Military Construction, Veterans Affairs, and Related Agencies Appropriations (June 23, 2021)
Summary
The transcript records the June 23, 2021 hearing on Military Construction, Veterans Affairs, and Related Agencies Appropriations for Fiscal Year 2022 before a Subcommittee of the Committee on Appropriations, with Hon. Martin Heinrich, chairman of the subcommittee, presiding. The witness was Hon. Denis R. McDonough, Secretary of Veterans Affairs. Heinrich states that the hearing covers the Department of Veterans Affairs' fiscal year 2022 Budget and fiscal year 2023 Advanced Appropriations Requests. According to the opening statement, the budget requests a mandatory appropriation of $153 billion and a discretionary appropriation of $113 billion, an 8.2 percent increase over fiscal year 2021. The hearing was adjourned at 11:02 a.m.
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[Senate Hearing 117-]
[From the U.S. Government Publishing Office]
MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES
APPROPRIATIONS FOR FISCAL YEAR 2022
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WEDNESDAY, JUNE 23, 2021
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 10:00 a.m. in room SD-138, Dirksen
Senate Office Building, Hon. Martin Heinrich, chairman of the
subcommittee, presiding.
Present: Senators Heinrich, Schatz, Tester, Baldwin,
Boozman, and Hoeven.
DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF HON. DENIS R. MCDONOUGH, SECRETARY OF
VETERANS AFFAIRS
OPENING STATEMENT OF SENATOR MARTIN HEINRICH
Senator Heinrich. This hearing of the Military
Construction, Veterans Affairs, and Related Agencies
Appropriation Subcommittee is now called order.
Today, we are going to be discussing the Department of
Veterans Affairs' fiscal year 2022 Budget and fiscal year 2023
Advanced Appropriations Requests. Veterans deserve more than
just words of gratitude for their sacrifice when they return
home. They deserve the quality care and benefits that they have
earned. This budget strives to do that and requests a mandatory
appropriation of $153 billion, and a discretionary
appropriation of $113 billion. That is an 8.2 percent increase
over fiscal year 2021.
It also requests 156 billion mandatory advanced
appropriation, as well as 111 billion discretionary advanced
appropriation just to support its medical programs in fiscal
year 2023. The cost of medical care continues to grow, and
there are a lot of issues that we want to discuss this morning.
We understand that VA's budget request is a bit complicated
this year. The Department's request reflects the direct and
indirect costs of the pandemic, including addressing the
increases in the disability claims backlog, as well as the
provision of deferred care, and increased mental health
services. Funding provided in the Families First Act, the CARES
Act, and the American Rescue Plan demonstrate congressional
support for veterans during this challenging time, and much of
the funding remains available for use in fiscal year 2022.
In addition, this is the first year VA is allowed to use
flexibility provided by Congress in the Recurring Expenses
Transformational Fund, and VA plans to use $820 million of
expired funds to support information technology and minor
construction projects. While this is a robust request,
especially considering all of the additional funding recently
provided to the Department, VA must have what is necessary to
respond to veteran demand.
VA's requests for fiscal year 2023 shows a decrease in this
program without supplemental funding. I hope that the need has
subsided by then, but VA must plan effectively to avoid service
cliffs relative to demand in these programs.
This budget was developed prior to your undertaking a
strategic review of the Electronic Health Record Modernization
Program. We look forward to receiving more information on the
results of the review, how the findings will affect the
remainder of VA's ten-year plan, and how VHA's infrastructure
costs will be incorporated into the total cost of the effort.
The budget reflects VA's need to invest in physical
infrastructure. As veterans come back to receive care at the
VA, they deserve to be treated in facilities that are up to
date and modernized. This year VA is planning to invest in its
infrastructure through base funding, the Transformational Fund,
and the American Rescue Plan funding.
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 would recognize the Ranking Member for his
opening statements.
STATEMENT OF SENATOR JOHN BOOZMAN
Senator Boozman. Thank you, Mr. Chairman. And thank you,
Mr. Secretary, for being here to discuss the Veteran's Affairs
fiscal year 2022 and 2023 budget request. The budget request of
$271 billion in fiscal year 2022 for the Department of Veterans
Affairs, including medical care, collections, and the new
Transformation Fund, represents a 10.4 percent increase over
fiscal year 2021 enacted levels.
This includes $118 billion in discretionary funds, a 10.4
billion or 9.7 percent increase over fiscal year 2021. The
budget also requests a total of $272 billion in advanced
appropriations for fiscal year 2023. The large fiscal year 2022
increase highlights the continued importance of programs for
veterans. It also reflects the continued growth and popularity
of the Veterans Community Care Program, which consolidated
multiple community care programs through the MISSION Act.
In fact, in this request the only dollars requested as part
of the second bite to supplement last year's advance
appropriations are for community care. Members of the
subcommittee remain committed to providing VA with the
resources needed to care for our veterans. However, continued
growth of 8, 9 and 10 percent gets really difficult, and
probably is unsustainable.
Mr. Secretary, we need to work together to make certain we
are prioritizing resources where they need to go, and to make
sure Congress does not mandate costly initiatives without
thoroughly considering the associated cost implications. Over
the last year VA received roughly $37 billion in emergency
funding to address COVID.
I have to say that, overall, VA performed admirably
throughout the crisis, and deserves praise and recognition for
that. There is no doubt that most of these funds were
absolutely necessary, and the obligation reports for the CARES
Act funding demonstrates this. I had the opportunity to be in a
number of facilities during that time, and again, the
Department, all of those on the frontlines, and just all of the
different areas really do deserve a big pat on the back.
I hope to hear more about the future needs of the VA,
especially after this large influx of emergency dollars; we
don't want to find ourselves in a situation where CARES and the
American Rescue Plan have reset the baseline for VA spending.
The budget requests $2.6 billion for electronic health
modernization, and many of us on this committee have long
advocated for single, joint medical record that will follow a
service member throughout their careers in the military and
into their time as a veteran. We understand that this strategic
review is nearing completion and we look forward to hearing the
new path forward for the program. In particular, we look
forward to receiving a revised deployment schedule as directed
in last year's Omnibus.
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. These initiatives to
prevent veterans' homelessness also are very, very important,
and efforts to improve care for our rural veterans, including
through the greatly expanded telehealth program which, again,
we can be so proud that the VA has been a leader.
We look forward to discussing these and other issues this
morning. And with that, I yield back, Mr. Chairman.
Senator Heinrich. Well, I want to thank our witnesses for
participating today. We have Secretary of Veterans Affairs
Denis McDonough; and Assistant Secretary for Management and
Chief Financial Officer, Jon Rychalski.
Did I get that right, sir?
Mr. Rychalski. That is correct.
Senator Heinrich. Great, fantastic. We are going to start
with questions, and I will recognize myself for five minutes
first and then head to the--I apologize.
With that, we will go to each of you for your opening
statement.
SUMMARY STATEMENT OF HON. DENIS MCDONOUGH
Secretary McDonough. Thank you, Mr. Chairman, very much.
Let me start by just offering my deep condolences to the
family of Senator Warner, who will be laid to rest today, a
Navy and Marine Corps vet of World War II and Korea, Secretary
of the Navy for 30 years, and an outstanding senator. He was a
true patriot, an iconic statesman, who always did what he felt
was right for his constituents and for America. We will,
obviously, all miss him.
Chairman Heinrich, Ranking Member Boozman, Senators Schatz
and Tester, thank you for the opportunity to testify today in
support of the President's fiscal year 2022 and fiscal year
2023 Budget Request, and for your steadfast support for
veterans; I am accompanied today, as the chairman just said, by
our assistant Secretary for Management and Chief Financial
Officer, and proud Montanan, Jon Rychalski. Let me also
acknowledge the Veteran Service Organizations, and our union
partners, all of whom make us a stronger agency.
Some good news: First, we have taken steps to reduce the
backlog log of claims caused by the pandemic. We ramped up
scanning efforts to digitize Federal records for claims
processing, and temporarily assigned VA personnel to the
National Personnel Records Center to pull records for claims
processing. Now most of VA's requests for records are answered
in two to three days. The number of pending VA-related record
requests has dropped by 90 percent to pre-pandemic levels.
Second, VBA rated our one-millionth veteran disability
claim two weeks ago, hitting this important milestone faster
than in all but 1 year in VA history, notwithstanding the
challenge posed by COVID.
Third, VA has now vaccinated 3.4 million people with at
least one dose, including veterans, family members, caregivers,
employees, and members of other Federal agencies.
Last, and most importantly, on May 24th, just a month ago,
there were no, that is to say no COVID-related deaths in any VA
facility for the first time in 448 days, since March 18, 2020.
These positive outcomes are a direct result of two factors:
resources, which you have been critical in providing, and
caring, compassionate people. Let me tell you about one such
outcome. At the height of the pandemic Marine Veteran, Michael
Novielli, developed fatigue, aches, and a fever. He never,
``Felt this sick in his whole life,'' and his diagnosis was
exactly what he feared. Like millions of other Americans, he
had contracted COVID-19.
After four days at Northport VA Medical Center, Michael was
well enough to be discharged, but we placed him on our VA
telehealth program to monitor his symptoms. That decision
likely saved his life. He shared his temperature, oxygen
levels, and heart rate every day for two weeks via telehealth.
Then his VA nurse, Marjorie Rogers, noticed something unusual
in his heart rate. She called him and told him to go to the
emergency room immediately, where he was diagnosed with
pneumonia, admitted--and admitted for another two weeks.
''Marjorie saved my life.'' he said. ``If I wasn't on
telehealth, I would have stayed home with pneumonia.'' And
Michael would be the first to tell you that that would have
been, or could have been disastrous. Now that is the kind of
experience every single veteran deserves at VA. VA people are
the ones who cared for Michael, they are the ones who risked
their lives to serve veterans during the pandemic, and they are
the ones who made zero COVID deaths on May 24th possible.
