizens following the inevitable escalation caused by the
removal of Title 42 orders.
    DHS officials have stated there's no way to accurately make
resource allocation decisions because of an inability to
forecast the number of migrants who will surge following the
removal of these orders.
    VA health care personnel may be on the hook if this surge
is as bad as reports indicate. The VA's Fourth Mission is a
valuable capability intended to respond to national
emergencies, but it's not a tool to clean up the mess from a
foreseeable and avoidable crisis, especially while the VA is
experiencing record-high turnover rates.
    Secretary Mayorkas confirmed VA resources will not be used.
Can we get the same commitment from you that the VA's Fourth
Mission will not be used to divert health care staff to the
border to treat non-citizens following the escalation at the
border?
    Secretary McDonough. You have my confirmation on that. You
have my commitment on that.
    Senator Boozman. Well, thank you very much, and again
congratulations on the VA doing such a great job--in that
regard during the pandemic.
    Secretary McDonough. Thank you.
    Senator Boozman. Mr. Secretary, it's no secret that the
massive increases in the VA budget are starting to squeeze
other government departments and agencies. This year the Biden
Administration's budget request proposes a change to the way we
traditionally look at Federal spending.
    It proposes we maintain the well-known Defense and non-
Defense discretionary categories but that we add a category for
veterans' medical care.
    Can you explain the rationale behind the proposal and why
we shouldn't view it as a step towards making veterans' health
care a mandatory program?
    Secretary McDonough. Yeah. Thank you very much, Senator
Boozman, and I appreciate your shout-out of the VA
professionals and their work throughout the pandemic. Frankly,
I'm very proud of them, too, but it wouldn't be possible
without your support and you've just gotten us a very generous
Omnibus and, importantly, the RAISE Act which will help us
invest in nurses which is a crisis in Arkansas and West
Virginia and Rhode Island. We just have to get more competitive
in keeping our nurses.
    The proposal that the President has submitted to the
Congress for consideration I think makes eminent sense. One, it
pulls out VA health care investments into its own category like
Congress decided, you know, some many years ago to do with
Defense, underscoring its critical importance to the national
interests.
    So, once, pulling it out underscores its importance. Two,
pulling it out also invites, I believe, even greater scrutiny
in what we invest, and we're ready for that scrutiny because we
are growing at the rates that you've just talked through and in
your opening statement.
    Senator Boozman. All right.
    Secretary McDonough. Third, we also think if we keep it in
the context of the non-Defense discretionary, our growth comes
at the risk of growth of other partners in the Federal
Government and there's any number of sources of programming and
investment that is made available in those other Federal
departments and agencies that are critical to outcomes for
veterans, whether that's job training, education, health care,
substance use disorder, homelessness.
    So that's the third point which is we want to make sure
that we can continue to provide all of government support for
our veterans, and then fourth and last is I just want to double
down on this point which is we are not trying to suggest that
this be turned into a mandatory program.
    What we're trying to say is let's pull this out, let's make
sure it doesn't come at the expense of other important programs
vital to veterans, and let's make sure that we're subject to
the scrutiny that will come with that.
    Senator Boozman. Very good. Thank you.
    Secretary McDonough. Thank you.
    Senator Reed.
    Senator Reed. Thank you very much, Senator Boozman.
    Welcome, Mr. Secretary.
    Secretary McDonough. Thank you, Mr. Chairman.
    Senator Reed. For the record, you have the best Veterans
Administration Hospital in the country in Providence, Rhode
Island, under the direction of Larry Connell.
    Secretary McDonough. We're very proud of it.
    Senator Reed. I mean, I am, too.
    In your written testimony, you talked about the VA's new
model for establishing a presumption of service connections.
    Could you give us a little walk-through on what that looks
like and also the budgetary and staffing implications?
    Secretary McDonough. Absolutely. So my belief is that
heretofore I think we've sole-sourced the science too much on
something as critical as toxic exposure. So we get really
important support from the National Academies of Science, but
my own view, having come here, having seen that the U.S.
Government works best when it works as an all of government
entity, we decided to change the model to ensure that we get
the best of science from everybody in the Federal Government
and that we do that with coordination from the White House.
    And so the President has stood up an interagency process
inside the White House, chaired by his Domestic Policy Council,
that includes Defense, HHS, Labor, and associated agencies,
sub-agencies, so that we're getting the best available science
on these questions of toxic exposure. So that's the process.
    The second thing is too often that process--that's an
improvement of the science. Too often this process has been
opaque to veterans. So we have undertaken to study for some
period, let's take hypertension, which has been an issue we've
been looking at for a long time, and then we make
determinations and oftentimes veterans or our veterans service
organizations would be confused as to why and when we made
those decisions.
    So we've put ourselves on the hook on a quarterly basis to
meet at the most senior level of policymakers inside the
department, informed by that interagency science group, and
then we'll make public the decisions we're making and why,
including if we're choosing not to make a presumptive decision.
    So the second thing is to make it more transparent and thus
more responsive to veterans.
    Third is the President's made clear, he's the first
President in 30 years of war in Southwest Asia that he thinks
we have to move on these presumptions. So he's now made 12
different conditions presumed to be service connected.
    We anticipate that's going to increase requirement for both
health care and claims processors. So we're hiring 2,094
additional claims processors. We are requiring overtime from
the existing claims processors which this committee has made
possible, and we're investing in a process to automate claims
processing to make it happen more quickly.
    We believe those steps are prudent investments now to
ensure that the decisions the President has already made are
handled quickly.
    If Congress moves, as the President has underscored he
hopes it will, to enact a version of what we call the Pact Act,
we're going to require additional investments in personnel and
we'll stay at very close coordination with the committee and
transparently ask for those increases as they come along.
    Senator Reed. Thank you very much, Mr. Secretary.
    One of the problems that's already been raised and you
might have other comments is the persistent staffing vacancies.
You just mentioned you're going to staff up the claims
processors.
    Are there other particular areas we should be aware of?
    Secretary McDonough. Right now--one, on the claims
processors, I would say this, which is that, you know, we've
advertised for basically 2,100 openings. We've had massive
demand for those jobs. I feel quite good about that. So we're
getting good talent there.
    There's a training tail on that which is a problem. So
basically it's six to 9 months of additional training once that
person's in the chair. So I feel pretty good about that.
    We have to get faster on how we hire at VBA, but I feel
okay about that. VHA. We are no different in the country's
largest integrated health care facility provider than you are
in Rhode Island where nursing market, lab tech market, docs
market, and perhaps most importantly HR professional market is
exceedingly tight.
    So we need and we're asking in this budget for additional
investments in each of those places. So that's what we're
asking for you.
    What I'm challenging us internally to do is be faster and
better about onboarding. Too often we'll actually hire someone
and then lose that nurse or that doc in the intervening
onboarding process which in some places, I've heard in Seattle,
for example, this is a months-long process. That's too long. So
we have to get better.
    So we're asking you for some help but we have to get better
at how speedily we fill those vacancies.
    Senator Reed. Thank you. My time's expired, but you might
comment later on. I've been told that caps on salaries have
been a factor that is dissuading medical professionals.
    Secretary McDonough. Yes.
    Senator Reed. No need to comment
    Secretary McDonough. Well, I'd love to, if you don't mind.
So you all did us a massive solid by passing the RAISE Act and
attaching that to the Omnibus which itself was very generous,
as I just said to Senator Boozman.
    That Act will make us much more competitive for nurses and
that's good news, but we are still not competitive with docs.
We're still not competitive with medical center CEOs. We call
them medical center directors. We are still not competitive in
a highly-tight lab tech market, and so we are asking Chairman
Tester and Ranking Member Moran as they consider the Pact Act
to add additional authorities mirroring the RAISE Act
authorities on that Pact Act so that we are ready to hire
people so that when veterans do qualify for additional care
associated as they should with their exposures to toxins in
Southwest Asia that we can hire the medical professionals to
take care of them.
    Senator Reed. Thank you. Thank you, Mr. Chairman.
    Senator Heinrich. Senator Capito.
    Senator Capito. Welcome and thank you for the time and
attention that you've paid to our West Virginia facilities.
We've had some ups and downs, as you know, and I appreciate the
constant communication. It's just been terrific.
    Because of the things that happened at the Louis Johnson
Veterans facility, I was able with the support of my colleagues
to ask the VA to install more cameras because that would have
helped us a lot in trying to get the perpetrator a lot quicker
than we did, and I think you have to report back by November
23rd. I just was wanting to put that on your radar screen and
see if you had any comments on how that project's going and
what kind of future you see.
    Secretary McDonough. Yeah. So it's on my radar screen,
partly because of this hearing, partly because you and I talk
on a very regular basis, and I know how important it is to you.
    Senator Capito. Yes.
    Secretary McDonough. We have deployed the cameras. So we
are beginning to use them and beginning to make these initial
assessments. There is some privacy concerns, as you're aware of
that we're working through, but we'll be in a position to
surely make that report to you in a timely way.
    Senator Capito. Good. Hopefully we won't have to use them
as we would have had to use them in Clarksburg.
    I want to ask you about the Asset and Infrastructure
Review. I want to make sure I understand the process. So we
have four VAs in West Virginia. It looks as though three of
them in this recommendation will be essentially closed,
emergency rooms closed, and other recommendations, and I'm
wondering, Number 1, how you came to the conclusions.
    There's a big uproar in our state and we've already sent
you a letter. I'm sure you've heard from other members of our
delegation on this.
    Secretary McDonough. Oh, yes. And other delegations.
    Senator Capito. And other delegations, yes. So can it be
changed? Is it like a BRAC where you come back with another
final recommendation?
    Secretary McDonough. That's a good question. So this is
enacted as part of the Mission Act in 2018. So this process was
underway when I arrived.
    Senator Capito. Right.
    Secretary McDonough. The first step was to do assessments
in 96 markets in the country. How many vets are there today?
What are the vets going to need today and then what do they
need in three decades? What is the infrastructure that we have
there? What's in the community, and so to make some informed
assessments as to how we can address what vets will need and
who can do it through accommodation as we always have at VA of
direct VA care and then care in the community and then care
with our academic affiliates?
    I make the recommendations to the Commission. The
Commission under the statute until next February to accept or
reject those recommendations.
    Senator Capito. Can they line item?
    Secretary McDonough. They can line item, but according to
the statute, I think the statute, frankly, was written with a
predisposition to close. They can only reject a recommendation
of mine if they find that I deviated significantly from the
criteria I published in May 2021 that would serve as the basis
for any decision.
    Now there's a curveball here which is some of that data on
which I made recommendations, I've acknowledged publicly and I
just did again here, may be dated itself because it predates
the pandemic.
    Health care delivery in West Virginia is different today
than it was then. Things like long COVID are probably
insufficiently considered when we think about long-term needs
of vets. Somewhere between four and seven vets who get COVID
are developing long COVID symptoms.
    So the Commission itself then can send it back to me to
say, hey, fix this. They can get data from you, from your
constituents, from trips that they'll take to your state.
    Senator Capito. Okay.
    Secretary McDonough. Then once they get comfortable with
it, they can recommend it to the President. The President then
can decide, hey, I don't like any of this, I'm done with it, or
he can send it up here to you.
    Senator Capito. Okay.
    Secretary McDonough. You can up or down it. You can down
it. You can disapprove it, but if he sends it to you, I'd
assume he's sending it to you because he agrees with it,
meaning if you disapprove it, I'd assume you have to disapprove
it at veto-proof majorities.
    Senator Capito. Right.
    Secretary McDonough. You see what I mean?
    Senator Capito. I do.
    Secretary McDonough. It kind of has sent all the gates
toward--I'll just be very candid with you. It's sent all the
gates toward close.
    Senator Capito. Right.
    Secretary McDonough. Now there's one last thing. I'm sorry
to drone on here. But the Commissioners themselves have not yet
been confirmed. They're pending your consideration.
    Senator Capito. Have they been nominated?
    Secretary McDonough. Eight of the nine have been nominated.
    Senator Capito. Okay.
    Secretary McDonough. The ninth is, you know, by tradition,
as laid out in the statute, the Senate Republican leaders.
    Senator Capito. Okay.
    Secretary McDonough. So he hasn't yet announced his pick or
he's obviously working with the President because the President
has to nominate him back to here. So we're sitting at eight of
the nine. They have not yet begun for consideration in the
Senate Veterans Affairs Committee.
    Senator Capito. So like I know I'm probably over time, but
just as an example, the Huntington VA is over Charleston.
Charleston has a CBOC.
    Secretary McDonough. Yes.
    Senator Capito. 15 years ago we moved the CBOC to a bigger
place to get better accessibility from Southern West Virginia
and other places.
    This recommendation is that you move it again, and I'm
thinking that sounds like a giant waste of money. The state's
moved their VA offices down there to co-locate and I'm thinking
I don't understand and so I'm putting it on your radar screen
just as it doesn't make sense to me, and the other thing is
when you looked at what local resources had, did they look at
what they could actually provide?
    So I'm talking to a hospital administrator. I said if they
close the Huntington VA, can you absorb these surgeries, and
they're like we don't really know.
    Secretary McDonough. Yeah. So the answer to that is yes,
and what we should do is make sure that we get you all that
data and I think we've offered this to your team and I hope
that you would then go to the Commission and say, hey, we don't
think this is right.
    Senator Capito. Right.
    Secretary McDonough. But we did make assessments--the team
that ran the market assessments, now this started 2019, did
make assessments as to what the capability in Huntington is.
    Senator Capito. Right.
    Secretary McDonough. And then we made some determinations
importantly about the quality of that care using the existing
Medicare and Medicaid quality ratings.
    Senator Capito. Right.
    Secretary McDonough. All of this is rebuttable and so I
think that's the importance of the Commission process, but
again statute envisions a fixed date, a fixed end date to the
Commission. So the longer we go without the Commission at the
start here----
    Senator Capito. Yeah. The harder it is.
    Secretary McDonough [continuing]. the less time they have
to consider the recommendations. So I'm a little concerned
about that.
    Senator Capito. Right. Thank you.
    Senator Heinrich. Senator Murray.
    Senator Murray. Thank you, Mr. Chairman.
    Good to see you, Mr. Secretary.
    Secretary McDonough. Nice to see you, Senator.
    Senator Murray. As you know, almost one in 10 Washington
State residents is a veteran.
    Secretary McDonough. Yes.
    Senator Murray. And regardless of where they choose to
live, you know I adamantly believe that the VA has an
obligation to reach them with high-quality care.
    Secretary McDonough. 100 percent.
    Senator Murray. While the fiscal year 2023 budget does
include a substantial increase in funding, I am very concerned
that there is a disconnect between the local VISN and the
national levels.
    VA's recommendation for the AIR Commission suggested
turning Walla Walla VA Medical Center into a CBOC while moving
services to Spokane, which would force a lot of our veterans to
drive over two hours in very tough conditions and VA has also