But VA employees will also tell you that their life-saving
work is not possible without the resources they need; that is
why this budget request is critical. The fiscal year 2022
budget request will ensure VA can provide care and services to
veterans, their families, caregivers, and survivors, and to
other Americans such as the 488 non-veterans treated at VA
facilities as pandemic-related humanitarian missions, including
citizens from Arkansas, Arizona, and Texas, among others.
These resources will be put to good use, empowering our
Department to fulfill President Biden's charter for me to fight
like hell for our vets. The budget ensures we can continue the
growth and success of our Caregiver Support Program by fully
integrating families and caregivers into the care plans of the
veterans they love, continuing to implement MISSION Act
expansion of our Program of Comprehensive Assistance to all
generations of eligible veterans, and supporting the power--the
training of over 1,900 field-based staff.
The budget provides needed funding for women veterans. The
number of women using VA health care has more than tripled
since 2001. And this budget funds recruiting and hiring for
women's health care providers, improving access to reproductive
health services, and emergency services. The budget allows us
to continue our success in reducing veteran's homelessness,
building on the success of the last decade during which we
decreased veteran homelessness by 50 percent. And this budget
allows us to provide strong, sustainable, high quality direct
care to our veterans at a time when they need it most.
Community care, as Senator Boozman said, and direct care
are both important, and care in both contexts is rising
dramatically as the pandemic ebbs, and veterans returned to VA
for care. And while both are growing, care in the community is
rising at a faster rate than direct care. Veterans need deserve
a thriving direct care system for generations to come, because
it provides high quality, evidence-based, integrated care
tailored to their unique needs.
Beyond that, our Nation depends on the research,
innovation, and medical education components of VA direct care.
As well as an effective backstop to our country's health care
system, VA's Fourth Mission has been critically important
during this pandemic, as well as multiple other national
disasters.
That is not all these budget resources will do: they will
fund mental health and suicide prevention initiatives, address
major deficits in construction, physical information technology
infrastructure, continue our electronic health record
modernization, address issues of veterans environmental
exposures, and continue to ensure VA is always a place where
diversity is--diversity, equity, and inclusion are valued and
sought.
In short, this proposed budget allows us to deliver high-
quality whole health care and benefits to our veterans, and it
does so, in large part, by enabling the work of great people,
like those who cared for Michael Novielli. I commit to using
these appropriated resources responsibly and transparently in
close consultation with you, and getting greatest value out of
every dollar.
Mr. Chairman, Ranking Member Boozman, other members of the
committee, I thank you for the opportunity to appear before you
today. And I look forward to your questions.
[The statement follows:]
Prepared Statement of Hon. Denis McDonough
Chairman Heinrich, Senator Boozman, and distinguished Members of
the Subcommittee. Thank you for the opportunity to testify today in
support of the President's Fiscal Year 2022 Budget and Fiscal Year 2023
Advance Appropriations Request for the Department of Veterans Affairs
(VA), and for your longstanding support of Veterans and their families.
I am accompanied by Mr. Jon Rychalski, Assistant Secretary for
Management and Chief Financial Officer.
President Biden defined 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. It is the honor of
my lifetime to join the dedicated, highly skilled professionals who
constitute the VA workforce-many of them Veterans themselves. VA
employees are committed to serving Veterans, their families, caregivers
and survivors. The President's FY 2022 Budget Request reflects this
commitment. This budget request will ensure VA is moving swiftly and
smartly into the future, with much- needed monetary investments in our
most successful and vital programs. 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.
VA faces critical challenges, many of them made even more complex
by the COVID-19 pandemic. Getting our Veterans through this pandemic
continues to be one of our department's highest priorities. As our
country re-opens after 14 months of closures and necessary restrictions
on some activities, all of us at VA remain focused on the robust
clinical response to COVID-19. Our efforts include expanding COVID-19
vaccinations; ensuring Veterans stay connected to longitudinal care
through telehealth and in person care where necessary; keeping
employees safe; and, planning how to address the pandemic's future
impacts on Veterans and our workforce in the health care, benefits and
cemetery systems. VA has demonstrated resiliency through this crisis by
providing continuous services in line with national policy, and we
continue to update our safety guidelines in accordance with Centers for
Disease Control and Prevention (CDC) guidance. We encourage every
Veteran to be vaccinated as soon as possible. That is why we thank
Congress for providing additional authorities and we have expanded our
efforts to include vaccinations for all Veterans, regardless of whether
they are enrolled or eligible to enroll in VA health care, for
Veterans' spouses, and for Veterans' caregivers, and, most recently,
for some 12- to 17-year-olds, including those serving as Veteran
caregivers and those who qualify as beneficiaries under VA's Civilian
Health and Medical Program.
As of June 11, VA has fully vaccinated more than 3 million
Veterans, family members, caregivers, employees, and federal partners.
We are seeing the positive results of those efforts. I am honored and
delighted to report that VA recorded zero deaths from COVID-19 in our
facilities on May 24 for the first time in more than a year. That is a
critically important indicator of significant progress in fighting this
pandemic. As we prepared for Memorial Day, a time of special
significance for us and our Veteran communities, we followed CDC
guidance and relaxed restrictions at our National Cemeteries which
allowed us to remember our fallen heroes in person again this year.
We are seeking input from VA employees about how we can safely and
confidently bring our teams back to work in a manner consistent with
CDC guidance and data- driven facts. We look forward to our continued
return to normal operations, while recognizing that this pandemic has
had an impact on every aspect of daily life for Veterans, their
families, and all Americans.
fiscal year 2022 budget and 2023 advance appropriations
The President's FY 2022 Budget Request includes $269.9 billion
(with medical collections), a 10.0% increase above 2021. This includes
a discretionary budget request of $117.2 billion (with medical
collections). The request includes $101.5 billion (with collections)
for VA medical care, $8.7 billion or 9.4% above the 2021 enacted level.
The 2022 mandatory funding request totals $152.7 billion, an increase
of $14.9 billion or 10.8% above 2021. This funding is in addition to
the substantial resources provided in the American Rescue Plan Act of
2021.
The 2023 Medical Care Advance Appropriations Request includes a
discretionary funding request of $115.5 billion (with medical care
collections). The 2023 mandatory Advance Appropriations request is
$156.6 billion for Veterans benefits programs (Compensation and
Pensions, Readjustment Benefits, and Veterans Insurance and
Indemnities).
strategic focus
To fulfill our country's most sacred obligation, every decision I
make will be determined by whether it increases Veterans' access to
care and benefits and improves outcomes for them. I will work
tirelessly to rebuild trust and restore VA as the premier agency for
ensuring the well-being of America's Veterans through a persistent
focus on the three core responsibilities of the Department:
1. Providing our Veterans with timely world-class health care;
2. Ensuring our Veterans and their families have timely access to their
benefits; and
3. Honoring our Veterans with their final resting place and lasting
tributes to their service.
Under my leadership, the Department will make it a priority to
implement management reforms to improve accountability and ensure
Veterans receive the care and benefits they have earned. In addition to
the funding for medical care, this Budget includes $3.4 billion for the
General Operating Expenses--Veterans Benefits Administration (VBA)
account, including funds to hire 429 new disability compensation claims
processors, and $394 million for the National Cemetery Administration
(NCA). The Budget fully funds operation of the largest integrated
health care system in the United States, with over 9.2 million enrolled
Veterans, provides disability compensation benefits to nearly 6 million
Veterans and their survivors and administers pension benefits for over
350,000 Veterans and their survivors.
In addition to focusing on these three core responsibilities,
President Biden also tasked me with:
1. Getting our Veterans through this COVID-19 pandemic;
2. Helping our Veterans build civilian lives of opportunity with the
education and jobs worthy of their skills and talents;
3. Ensuring VA welcomes all our Veterans, including women Veterans,
Veterans of color, and LGBTQ+ Veterans; and Diversity, Equity and
Inclusion are woven into the fabric of the Department;
4. Working to eliminate Veteran homelessness and prevent suicide; and
5. Keeping faith with our families and caregivers.
Key Challenges:
As VA addresses the numerous challenges brought on or exacerbated
by the COVID-19 pandemic, we also will need to tackle other
longstanding issues that are essential to the Department's ability to
sustainably and effectively execute its mission, including (1)
establishing the right balance of direct care and purchased care, (2)
delivering timely access to high-quality mental health care, including
substance use disorder care, and preventing Veteran suicide, (3)
increasing support to families and caregivers, (4) increasing support
for the growing number of women Veterans who utilize VA services, (5)
providing a whole of government solution to drive progress to eliminate
Veteran homelessness, (6) improving support for transitioning
servicemembers through improvements to the Transition Assistance
Program (TAP), education and job training programs, and (7) addressing
an aging medical infrastructure.
establishing the right balance of va and community care
Providing Veterans with timely access to high quality health care
is essential. VA remains committed to a strong, thriving direct VA
health care system, augmented by a robust and high-quality community
care network. We will continue to expand access, innovate, and leverage
our research and education missions to push the boundaries of what is
possible in serving our Nation's Veterans. In short, we will lead--
empowering each Veteran with the confidence that their trusted system
will lead with sustained excellence on their behalf and on behalf of
future generations of Veterans. For the Veterans listening today: VA is
here as a welcoming, steady force ready to help you grow your health
and well-being with the excellence you expect from us.
access to mental health and suicide prevention
VA has made suicide prevention a top clinical priority and is
implementing a comprehensive public health approach to reach all
Veterans. The 2022 Budget Request includes $598 million, nearly $287
million above the 2021 enacted level, for existing programs dedicated
to suicide prevention outreach and related activities, including
funding to increase the capacity of the Veterans Crisis Line. Funding
for mental health in total grows to $13.5 billion in 2022, up from
$12.0 billion in 2021. 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.
VA developed the National Strategy for Preventing Veteran Suicide
(2018),\1\ which laid the foundation for VA's approach to suicide. This
national vision for preventing Veteran suicide is grounded in three
major tenets in which we firmly believe: (1) suicide is preventable,
(2) suicide requires a public health approach, combining community-
based and clinical approaches and (3) everyone has a role to play in
suicide prevention. While the development of the National Strategy was
groundbreaking in defining the vision of reaching and serving Veterans
within and outside Veterans Health Administration (VHA) clinical care,
VA moved to translate the vision of the 10-year National Strategy into
operational plans of actions in: Suicide Prevention 2.0 (SP 2.0)
combined with the Suicide Prevention Now initiative.
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\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.
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My promise to Veterans remains the same: (1) to promote, preserve
and restore Veterans' health and well-being, (2) to empower and equip
them to achieve their life goals using a whole health approach and (3)
to provide state-of-the-art clinical treatments. We will continue to
invest and share resources with community organizations in the fight
against Veteran suicide. We understand Veterans possess unique
characteristics and experiences related to their military service that
may increase their risk of suicide. Additionally, Veterans also tend to
possess skills and protective factors, like resilience and a strong
sense of belonging to a group.
supporting caregivers
The 2022 request includes $1.4 billion, an increase of $350 million
above 2021, in funding dedicated to the Caregiver Support Program
(CSP). The CSP empowers caregivers to provide care and support to
Veterans with a wide range of resources through the Program of General
Caregiver Support Services (PGCSS) and the Program of Comprehensive
Assistance for Family Caregivers (PCAFC). As a result of the John S.
McCain III, Daniel Akaka, and Samuel R. Johnson VA Maintaining Internal
Systems and Strengthening Integrated Outside Networks Act of 2018, or
the VA MISSION Act of 2018, VA began a major expansion of PCAFC.
PCAFC expansion rolls out in two phases. The first phase, which
began on October 1, 2020, expands PCAFC eligibility to include eligible
Veterans who incurred or aggravated a serious injury in the line of
duty on or before May 7, 1975. Effective October 1, 2022, the second
phase will expand PCAFC eligibility to include eligible Veterans who
incurred or aggravated a serious injury in the line of duty between May
7, 1975, and September 11, 2001.
Expansion of this Program was contingent upon the implementation
and certification of the new IT system, Caregiver Record Management
Application (CARMA). CARMA automates manual processes and integrates
with other VA systems, increasing efficiencies and effectiveness, and
allowing for more effective monitoring and management of the program
for caregivers and VA staff.
CARMA supports consistency through systematic calculations of
monthly stipend payments and provides a mechanism for CARMA users to
identify upcoming reassessments of PCAFC participants, among other key
functions. A new digital version of VA FORM 10-10CG allows online PCAFC
applications.
VA also expedited the hiring of key staff with clinical
qualifications and organizational skills to support program needs,
provide a strong infrastructure and standardize application processing
and adjudication, ensuring consistent eligibility decision-making. The
expansion funded by this request will support providing training and
education to over 1,900 field-based staff dedicated to the caregiver
program. CSP has already expanded to approximately 1,800 staff. These
changes will help ensure Veterans and caregivers receive timely,
accurate assessments and eligibility determinations, as well as an
improved customer experience.
improving support for women veterans
As the number of women Veterans enrolling in VA health care
continues to increase, VA must be prepared to meet their needs. Women
make up 16.5% of today's Active Duty military forces and 19% of
National Guard and Reserves. Based on the trend, the expected number of
women Veterans using VA health care will rise rapidly. More women are
choosing VA for their health care than ever before, with women
accounting for over 30% of the increase in Veterans enrolled over the
past 5 years. The number of women Veterans using VA health care
services has more than tripled since 2001, growing from 159,810 to more
than 550,000 today. To support the growing number of women Veterans, VA
will increase total planned obligations from all funding sources for
gender-specific care from $630 million in 2021 to $706 million in 2022,
an increase of $76 million, or 12%.
To address the needs of the growing number of women Veterans who
are eligible for VA health care, VA is strategically enhancing services
and access for women Veterans by hiring women's health personnel
nationally to fill any gaps in capacity to provide gender specific
care--this includes hiring primary care providers, gynecologists,
mental health care providers and care coordinators across all VISNS so
that VA is able to fulfill the mission of caring for those we serve.
Funds also are available for programs such as pelvic floor physical
therapy or lactation support. These efforts will be sustained by the
2022 request, which includes $105 million for the Office of Women's
Health.
Each of the 171 VA medical centers across the United States now has
a full-time Women Veterans Program Manager tasked with advocating for
the health care needs of women Veterans. Mini residencies in women's
health with didactic and practicum components have been implemented to
enhance clinician proficiency. Since 2008, more than 7,600 health care
providers and nurses have been trained in the local and national mini-
residency programs and even more have participated in monthly webinars
and Talent Management System (TMS) trainings, not only developing
women's health experts, but also enhancing competency of all clinicians
across the system.
Under a new collaboration with the Office of Rural Health, we
established a pathway for accelerating access to women's health
training for rural primary care providers. VHA actively recruits
providers with experience in women's health care to join its care team.
VHA has launched numerous initiatives to improve access to state-of-
the- art reproductive health services, mental health services and
emergency services for women Veterans, as well as focusing on enhancing
care coordination through technological innovations such as registries
and mobile applications.
To provide the highest quality of care to women Veterans, VA offers
women Veterans trained and experienced designated Women's Health
Primary Care Providers (WH-PCP). National VA satisfaction and quality
data indicate women who are assigned to WH-PCPs have higher
satisfaction and higher quality of gender specific care than those
assigned to other providers. Importantly, we also find women assigned
to WH- PCPs are twice as likely to choose to stay in VA health care
over time. Designated WH- PCPs are available across all VA Health Care
Systems, and VA is actively recruiting additional new providers with
even more enhanced proficiency in women's health care. VA provides full
services to meet specific needs of women Veterans, such as gynecology,
maternity care, infertility services, reproductive mental health
services and military sexual trauma assistance.
eliminating veteran homelessness
VA remains committed to ending Veteran homelessness. The 2022
Budget Request includes $2.2 billion for Veteran homelessness programs,
an increase of 8.4% over the 2021 enacted level (base funding only). In
addition, VA will obligate $486 million in ARP funding in 2022, for a
total of $2.6 billion dedicated to reducing Veteran homelessness in
2022. The goal is to ensure every Veteran has permanent, sustainable
housing with access to high-quality health care and other supportive
services to prevent Veteran homelessness. VA has partnered closely with
other Federal agencies and with State and local programs across the
country to:
--Identify all Veterans experiencing homelessness;
--Provide shelter immediately to any Veteran experiencing unsheltered
homelessness;
--Provide service-intensive transitional housing to Veterans who
prefer and choose such a program;
--Move Veterans swiftly into permanent housing; and
--Have resources, plans, partnerships and system capacity in place
should any Veteran become homeless or be at risk of
homelessness.
VA has made significant progress to prevent and end Veteran
homelessness. The number of Veterans experiencing homelessness in the
United States has declined by nearly half since 2010. On any given
night in January 2020, an estimated 37,252 Veterans were experiencing
homelessness. Since 2010, over 850,000 Veterans and their family
members have been permanently housed or prevented from becoming
homeless. Efforts to end Veteran homelessness have resulted in an
expansion of services available to permanently house homeless Veterans
and the implementation of new programs aimed at prevention, including
low-threshold care/engagement strategies and monitoring homeless
outcomes. VA offers a wide array of interventions designed to find
Veterans experiencing homelessness, engage them in services, find
pathways to permanent housing and prevent homelessness from
reoccurring.
economic opportunity
As an overall group, Veterans fare better economically than the
average American. However, Veterans and their spouses still face
economic challenges. Helping Veterans build civilian lives of
opportunity with the education and jobs worthy of their skills and
talents is a critical priority. The budget request supports this
commitment by making key investments in VBA, including an increase of
$81.5 million to support the Digital GI Bill Modernization effort, as
well as an increase of $5 million for the Veterans' Clean Energy Job
Training program in conjunction with the Department of Labor, and $3.6
million for the VA Disability Employment Pilot Project to assist
Veterans with service-connected disabilities seeking employment
opportunities.
VA military-to-civilian transition programs are designed to give
transitioning Service members the best possible start to their post-
military lives. The VA Benefits and Services course, as part of the
interagency Transition Assistance Program (TAP), helps Service members
and their spouses understand how to access the VA benefits and services
they have earned. VA TAP provides resources and tools Service members
need to achieve emotional and physical health, attain economic
stability in civilian life and become career ready. Although TAP has
evolved significantly over the years, we continue to assess its
effectiveness and evolve where appropriate to promote meaningful and
economically enriching lives for Veterans and their families.
addressing an aging infrastructure
The 2022 request includes $2.2 billion, a 26.8% increase over 2021,
for Major and Minor Construction. The Major Construction request
includes funding for 12 medical facility and two cemetery expansion
projects. Additionally, the President requests $18 billion in mandatory
funding in the American Jobs Plan (AJP) to modernize VA health care
facilities with $3 billion to address immediate infrastructure needs
within VA health care facilities and the remaining $15 billion to fully
modernize or replace outdated medical centers with state-of-the-art
facilities. We look forward to working with Congress to achieve our
shared goal of addressing VA's aging infrastructure.
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. The median age of U.S.
private sector hospitals is 11 years; however, the median age of VA's
portfolio is 58 years, with 69% of VA hospitals over the age of 50.
With aging infrastructure comes operational disruption, risk and cost.
VA estimates that between $49 and $59 billion in short- and medium-term
investments will be needed to maintain our infrastructure using our
annual Strategic Capital Investment Planning process. However, any
effort to fully address the aging infrastructure portfolio needs would
likely far exceed those estimates and occur over a significant
timeline.