suggested reducing services at Mann-Grandstaff VA Medical
Center, and now I'm hearing reports from Spokane that the VA's
considering reducing inpatient services before the AIR
Commission process even is complete.
    As you know, VA spent the last years reducing services in
Washington State and I want to be very clear, I will not stand
for this. A reduction of inpatient services is just a complete
nonstarter for me.
    Secretary McDonough. And for me.
    Senator Murray. There is a reason that we have a commission
in place for this.
    So tell me why is VA skipping steps in the process and
continuing to cut services in Eastern Washington.
    Secretary McDonough. So this is specifically at Mann-
Grandstaff?
    Senator Murray. Yes.
    Secretary McDonough. So there's no plan to do that. I
wouldn't agree to a plan to do that. You know, you've got my
commitment on that, and, you know, as you say, we have a
Commission for a process. We have this process at the
Commission for a reason, and we should let it play out.
    Senator Murray. Okay. Well, I'm going to be in this game
because I don't think my veterans should get less services in a
very tough part of our state.
    Secretary McDonough. There's a lot of people up here who
fight like hell for their vets, but I don't think anybody more
than you do. So I have every confidence that's the case.
    Senator Murray. Okay. Well, I wanted to ask you about
caregivers. This is a conversation we've had often, but overly-
restrictive regulations that go beyond statutory authority are
really contrary, as you know, to the intent of Congress when we
passed this and it's now really causing a lot of hardships for
a lot of our veteran families.
    We've just got to get this right. We've talked about this
often. I know you're aware of it. I've been holding roundtables
in my state to hear directly from people on this, and I wanted
to ask you today what kind of progress have you made on this.
    Secretary McDonough. Well, you and I have talked a lot
about this and I appreciate (1) all the work that you've done
and many in this room have done to give us the authority to run
the Caregiver Program. I think it's among the most innovative
things that we're doing at VA, one. So one is thank you.
    Two is we have paused the review of eligibility for the
program pending looking at the first issue you raise which is
what I believe to be overly-restrictive regulations on who
qualifies. In terms of progress, what I can report is last
Thursday we met with veterans services organizations from
across the country to talk through their experience with the
program and talked through the nature of this first regulatory
screen and we've not made a decision as to whether we need new
regulation or whether we can do this absent new regulation, but
we will not--nobody will leave the program, whether they've
received a letter from us to date or not, until we've completed
that review of the regulatory screen and then run everybody
back through any more inclusive screen that we determine is
necessary for the program.
    Senator Murray. Well, thank you. You know I am just
screaming about this and I have this very large guy next to me
screaming louder. So I know you're listening.
    Secretary McDonough. I am kind of scared of him, too, but I
have to tell you that I don't think the physical stature of you
reflects in any way how aggressively you have made your views
known on this.
    Senator Murray. Well, thank you, and on a final note, this
is really important and very serious, I want to make sure that
the VA is keeping Washington State veterans and our VA
workforce, many of whom, as I said, are veterans themselves----
    Secretary McDonough. Yes.
    Senator Murray [continuing]. in mind as this Electronic
Health Care Record Modernization Program continues. You know
that in recent years Washington State has been used as a pilot
site for a number of these VA programs. Many have resulted in
expanded services for veterans and growth opportunities for
employees dedicated to the mission of serving veterans. That's
good.
    But the EHR rollout has been very frustrating, very
disruptive, and even dangerous for some of our patients. So I
am asking you today that you reconsider the current schedule
for the rollout of the new electronic health record. We need to
continue to fix the issues that have been raised in Spokane and
in Walla Walla, and then only return back to Washington State
for any new deployments after demonstrating that the EHR is
ready and successful at different facilities.
    This is just really important to me. I do not want EHR to
move an inch further in my state until all of this is fixed and
ready to go and it's really abundantly clear from what my
constituents are telling me, from the IG's reports, and from
public reporting the system is plagued with ongoing issues, and
so I want to work together with you and I really want a
commitment that we don't go to any other Washington State sites
with this until we have these issues fixed.
    Secretary McDonough. So like you've got my commitment that
we'll keep working very closely with you and you're very
concerned. You've voiced this in our most recent conversation
about what happens in Seattle and the experience at Walla
Walla. Spokane's getting better but it's not perfect. I'm not
suggesting it is. Walla Walla has not been perfect but it's
been better.
    So far in Day 6 in Columbus we're seeing reasonable
results, but again it's early. We will make every decision
based on the experience of the learning to date. So you have my
commitment on that.
    I'll just say for purposes of clarity that since March 3rd
we've had six outages at Cerner, which impacts, us, DOD, and
the Coast Guard.
    Senator Murray. The Veterans.
    Secretary McDonough. Right. Us, so VA, and the Veterans,
and I'm frustrated with that.
    Senator Murray. So am I, and I just don't want it expanded
again to another site in my state until we have those fixed.
    Secretary McDonough. Understand.
    Senator Murray. Thank you.
    Senator Heinrich. Senator Tester.
    Senator Tester. Thank you, Mr. Chairman.
    I want the record to reflect that nobody, nobody has fought
harder for caregivers than Patty Murray and we appreciate your
continued input on this issue.
    Mr. Secretary, it's good to be with you up close and
personal and recently when you testified before--and by the
way, your crack staff behind you, it's good to have them here,
too.
    Secretary McDonough. Always good to have them.
    Senator Tester. Was that from Heinrich? Oh, okay, okay.
    When you recently testified before the Senate Veterans
Affairs Committee on the PACT Act, one of your chief concerns
was addressing the impacts of making 26 new presumptive
conditions effective immediately in terms of--your concerns
were in terms of manpower and claims.
    So let's assume the effective dates of those conditions
were phased in over time and let's also assume that we were
able to provide significant amounts of new resources and
authorities that were made immediately available to the VA to
help bolster capacity.
    Now what I'm talking about is funding for things like IT
and new hires but also priorities like leases, automation,
workforce authorities.
    So my question is this. Would those steps help address your
chief concerns with Pact and would they help set up the VA for
success once toxic exposure legislation is ultimately passed?
    Secretary McDonough. Yeah. Thanks very much for the
question, Mr. Chairman, and let me start by reiterating what I
said in the committee but, more importantly, what the President
said in the State of the Union, which is that we support the
PACT Act and we do that for important reason, because it will,
from my perspective, it will help us get access to more vets
and get those vets into our care.
    CBO estimates as many as two million additional veterans
will be enrolled for health care at VA. I think that's a net
positive.
    The second point, I'm very grateful for the way you've been
as hospitable to our arguments and our requests for additional
authority, for additional leasing authority, for additional
flexibility on workforce authorities, as you have been, and we
look very much forward to continuing that conversation with
you.
    Third, those kinds of authorities, fixing the way we do
leasing, which, you know, we are now 31 leases behind at VA,
and making it easier to hire and making us more competitive to
retain staff are critical, and that, plus the steps that we've
taken to get ready, I think gets us beset and more prudently
positioned to perform against the kinds of conditions that I
see in the House-passed bill.
    That said, I want to be very candid with you that we will
continue to need additional authorities and additional
capability as we develop these numbers and so but being able to
space that over time helps, having additional authority and
additional resources absolutely helps.
    The last point, which is the same as the first point, at
the end of the day, our veterans deserve access to this and
have earned access to this care and these benefits. So we
should give it to them.
    Senator Tester. I want to give you a data point of one.
    Secretary McDonough. Yes.
    Senator Tester. I had a lady bring in her three kids today
who were touring Washington, D.C., as part of a trip. I didn't
know the lady. She told me that she served at the Pentagon for
a period of time. She asked me what we were doing on the VA
Committee and I said we're working on toxic exposure to make it
so that folks who've been exposed to toxins are taken care of.
Her eyes got big. She looked at me and said, ``This is a
massive issue. It's an issue that's been ignored for far, far,
far too long and you guys need to step up and get this done,''
and it was like she had my talking points, went into the all
volunteer military, talked about the fact that if we're going
to put our folks in conditions that aren't safe, then we damn
well better do right by them when they come back home.
    I bring that up because very seldom do I talk about
veterans issues with people that just come in my office
randomly and she didn't come to talk about veterans issues. She
came to bring her kids to talk to me, but in the end this is
something that is really important and we need to get it done
and I appreciate your willingness to work to get this done and
not just, you know, a piece here and a piece there but to get
it done so that, quite frankly, the VA Committee and this
committee doesn't have to address this issue anymore. It'll be
done.
    So thank you. I'm out of time and appreciate you being here
up close and personal.
    Secretary McDonough. Thank you. Right back at you.
    Senator Heinrich. Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.
    Mr. Secretary, good to see you.
    Secretary McDonough. And you, too.
    Senator Murkowski. Thank you for all you're doing for our
veterans. Really appreciate it.
    Secretary McDonough. Thank you.
    Senator Murkowski. And appreciate hearing the comments from
Senator Tester there.
    We're dealing with a situation up north at Eielson Air
Force Base in the Fairbanks Interior Region. We've got a
serious housing shortage that we're dealing with. We're trying
to get all geared up for the F-35s that are coming in and the
KC-135s. We welcome them, but these airmen and their families
need housing and one of the difficulties that we have
encountered has been with the VA loan appraisal process, and I
know you've heard this.
    But apparently due to stricter appraisal and contingency
requirements and some would say perhaps a lack of understanding
with the program, we see delays.
    I'm told that this appraisal challenge is not unique to
Alaska, but its impact right now on this very, very limited
housing market that we have is causing a great deal of concern
with the potential to even slow the deployment schedules and so
I would ask you and your team if you could look at perhaps any
policy changes, perhaps maybe short-term staffing reassignments
or anything that might be within your purview to help alleviate
some of the challenges that we're seeing up there.
    It's not that there's a lot of housing stock, but they keep
coming back to us and saying it's this VA appraisal process
that is slowing things down in ways that don't make sense.
    Secretary McDonough. So I heard about this last week in the
House, too. So you've got my commitment on this to get to the
bottom of it. So I'll make sure that we get to the bottom and
will keep you up to date on it.
    Senator Murkowski. Well, I appreciate it. I know you've
been invited to come up to the state to get a sense of things
on the ground.
    Secretary McDonough. I look forward to that.
    Senator Murkowski. And we look forward to being able to
welcome you and we'll take you out there to the Fairbanks North
Star Borough.
    Secretary McDonough. I'm insisting on going in the winter.
I don't want to go in the summer.
    Senator Murkowski. There you go. All right. Well, you
missed your opportunity because it's getting nice.
    Secretary McDonough. I tried, I tried.
    Senator Murkowski. The ice just went out.
    Secretary McDonough. Yes.
    Senator Murkowski. With regards to the Assets and the
Infrastructure Review that was required under the Mission Act,
one of the recommendations for Alaska was a complementary
strategy recommendation to bring in ANTHC, which is the Alaska
Native Tribal Health Consortium, bring in their leadership to
improve and work on existing partnerships and resource-sharing.
    I think it's a good idea. I don't know how far along you
may be in that, if you have any updates on status, or whether
that's something that you're still working out the details on.
    Secretary McDonough. You know, as a general matter, we're
trying to intensify cooperation. I don't have a particular
update for you right now related to the AIR Commission since
that's in some ways quite distant but also in some way kind of
stalled inasmuch as we don't have a Commission yet.
    But we're trying to work that as a general matter. So it
probably makes sense for us to put together a paper for you to
give you a sense of where we stand on that and we'll do that.
    Senator Murkowski. Well, I think it would be helpful and I
think it would be instructive for your team because I think in
doing so they'll recognize what a significant asset that
partnership with ANTHC can be. There's no need to reinvent
wheels here.
    Secretary McDonough. I agree with you on that.
    Senator Murkowski. Lastly
    Secretary McDonough. We hope emulate in other places, by
the way.
    Senator Murkowski. I think you're going to have great
partners up there.
    Last point that I want to raise is a focus on women
veterans and being prioritized in our health care system. I'm
glad that you're putting a focus on this. I appreciate that
priority.
    We've got something we call Operation Mary Louise up north.
It's a women's veteran-focused organization there in the state
and what they're telling me is that less than one-third of
Alaskan female veterans use our VA health services and I don't
know whether this is the same in other parts of the country,
but it's something that I think we need to look at and make
sure that our women veterans know that it's your VA, too, and
so how we can make sure that they feel supported and reached
out to.
    I don't know what efforts are being made there, but I raise
that and apparently it's the same in other places.
    Secretary McDonough. You know, so, one, I'd love to be--
we'll check the team, but I'd want to make sure that our
Women's Health Team gets in touch with Operation Mary Louise
and talks to them, one.
    Two, you know, va.gov/trusts, we put all of our trust
scores up. This is where we have an interaction with the
veteran. We get her kind of record of that, how it went, how
she assessed it.
    Our best scores are for outpatient care and we score
higher, that is to say, more trusting the older and the less
diverse and the more male the vet is, meaning the younger and
the more female the vet the less well we do. This is why the
President's prioritized and why you have helped us now for
successive years in giving big set-asides for what the Women's
Health Program.
    Remember that we have both the health account itself, which
funds all of care, and the President's asking for the biggest
increase in the Women's Health Program bucket this year for the
simple purpose of making sure that we have gender-specific care
providers and technology.
    So where we do this well, we do it well. I saw CBOC here in
suburban Washington, D.C., where on one visit a woman veteran
can get primary care, can see her health care professional, can
get mammography, can see her GYN, and she can do that all in
one stop. That is not the case in too many places.
    So I believe we'll grow the 34 percent number by
performance. You've given us enough resources to fund this
effort. It's on us now to perform and make sure that we provide
the care that women have a right to seek and it's in a climate
where they're not harassed, they're not-- somebody doesn't
approach them and say, hey, are you here with your dad or are
you here with your husband, you know. No, I'm a vet. In many
cases very highly-decorated vet, by the way, who's been
fighting now for 20 years in Southwest Asia.
    So we got to do a better job of that and I think we'll do
that through the effective use of the resources that you all
have given us.
    Senator Murkowski. Sometimes it's the facility, just
walking into it, it is your father's VA building and so for a
young woman vet, she looks around and says I'm not comfortable
here.
    Secretary McDonough. Exactly, exactly, and even worse if
she's been harassed or, you know, by the way, she comes there
and we don't have the kind of services that she is right to
expect in any way case. So I think we're getting up to par.
You've helped and given us the resources to do it. It's on us
now.
    Senator Murkowski. Thank you. Thank you, Mr. Chairman.
    Senator Heinrich. Thank you, Secretary McDonough, and
thanks to all the Senators who participated in today's hearing.
    I look forward to working together on this year's
appropriations to ensure that veterans have access to the
benefits, services, and supports they need and earned, all
veterans, as the Senator from Alaska pointed out.