VA's market assessments have been on-going for nearly two years,
allowing VA to gain significant insights into trends and needs in the
VA health care delivery system--with enhancing Veteran access and
outcomes at the core. The VA MISSION Act requires VA to continue
construction, leasing, budgeting, and long-range capital planning
activities while the market assessment and Asset and Infrastructure
Review (AIR) Commission activities are occurring. The additional AJP
investment would enable planning to start sooner to address facilities
we know are not conducive to future health care delivery, while still
being informed by outcomes of the AIR process.
Health care innovation is occurring at an exponential pace and the
comparative age between VA facilities and private sector facilities is
informed by these trends. The architects who designed and constructed
many VA facilities in the decades following World War II could not have
anticipated the requirements of today's medical technology and the key
role infrastructure-and technological infrastructure-now plays in
delivering safe and high-quality health care. As a result, many of VA's
facilities were not designed with these technology and infrastructure
requirements, which limits our agility and ability to meet the evolving
health care needs of Veterans.
The experience of responding to the COVID-19 pandemic brought
critical lessons. Uncertainty regarding the timing and location of the
next surge or surges in cases across the country underscored the
importance of portable capabilities (e.g., 24- bed Intensive Care Unit
that can be transported) for VA health care's Fourth Mission role in
future public health emergencies.
Transforming VA health care to achieve a safer, sustainable,
greener, person- centered national health care model requires VA to
leverage innovations in medical technology and clinical procedures. As
technology-enabled trends in U.S. medicine bring health care closer to
individuals and communities, there is less demand for prodigious,
sprawling campuses and more demand for emphasis on ambulatory
facilities and virtual care. Many surgical, medical and diagnostic
procedures that once required a hospital stay now are performed safely
in the outpatient setting, and telehealth and tele-service delivery
bring expertise to a patient's own home.
This evolving landscape requires VA to rebalance and recapitalize
its infrastructure to optimize the mix of traditional inpatient
hospitals with outpatient hospitals, multi-specialty Community Based
Outpatient Clinics, single specialty Community Based Outpatient Clinics
and virtual care.
leveraging 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. The 2022 Budget Request includes $4.8 billion in
appropriations for the Office of Information and Technology to pilot
application transformation efforts, support cloud modernization,
deliver efficient IT services and enhance customer service experience.
Our three main transformative projects are the implementation of the
Electronic Health Record Modernization (EHRM); the replacement of VA's
multiple, aging systems to manage its inventory and assets with the
enterprise-wide inventory management system used by the Department of
Defense (DoD)-the Defense Medical Logistics Standard Support (DMLSS);
and the adoption of a new financial and acquisition management system-
our Financial Management Business Transformation (FMBT).
ehrm
In October 2020, VA deployed a new electronic health record (EHR)
system at the Mann-Grandstaff VA Medical Center in Spokane, Washington.
This effort is one of the most complex and transformational enterprise-
wide endeavors in the Department's history. The Budget includes $2.7
billion in FY 2022, which maintains a significant level of investment
in FY 2022 and in future years and ensures necessary infrastructure
upgrades are in place. This EHRM appropriation is in addition to the
request for the central IT appropriation. The vision for the new EHR
system is to empower Veterans, Service members and care teams with
longitudinal health care information to enable the achievement of
health and life goals from Service in the military to Veteran status.
The new EHR system also presents the opportunity to achieve
unprecedented interoperability with the DoD and functions as a catalyst
for advancing VA's leadership of health care in the United States.
In my first weeks in VA, I directed a 12-week strategic review of
the EHRM program, which consists of a full assessment of ongoing
activities in order to ensure the success of future EHR deployments.
Based on opportunities identified at the first ``go- live'' site in
Mann-Grandstaff, the strategic review is focused on ensuring patient
safety, identifying areas for additional productivity and clinical
workflow optimization, change management and team-based training; and
driving enhanced rigor into VA's management of cost, schedule, and
performance. Additionally, we are conducting a human-centered design
initiative to optimize the patient portal experience. We intend not
only to get this right but to drive the industry forward alongside DoD.
Furthermore, establishing strong, effective management of the EHRM
program sets the tone for our other key efforts: modernizing supply
chain management and enhancing financial and business transactions.
va logistics redesign (valor)
VA's response to COVID-19 highlighted the shortcomings of the
software and business practices supporting VA procurement, logistics
and infrastructure operations, including a 50-year-old inventory
system, separate procurement system and multiple stand-alone systems to
manage property accountability, distribution and transportation. VA
also uses multiple, stand-alone systems for health care technology and
facility management, which limit enterprise visibility of assets and
their respective readiness conditions. VA is requesting $299 million in
FY 2022, an increase of $103 million (53%) from FY 2021, to continue
its efforts in replacing these systems.
VHA is adopting DoD's proven software platform implementing the
Defense Medical Logistics Standard Support (DMLSS) information
technology system to modernize and standardize our supply chain,
property, health care technology and facility management business
lines. This improvement will allow us to manage the VHA supply chain
and support functions and operate like other integrated medical
systems. In doing so, we will ensure clinicians have the supplies and
equipment where and when needed to provide safe and high-quality care
to our Veterans. VA completed the first DMLSS deployment at the James
A. Lovell Federal Health Care Center in Chicago, Illinois, on September
21, 2020, and is continuing deployment on an accelerated schedule. We
are grateful for the ARP funds that will help facilitate the continued
modernization of VA's badly antiquated supply chain system.
By implementing DMLSS and standardizing our business practices,
leaders at every level will be able to leverage new capabilities and
capitalize on enterprise data to drive insights into operations and
enable evidence-based decision-making. This implementation, too, offers
significant opportunity for cost avoidance.
financial management business transformation
In support of VA fiscal stewardship, the Financial Management
Business Transformation (FMBT) program is increasing the transparency,
accuracy, timeliness and reliability of financial and acquisition
activities across the Department. The 2022 Budget includes $357 million
for FMBT, a program that is improving fiscal accountability to
taxpayers and enhancing mission outcomes for those who serve Veterans.
Our recent roll-out of the new Integrated Financial and Acquisition
Management System (iFAMS) at NCA and VBA has not been without
challenges and has exposed the incredible complexities inherent in a
financial and acquisition system implementation of this magnitude. We
are learning from these early deployments and adjusting our strategy
accordingly. Nonetheless, these implementations bring 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 legislation and directives. The
next system rollout is Enterprise Acquisition for NCA, which is
scheduled for April 2022. System rollouts will then continue across the
remaining Administrations and Staff Offices until enterprise-wide
implementation is complete.
an evolving landscape will influence how va cares for veterans
As VA addresses challenges and longstanding issues, several long-
term demographic and fiscal trends will shape VA's ability to serve
Veterans in the future. Although the U.S. Veteran population is aging
and shrinking and simultaneously becoming more diverse, demand for VA
services continues to increase. As the Veteran population continues to
evolve, it also continues to use VA more-most likely the result of
nearly 20 years of sustained conflict, longer average terms of service
for military personnel and rising health care and educational costs
that will incentivize more Veterans to use the VA benefits they have
earned. U.S. health care is changing, too, from a hospital-centric
model of care to dispersed (and even virtual) care that can be
delivered through networks of direct and purchased-care providers.
congressional support
Over the past several years, Congress has generously supported VA's
budget requests, which have enabled the Department to address new and
growing challenges. More recently, Congress passed the ARP, which will,
among other things:
1. Help ensure health care access for the 9.2 million enrolled
Veterans who may have delayed care or have more complex health care
needs because of the COVID-19 pandemic;
2. Forgive Veteran health care copayments and other cost shares and
reimburse copays and other cost shares for care and prescriptions from
April 6, 2020 through September 30, 2021;
3. Fund construction grants and payments to State Veterans Homes to
greatly improve the living conditions of our most vulnerable Veterans;
4. Provide up to 12 months of training and employment assistance
for unemployed Veterans to enter high demand occupations; and
5. Help reduce the backlog of disability compensation and pension
claims, which has grown from 73,000 in March 2020 to 188,000 in May
2021.
The Department is grateful for the ARP, which not only will enhance
VA's ability to deliver world class services to Veterans and their
families, but also will ease thousands of Veterans' worries by
forgiving some debt, speed up VA disability compensation claims
adjudication and provide much needed funding to retrain Veterans in
high-demand occupations. We will work diligently to ensure these funds
are effectively and efficiently used.
new statutory authorities
Over the past 3 years, Congress has passed into law numerous, far-
reaching pieces of legislation, including the John S. McCain III,
Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems
and Strengthening Integrated Outside Networks Act of 2018 (VA MISSION
Act of 2018), the Commander John Scott Hannon Veterans Mental Health
Care Improvement Act of 2019, the Veterans Comprehensive Prevention,
Access to Care, and Treatment Act of 2020 (Veterans COMPACT Act of
2020), the Johnny Isakson and David P. Roe, M.D. Veterans Health Care
and Benefits Improvement Act of 2020 and the National Defense
Authorization Act (NDAA) for Fiscal Year 2021.
The 2022 Budget Request includes over $500 million within VA's
Medical Care accounts to begin implementing new and recently expanded
health care programs for Veterans, including a new grant program for
suicide prevention outreach, increased eligibility for emergency
suicide prevention treatment, new investments in women's health
programs, expansion of homeless programs, and military sexual trauma
services. The funding also will further support the Department's
efforts to address substance use disorders.
environmental exposures
For some medical conditions that develop after military service,
the information needed to connect these conditions to military service
may be incomplete. Information may be needed about specific in-service
exposures or there may be incomplete scientific or medical evidence as
to whether an exposure causes a particular condition. These issues loom
large for all Veterans, represented currently by post-9/11 Veterans,
whose exposures to airborne and other environmental hazards may result
in unknown long-term health impacts. I am committed to a full review of
how VA provides health care and benefits to Veterans exposed to
environmental hazards to be responsive to the Veterans we serve. I
believe it is possible to strike a balance between the needs of
Veterans and the need for an evidentiary scientific basis for action.
In 2019, Congress passed legislation expanding benefits to tens of
thousands of Blue Water Navy (BWN) Vietnam Veterans. As of May 1, 2021,
VA has completed more than 54,000 BWN claims and paid out nearly 900
million in retroactive benefits. More recently, VA added three new
diseases to the Agent Orange presumptive conditions list in the FY 2021
NDAA. VA will begin implementing these provisions so that Vietnam
Veterans will no longer wait for these earned benefits. As the
Department harnesses its resources to execute these new requirements
and ensure Veterans receive the benefits they have earned, I have also
recommended initiation of rulemaking to establish a presumption of
service connection for respiratory conditions related to exposure to
particulate matter and other airborne hazards, which may conclude such
conditions as asthma, rhinitis, and sinusitis for Gulf War Veterans.
This decision was based on the first iteration of a newly formed
internal VA process to review scientific evidence relating to
exposures. VA will conduct broad outreach efforts to reach impacted
Veterans and encourages them to participate in the rulemaking process.
research
The Budget includes $882 million, the largest year-over-year
increase in recent history, for medical and prosthetic research. This
historic investment will advance the Department's understanding of the
impact of traumatic brain injury (TBI) and toxic exposure on long-term
health outcomes while continuing to prioritize research focused on the
needs of Veterans to include Mental Health and Suicide, Rare Cancers
and Prosthetics as well as other disease areas.
Increased TBI investment will enhance cutting-edge diagnostics and
treatments such as investigating the role genomics plays in resilience
and recovery from blast exposure, validating blast models, and studying
the link between TBI and suicide. Further investment in environmental
exposure includes the VA Military Exposures Research Program (MERP),
capacity building with Federal partners, and expanding the workforce in
military exposures research and training.
VA will also invest additional resources, including from the
American Rescue Plan, to advance the Department's understanding of
coronavirus related research and impacts. To remain on the cutting edge
of technology, VA will focus on software-as-a- service, cloud
computing, and data security, and will continue to partner with the
Department of Energy (DOE) to capitalize on DOE's computing power and
technical expertise to put Veteran data to work.
diversity, equity and inclusion
Diversity, equity, and inclusiveness are standards fundamental to
everything we do. We will welcome all Veterans, including women
Veterans, Veterans of color, and LGBTQ+ Veterans. Every person entering
a VA facility must feel safe, free of harassment and discrimination,
and we will never accept discrimination, harassment or assault at any
VA facility. We will provide a safe, inclusive environment for Veterans
and VA employees.
Diversity is a strength, never a weakness, among Veterans, VA
employees and all of America. Leveraging diversity, equity and
inclusiveness will produce the excellence in all our interactions with
Veterans. I recently instructed my team to establish a 120-day task
force on diversity, equity and inclusion. The task force's goal is to
offer concrete, actionable recommendations while building solidarity
across the VA system on diversity, equity and inclusion. To support the
Department's commitment to strengthening VA's diversity program and
preventing and resolving discrimination at the early stages, the Office
of Human Resources and Administration created the new Office of
Resolution Management, Diversity, and Inclusion (ORMDI) by
consolidating the Office of Diversity and Inclusion and with the Office
of Resolution Management. The budget for this combined office will
increase by $12.9 million and 74 FTE. These resources will also provide
a robust harassment prevention program and counseling services while
advancing equity for all who have been historically underserved.
The Budget Request also furthers the commitment of the VHA Office
of Health Equity to help eliminate health disparities based on race,
gender, age, religion, socio- economic status or disability by
improving health outcomes for underserved Veteran populations.
empowering leaders to implement positive change
I am mindful VA's capabilities have not always risen to the needs
of our Veterans. Consistent throughout many of these past shortcomings
has been a theme of leadership inconsistency and cultural challenges.
To rebuild trust and restore VA as the premier agency for ensuring the
well-being of America's Veterans, I am focusing on building a diverse
team of professional, experienced leaders who bring a great breadth and
depth of knowledge in government and Veterans issues. To that end, we
recently stood up a commission to identify candidates to lead and
manage VHA.
At the same time, I also am working to retain the talented and
hard-working leaders we currently have by empowering them to make
decisions in a structure that allows them to do what's right for
Veterans. As an initial step in support of that effort, I recently
signed a memo for VA employees emphasizing my intent to lead with VA's
ICARE Core Values-Integrity, Commitment, Advocacy, Respect and
Excellence--and have been seeking opportunities to engage with leaders
across the system to drive this point home. VA's success as a team-our
ability to deliver world-class care for our Veterans-also depends on
how employees treat one another and Veterans. Our respect for our
fellow VA employees and the Veterans we serve is critical to everything
we do.
Essential to ensuring a healthy and accountable culture at VA is
the Office of Inspector General's oversight. The 2022 Budget includes
the OIG's request of $239 million for 1,100 FTE to support its programs
and operations through independent audits, inspections, reviews, and
investigations. The OIG's efforts have a significant impact on the
services and benefits provided to Veterans. This funding level is
prudent to safeguard the significant investments in VA and to help
improve services and benefits for Veterans and their families.
I take full responsibility to ensure VA employees have everything
they need to carry out the important work before us and we operate in a
culture that celebrates and draws strength from our country's great
diversity. To ensure a welcoming environment for Veterans, we must
foster fair and inclusive VA workplaces where the experiences and
perspectives of our diverse employees are valued. The success of our
mission depends on everyone being able to contribute their expertise,
experience, talents, ideas and perspectives. I commit to advancing
equity in VA and providing all employees with opportunities to reach
their full potential. I commit to these principles and will make sure
my senior leadership team reflects and embeds them in everything we do.
At this moment when our country must come together, caring for our
country's Veterans and their families is a mission that can unite us
all, and I look forward to working with this Committee, Congress as a
whole and our many other partners to embrace our collective
responsibility to serve Veterans.
Mr. Chairman, Ranking Member Boozman, I look forward to working
with you and this Committee. Thank you for the opportunity to appear
before you today to discuss my priorities for the Department and how
the President's FY 2022 and FY 2023 Advance Appropriations Request will
serve our Nation's Veterans.
Senator Heinrich. Well, I want to thank you both. And, the
fiscal year 2022 request and the fiscal year 2023 advanced
appropriations request, Mr. Secretary, are record levels coming
on top of a record fiscal year 2021 appropriation, and
significant supplemental funding. The pandemic provided unique
challenges to projecting where veterans will demand those
services.
For instance, through transfers, and the second bite, VA is
significantly increasing resources to meet community care
demand in fiscal year 2022, yet, this budget assumes a decrease
in demand in fiscal year 2023. So, what is VA's vision for the
right balance between in-house and community care going into
the future; and is the medical community care request in 2023
the right number?
Secretary McDonough. Thank you very much. Thank you very
much, chairman. We have been talking with all of you and with
your teams, as well as within the agency about the right
balance. We are driven first and foremost by the requirement in
statute that we make decisions based on best outcome for
veterans. That is also the commitment I have made to the Senate
in the context of my confirmation, which is, every decision I
make will be based on increasing access and improving outcomes
for veterans.
So first and foremost, we will make a determination based
on what is medically best for our veterans. Second, I happen to
believe, and I think the data shows, that veterans in our care
do better than veterans not in our care. So, I think it is very
important that we maintain a sustainably funded, whole health
care system in VA, with the full range of specialties that our
vets have demanded over time, and with care provided by
providers who have particular understanding of the challenges
facing vets.
The fact is, however, that--and particularly in highly
rural areas--our vets will continue to be dependent on the
community as well. And this is something I have talked at
length with many members of this body about, and traveled to
see the impacts of our partnership with the community.
And so, we will be working over the course of this year and
next, as we manage this bow wave of care, our next year's
appropriation, advanced appropriation request, recognizes that
the expansion of provision of care is not as I think Senator
Boozman fears it may be, or asked for clarity, that it not be a
resetting of the baseline. But it is rather an ability to
manage this bow wave of care now, and then over time as we get
to post-pandemic, we will be in a position to right-size that
care in the system and find where we need to augment that care
in the community.
Senator Heinrich. Mr. Secretary, I know the AIR Commission
work is ongoing, but one of the concerns I have is that, to do
a market assessment during a pandemic raises a lot of questions
about the data that will go into those final decisions. We had
enormous market distortions. We saw that in impacts to your
budget, we saw it in the private sector. Will you provide that
data to the committee, but also, do you have concerns about the
quality of that data?
Secretary McDonough. So, our teams have been looking at
these market assessments now going back a couple of years. I
have not dug into that data aggressively myself. I do have a
belief. I do believe that it makes sense for us to relook that
data in light of the pandemic, also in light of the fact that
the U.S. Government has just gone through the decennial Census,
for example. So, there may be data there, too, for us to
prosecute as we do these market assessments.
So, we will be augmenting the review that we have had to
date. We are also committed, I have made this commitment in
other public hearings, and I reiterate it here, to provide you
that information for you to make your own decisions about this.
I think it is only right that we make decisions like this with
such import for the national interest in the light of public
day--in public light. And that is what we intend to do. So, I
would be more than happy to make sure that we get the committee
information.
Senator Heinrich. Great. I look forward to taking a look at
that, and I have concerns given what a unique year it is to
make very long-term impactful decisions based on data, in what
may be a year that is a complete anomaly. With that, we will go
to the Ranking Member for his questions.
Senator Boozman. Thank you, Mr. Chairman. The CARES Act and
the American Rescue Plan provided VA with $37 billion to
respond to the pandemic. One of the conditions in the CARES Act
was that any personnel hired using this money can only be
temporary employees, so as to avoid building a ``budget tail''
in years to come. And you discussed a little bit about this in
your previous question, but I want to follow up. The fiscal
year 2023 medical care advance appropriations requests $111.3
billion is an increase of $13.8 billion over fiscal year 2022
revised request.
So, I guess the question is, what is driving the 14 percent
increase? Is the budget proposing to make the temporary hires
permanent? Has the sudden influx of COVID-related funding reset
the VA baseline significantly higher than it was before the
pandemic?