                     ADDITIONAL COMMITTEE QUESTIONS

    Finally, I will keep the hearing record open for a week.
Committee members who would like to submit additional written
questions for the record should do so by 5 o'clock p.m.
Wednesday, May 11th. We appreciate the department's responding
to them in a reasonable period of time.
             Questions Submitted by Senator Martin Heinrich
                           workforce planning
    Question. The Department, and particularly the Veterans Health
Administration, has struggled to address workforce vacancies.
    What is VA's personnel strategy, and how does it plan to recruit,
retain, and train staff in regions where they are needed the most,
including rural areas?
    Answer. As we have seen during the Coronavirus Disease of 2019
(COVID-19) pandemic, we need to do more to invest in our employees,
because VA's employees are the foundation that make all the services VA
provides possible. To attract qualified, diverse talent, VA is seeking
funding for a critical investment in talent teams, which will be
instrumental in improving the hiring experience for applicants and
managers. These talent teams will conduct outreach and recruiting for
interns and early career positions and will be responsible for
designing and deploying assessments that can be used to reduce time to
hire and improve identification of qualified candidates. VA is also
seeking legislative relief from certain limits on pay in order to
recruit and retain employees in mission critical occupations, in a
particularly competitive market.

    Overall, VA seeks to do the following:

  --Promote employee whole health and reduce employee burnout;

  --Develop and implement staffing models throughout VA;

  --Promote strong labor relations with our National unions;

  --Lead our post-pandemic occupational safety and health planning and
        programs; and

  --Improve the hiring experience for applicants, managers and Human
        Resources professionals.

    Specific to rural areas, VA is taking the following steps that will
increase rural workforce staffing levels to improve rural Veteran
satisfaction by:

  --Expanding the number of sites offering Rural Health Initiative-
        funded rural Career Development Awards and Rural Quality
        Scholars grants from six to seven;

  --Providing additional health professions scholarships to medical
        students and additional loan repayments for residents serving
        rural Veterans;

  --Standing up a new Veterans Health Administration (VHA) Office of
        Tribal Health with the mission of ensuring equitable access to
        care for American Indian/Alaska Native (AI/AN) Veterans; and

  --Completing a needs assessment on the effectiveness of AI/AN Veteran
        cultural competency instruction and content available across
        the enterprise, to include both existing programs and new
        rural- and Native American-facing programs.

    Question. How aggressive has VA been in efforts to hire in areas
where there are now proposed closures?
    Answer. Many of the potential changes to VA's health care
infrastructure recommended in the Asset and Infrastructure Review (AIR)
report may be several years away and are dependent on Administration
and Congressional decisions, as well as robust stakeholder engagement
and planning. VA recognizes that it is not its infrastructure that
cares for Veterans or saves their lives-it is the VA workforce; VA's
incredible public servants. Through this process, VA is not looking
only to invest in its physical infrastructure, but also actively
looking to invest in the VA workforce because they are a critical part
of VA's future.
                             tribal health
    Question. VA provides for direct health care for Tribal veterans
through partnerships with the Indian Health Service and Tribal Health
Programs, as well as through VA facilities. As veterans may need to go
to different facilities for different types of services, coordination
of care can be challenging.
    How does VA plan to improve access to care for veterans who live in
Indian Country?
    Answer. VA has continued to assist with the challenges of providing
access to health care services in the Indian Country through its care
delivery options. To support the eligible AI/AN Veterans receiving care
directly from Indian Health Service (IHS) and Tribal Health Program
(THP) facilities, VA expanded the scope of the agreements under the VA
Reimbursement Agreement Program (RAP) to include reimbursement of
telehealth services in 2021. VA is in the process of drafting a new IHS
and THP agreement through collaborative Tribal consultations to
incorporate the reimbursement for care purchased under the Purchased
Referred Care program to further increase the AI/AN Veteran access to
health care services in the community.
    In 2022, VA expanded its RAP to include Urban Indian Organizations
(UIO) providing access to culturally sensitive care to eligible AI/AN
Veterans residing in urban areas. VA's Community Care Network (CCN) \1\
provides additional access to providers through the National contract,
including in rural locations and Indian Country. In New Mexico alone,
which has a large Tribal Veteran community, the CCN includes 7,028
providers who provide 16,648 services. As an additional means of care
delivery designed to address hard to reach communities and sparce
specialties, VA can establish Veteran Care Agreements (VCA) which may
be used when authorized. In New Mexico, VA currently utilizes 134 VCAs.
---------------------------------------------------------------------------
    \1\ The CCN is a separate VA community care program that the IHS/
THP RAP sites can leverage when needs exceed the direct care offered at
the IHS/THP facilities. VA contracts with Optum and TriWest to build
the CCN Network.
---------------------------------------------------------------------------
    To directly address care coordination when Veterans need services
beyond what their community or participating RAP facilities can
provide, VA established the Community Provider Order process, a
standardized approach for managing requests for service from external
providers to VA for clinical services. VA staff can coordinate the care
needed by the Veteran either in a VA facility or through a community
provider through VA's CCN.
    Additionally, to help AI/AN Veterans navigate the complex health
care system and provide extensive care coordination, the Office of
Rural Health engaged in the development and pilot of the Rural Native
Veteran Health Care Navigator Program. This pilot aims to increase
rural AI/AN Veteran access to health care and Veteran-associated
resources.
    Question. What are VA's plans to launch a Tribal Health Office in
fiscal Year2023? The response should include a description of roles and
responsibilities, as well as planned resources.
    Answer. As announced by the Secretary at the Nation-to-Nation
summit in October 2021, VHA is establishing the Office of Tribal Health
(OTH) to advance efforts and opportunities for VA with Tribal nations,
to oversee, maintain and improve VHA's relationship with IHS to
facilitate access to high-quality and timely health care and related
services for AI/AN Veterans. Once fully implemented, OTH will provide
VHA with centralized leadership and strategic direction on national
policy relating to AI/AN Veterans, align resources and efforts
pertaining to AI/AN Veterans across the organization and develop clear
and consistent messaging for both internal and external stakeholders
for topics effecting AI/AN Veterans.
    OTH provides VHA with national leadership, guidance, strategic
direction, and policy to support AI/AN Veteran health care, access, and
Fourth Mission activities across the enterprise. Serves as a consulting
partner on the VHA/IHS Memorandum of Understanding (MOU) and pertinent
legislation. Additional responsibilities of OTH are as follows:

  --Engage with Tribal nations: Collaborate with the VA OTGR on formal
        Nation-to-Nation consultation and in the development of VHA/
        Tribal communications.

  --Build national partnerships: Support the health care system by
        establishing and strengthening relationships with Federal,
        State and local partners in support of programs that seek to
        enhance AI/AN health.

  --Advise on Tribal health care issues: Act as VHA's subject matter
        expert on all matters related to AI/AN health care and services
        programs providing informed advice on AI/AN health matters to
        the Undersecretary for Health, VA Senior Leaders, the White
        House, and Congress.

  --Support VHA programs, Veterans Integrated Service Networks (VISN)
        and VA Medical Centers (VAMC) in delivering health care
        services to AI/AN Veterans: Provide communications and
        coordination support to VHA programs aiming to improve health
        care for AI/AN Veterans and support VHA's Fourth Mission
        responsibilities, as well as standardized guidance to support
        AI/AN Veteran health care, access, enrollment and Fourth
        Mission activities between all levels of VA, VHA and other
        organizations, such as IHS, THPs and UIO.

  --Enhance coordination, education and resource sharing: Enhance
        coordination of data, medical resources and best practices
        sharing.

    A total of eight full time equivalents (FTE) will be allocated to
OTH to support its goals and objectives. The Executive Director was
onboarded in June 2022 and the Deputy Director was onboarded in July
2022.

    A breakdown of the planned resources is as follows:

  --Director;

  --Health System Specialist Supervisor (Deputy Director);

  --Administrative Support;

  --Data Analyst;

  --Education and Training Specialist;

  --Communications Specialist;

  --Strategic Planner; and

  --Community Outreach Manager.

                          state veterans homes
    Question. State veterans homes face similar challenges to hire and
retain staff as VA. While the States have, and should retain,
operational control over the homes, supplemental appropriations were
provided to support their continued operation during the COVID-19
response.
    Did VA financially support state veterans homes during the pandemic
to the maximum of its current authority?
    Answer. Congress authorized up to $100 million transfer of
unobligated funding originally appropriated in Title X of Division B of
the Coronavirus Aid, Relief and Economic Security (CARES) Act (Public
Law 116-136) from Medical Services to the Medical Community Care
account in section 517 of Division J, Title II of the Consolidated
Appropriations Act, 2021 (Public Law 116-260), which was allocated to
State Extended Care Facilities for Veterans to prevent, prepare for and
respond to COVID-19. VA then obligated all of the authorized $100
million from section 517 of the CARES Act appropriations in 2021 to
support State Veterans Homes (SVH). VA also waived the occupancy rate
(90 percent) and the Veteran percentage requirement (75 percent Veteran
and 25 percent non-Veteran) pursuant to section 20005(a)-(b) of the
CARES Act. In addition, an early 2.9 percent increase in per diem was
approved for Veterans paid at the basic and prevailing rates in all
three levels of care.
    The Medical Community Care account received an additional $250
million through Section 8004(2) of the American Rescue Plan (ARP) Act
of 2021 (Public Law 117-2). This section authorized VA to provide a
one-time emergency payment to existing SVH for operational expenses.
Payments were made in proportion to each State's share of the total
number of residents in SVHs on March 11, 2021. All payments for this
$250 million were made to the SVHs by September 30, 2021.
    The number of Nurse Retention Grant applications from States
increased from 4 in 2021 to 54 in 2022 to assist with hiring
difficulties. These grants are authorized by 38 U.S.C. Sec. 1744.
Approved applications totaled $3.2 million in fiscal Year2022 funds to
support SVHs in hiring and retaining nurses at SVHs.
    Question. Are there additional ways or flexibilities that would
improve the Department's support of state veterans homes?
    Answer. The Geriatrics & Extended Care (GEC) Facility-Based Program
continues to provide education to SVH Leadership in collaboration with
the National Association of State Veterans Homes (NASVH) with annual
education on how to apply for the Nurse Retention Grants under 38
C.F.R. part 53 grants. In addition, GEC meets monthly with NASVH for
additional ways or flexibilities in which VA can support the SVHs.
NASVH and GEC are collaborating on several initiatives and best
practice sharing on such topics as suicide prevention, age-friendly
health systems, mental health, wound care and oral care, just to name a
few. VA also recently approved a 2.6 percent per diem supplemental
increase for both basic and prevailing rates.
                infrastructure/clean energy initiatives
    Question. As VA plans for and undertakes infrastructure
improvements it should strive to improve efficiency and energy savings
wherever possible. What steps is VA taking to promote energy efficiency
and clean energy building initiatives through these infrastructure
improvements?
    Answer. VA now requires third-party sustainability certification of
new construction and major renovation projects using the U.S. Green
Building Council's Leadership in Energy and Environmental Design (LEED)
certification program. LEED aims to reduce energy consumption, conserve
water, improve indoor air quality and lower operating costs.
    In line with the requirements of Executive Order (EO) 13990, VA is
also updating its Sustainable Design Manual and master specifications
related to equipment selection to incorporate the social cost of
greenhouse gas (GHG) emissions for life cycle cost analysis of non-
recurring maintenance, as well as major and minor construction
projects. The updates will require VA to account for the impact of GHG
emissions more accurately within project planning decisions.
    Additionally, VA is taking steps to plan for net-zero emissions
buildings and carbon pollution-free electricity to meet the
requirements of EO 14057. These efforts will involve additional updates
to VA design standards and specifications, a continued push for energy
and water efficiency within VA infrastructure projects and partnerships
with agency and private sector organizations.
    The Energy Act of 2020 (Division Z of Public Law 116-260) requires
agencies to implement all energy and water conservation measures within
2 years after being identified as life cycle costs, effective from the
date of mandatory quadrennial audits. VA issued Interim Guidance to
ensure its facility engineers are pursuing implementation of these
efficiency measures through both appropriations as well as alternative
financing resources.
    These initiatives are reflected in updates to VA's Strategic
Capital Investment Planning (SCIP) process. The Energy, Water and
Sustainability Management criteria for construction projects are being
adjusted to further align with priorities from the latest
sustainability and climate related EOs, including reducing GHG
emissions. These adjustments will build on existing goals and targets
for building sustainability, energy use intensity, renewable energy
generation and potable water use intensity. Relative weighting for this
criterion was evaluated and increased 78 percent during the 2023 SCIP
process and an additional 5 percent in the 2024 SCIP process to ensure
sustainability and climate resiliency initiatives are accurately
evaluated and prioritized in our enterprise-wide capital planning
efforts and resulting budget requests.

                                 ______

              Questions Submitted by Senator Patty Murray
    Question. In conversations with providers across Washington state,
it is clear that the Housing First model is the most effective approach
to ending homelessness, and VA has successfully utilized the model to
reduce the number of veterans experiencing homelessness.
    How is the Department addressing veteran homelessness using the
Housing First model and how does the President's budget request for
fiscal year 2023 advance this effort?
    Answer. Housing First is an evidence-based, cost-effective approach
to ending homelessness for the most vulnerable and chronically homeless
individuals. The Housing First model prioritizes housing and then
assists the Veteran with access to health care and other supports that
promote stable housing and improved quality of life. The VHA Homeless
Program Office (HPO) continually reinforces adherence to the Housing
First approach in program implementation and community-level efforts to
address Veteran homelessness. The focus of VA homeless programs is to
ensure that Veterans' immediate needs for housing are met while also
providing wrap-around supportive services. It is important to note that
Housing First is a ``First'' step. Program participants who move into
new housing need to meet the same demands as other tenants: paying rent
and not engaging in behaviors that could lead to eviction or non-
renewal of their lease and potentially a return to homelessness.
Programs must partner with these newly-placed tenants to identify the
information, skills and services that will support their housing
stability. However, these services should not be a condition of
receiving housing support. Housing First is important because research
indicates that it reduces housing placement time, improves retention
rates and reduces emergency room use.

    VA homeless programs are expected to embrace these principles and
apply the practices across programs in the following areas:

  --Health Care for Homeless Veterans and Grant and Per Diem programs
        utilize Housing First principles by transitioning Veterans to
        permanent housing as quickly as possible based on Veterans'
        clinical needs without imposing barriers to engagement in
        emergency/transitional housing.

  --VA homeless programs are expected to minimize barriers to program
        engagement and admissions and establish flexible exit policies
        to ensure that Veterans remain engaged in services to secure
        permanent housing. For example, Supportive Services for Veteran
        Families (SSVF) and Housing and Urban Development--VA
        Supportive Housing (HUD-VASH) programs provide permanent
        housing and supportive services without preconditions for entry
        or placement into such permanent housing.

  --VAMC Homeless Program Leads are responsible for ensuring that staff
        understands and can apply a Housing First approach to services,
        including how to focus on harm reduction strategies to respect
        Veteran choice, facilitate engagement and rapidly house
        Veterans. Homeless Program Leads also communicate in team
        huddles to ensure that clinical recommendations are aligned
        with a Housing First approach.

  --HPO is engaging in collaborative efforts with VAMCs to (1) review
        local standard operating procedures and training materials to
        ensure that VAMC practices align with Housing First; (2) review
        grantee and contractor policies to ensure a Housing First
        approach is applied; and (3) review Veteran-level admission and
        exit information for grantees and contractors to ensure that
        programs are conducting outreach to engage the hardest-to-serve
        Veterans and admitting Veterans regardless of their status with
        sobriety or other service engagement. HPO also uses progressive
        engagement with SSVF to house Veterans quickly or transition
        them to HUD-VASH. Progressive engagement is the practice of
        augmenting services when initial efforts do not adequately
        support housing stability. It provides critical flexibility so
        service plans can be revised as necessary to meet Veteran
        needs.

  --VA implements the SSVF Program in 38 C.F.R. part 62. In November
        2021, VA amended 38 C.F.R. Sec. 62.34(a)(8), which provides for
        Shallow Subsidy funds to increase the Shallow Subsidy rate from
        35 percent to 50 percent. VA's fiscal Year2023 budget request
        proposes $730 million for SSVF. This funding level will allow
        SSVF to sustain the increased Shallow Subsidy rate. Shallow
        Subsidies provide 2-years of rental support to homeless and at-
        risk Veterans. Rental supports can be up to 50 percent of
        actual rent and do not decline during the 2-year period,
        providing an incentive for Veterans to increase their income.
        An important feature of the Shallow Subsidy initiative is the
        collaboration with the Department of Labor's Homeless Veterans
        Reintegration Program (HVRP), which seeks to help Veterans
        achieve self-sufficiency by the end of the 2-year subsidy
        period. SSVF and HVRP have issued a joint coordination plan
        directing their respective grantees to work collaboratively and
        co-enroll where possible.

  --HUD-VASH has used the principles of Housing First since fiscal
        Year2012. As a permanent supportive housing program utilizing
        the principles of Housing First, HUD-VASH pairs HUD rental
        subsidies with VA clinical case management and supportive
        services without the preconditions found in more traditional
        models, such as housing-ready programs. The bulk of VA's HUD-
        VASH budget supports the VA FTE and contract staff who provide
        these services. The President's budget request for fiscal
        Year2023 shall support the program's operations and will allow
        the program to staff a new 8,500 voucher allocation which HUD
        anticipates awarding in late 2022 or early 2023. fiscal
        Year2023 funds will also support additional staffing to support
        a new expansion of Tribal HUD-VASH grant awards to serve
        additional Tribal HUD-VASH Veterans. Additionally, as nearly 60
        percent of HUD-VASH Veterans are currently over the age of 60,
        the program has been focusing on developing models of care
        better suited to meet the housing needs of aging and disabled
        Veterans. The requested Medical Support and Compliance funds
        will support the development of these partnerships.

    Question. Does VA have access to the funding necessary to achieve
the Department's goal of permanently housing 38,000 veterans by the end
of fiscal Year2023?
    Answer. VA currently has sufficient access to the funding necessary
to achieve the Department's goal of permanently housing 38,000 Veterans
by the end of calendar year 2022. In addition to discretionary funds,
the HPO received $486 million in ARP funds (Public Law 117-2 Sec. 8002)
that are being utilized to implement strategies that ensure access to
permanent housing and reduce homelessness. These funds also are being
used to increase permanent housing placements to further the
Department's 38,000 permanent housing placement goal.
    For example, on June 24, 2022, SSVF published a Notice of Funding
Availability (NOFA) that introduced landlord incentives, tenant
incentives and augmented housing navigation services to help homeless
Veterans find and move into housing. This NOFA awards an additional
$137 million to support these new authorities, with much of the funding
coming from ARP. These incentives will be expanded nationally if the
President's proposed fiscal Year2023 budget passes, as it will
appropriate $731 million to SSVF grants. VA has not set an equivalent
goal for fiscal Year2023.
    Question. In 2021, VA released a climate action plan, which
outlined climate-related priorities including steps to reduce their
carbon footprint and expand climate resilience.
    Over the last few years, how has VA reduced waste produced at VHA
facilities?
    Answer. During the pandemic VA medical facility waste generation
rates were reduced by 20-30 percent across the board due to telehealth
consults, reduction of onsite care and curtailing elective procedures/
surgeries. Currently, levels of waste are slowly returning to pre-
pandemic rates.
    VHA educates facility program managers and staff on opportunities
to increase waste diversion rates through recycling and reuse via
Environmental Programs Service (EPS) national conference calls, EPS
sponsored Educating for Excellence conference calls and orientation
programs. The U.S. recycling market declined between 2018 and 2020 due
to recycling material restrictions from the international community.
During this period, there was little to no demand for recyclable
materials. The recycling market improved in 2021 due to increased US
recycling infrastructure and demand for recyclable material (plastics,
cardboard and paper). VA medical facilities are encouraged to
reinvigorate in-house recycling programs by communicating with their
regional waste haulers to identify desired recycled material for
collection. Examples of materials being recycled currently include
electronics, yard composting, batteries, single use medical devices
(for material only), reusable sharps containers, used cooking oil,
textiles/linens and construction and demolition waste.
    Question. Are there other ways for VA health care facilities to
reduce their carbon footprint?
    Answer. VA has prioritized the pursuit of cost-effective strategies
to reduce its carbon footprint for many years and is scored on that
progress annually. EO 14057 (December 8, 2021) established requirements
for agencies to reduce their GHG emissions by 65 percent by 2030 and
aim for net-zero emissions across Federal operations by 2050. In
response, VA continues to build upon progress to date and implement
options, as appropriate, for reduction of GHGs across its portfolio
including VHA health care facilities. Efforts include increasing the
energy and water efficiency of existing buildings, electrification of
equipment and vehicles, pursuit of carbon pollution-free electricity,
further reduction of municipal solid waste and waste from construction
and demolition, purchasing more low-carbon materials and enhanced
accountability of VA suppliers to disclose and reduce their own GHG
emissions.
    Question. Many veterans enrolled in VA health care benefit from the
unique care of neurology-related centers of excellence.
    In fiscal Year2022, Congress directed the VA to expand the Headache
Centers of Excellence to 28 sites nationally. What is the status of
this expansion and what additional resources are being allocated to
this accomplish this directive?
    Answer. VA currently has 18 Headache Center of Excellence (HCoE)
sites, one in every VISN. Ten additional sites have been identified in
VISNs with a greater number of Veterans living with headaches as well
as for States within these VISNs that do not have a HCoE.
    Question. The centers focused on Parkinson's disease and Multiple
Sclerosis have not received a significant funding increase for many
years. Does VA have any plans to expand or further fund these centers?
    Answer. The 2023 President's Budget includes funding to sustain the
Office of Neurology's efforts. Details regarding maintenance and
expansion of the neurology Centers of Excellence, as well as
opportunities for collaboration among the neurology Centers of
Excellence, will be outlined in a forthcoming report to the Committee.
    Question. The health care market assessments for the AIR Commission
report were started before the COVID pandemic. The Department has since
stated it is working to update and correct the outdated assessments.
    How long did it take the contractors to complete the original
market assessments for the AIR Commission report?
    Answer. The original market assessments required 4 years to
complete. The recommendations were published in the Federal Register in
March 2022.
    Question. Who is conducting the new market assessments and what is
VA's estimate for when will the new assessments be completed?
    Answer. New market assessments have not yet begun. The VA MISSION
Act of 2018 requires VA to conduct quadrennial market assessments,
which are not yet underway. The next quadrennial market assessments are
projected to be completed by January 2026. VA anticipates beginning the
next round of market assessments in calendar year 2023.
    Question. It is important that these assessments include input from
those who know the facilities the best. What are the Department's plans
for consulting with health care professionals at VA medical centers,
outpatient clinics, nursing homes, readjustment centers, and other
health facilities?
    Answer. As part of the market assessments, VA conducted more than
1,800 interviews and more than 120 site visits. The interviews included
both VISN and VAMC leadership. In addition, VA hosted 56 local public
virtual listening sessions to hear from Veterans and other stakeholders
on how to design a health care system of the future and grow services
for Veterans in a way that reinforces VA's role as a leader in the U.S.
health care system. The 56 sessions included four national sessions
that occurred during evening hours in different time zones across the
country, as well as a national session that was held in Spanish. On
June 27, 2022, the SVAC Chairman Jon Tester announced that the Senate
will not move forward with confirming the nominees to the AIR
Commission. Without the Senate's approval, no Commission will be
formed, and the process outlined in the VA MISSION Act of 2018 will not
move forward. However, President Biden has insisted that Veterans in
the 21st Century should not be forced to receive care in early 20th
Century buildings. The median age of VA's hospitals is nearly 60 years
old, which is why the President requested nearly $20 billion in new VA
infrastructure spending last year and why he requested the largest ever
investment in VA infrastructure in his fiscal Year2023 budget.