Secretary McDonough. Yeah, we don't--I will ask Jon to pile
in with some additional specifics on this, Senator Boozman, but
we don't seek to reset the baseline. We are seeking to manage
both a strong pandemic response, which the CARES Act allows us
to do, and then ARP really allows us to sustain that response,
which is going to need to be sustained through this year,
because of this bow wave of care, and supports recovery.
But really what is happening, as we see care for our
veterans, is a series of fairly substantial, big-moving pieces
that include the fact that vets are living longer, that the
pandemic has increased the complexity of care that our vets are
facing. By the way, I think we have a better handle on that
than anybody. We are doing--if you look in--you can't open a
newspaper any morning now without seeing a story about VA-based
research on Long COVID, and to be honest with you, no other
system is doing that. We are doing that, thanks to your
support.
We have a particularly soft economy right now, and
historically what we know in soft economies is that vets who
were reliant on employer-provided care, until now, are relying
on their care for us. Lastly, all those things contribute to a
trend line towards complexity of care for our vets. That means
that any incident of care is more complex and therefore more
costly.
That is coming at a time when, for example, the MISSION Act
has increased what we call ``reliance on us.'' So, more vets
are getting more services from us, as a result of some of the
authorities in the MISSION Act, so what you see in that budget
is our best assessment based on our model, and a model that has
proven pretty decent over time, at what we anticipate in terms
of complexity of care, and reliance on us for our services from
our vets.
Anything you want to add, Jon? Did I miss anything?
Mr. Rychalski. Yeah, just one thing. I think when you look
at our budget, there is a request--an increase in the requests,
but when you compare how much we plan to spend in 2022, which
includes ARP funding, and then you compare what we plan to
spend in 2023, our budget actually goes down by about $4
billion. And I think from a strategic standpoint, what you see
is us hiring up, and then those FTEs staying on, but we are
putting most of our requests in 2023 in the direct care system,
and as the Secretary mentioned, we are betting that is going to
be where people are going to want to get their care.
And that this dramatic increase in community care is going
to level off a bit. And you also see, going back to what I
said, the $4 billion--sort of comes down about $4 billion in
2023, because we think that the community care will level off,
you know, that the demand for services in the direct care
system will rise. But net-net, we actually have a lower planned
expenditure in 2023 than 2022, because we don't have the same
supplemental funding.
Senator Boozman. So, what do you all feel, like is driving
the increased demand for community care now? Because when you
look at your modeling, and you look at the numbers that you are
requesting, certainly, you know, there is a bunch of community
care dollars now, but not in the future. And again, don't
misunderstand, myself, the entire committee is committed to in-
house specialists, you know, the quality of care, you know,
again, as good as anybody. And I think we can be very proud
that the VA has achieved that. On the other hand, I think what
we don't want are a bunch of surprises, going down the line,
which we have really seen in the last year or two.
Secretary McDonough. Look, I couldn't agree more Senator.
And I would start on your last point, which is, I don't
misunderstand you, and we couldn't misunderstand you because
you have been regularly supportive of all of our efforts. So we
are very grateful for that.
I think that what is driving community care at the moment
is that, by necessity, I think many providers in the community,
open to full services sooner than many of our providers did. So
that is one of the things that is driving this. The other is
that we are experiencing now what we have been talking about
for some months, which is that as the pandemic ebbs more of our
vets are coming back to address care that they forewent during
the pandemic. And that is also happening at a time when not all
of our facilities are fully open. And so, we do think that what
is driving the care in the community are the particulars of the
pandemic, and less a stated desire of our veterans to get into
the community.
That said, partly to inform our going-forward process. We
are in the field right now through our Veterans Experience
Office, talking to veterans about what their experience in care
during the pandemic was, and what that says about what they
expect going forward.
Senator Boozman. Good, very good. Thank you, Mr. Chairman.
Senator Heinrich. Senator Schatz.
Senator Schatz. Thank you, chairman; vice chairman.
Secretary, Assistant Secretary, thank you for being here.
Thank you for your service. I want to talk first about
telehealth.
Secretary McDonough. Yes.
Senator Schatz. Obviously VA has made tremendous strides in
telehealth as has the private sector, Medicare, Medicaid, DOD,
it is happening everywhere. The specific question I have to
start is: To what extent are any of the expansions of
telehealth services, dependent on or precipitated by the
pandemic, and likely to snap back to the Stone Ages when the
pandemic is over? Or are there plans in place to not only
institutionalize all these expansions of services, but to
expand them?
Secretary McDonough. Yes. So bottom line is that we have--
let me just give you some numbers around the expansion,
basically, we estimated at about an 1,800 percent increase in
video visits from VA to home, going from about 10,500 visits in
the first week of March 2020, to 220,000, or almost 230,000
visits at the end of February of this year. So, the numbers are
a dramatic expansion.
Another way to look at it is, halfway through this year,
nearly two million vets--this fiscal year--have had one or more
episodes of video care through our vets' Video Connect Program.
So that tells us that there is massive demand. We are
institutionalizing that as you say, we want to maintain it
because it is ease of access for vets who don't need to be seen
in person. We see a large degree of satisfaction from our vets.
In full candor, our clinicians sometimes are less excited about
it than our vets, but we are working that.
Senator Schatz. That is kind of what I am trying to get at,
is to what extent are any of these, at least currently
temporary changes in clinical standards, or standards of care
that need to be made permanent lest we go back to where
something is more comfortable for either VA docs, or
supervisors, or fiscal people.
Secretary McDonough. Yeah.
Senator Schatz. Do we need to institutionalize some of
these. Like, are there specific places we need to burrow into
the bureaucracy, or into the statutory law to make sure these
things stick?
Secretary McDonough. We are looking at exactly those
questions. I think overwhelmingly there is going to continue to
need to be things that are done in person, and we are looking--
we are developing those lists of what those are, working with
VHA. But I think as a system, we recognize the huge efficiency
gains and huge satisfaction gains, which come from the fact
that vets are spending less time traveling to our facilities,
while getting good care.
And so, we have a bias toward institutionalizing, but we
are going to let the data drive that too. So we will be more
than happy to stay in close touch with you on that.
Senator Schatz. Okay. I think I will send a QFR on this.
Secretary McDonough. Good.
Senator Schatz. So that we can get a little bit deeper
fidelity on----
Secretary McDonough. Fair enough.
Senator Schatz [continuing].--what changes you need to make
and how we can be supportive of it, because I have just seen in
Private Pay and Medicare, you know, there is going to be a
tendency to want to snap back to pre-pandemic time. And, I just
think there is going to be a patient revolt if--you know, 10
years ago if you told someone to interact with their clinician
via their iPhone, it would be an insult. And now if you can't
do that, it is an insult.
And so, I just think we are underestimating the extent to
which people are going to freak out in 18 months, if something
that was fantastic and available is suddenly not. And we want
to help you to make sure it is all permanent.
Secretary McDonough. I agree with that. And I don't want to
waste any more of your time, but I just make this point, which
is, we have such demand for mental health care, like everybody
else in our health care system, writ large, at such a position
of competing for providers, we get not insignificant marginal
gain of access through using video platforms, that it would be
foolhardy to walk away from that.
Senator Schatz. And there is at least anecdotal evidence
among veterans that accessing mental health services via
telemedicine can sort of overcome or circumvent the stigma.
Secretary McDonough. No doubt.
Senator Schatz. And so, it is all to the good, we just want
to help you to make it permanent. Final question, when we spoke
in January I mentioned the veterans on Hawaii Island are still
waiting for VA to break ground on the new outpatient clinic in
Hilo, Hawaii.
Secretary McDonough. Yes.
Senator Schatz. Can you please give me an update?
Secretary McDonough. Yes, so we have an interim lease, fix
in place, the permanent lease is taking far too long, both in
Hilo, but across the board. So, we are looking at that
systematically. The interim lease is in place, and I think we
are in a position now to execute against that interim lease as
we try to push on the permanent lease, which is now about 9
months delayed. So, we are staying on top of it.
Senator Schatz. Thank you.
Senator Heinrich. Senator Hoeven
Senator Hoeven. Thank you, Mr. Chairman.
Secretary McDonough, it is good to see you again.
Secretary McDonough. Nice to see you.
Senator Hoeven. For all that work you did as chief of
staff, and good to see you in your new role, congratulations on
that.
Secretary McDonough. Thank you.
Senator Hoeven. Appreciate the opportunity to work with you
again. Thanks for being here today, to both of you. One of the
things that I have been working on for a long time is--and we
have included language in a number of the bills, we passed the
VA MISSION Act, and a number of the other veterans' bills that
we passed.
If a nursing home takes Medicaid or Medicare reimbursement,
they have a set of standards and inspections that they have to
meet. But if they take VA reimbursement, then they have
additional standards they have to meet. So, they ended up with
multiple inspections and additional regulations. As a result,
only about 20 percent of the nursing homes in the country take
VA reimbursement for long-term care.
That makes a huge difference to our veterans because
qualifying veterans can actually draw on the VA benefit without
having to expand all our assets, unlike Medicaid, for example,
where they would have to first dissipate their assets down to,
you know, standard testing, varies a little bit by state. So,
for qualifying veterans, this is a big deal.
Now, about 20 percent of the nursing homes do take VA
care--or VA reimbursement, but a lot don't for that reason. And
so, we are trying to work with you, and with Labor, and with
HHS to get these veteran care agreements simplified so that,
you know, these nursing homes will take veterans with VA
reimbursement, because like I say, the asset test.
And so I would ask for your help. And we have just had a
number of different challenges. Sometimes the VA tells us,
``well, you know, those additional requirements, and those
additional inspections are--we are just trying to take care of
veterans,'' and ``we are just trying to protect the veterans.''
Well, I mean, that almost kind of makes the assumption that,
you know, HHS and states are not taking care of other seniors.