                                 ______

            Questions Submitted by Senator Patrick J. Leahy
                 compensation and pension (c & p) exams
    Question. With the recently announced presumptive conditions and
the outstanding backlog in Blue Water claims from the Vietnam era, the
VA needs to continue to ensure that Compensation and Pension (C&P)
exams are conducted timely, accurately, and within a reasonable
distance for the veterans. Yet the capacity of the VA Medical Centers
(VAMCs) to conduct these exams in-house has dramatically decreased in
recent years, particularly during the COVID-19 pandemic, while the cost
to the C & P fund of contracted exams has increased dramatically. Many
Vermont veterans have complained to me about having to travel long
distances to have their examinations conducted in trailers, in New York
or New Hampshire, and others have raised concerns about the
qualifications of the contracted examiners.
    What can the VA do to rebuild the capacity of local VAMCs to
conduct the C&P exams in house?
    Answer. VHA remains committed to VA's Compensation & Pension (C&P)
Disability Examination Program as part of a shared Department mission
with the Veterans Benefits Administration (VBA). As demand for medical
disability examinations fluctuate over time, VHA facilities are
expected to maintain core C&P capabilities and expand their capacity to
complete C&P examinations. Maximum flexibility is given to VHA
facilities to determine the level of access to C&P exams that can
safely be provided with priority given to critical Veterans' health
care delivery. VHA will continue its collaborative approach with VBA to
pursue a unified and coordinated Department C&P strategy, utilizing
both VHA resources and VBA contractors. The utilization of contract
vendors in addition to increased collaboration with VHA has allowed VBA
to complete more claims than any previous year. Additionally, vendors
have provider availability worldwide in locations where VHA is not
available.
    As part of an overall integrated strategy, VHA and VBA will
continue to emphasize the modernization of C&P delivery at local VAMCs
through efficient use of technology and virtual modalities, such as
Acceptable Clinical Evidence and tele-C&P to expand access and
throughput of C&P services. VHA will continue to evaluate innovative
ways to balance critical health care delivery with the needs of
Veterans requiring C&P exams to support their disability claims. VHA's
Office of Disability and Medical Assessment (DMA) is considering
technology solutions to modernize the routing of C&P exam requests
throughout the VHA enterprise. Currently, DMA is coordinating with
internal VA Offices and working through the strategic planning process
for new technology to evaluate the options available to modernize the
C&P exam process. Options that local VAMCs may use to increase the
capacity for C&P examinations may include the use of flexible hiring
authorities to complete C&P exams, technology investments to improve
virtual care utilization and efficiency and expanding C&P training to
currently employed VHA clinicians to expand the pool of trained and
certified VHA workers who could participate in virtual hubs and/or
weekend or after-hours C&P clinics. Finally, as some expected workload
shifts back to VHA, a critical component of VHA's overall integrated
strategy is consideration of establishing a separate and distinct
budget allocation for exclusively VHA supported disability examinations
provided solely by VHA C&P examiners at VA medical facilities.
    Question. What is the per exam cost of contracted exams vs. exams
conducted in-house?
    Answer. Both the VBA and VHA figures are based on obligations and
include direct as well as indirect costs associated with C&P exams.
Although the average cost for VBA appears to exceed VHA's average cost
in recent years, VBA anticipates significant decreases in average costs
for fiscal Year 2020 and fiscal Year 2021 once final invoices are
received. VBA experienced difficulties completing exams due to the
COVID-19 pandemic and disruptions of in-person exams during this time.
When final invoices are received, obligations will be reduced to better
reflect the actual experience and cost of exams.

    Please see the table below:

----------------------------------------------------------------------------------------------------------------
            C&P Exams                 FY 2017         FY 2018         FY 2019         FY 2020         FY 2021
----------------------------------------------------------------------------------------------------------------
VBA Average Cost................          $1,211          $1,065          $1,148          $1,676          $1,339
VHA Average Cost................          $1,081          $1,184          $1,066          $1,283          $1,308
----------------------------------------------------------------------------------------------------------------

    Question. What type of legislation would be required to allow the
VHA to reimburse the VAMC from the C & P fund on an equal basis with
the contractors?
    Answer. VA would need adjustments to appropriation language for the
mandatory C&P account specifically authorizing the transfer of funds
from the C&P account to the Medical Services account. A new
reimbursement for necessary expenses of carrying out VHA's C&P
examinations would be significantly more complex to administer and
account for than existing reimbursements. VA would appreciate the
opportunity to provide technical assistance on draft legislation on
this matter.
    In addition to the legislative change that would be required, VBA
contract vendors sub-contract with more than 14,054 examiners, both
foreign (762) and domestic (13,292), to successfully perform work in
support of the medical disability contracts. The logistics associated
with exam room space, medical equipment, examiner training and sub-
contracted agreements for diagnostic testing within the United States
and internationally, would be additional costs incurred to ensure that
VHA is able to provide the same level of service as VBA for Veterans
residing within the United States and abroad.
                      interagency veteran support
    Question. The President's budget request represents a significant
increase over enacted funding levels for the Department of Veterans
Affairs. This appropriately reflects the importance of caring for and
supporting our veterans. As Chairman of the Appropriations Committee,
though, I know that our veterans benefit from federally supported
programs outside the purview of the Department of Veterans Affairs.
    Would you agree that caring for our veterans requires that we not
only address health care needs, but also housing, education,
employment, and small business needs?
    Answer. Yes, Veterans often benefit directly from the Federal
programs that are currently competing with VA for resources within the
non-Defense discretionary budget. This includes the Department of
Health and Human Services, for example, which has saved countless
Veterans' lives during the pandemic by leading the development of the
COVID-19 vaccine; the Department of Housing and Urban Development
(HUD), as one of VA's steadfast partners in our efforts to end Veteran
homelessness; the Department of Education, which provides Veterans with
student loans; and the Department of Labor, which supports programs
related to Veteran employment. VA strongly agrees that adequate
resources for our partner Federal agencies is critical to caring for
Veterans.
    Question. How does the Department of Veterans Affairs work with
other Federal agencies to meet veteran needs to ensure that those who
have fought for our country receive the assistance they need?
    Answer. VA's Office of Enterprise Integration serves as the
interagency portal to assess and align coordination among Federal
agencies to provide care and services to Veterans, with synchronization
focused on U.S. Departments of Labor, HUD, Health and Human Services
and the Indian Health Service. In addition, staff at VHA, VBA, NCA and
other VA components work closely with their counterparts at these
agencies.
                         veteran care at the va
    Question. The Department has completed a comprehensive review of
projected demand for VA services as well as an evaluation of how
existing facilities meet demand. Like many other Senators, there are
areas where I agree with your assessment and areas of disagreement. I
am struck by a line in your written testimony, however, that your
review overwhelmingly confirmed nationwide what I have always found to
be true in Vermont: veterans want to receive their health care from a
world-class VA facility where people understand the needs of veterans.
Veterans, at least those I hear from in Vermont, want neither
privatization of their care, nor a voucher system that removes them
from the VA-system.
    I am sure you agree that our Nation's veterans should continue to
receive the world-class care that they are not only entitled to, but
that they have earned and deserve. How will the VA ensure this care
continues, and remains accessible, amid the closures it proposes to the
AIR Commission?
    Answer. VA aims to build a health care network with the right
facilities, in the right places, to provide the right care for all
Veterans, including underserved and at-risk Veteran populations in
every part of the country-making sure that facilities and services are
where Veterans are. As required in the VA Maintaining Internal Systems
and Strengthening Integrated Outside Networks (MISSION) Act of 2018
(Public Law 115-182), VA researched, developed and published a list of
recommendations intended to modernize VA medical facilities and health
care delivery-including through facility expansions, relocations,
closures or changes in services. On June 27, 2022, the Senate Veterans'
Affairs Committee (SVAC) confirmed that it would not hold a hearing or
proceed with confirmation of the nine nominees for the AIR Commission.
VA will remain focused on modernizing our health care delivery system
to best serve Veterans. The recommendations published represent VA's
plans to modernize and realign our delivery system in a model that
enhances Veterans' access to care, aligns our capacity with projected
future demand, solidifies our Fourth Mission capabilities and maintains
and improves the quality of the care we deliver in a sustainable
manner.
    Question. What efforts is VA taking to bring care to veterans who
may ultimately end up being further from care than they are now, if the
recommendations are accepted?
    Answer. VA's market assessment recommendations were developed with
a requirement that geographic access to care be maintained or improved.
In essence, the recommendations would lead to care being closer to
Veterans rather than further away. In some markets this includes adding
additional VA sites of care, while in other markets the recommendation
is for VA to work with community providers for care closer to Veterans.

                                 ______

             Questions Submitted by Senator Mitch McConnell
                             claims backlog
    Question. Reports have indicated that more than 200,000 claims for
VA benefits have been pending longer than 4 months. What is the total
number of claims currently experiencing this type of backlog? If
available, please provide specific data on the number of Kentucky
veterans impacted by delays. What is the VA's strategy for decreasing
the backlog?
    Answer. As of September 24, 2022, VA had 641,694 pending rating
claims with 148,507 pending longer than 125 days and considered to be
part of the claims backlog. There are currently 9,090 rating claims
pending for Kentucky Veterans with 2,197 considered in the backlog.
Nationally, the percentage of claims pending in the backlog is similar
to the percentage of claims pending in the backlog prior to COVID-19.
    VA is taking the following proactive steps to accelerate processing
and reduce the number of Veterans awaiting claim decisions:

  --Hire and train approximately 2,000 employees to assist and support
        disability benefits claims processing.

  --Additionally, the fiscal Year 2023 President's Budget requests
        additional resources to support C&P claims processing.

    Question. Has the National Personnel Records Center at the National
Archives resumed full operations? What resources are available to
veterans who experienced significant delays in accessing their records
during the pandemic-related closures? What steps has the VA taken to
prevent these delays from taking place in the future?
    Answer. The National Personnel Records Center (NPRC) lifted
building occupancy restrictions and directed its workforce to return to
on-site operations on March 7, 2022. To reduce the records request
backlog for Officially Military Personnel Files and Service Treatment
Records that accumulated as a result of the pandemic, it continues to
operate multiple shifts each day and is working overtime on most
Saturdays, Sundays, and on some holidays.
    NPRC's service to VA has been restored to pre-pandemic levels. Most
VBA requests are serviced by NPRC within 3 business days. In addition,
records are digitized by VA within seven calendar days of receipt from
NPRC, on average.
    Veterans may submit disability compensation claims to VA, and VA
will work directly with NPRC to promptly secure any records that are
needed to process the claim. Veterans do not need to obtain access to
records from NPRC in advance of submitting a disability claim to VA.
They would be better advised to allow VA to acquire the records
directly from NPRC.
    Veterans who submitted requests to NPRC during the pandemic do not
need to submit another request. They may check on the status of their
request by contacting NPRC at 314-801-0800, or, if they submitted their
request electronically, they may check the status online using the
National Archives and Records Administration's (NARA) eVetRecs
application. If the records are needed for an urgent matter, such as a
funeral service or admittance to a homeless shelter, they may call NPRC
at 314-801-0800 and request expedited service.
    NPRC holds over 60 million military service records (personnel
folders, service treatment records, clinical records, etc.) in paper
and micrographic formats. In their current format, these records can be
accessed only by staff working on-site. During the pandemic, to prevent
the spread of the virus, NPRC operated with on-site occupancy
limitations significantly below its normal capacity.
    To prevent these delays from taking place in the future, VA
partnered with the NPRC to establish an on-site scanning operation to
scan records needed for processing VA claims for benefits and those
records necessary for responding to requests for records submitted to
NARA. This allows NPRC to respond in a secure, digital manner to
records requests and has significantly reduced processing times for
both VA and NARA. As more records are digitized, there will be less of
a dependency for on-site staff to access paper records and a risk
reduction of a recurrence of significant record request delays.
                rural veterans' access to va health care
    Question. As you know, rural veterans often must travel long
distances to access care at VA facilities and often have limited
options for high quality care through the community care network. The
VA recently published its recommendations to the Asset and
Infrastructure Review (AIR) Commission and proposed to close several
Community Based Outpatient Clinics in Kentucky and relocate them closer
to higher population centers. During this process, what metrics were
used to evaluate the unique needs of rural veterans and how were they
incorporated into the VA's AIR recommendations? Did the VA consider the
potential harm to rural veterans when recommending the consolidation of
CBOCs closer to major population centers in Kentucky?
    Answer. The potential impact on rural Veterans was considered in
VA's market assessment recommendations. Rurality by county (the total
and overall percentage of enrollees residing in rural areas) was
evaluated with other demographic metrics, including current and
projected enrollees by market, sector and county and current and
projected enrollees by age, gender and priority. Analysis was also
significantly informed by input from local VA medical facilities,
including site visits and more than 1,800 interviews with field staff.
Veterans were also able to directly relay any questions or concerns
through VISN-coordinated Listening Sessions. The recommendations were
developed with consideration of each market's unique needs to ensure
Veterans have access to high quality care now and in the future.
    Nationwide, VA's market assessment recommendations, if implemented,
will improve Veteran access to outpatient and inpatient care-by adding
new sites of care, and in some cases, moving existing clinics to
locations closer to where Veterans live in modern facilities.
    Section 203 of the VA MISSION Act of 2018 required VA to establish
specific criteria to use in the development of the recommendations. In
May 2021, VA released criteria which specified the key sets of metrics
used in the recommendations. The final criteria included: Demand
(Veterans' Need for Care & Services and the Market's Capacity to
Provide Them); Access (Accessibility of Care for Veterans); Impact on
Mission; Quality (Providing the Highest Quality Whole Health Care);
Cost Effectiveness (Effective Use of Resources for Veteran Care); and
Sustainability (Ensuring a Safe and Welcoming Health Care Environment
of Care). All recommendations were formulated to meet the criteria. The
access criteria specifically ensured that VA points of care and
services were aligned with projected Veteran needs across demographics
and geography. VA assessed the Access domain not only for the overall
enrollee population but also for specific subpopulations that have
historically faced barriers accessing care, including rural enrollees.
    The criteria set forth for VA's market assessment recommendations
ensures that all recommendations align with VA's goal to be a high-
performing integrated network where resources are used to effectively
meet the future health care demand of the Veteran enrollee population
with the capacity in the market. This ensures that not only will sites
of care have enough workload to provide a good return on investment,
but that we are able to effectively recruit service providers.
Recommendations will either maintain or improve Veteran access to care,
maximizing access when 30-minute drive time bands for primary care and
60-minute drive time bands for specialty care do not overlap. VA's
market assessment process also confirmed that no VA clinic was
recommended to be moved or deactivated without ensuring Veterans would
be provided with a range of integrated health care options, such as
through community care or Federal partners. Lastly, recommendations
must support VA's four missions (care delivery, education, research and
emergency preparedness), as well as consider the quality and delivery
of health care services available to Veterans (including the
experience, safety and appropriateness of care) and provide a cost-
effective means to provide Veterans with modern health care.
    VA's market assessment recommendations for VISN 9 Northern Market
specific to Kentucky would expand Veteran access to care by creating
new sites in Frankfort, Elizabethtown and La Grange, as there are
currently no VA clinics in these areas. There is also an ongoing Major
Construction project to replace the Louisville VAMC. There are utility
and architectural issues with the current main hospital building that
render it unsuitable for continued delivery of modern clinical
services. The new location of the Louisville VAMC will be approximately
4.4 miles from its existing location and approximately 5 miles from I-
71 North.

    VA's market assessment recommendations for VISN 9 Northern Market
specific to Kentucky clinic relocations, closures and rationale include
the following:

  --Relocating the Berea Clinic to a new site in the vicinity of
        Richmond, Kentucky and closing the existing Berea Clinic. The
        existing Berea Clinic is located 15 miles south of the larger
        Veteran population in Richmond. Relocating to the vicinity of
        Richmond places primary care, outpatient mental health and
        outpatient specialty care services in a more accessible and
        sustainable location. Richmond is also home to Eastern Kentucky
        University where affiliated training programs can strengthen
        staff recruitment and younger Veteran outreach. In fiscal Year
        2019 there were 8,231 enrollees within 30 minutes of the
        proposed site and 27,902 enrollees within 60 minutes, as
        opposed to 4,258 enrollees within 30 minutes of the current
        site and 27,467 enrollees within 60 minutes. With the
        relocation and addition of specialty care services, the Berea
        Clinic will be renamed and reclassified to the Richmond Multi-
        Specialty Clinic.

  --Relocating the Newburg Multi-Specialty Clinic to a new site in the
        vicinity of south Louisville, Kentucky and closing the existing
        Newburg Multi-Specialty Clinic. The existing Newburg Multi-
        Specialty Clinic is at the end of its lease and does not meet
        current VA design standards. Its existing location has
        overlapped with the new Greenwood Clinic and Stonybrook Multi-
        Specialty Clinic. Relocating to the vicinity of south
        Louisville places primary care, outpatient mental health and
        outpatient specialty care services in an appropriately designed
        facility and will extend access to the rapidly increasing
        enrollee population in counties south of Louisville. In fiscal
        Year 2019, there were 24,110 enrollees within 30 minutes of the
        proposed site and 50,492 enrollees within 60 minutes.

  --Relocating all services to the proposed La Grange Clinic and
        closing the Carrollton Clinic. The existing Carrollton Clinic
        is not conveniently located for Veterans or sustainable for
        staffing. In fiscal Year 2019, there were 3,056 core unique
        patients but only 2,375 enrollees lived within 30 minutes of
        the current location. Enrollees in Carroll County are projected
        to decrease by 0.9 percent from 356 to 353 between fiscal Year
        2019 and fiscal Year 2029. The Carrollton Clinic is within 30
        minutes of the proposed La Grange Clinic with 14,425 enrollees
        within 30 minutes in fiscal Year 2019. The larger La Grange
        health care community will improve stability of staffing and
        its proximity to the Louisville VAMC will improve the ability
        to support more services with visiting providers.

    Question. What is the VA's plan for leveraging new Federal
investments in broadband infrastructure to increase rural veterans'
access to telehealth options?
    Answer. VA has established a 5-year strategic vision for connected
care that will enhance Veteran digital engagement, deliver health care
without walls, sustain and increase capacity in rural and highly rural
locations and solidify VA's connected care foundations. The strategy
depends on having reliable and affordable internet infrastructure to
ensure VA can equitably serve Veterans in their homes, communities and
other places they choose to be in the country.
    VA's connected care strategy includes initiatives that will enhance
the accessibility of VA health care in rural areas by delivering
enhanced video telehealth care in the home using VA Video Connect and
VA-provided examination peripherals (e.g., digital stethoscopes, blood
pressure cuffs, pulse oximeters, thermometers, etc.). The strategy also
includes continued focus on expanding the capacity of VA services in
rural and underserved areas by distributing clinical resources using
telehealth through clinical resource hubs and other virtual health care
delivery initiatives. Services that will be distributed include
inpatient services such as tele-critical care, high-volume outpatient
services (such as primary care and mental health) and low-volume,
highly specialized services such as stroke neurology. Additionally, the
strategy supports expanding remote patient monitoring capabilities,
allowing rural and highly rural Veterans to attentively monitor and
manage chronic health conditions, in partnership with VA, from their
homes.
                  louisville va medical clinic (vamc)
    Question. I understand the VA has requested an additional $35
million for the new Robley Rex VAMC in the Fiscal Year 2023 budget to
address additional costs from lawsuit-related delays. Please provide an
update on construction of the new VAMC, the expected timeline for
completion, and details on how this additional funding will be spent.
Do you anticipate any additional cost increases for any reason?
    Answer. Construction is ongoing, with site work for underground
utilities and foundations progressing on schedule. VA anticipates
beneficial occupancy for the project no later than June 2027. The
additional $35 million of fiscal Year 2023 funding will provide
necessary contingency for ongoing construction. VA and the U.S. Army
Corps of Engineers (USACE) are monitoring and aggressively mitigating
risk to manage the project within the funding requested through fiscal
Year 2023.
    Question. Is the VA working with local and State officials to
ensure community concerns about increased vehicle traffic from the new
VAMC are addressed?
    Answer. Yes, there are monthly public engagement meetings with all
elected officials from the surrounding communities including the one
that led to the litigation against VA. As this project is in
construction, the monthly public engagement is led by USACE, Louisville
District, with Public Affairs Officers (PAO) from the VAMC. It is
supported by a USACE Project Manager, Area Engineer and PAO.
    Question. The new Robley Rex VA Medical Center (VAMC) in Louisville
will include a dedicated Women's Health Clinic with four Patient
Aligned Care Teams (PACT). Do you maintain your commitment to ensuring
female veterans have access to state-of-the-art health services at the
new Robley Rex VAMC?
    Answer. To specifically address the needs of our Women Veterans,
the new hospital will include a Women's Health Clinic with four Patient
Aligned Care Teams (PACT). The clinic will include a dedicated
reception and waiting area, gynecology examination rooms with private
restrooms, general examination rooms, telehealth examination rooms,
Doctor of Pharmacy consultation/examination, behavioral health
consultation, nutritional consultation, phlebotomy laboratory,
procedure room with a private restroom and an imaging suite. The
imaging suite will include equipment needed for comprehensive women's
health care including ultrasound, bone densitometry and mammography. In
addition, the Women's Health Clinic will have dedicated support space
for all assigned staff. For cases in which a woman Veteran would like
to see a provider not assigned specifically to the Women's Health
Clinic, all other PACT modules include gynecology examination rooms
with private restrooms.
                             women's health
    Question. What VA programs are available to meet the specific needs
of women veterans? What steps has the VA taken to increase access to
specialized health care for women veterans? How does the VA work with
community care providers to help ensure women's access to health
services that are not provided at nearby VA facilities?
    Answer. VA provides high-quality comprehensive care that includes
basic preventive care, acute care and chronic disease management,
reproductive health care (such as maternity and gynecology care) and
treatment for all gender-specific conditions and disorders, as well as
mental health care.
    VA provides comprehensive specialty medical and surgical services
for women Veterans either on site or through referrals to the
community. In addition, VA is providing infertility counseling and
treatment as well as assistive reproductive technology and in vitro
fertilization services for eligible Veterans through care in the
community.
    To address the growing number of women Veterans who are eligible
for health care, VA is strategically improving services and access for
women Veterans. VA enhanced quality of care for women Veterans by
requiring that women are offered assignment to designated Women's
Health Primary Care Providers (WH-PCP). These providers offer general
primary care and gender-specific primary care in the context of a
longitudinal patient/provider relationship. All VAMCs have at least two
designated WH-PCPs and 93 percent of Community Based Outpatient Clinics
have at least one WH-PCP. To enhance access for women Veterans, VHA is
addressing this gap by hiring more primary care women's health
providers through the Women's Health Innovations and Staffing
Enhancement initiative.
    Between fiscal Year 2021 and fiscal Year 2022, VA will have
distributed $150 million to the field across all 18 VISNs to enhance
services for women Veterans. This includes support of over 800 FTEs, as
well as mammography equipment and low mobility equipment designed to
allow women Veterans with low mobility to access services such as
mammography.
    VA is building a gynecologic workforce equipped to meet the unique
needs of the Veterans we serve. VA holds National Gynecology
Conferences biannually to provide training on the specific gynecologic
needs of Veterans. VA has also built an enterprise-wide gynecology
community of practice as a vehicle for VA gynecologists to share best
practices and clinical expertise. VA is proud to offer high-quality
comprehensive gynecologic services, including complex gynecology care
such as gynecologic surgery and treatment of gynecologic cancers to
Veterans.
    In fiscal Year 2021, 64,000 unique women Veterans had visits with
VA gynecologists and 80 percent of VA health care systems had a
gynecologist on site.
    A significant number of Veterans use maternity services. In fiscal
Year 2021, 39 percent of women Veterans using VA were of childbearing
age (between age 18 and 44). In fiscal Year 2021, VA provided coverage
for 5,904 deliveries. Maternity care is not provided in VA facilities;
instead, it is provided through VA-authorized Community Care. Pregnant
and postpartum Veterans continue to receive care in VA for other
conditions and may also need primary care and emergency care and
require coordination of Community Care services. To support pregnant
and postpartum Veterans, VA developed a Maternity Care Coordination
program in all VA health care systems to ensure coordination of care
both in VA and in the community. In fiscal Year 2021, there were 154
Maternity Care Coordinators (MCC) across the system.
    VA MCCs support pregnant Veterans through every stage of pregnancy
and postpartum. MCCs help pregnant Veterans navigate health care
services both inside and outside of VA, connect to community resources,
cope with pregnancy loss, connect to needed care after delivery and
answer questions about billing. MCCs screen Veterans for intimate
partner violence, perinatal mental health conditions, substance use
disorders, homelessness and food insecurity and ensure Veterans are
connected to appropriate resources and needed services.
    VA is also focusing on enhancing care coordination for gender-
specific care, such as breast and cervical cancer screening. Breast and
cervical cancer screening programs require meticulous tracking to
ensure that all eligible Veterans receive appropriate screening,
receive results of screening tests and that follow-up care is arranged
as needed. VA policy requires each facility to have a process for
tracking results and timely follow-up for breast and cervical cancer
screening. VA policy also requires that facilities have personnel
assigned to breast and cervical cancer care coordination. Eighty-four
percent of sites had a full or part-time Breast Cancer Screening
Coordinator, and 73 percent of sites had a full or part-time Cervical
Cancer Screening Coordinator. To ensure accuracy, timeliness and
reliability, VA tracks the provision of breast and cervical cancer
screening and the availability of breast and cervical cancer care
coordinators across the system. In fiscal Year 2021, 82 percent of age
eligible women had received breast cancer screening and 84 percent had
received cervical cancer screening, far exceeding rates in Medicaid,
Medicare and commercial populations.
    VA utilizes the VA CCN to ensure VHA provides women Veterans a
broad spectrum of health care, including maternity, mammography,
obstetrics and gynecology. VA's Third-Party Administrators (TPA) and
facility staff provide a direct link to community providers to ensure
Veterans receive timely, high-quality care for eligible Veterans. The
TPAs contract with providers in the community to provide a network that
must meet applicable drivetime and appointment timeliness measures. In
circumstances where the networks administered by VA's TPAs do not offer
adequate access, VA facilities can procure needed Community Care
through other means, including through use of local procurement
instruments.
                                 ______