So, I mean, that does not really seem to fly. It really is
a red-tape problem. And so, if we could work with you to
streamline that, so that if a nursing home meets all the
requirements for Medicare or Medicaid, then they should not
have additional set of requirements for VA reimbursement. So
that is the issue, and I would ask for your help on it.
Secretary McDonough. Thank you, Senator. I confess that it
is, and I know you have been working with us, I am not deep on
this. I will just say the following, which is that our
experience during the pandemic is that our clinicians far
exceeded performance on reduction of COVID infection in our
facilities, as related to other facilities, both state-run
facilities, state-run veterans' facilities, and private
privately-run facilities. So, I think there is a lot of work
that we have done in this space, but I would be more than happy
to take this and commit to work with you on it.
Senator Hoeven. Yeah. And the key is access, you know,
because you may have loved ones that have to travel a distance
if they can't get their loved one in a nursing home close.
Secretary McDonough. Yeah.
Senator Hoeven. And this is not just a North Dakota
problem, this is a nationwide--that stat I have cited is a
nationwide stat.
Hyperbaric Oxygen Therapy, HBOT: the veterans really feel
that this is important to them, particularly for PTS. And we
have got a pilot program going, there is a number of locations,
including the VA center in Fargo, which is a high quality
outstanding center, serves a lot of North Dakota, but a lot of
Minnesota too. But are you committed to making sure that our
veterans can get access to HBOT?
Secretary McDonough. Yeah. Well, we are running that pilot
currently. I just asked for an update on it yesterday. It runs,
as you know, through this fiscal year, so we are absolutely
committed to making sure that we run this through, we get high
quality review of this, and then as we have assured you, we
will make the decisions based on that. So, I will be more than
happy to do that and stay in close touch with you.
Senator Hoeven. Yeah. We would like to work with you on
that too. We have talked to so many veterans that really,
really swear by it, and so I think this is going to be
something, and not just veterans, as you know, for concussions
and other things as well.
Secretary McDonough. Yeah.
Senator Hoeven. You know, All-Star football players like
John Boozman, and others, you know, sometimes--I think it has
been very beneficial to them. I am sure you have seen the Joe
Namath commercials, and he talks about it. The last thing I
will bring up.
Senator Boozman. The secretary played.
Senator Hoeven. Oh, is that right?
Senator Boozman. Yeah.
Secretary McDonough. Yes, I did.
Senator Hoeven. Where did you--where at, Minnesota
somewhere?
Secretary McDonough. I played at St. John's University.
Senator Hoeven. Oh, you are a Johnny. Was that back when
they had the fabulous teams? They had a long string of
championships.
Secretary McDonough. Yeah, they had a bad defensive back in
me, but very good teams.
Senator Hoeven. Good for you, fantastic.
A last question, I will be quick. I am sorry, Mr. Chairman.
It is just, ask for your help at the rural--we have the Rural
Initiative (cemeteries), great program.
Secretary McDonough. Yes.
Senator Hoeven. Huge kudos to you. We have one now in
eastern North Dakota. I just ask for your continued commitment
as we add, you know, really important things, like restrooms,
and storage, and wind walls, and things like that. Fabulous
initiative in rural America, and I would just ask your strong
support for it.
Secretary McDonough. Yes. You got it.
Senator Hoeven. Yes. Thank you. Thank you, Mr. Chairman.
Senator Heinrich. Senator Tester.
Senator Tester. Thank you, Mr. Chairman. A couple of
housekeeping things, first of all: I want to thank Secretary
McDonough for bringing up John Warner. John Warner gave me the
best advice I have had since I got here. And I have seen this
advice play out several times. His advice was, ``Don't stay
here too long, kid'' which was, which is good advice.
And then the other thing, Mr. Chairman, I just want to
point out that you have possibly the best staff director of any
of the appropriations committees, in Michelle Dominguez, she is
absolutely the most competent staff member on the
Appropriations Committee that I have ever been affiliated with.
And she used to work for me.
So, Mr. Secretary, you, or the VHA, brought on nearly 8,000
employees under the Temporary Emergency Funding of COVID-19.
What is your plan to keep those folks on board when the ARP
money runs out?
Secretary McDonough. Well, we are letting the demand for
services inform that. We have a particular set of demands, and
I know this is particularly important to you, around mental
health. So, our first and biggest effort is to retain the
excellent clinicians that we have, even as we approach a series
of expected retirements.
We are right in the middle of the annual Employee Survey at
the moment, we will get data from that, which will give us a
sense of what to expect coming in the new year. But the first
and biggest challenge for us is to retain the people that we
have. And then next is to make sure that we are not just out
competing with other health care systems, but that we are
adding to the available clinicians. And this is where our
education component and our residency programs become so
important to us. So, that is why we have the funding that we
have requested in the budget. And we will continue to work with
you guys on precisely that.
Senator Tester. Thank you. Community care was brought up
previously, but I just want to approach this from a little
different angle. There has been a lot of talk about the wait
time to see a doctor within the VA. And correct me if I am
wrong, but I understand you are meeting the guidelines for wait
time, is that correct?
Secretary McDonough. We are. Yes.
Senator Tester. Okay. Are you able to track the wait times
in the private sector?
Secretary McDonough. We are looking at that now to make
sure that we have a good handle on this. You know, come a year
from now, we have to make some decisions about our access
standards. That is what the law requires us to do. I have
implemented and started a process over the course of the last
six weeks, or so, where we get the data to help us inform the
decisionmaking that we have to make in consultation with you
for a year from now.
Among the data I am asking for is veteran satisfaction,
health outcomes, wait times, and commensurate wait times for
care in the community.
Senator Tester. I think it is really, really important,
because, the fact is wait times have been an issue which, by
the way, why we have community care to begin with. And if we
are not addressing that issue, the community care, then we need
to go back and address it.
Speaking of mental health, I was surprised in this year's
budget that the VA projects treating 6,000 fewer vets via
inpatient mental health care in 2022 than it did in 2021. Is
that because of telehealth, or is there another reason here?
Secretary McDonough. I think it is principally due to
telehealth. But, Jon, am I missing anything on this?
Mr. Rychalski. Don't have the answer to that.
Secretary McDonough. Okay. Well, let me take that
specifically, Chairman. But I think that is due to telehealth
because frankly we will see our demand is up across the board.
Senator Tester. Appreciate that. And I agree. Now I want to
talk about something that is near and dear to both our hearts;
and that is toxic exposure, and in a bill that Senator Boozman
is very familiar with, as well as myself, and other folks that
are on a VA committee. The budget supports about $7 million in
new spending on toxic exposure research, to focus on
collaboration between the VA, DOD, and the national academies,
and other stakeholders. My question is: Do you think the VA
should be the lead Federal agency on veteran toxic exposure
research?
Secretary McDonough. I do believe we should be. And I think
that we are.
Senator Tester. And do you feel that that increase of $7
million establishes the VA as a leader on this research?
Secretary McDonough. I think it does, but I also think,
Chairman, as you are aware, we have also set up a process
whereby we are getting the benefit of all the other science
agencies, DOD, Department of Labor, HHS, and their attendant
offices and capabilities on a very regular basis, in addition
to the National Academy of Science. And my commitment to you
all is to not only to continue to get that science, but to
report to you on a quarterly basis what that science is telling
us, including about whether we are in a position to connect
other conditions to service in Southwest Asia.
Senator Tester. I know that community care was talked about
earlier, and the amount of money that is being spent on
community care. And in some aspects, that is simply not
sustainable, especially as it applies to emergency room
treatment. I want to give you an example. And if I might, Mr.
Chairman, of a story that was relayed to me just last week by a
doctor that works for the VA, and is very proud to work for the
VA. And a patient came in, I believe he had kidney stones, and
he got to see him at about 4:30. And, of course the day ran out
at 5:00.
And the advice that was given to him by his superiors was:
just send him to the private sector. The guy wanted to be
treated by the VA and the easy way to do it--and maybe this is
the problem--the easy way to do it was just get him to the
private sector. I know you are concerned about this, and I
appreciate your concern. And I just think that we need to be
wise about how we utilize the private sector. It is the
veteran's choice, it is not the VA's choice. Thank you.
Secretary McDonough. Yeah. I would just say one thing about
that is--two things about that. One, what the clinicians tell
me is that to refer a vet to the community takes, in our
current electronic system, two clicks. To refer somebody back
into care in the system is something like 18 to 20 clicks. That
does not seem right to me.
That suggests, I think, as Senator Schatz was asking, a
kind of an institutional direction. So, have asked us to look
at that. The second is our facility in Ann Arbor is going
through and running a pilot about access to emergency care,
including access to mental health services. And this is
anecdotal, this is why we are out getting some kind of
statistically significant information from our vets.
But the anecdote there was, our hospital administrator told
me, is that when she invited vets back into care in the system,
they all asked--three of them said to her: I am grateful that
you ask, and I always wondered why he pushed me into the
community in the first instance.
And so, I don't know that that anecdote adds up to
something statistically significant, but I want to make sure
that we are giving the vet and the clinician the opportunity to
make the best--what the statute requires, the best possible
outcome for the vet deciding this. That requires us meeting our
wait times, but it also requires us making sure that we don't
tilt the--tilt the record.
Senator Tester. Thank you.
Senator Heinrich. Senator Baldwin.
Senator Baldwin. Thank you, Mr. Chairman.
And welcome, Secretary McDonough.
Secretary McDonough. It is good to see you, too.
Senator Baldwin. I know that when we spoke earlier this
year that we talked a bit about bipartisan legislation that I
had sponsored: the Jason Simcakoski Memorial and Promise Act.
Secretary McDonough. Yes. Jason's Law.
Senator Baldwin. Jason's Law. And, it was signed into law
in 2016, and the law has been effective in strengthening
oversight of the VA's opioid prescribing practices and
providing safer care for our veterans. So, I thank you for the
Department's support of Jason's Law in the fiscal year 2022
budget. The progress that Jason's law is making to improve the
care of veterans is, I think, really quite remarkable.