                                 ______

               Questions Submitted by Senator John Hoeven
    Question. The VA's National Cemetery Administration (NCA) has
determined that additional infrastructure--restrooms, storage sheds,
and wind walls--are necessary at each of the rural initiative
cemeteries in order to better serve veterans and their families. These
projects are expected to be completed at Fargo National Cemetery this
summer. While these can be considered upgrades, more can be done to
meet the needs of our veterans, their families, and the local
community.
    Will you agree to work with my office, including by offering
technical assistance, on legislation that would establish a grant
program for community projects that support rural initiative national
cemeteries?
    Answer. VA is always willing to work with Congress to address the
needs of Veterans. Currently, VA has sufficient funding to provide
planned infrastructure improvements throughout our rural cemeteries, to
include Fargo National Cemetery.
    Question. Will you commit to furthering discussions and
collaboration between the National Cemetery Administration and local
stakeholders on a cooperative agreement that could allow for further
infrastructure improvements at or adjacent to Fargo National Cemetery?
    Answer. The National Cemetery Administration (NCA) is committed to
working with its community partners, including the various volunteers
and stakeholders supporting the Fargo National Cemetery. NCA strives to
achieve open lines of communication and responsiveness from those in
the field, through our district office and in headquarters. To that end
the Executive Cemetery Director, Fort Snelling National Cemetery, who
has responsibility for overseeing Fargo National Cemetery, met with
local stakeholders and representatives from your office on May 10,
2022, to discuss community plans for infrastructure enhancements at or
near the cemetery. As communicated during that meeting, NCA encourages
local stakeholders in coordination with your office to submit a
business plan detailing the goals and objectives for a potential
public-private partnership agreement. Once the plan is received, NCA
will consult with VA's Office of General Counsel and the Center for
Strategic Partnerships to determine the feasibility and mechanics of a
potential public-private partnership agreement.
    Question. Section 102 of the VA MISSION Act called for the creation
of Veterans Care Agreements (VCAs), a new type of contract between the
VA and community care providers. These types of contracts are intended
for use in areas where VA community care is either not provided or not
sufficient to ensure that veterans can receive the care they need. For
example, Bismarck--the second largest city in North Dakota--has zero
nursing homes contracting with the VA, resulting in veterans having to
pay out of pocket to receive long-term care, or having to relocate away
from family and friends. While the Fargo VA has contacted Bismarck
nursing homes, these long-term care facilities are still declining to
participate in the community care program due to duplicative,
burdensome red tape.
    Is the situation in Bismarck not a prime example of where a VCA
should be used?
    Answer. Beginning in fiscal Year 2023, VAMCs will adopt a more
concerted strategy to utilize VCAs to procure care-when indicated under
the specific legal criteria set forth in the VA MISSION Act of 2018-
from community nursing homes providing quality care that are not
currently participating in the Community Nursing Home program. VA
expects this approach will improve Veteran access to quality nursing
homes. Homes with contracts will remain the preferred placement site.
However, in instances where the required care is not otherwise feasibly
available to the recipient from a VA facility or through a contract or
sharing agreement entered into pursuant to another provision of law, VA
will pursue use of a VCA to obtain the required care. VA anticipates
that the MISSION Act's criteria for using VCAs may be met in various
circumstances, including where the needed care would only otherwise be
available from homes that are geographically distant from the Veteran's
home and community, from homes that do not provide a specialized
service the Veteran needs and/or from homes that provide demonstrably
lower quality care, as measured by the Medicare Compare score.
    In addition, VHA has streamlined its annual review process to
reduce the burden on homes and VA staff while improving its oversight
of the care delivered to Veterans.
    Question. In August 2021, the Department of Labor's Office of
Federal Contract Compliance Programs (OFCCP) published a final rule
exempting TRICARE providers from its authorities. This decision was
made in order to increase access to care for servicemembers and their
families, as well as provide certainty for TRICARE providers. During
the rule's comment period, several requests were made encouraging OFCCP
to also remove its authority from Veterans Affairs Health Benefits
Providers (VAHBPs).
    Do you believe that extending the OFCCP exemption to VA community
care providers on a permanent basis would increase veterans' access to
long-term care?
    Answer. Any additional requirements imposed on providers treating
Veterans versus non-Veterans make it more difficult to recruit
providers to serve Veterans and give them access to long-term care. VA
agrees that extending the Office of Federal Contract Compliance
Programs exemption to providers operating pursuant to an agreement with
VA in addition to TRICARE is a good idea.
    Question. Beginning in 2019, the Fargo VA carried out a hyperbaric
oxygen therapy (HBOT) clinical demonstration project. Under the
project, veterans who have yet to experience positive outcomes from two
traditional therapies can be referred for HBOT in the community. I am
disappointed that the Department decided to end the demonstration
project in September 2021. My office continues to hear that Veterans
are interested in undergoing HBOT for post-traumatic stress disorder
(PTSD) and traumatic brain injury (TBI).
    Section 703 of the Fiscal Year 2018 National Defense Authorization
Act (NDAA) authorizes the Secretary of Defense to furnish HBOT at
military medical treatment facilities to covered servicemembers if HBOT
is prescribed by a physician to treat PTSD or TBI.
    What should my office tell veterans who are inquiring about
receiving HBOT for PTSD and TBI?
    Answer. Hyperbaric Oxygen Therapy (HBOT) is not currently part of
the standard of care for treatment of mental health conditions at VHA.
Any decision to offer HBOT as an experimental procedure for mental
health conditions would be made by the local VA facility leadership.
    HBOT is not an effective treatment for posttraumatic stress
disorder (PTSD). The 2017 PTSD Practice Guideline, jointly issued by VA
and the Department of Defense (DoD), rated the evidence as insufficient
for recommending the use of HBOT for the treatment of PTSD and
concluded that HBOT was not a promising treatment for further study
(https://www.healthquality.va.gov/guidelines/mh/ptsd/index.asp). A
review of the available evidence by VA's Evidence Synthesis Program in
2021 concluded that HBOT was not effective for treating PTSD and
suggested that any benefits observed in studies were likely due to
placebo effects (https://www.hsrd.research.va.gov/publications/esp/
hbot-brief.cfm). The review also noted that the evidence is not
applicable to individuals with PTSD who have not experienced a
traumatic brain injury (TBI) because there have been no studies of HBOT
for PTSD alone.
    Rigorous scientific study of the use of HBOT for the treatment of
TBI has not demonstrated benefit beyond that of placebo. This is
further supported by the 2021 VA and DoD Clinical Practice Guidelines
(CPG) for TBI that recommend against the use of HBOT for the treatment
of mild TBI. The CPGs are available at Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury (mTBI) (2021)--VA/DoD Clinical
Practice Guidelines.
    Question. Why is this form of treatment available to active duty
servicemembers, but not to PTSD and/or TBI service connected veterans?
    Answer. VA cannot comment on services available in DoD. Please see
the response to 4a for the VA position on HBOT for PTSD and/or TBI.
    Rigorous scientific study of the use of HBOT for the treatment of
TBI has not demonstrated benefit beyond that of placebo. This is
further supported by the 2021 VA and DoD CPGs for TBI that recommend
against the use of HBOT for the treatment of mild TBI. The CPGs are
available at Management and Rehabilitation of Post-Acute Mild Traumatic
Brain Injury (mTBI) (2021)--VA/DoD Clinical Practice Guidelines

                                 ______

            Questions Submitted by Senator Susan M. Collins
    Question. Earlier this year Maine Veterans Homes, which operates
six state veterans' homes in Maine, announced it would close two of its
homes, one in Machias and one in my hometown of Caribou where my
father, a World War II combat veteran with two Purple Hearts, spent the
last years of his life. These are both rural communities with an urgent
need for residential care for our veterans.
    After intense advocacy by the Federal delegation, the state
legislate, and the governor, these homes will now remain open with an
infusion of emergency funding to be provided by the state.
    One thing that will help keep our state veterans homes viable would
be for the VA to quickly finish its rulemaking to implement legislation
I authored, the State Veterans Homes Domiciliary Care Flexibility Act,
which was enacted into law in December 2020. That legislation requires
VA to implement a waiver authority to provide VA the flexibility to pay
per diem for veterans with early-stage dementia when in the veteran's
best interest.
    Can you please give me an update on the status of that rulemaking
to implement this authority and when it can be expected to come into
effect?
    Answer. The rulemaking is currently going through VA clearance.
This process takes 18 to 24 months.
    Question. In a letter to me last year, a VA official pledged that
it will continue to grant equitable relief for veterans who were
admitted to Maine Veterans Homes with early-stage dementia prior to
January 17, 2020, when unanticipated changes in the processing and
treatment of domiciliary care claims was made. Will you continue to
grant this equitable authority annually for this group of veterans?
    Answer. Yes, VA will continue to consider awarding equitable relief
each year.
    Question. Will you work with me to identify potential ways the VA
can help to ensure state veterans homes in underserved areas like rural
norther and eastern Maine can remain viable?
    Answer. Yes, VA will continue to work with Congress to identify
potential ways that VA can help State Veterans Homes in underserved
areas.
    Question. I appreciate the VA's continued focus on addressing the
mental health of veterans. Of particular interest in Maine, the VA
approved the construction of a Residential Treatment Program facility
at Togus in 2020. This facility is vitally important because currently,
veterans in Maine who require overnight substance use disorder
treatment must now travel far away from their families to VA facilities
in other States.
    Because of unforeseen design costs, the scope of this initial
project had to be cut in half to a 12-14 bed facility, so VA now has a
pending Phase II Strategic Capital Investment Planning request for this
facility to add an additional 12-14 beds, which would complete the
facility as initially approved. The entire Maine delegation recently
wrote to you urging your support for this request.
    Will you please review this request as soon as possible and ensure
Maine veterans can receive the care they need close to their families
in Maine?
    Answer. As VA works through the design of this project, the goal
remains to provide the maximum number of beds while also making
provisions to allow expansion for future demand. Upon completion of the
design of this project, the Togus VAMC and the VISN will evaluate the
Residential Rehabilitation Treatment Program (RRTP) design against
current and future workload projections for the RRTP. If additional
beds are required, they will be integrated into the annual VA Strategic
Capital Investment Planning (SCIP) process, which is used to help
prioritize our infrastructure needs to ensure maximum impact and
effectiveness of limited capital funding.
    Question. Maine is a large, rural state and we have several
important CBOCs and smaller clinics that serve our veterans in parts of
the state with limited access to healthcare.
    In reviewing the VA's recent recommendations to the Asset and
Infrastructure Review Commission, I was concerned by what appeared to
be a proposed shifting of resources for veterans in rural northern
Maine towards more populous southern Maine. I am also concerned by a
proposal to shift inpatient/outpatient surgical care and inpatient
medical care at the Togus hospital in August down to Portland, about 60
miles away.
    I intend to engage with the Commission as its review process gets
underway. I hope you will also work to ensure the VA continues to
support the needs of our rural veterans who may have limited health
care access without VA's support and not make VA care available only to
those veterans in major population centers.
    Will you ensure that the administration and the Commission
adequately consults with Congress and all of the relevant stakeholders
prior to the President reviewing or approving the final recommendations
that come out of the Commission?
    Answer. On June 27, 2022, SVAC Chairman Jon Tester announced that
the Senate will not move forward with confirming the nominees to the
AIR Commission. Without the Senate's approval, no Commission will be
formed, and the process outlined in the VA MISSION Act of 2018 will not
move forward. In the absence of an AIR Commission, VA will continue to
work with local, State and national stakeholders to ensure plans for
the future enhance Access to Care and are transparent as they evolve.
    Question. As you are aware, Congress and the Senate have been
debating how to ensure veterans exposed to toxic substances, such as
smoke from burn puts, receive all the care and benefits to which they
are entitled. You recently used the authority Congress provided you to
add nine respiratory cancers to the list of illnesses presumed to be
caused by burn pit exposure, and I encourage you to continue to use
this authority to cover new conditions as warranted.
    Is the VA's FY23 budget request adequate to address additional
claims and healthcare costs that will result from these nine new
presumptive illnesses you designated recently?
    Answer. The additional $3 million in projected VHA costs for the
nine rare respiratory cancers are expected to be an insignificant
portion of the fiscal Year 2023 budget and can be subsumed within the
overall VHA medical care funding request.
    Specific funding requirements for the nine rare respiratory cancers
were not included in the VBA 2023 request. VA's decision was announced
after the 2023 budget was finalized and therefore costs were not
included. VBA discretionary costs are estimated at $3.3 million in
2023, $13.6 million over 5 years and $29.3 million over 10 years. VBA
can subsume these costs within its overall fiscal Year 2023 request.
    Question. Last year, I introduced the Auto for Veterans Act, which
would allow severely disabled veterans to receive a grant to help them
purchase a new adaptive vehicle once every 10 years. Several members of
this committee are cosponsors of the bill, including Senators Boozman,
Capito, Coons, and Baldwin.
    Under current law, VA is only authorized to provide a one-time
grant for the purchase of an adapted automobile. Because the average
cost to replace modified vehicles ranges from $20,000 to $80,000,
replacing these vehicles when they reach the end of their service-life
can be an insurmountable cost.
    During the Veteran Affairs Committee's legislative hearing that
included the legislation, VA provided testimony offering its support
for the proposal. Will you work with me and our committees to get this
bill enacted into law?
    Answer. Yes, as noted in testimony before SVAC on April 28, 2021,
VA supports the Advancing Uniform Transportation Opportunities for
Veterans Act in principle, and subject to the availability of
appropriations, as it expands eligibility for the automobile allowance.
VA made a recommendation to clarify the bill's language and remove
ambiguity about whether the Veteran would be eligible for one
additional vehicle after a 10-year span or more than one vehicle after
each 10-year span.
    VA would take expeditious action to implement any enacted
legislation, as this impacts Veteran entitlement to expanded benefits.
In anticipation of the influx of increased automobile allowance
applications, VA notes that additional resources would be required to
fully implement this bill.
    Question. This subcommittee's report accompanying the FY22 bill
included language directing the Department to provide a timeline for
implementing the Standardized Pressure Injury Prevention Protocol
Checklist to improve pressure injury prevention and support the
development of best practices through the VHA medical system.
    When can the subcommittee expect a timeline on implementation of
this effort?
    Answer. VHA Directive 1352, Prevention and Management of Pressure
Injuries, and the VA Skin Bundle were previously developed by VA wound
and pressure injury subject matter experts to ensure there was a
standardized approach to pressure injury prevention and management
throughout the organization. VHA is actively working to update VHA
Directive 1352 to ensure language is consistent with evidence-based
pressure injury recommendations and guidelines, which include relevant
content from the 2019 International Guidelines for the Prevention and
Treatment of Pressure Injuries. Implementation of the updated directive
will begin upon completion of the concurrence process, which may result
in further revisions. As a result, VHA is unable to provide an exact
date of publication.
    VHA will continue to use VHA Directive 1352 to guide the
prevention, assessment and management of pressure injuries in clinical
settings. Current evidence-based clinical practice recommendations from
multiple national and international resources for the prevention and
treatment of pressure injuries are expected to be included in the
revised VHA Directive 1352 and VA Skin Bundle.
    Question. Can you summarize VA's current progress towards adoption
of these guidelines by VHA facilities?
    Answer. In 2020, VHA released the VA Approved Enterprise Standard
(VAAES) Skin Inspection/Assessment Electronic Health Record (EHR)
template. The VAAES EHR template includes language and content
consistent with Clinical Practice Guidelines and the Standardized
Pressure Injury Prevention Protocol (SPIPP) checklist. The VAAES
template is clinically mapped to the new EHR, thus ensuring consistency
with evidence-based recommendations and guidelines for Pressure Injury
Prevention (PrIP) and management. VHA is committed to adopting current
guidelines to improve PrIP and risk assessment as demonstrated by the
development of the VAAES template, the new EHR and revision of VHA
Directive 1352. Through these developments, VHA has implemented all
applicable elements of the SPIPP checklist by integrating the
foundational evidence.
    Question. This subcommittee's report accompanying the FY22 bill
also included language urging the Department to explore the need for
commercial-off-the-shelf negative air pressure containment systems to
ensure readiness and surge capacity to respond to surges during
pandemics and other infectious disease events at VA hospitals and
clinics.
    Answer. Can you summarize any investments in these types of systems
using funding provided to the Department by Congress in order to
respond to the COVID-19 pandemic?
    Question. VHA purchased 1,094 (at a cost of $4,322,170) portable
high-efficiency particulate air exhaust and circulation devices to aid
in surge capacity at VA medical facilities. The equipment purchases and
delivery was coordinated with individual sites based on request. Some
facilities were able to procure equipment locally and did not request
national assistance.
    Has the Department examined the need for these types of systems to
address readiness and surge capacity requirements to prepare for future
surges of COVID-19 variants or other pandemic pathogens?
    Answer. While VHA did purchase equipment for surge and does still
have those units to use, if necessary, our goal is to update systems
with permanent means of addressing pandemic surge. VA reviewed and
revised its 2017 Heating, Ventilation and Air Conditioning (HVAC)
Design Manual (PG-18-10) as part of lessons learned in response to the
COVID-19 pandemic. The HVAC Design Manual includes air filtration
requirements for all functional areas. VA has posted two updates to the
2017 HVAC standards, one on November 1, 2021, and the other on March 1,
2022. A summary of the updates is available at https://www.cfm.va.gov/
til/dManual/dmHVACSumm.pdf. The full policy is available to the public
in the VA Office of Construction and Facilities Management (CFM)
Technical Information Library at https://www.cfm.va.gov/til/dManual/
dmHVAC.pdf and is embedded on the next page.

                                 ______

           Questions Submitted by Senator Shelly Moore Capito
               electronic hospital medical records (ehrm)
    Question. Background: It appears that much of the work previously
performed and developed with KRM knowledge, ideas and experience is
currently being performed or attempted to be performed by inexperienced
technical resources with little VA oversight. KRM has seen an 85
percent reduction in revenue and work over the past 2 years even while
receiving excellent technical evaluations. Cerner is hiring 9 people in
KC for work KRM performed in the past and wrote the original software
for. Cerner is utilizing the design, ideas, and architecture that KRM
developed to perform this work and solicit it from the VA. The VA is
funding the buildup of Cerner Intellectual property and knowledge.
    How can the VA assure that EHRM program maintains the knowledge,
talent, and capabilities businesses such as a West Virginia small
business constituent company with over 30 years of VA experience?
    Answer. VA exercises its oversight with a highly trained cadre of
contractor and government personnel. To maintain its talent, knowledge
and capabilities, VA's Electronic Health Record Modernization (EHRM)
Integration Office (IO) employs highly trained Government and
contractor personnel to provide expert oversight in a myriad of
professional disciplines including clinical, technical, engineering,
information assurance, security, testing, acquisition, contracting,
data migration, communication, independent validation and verification,
training, change management, governance and many more.
    EHRM-IO's Program Management Office oversees contractor management,
including Cerner's performance and delivery of services. As the prime
contractor, Cerner is responsible for partnering with vendors to
deliver contracted services. Additionally, VA has a process in place
for interested parties to share information, allowing coordination with
companies with the requisite expertise to integrate with the EHR. VA's
Office of Small and Disadvantaged Business Utilization (OSDBU) provides
resources for businesses interested in learning more about the
procurement process and Federal contracting.
    Question. How can the VA assure long term engagement of small
businesses such that the required knowledge and experience to assure
veteran safety and welfare is not lost?
    Answer. To continuously provide innovative technology solutions for
our Veterans and the required knowledge and experience, VA's indefinite
delivery/indefinite quantity contract with Cerner includes significant
innovation requirements for Application Programming Interfaces built to
a variety of open standards that promote innovative third-party
development. VA has a process in place for interested parties to share
information, allowing coordination with companies with the requisite
expertise to integrate with the EHR. This plan also includes a
commitment to performing ongoing market research to identify small
businesses that can provide value to the EHRM program. These
engagements and collective experience help VA fulfill its promise of a
modern, integrated record to benefit the health, safety and well-being
of those VA serves-America's Veterans. Additionally, the current Cerner
contract has reportable small business metrics and KRM Associates is a
small business partner.
    Question. How can the VA better interface directly with experience
EHRM small business subcontractors to assure that benefits, ideas, and
concepts are correctly conveyed and understood?
    Answer. As stated above, VA has a process in place for interested
parties to share information, allowing coordination with companies with
the requisite expertise to integrate with the EHR. VA's OSDBU provides
resources for businesses interested in learning more about the
procurement process and Federal contracting, including the following:

  --The Doing Business with VA Reference Guide is a simple tool to help
        small businesses navigate the contracting and procurement
        process.

  --The Procurement Readiness Reference Guide provides information to
        help small businesses prepare to do business with VA.

    For information regarding VA Information Technology contracting and
procurement opportunities, contact OSDBU at [email protected].

                                 ______

               Questions Submitted by Senator Marco Rubio
    Question. In Florida, we have seen appeal decisions for the Program
of Comprehensive Assistance for Family Caregivers (PCAFC) take up to 24
months--an inexcusable amount of time given the VA-planned
disenrollment of denied legacy caregivers come March 2023 that will
place many Floridians in difficult financial positions.
    If one of my constituents, who is a legacy participant of the
program, has been denied under the new program criteria submits an
appeal today, what steps is the VA taking to ensure that they receive a
decision ahead of the March 2023 deadline?
    Answer. As announced on March 22, 2022, the Caregiver Support
Program is reviewing and examining the current Program of Comprehensive
Assistance for Family Caregivers eligibility criteria listed in 38
C.F.R. Sec. 71.20(a)(1)-(4) and the stipend level criteria listed in 38
C.F.R. Sec. 71.40(c)(4)(i)(A). During this review and examination
period, no reductions in stipend level or discharge based on
eligibility and stipend level criteria will occur for either the legacy
or post-expansion cohort based on such a reassessment.
    Legacy Applicants, Legacy Participants and their Family Caregivers
have the following appeal options available for decisions which they
disagree with:

  --VHA Clinical Appeal/Review (which averages less than 14 days for a
        determination);

  --A second VHA Clinical Appeal/Review (which averages 45 days for a
        determination); and

  --Appeal to the Board of Veterans' Appeals via Appeals Modernization
        Act (Public Law 115-55).

    Question. It is obvious that the current process the VA is using
right now is not working to the benefit of veterans. Can you commit to
ensuring that the VA will examine alternative pathways for appeals to
ensure timely decisions?
    Answer. VA is committed to ensuring that appeals are processed
expeditiously to ensure timely appeal decisions for Veterans and Family
Caregivers. VA continues to leverage and adopt best practices from the
VBA to promote timely decisions.
    Question. I am concerned with the current shortage of qualified at
home caregivers for veterans, and the VA's decision to exclude licensed
caregiver and nurse registries from participating in the Community Care
Network. Veterans should be able to choose the care they receive, and
it is concerning that the VA is restraining already limited options for
veterans, leading to headaches for veterans and their family members
that are unnecessary and avoidable.
    What factors did the VA take into consideration when deciding to
deny caregiver and nurse registries from participating in the Community
Care Network?
    Answer. VA shares the goal of ensuring Veterans in Florida and
across the country have access to excellent health care professionals.
The VA MISSION Act of 2018 added a credentialing process to VA's
Community Care requirements, and VA also strengthened quality and
safety assurance mechanisms with the implementation of the Veterans
Community Care Program to ensure our Veterans have the exceptional and
safe care they deserve. Providers are not excluded from participation
in the CCN contracts, but they must meet these certain requirements.
The credentialling review found that there was a lack of sufficiency of
licensing and oversight requirements, and this unfortunately led to a
denial of participation for most registries. Specifically, VHA is
concerned with registry oversight, training requirements, liability
insurance and customer service that were not at the level VA seeks for
Veterans. Due to the inability of certain nurse registries to meet the
requirements of the CCN contracts, these providers were unable to
participate as providers under those contracts. However, agencies with
a higher level of licensure that meets these requirements are eligible
to participate. VHA's top priority is providing safe, high-quality care
to Veterans.
    Question. What is the VA doing to ensure that veterans are not left
without caregivers?
    Answer. VHA's goal is to ensure that a network of caregivers is
available for those Veterans who need these services. The CCN contracts
were designed to structure the network based on the unique demands of
each VAMC catchment area, with requirements for the contractor to meet
network adequacy standards. In areas where a certain medical service
demand is low, the Third-Party Administrators (TPAs) would not need to
immediately expend resources to add organizations to the network that
would not be utilized if the TPA was otherwise meeting the network
adequacy standards in the contract. In areas where additional providers
are needed due to demand, VA facilities also have the ability to enter
into and use VCAs with these providers to assist with the immediate
need when the legal requirements for these agreements are met. These
providers' information is sent to the TPAs so they can potentially be
included in the network in the future.
    If circumstances change, and VAMCs are unable to schedule home
health aide services in a reasonable time due to a shortage of aides,
VAMC staff will look for alternative services to meet the Veteran's
needs. A referral to adult day health care may assist in some cases.
VAMC staff may also consider a referral to Veteran Directed Care, a
program operated under contract with Area Agencies on Aging. This
program allows Veterans to hire and train their own workers, who can be
family, friends or neighbors. VAMC staff will also keep the home health
aide referral open for the next available agency.
    Question. What plan does the VA have to address the shortage of
home caregivers for veterans?
    Answer. VHA is continually working directly with VA facilities to
identify and satisfy any shortage of home care providers for Veterans;
providing any needed medical care to Veterans is VA's top priority. The
TPAs have provided a vast network of home care providers that VA
facilities are able to utilize for referrals. Currently, there is no
indication that there is a shortage of home caregivers available for
Veterans in Florida. Based on the network adequacy standards of the CCN
contract, home health care services are performing consistently above
the contract requirement of 90 percent. The 90 percent performance
rating indicates that greater than 90 percent of Veterans received care
in their home within 30 days of the date the provider received the
referral. For the same 3-month period, the average waiting period is
9.7 days for Veterans to receive their first visit from a home health
care provider.
    Through the CCN contract, if a VAMC finds it needs more agencies to
meet the home health aide needs of Veterans, it will request the
contractor to find and certify more agencies. The contractor meets with
VAMC staff on a monthly basis to discuss network adequacy.

                          SUBCOMMITTEE RECESS

    Senator Heinrich. And we stand adjourned. Thank you,
Secretary.
    Secretary McDonough. Thank you very much.
    [Whereupon, at 4:29 p.m., Wednesday, May 4, the hearing was
adjourned, and the subcommittee was recessed, to reconvene at a
time subject to the call of the Chair.]

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