And I remain committed to working with you to ensure
delivery of the highest quality of care to our nation's
veterans. But I also want to thank you for your commitment to
meet with this Simcakoski family, to discuss implementation of
the law that is named after their son, Jason. Can you give me
any updates today on the VA's effort to reduce or right-size
the prescribing of opioids, in addition to the latest VA-wide
statistics on the rate of opioid and benzodiazepine
prescribing?
Secretary McDonough. I don't have those. I would be more
than happy to provide those data to you, you know, when we
leave here, I don't have those at my fingertips here. I believe
informed both by the tumultuous experience--traumatic
experience at Tomah, as well as, a national epidemic on
substance use disorder.
Our programming continues, as you suggest, to make good
progress. This includes very aggressive recordkeeping about
prescription practices, and that includes us working very hard
to harmonize our records, for prescribing in the community, as
well as for prescribing in the system. So, I think we are
making good progress there. But the fact is that substance use
disorder remains an epidemic in the country. And so, we will
stay on top of this.
Senator Baldwin. You know, on that note, the COVID-19
pandemic has, I think, increased the severity of our opioid
epidemic.
Secretary McDonough. Yeah.
Senator Baldwin. And I am wondering if there are any
particular Departmental programs to address this within the
veterans population, you know, pandemic-related, adverse mental
health and opioid abuse, or is this----
Secretary McDonough. There has been reporting on incidences
of increased prescription of opioids for pain treatment in Long
COVID. And overall, there has been reports, and across the
health system, not the VA system, but across U.S. health
system, of prescription of opioids for pain management in the
context of COVID.
In light--in reaction to those stories we went back in VHA
to look at prescribing practices. We don't see that currently
in our system. We have looked at that and we will stay on top
of that for the obvious reasons. But it also goes to the point
that I think the budget request also goes to, which is, the
research capacity that you enable through the budget at VA is
incredibly important.
Nobody is doing as much research right now on Long COVID as
we are. That is facilitated by how we aggregate data, and that
will be improved even greater when we get this electronic
health record on track. But it also speaks to the fact that
that is a fundamental capacity we need in house, and that we
need to make sure that we sustain over time. And we are using
that expressly on substance use disorder and watching it very
closely. And we will--obviously we know of your personal
interest in this, and we will stay in close touch with you on
it.
Senator Baldwin. Thank you very much, Mr. Secretary. I have
run out of time. I will submit two additional questions for the
record, one pertaining to K2 veterans and exposures. And the
other, dealing with, partnerships between the VA and, county or
tribal veterans, service officers, to make veterans in local
communities aware of the full array of services that they might
be eligible for.
Secretary McDonough. I would just--at the risk of going
over, we have the Annual Tribal Nations Summit at the White
House in this fall. This is one of the things that we will be--
we are trying to develop more robustly in anticipation of that.
We are seeing really useful, collaboration between our national
facilities, and local, and community facilities, and IHS
facilities that build on some authorities you have given us.
That might be something that we should follow up with.
Senator Baldwin. Great. Thank you.
Senator Heinrich. Mr. Secretary, I look forward to hearing
more on that front. Actually, I think Senator Baldwin and I
share an interest in, and that is a very complicated,
coordinated care model that oftentimes our tribal veterans have
to utilize.
I want to ask you a question about compensation and pension
exams. Under the previous administration, the Department
indicated that it planned to contract out nearly all of the
compensation and pension medical exams, and despite a number of
VSOs, many senators raising concerns, the VA continues to,
largely, privatize this component of its mission, and it is
requesting funding for more staff to oversee those contracts.
What is the financial basis, first off, for contracting out?
And how does the cost of providing this service internally
compare with providing it through these contracts?
Secretary McDonough. Yeah. So first and--first and
foremost, we have a significant backlog at the moment which--
so, I think part of the funding that you see reflected in the
budget is our commitment to get that backlog down. That backlog
springs from the pandemic. There is about a two-month period
during which we did no exams, out of deference to the safety
and health of our vets. That number is now at about 180,000
[sic]. That is down from about a hundred--sorry, about 220,000.
So, I don't have the dollar-for-dollar comparison, but I
will get that for you and submit that. But I think you are
right that we continue to rely a great deal on contracted C&MP
exams, but we have cranked up volume on two other ways to
administer the exams. One is in the system that is out of a
collaboration among Dr. Stone at VHA and Tom Murphy at VBA,
where VHA is now providing additional in-system C&MP exams.
That does come at the expense of other, or at the cost of other
services that VHA is providing. So, we are looking closely at
that and tracking that closely to make sure that that does not
tip in the wrong direction.
And then we are providing C&MP exams through video
telehealth, video and telehealth, and so that also increases
demand on our in-house practitioners. But I think it is really
important that we not--that we get that backlog down. So that
is what is reflected in the budget. As to the specific dollar-
for-dollar comparison, to let us make that, and we will get
that back to you unless you have that off the top of your head.
Mr. Rychalski. No.
Secretary McDonough. Okay.
Senator Heinrich. Great. No, I appreciate that. We have
talked a little bit about the unique challenges that rural
veterans face but, you know, access to care in-person or via
telehealth, it is just hard recruiting and retaining primary
care and specialty providers. This budget requests $307 million
to support rural health initiatives. It is a modest increase
over prior years, especially in comparison to the overall
budget growth, but can you talk to us just how is--how is VA
developing and implementing enterprise-wide initiatives to make
sure that we are serving veterans in those rural areas
adequately?
Secretary McDonough. Yeah, it is a great question. I mean,
we have our Office of Rural Health, which is kind of the
principal place where we are innovating on policy there. I will
give you a couple of examples that I think are useful.
And let me just correct the record on one thing. I looked
at my notes after my answer, and what it says here as, as of
June 21, the rating claims pending over 125 days is 190,000,
not 180,000. So, I misspoke there.
What we find is, a couple of different things about our
primary care physicians in rural areas. One is, obviously,
distances traveled. We have a relatively small number of
practitioners covering a lot of different CBOCs over, as you
know very well, over a wide expanse. We are trying to address
that by increasing the number of practitioners.
You have some isolation, professional isolation, where it
may be a very vibrant, and I know it does not happen with my
colleagues who work with me, but sometimes you work with a
colleague who happens to be, or colleagues who happen to be
very smart, very engaging, gives you opportunities to grow.
When you are on the road all the time, you get less of that.
So, we are trying to use, for example, telehealth
opportunities--sorry--and video connect opportunities to
increase that interaction.
We are also using available authorities through that same
Office of Rural Health to increase travel options for those
practitioners, so they are getting to additional career
development, specialty development options. Lastly, we are
increasing the use of econ--sorry--educational partnerships to,
again, enhance career building opportunities. So, none of these
alone adds up to everything we need, but each innovation in
that space I think is important. And we will continue, and this
budget does continue, to invest in our ability to do that.
Senator Heinrich. Yeah. I think all of us up here would
agree that that is incredibly important. And I am running short
on time, but I will just raise one more issue that is related
to that, which is the VA's Highly Rural Transportation Grant
Program. In fiscal year 2021, it was funded at less than $3
million. You know, our discretionary budget this year is $113
billion. I just think this is a place where we need to look to
make sure we are actually meeting demand, and that number in
fiscal year 2022 as it actually gets implemented, I think is a
place we need to look at beefing things up.
And with that, turn back to the ranking member.
Senator Boozman. Thank you, Mr. Chairman. I just want to
touch base on the Electronic Health Record Modernization
Program.
Secretary McDonough. Yes. Yes.
Senator Boozman. It is such a huge, huge issue, a big
expense, and just, you know, a gigantic project that is so, so
very important. I know the budget requests $2.7 billion for
fiscal year 2022, I understand there the review will reshape
the program significantly in every facet and, again, its
financial needs. The House is going to begin marking up their
version of this bill on Friday without the benefits of the
results of the strategic review.
So, I know you can't go into it, you know, in the sense
that it is not done, but can you just, kind of tell us how it
is going and when we can expect the information to come out?
Secretary McDonough. Yeah.
Senator Boozman. And the deployments.
Secretary McDonough. We don't anticipate changing the
budget request, the shape of it may change, but the numbers
themselves will not change as a result. You know, I am tempted
to try to say: it will be reduced over time, but I am not, I am
not going to say that.
Senator Boozman. Sure.
Secretary McDonough. But hopefully we can do that. We have
identified that--we believe that the technology, basically, is
sound. We think that we probably undervalued and underinvested
in training and support to our team in the field. And as they
are going through the change of this process, we also, I think,
have identified some structural inefficiencies in headquarters
in how we govern the project, so that--we will be changing
that, too.
We have not--the big question is, when we go to a next site
to deploy the system and the next site, under current--under
previous course and speed, we would be going next to Columbus,
Ohio, in fairly short order. That decision, I have not yet made
that, but that is a threshold decision. I anticipate making all
those decisions and talking to you about the full shape of this
by the middle of next week, by the 30th.
We owe you some answers, as you laid out in your opening
statement, pursuant to statute from last year. We are going to
live up to that and make sure that we get you the information
you need immediately on the 30th, but we will maintain a very
fluid conversation with you on this.
The last thing I would just say is, one of the reasons I
really want our deputy who is, you know, still pending here,
confirmed is, he is the person who will be overseeing this,
given both the traditional, the deputy in our Department, and
the statutory requirements that he personally oversee the
budget. I would love to get him down there soon, so he and I
can spend some time over the weekend, making sure that we are
on the same page before we submit all this paperwork to you on
Wednesday.
Senator Boozman. Good. We appreciate that. And again, you
know, the committee is very, very supportive of the project and
understands how important it is. I think I can speak for all of
us. And so, like I say, all of this is an effort to help you,
you know, push forward and, you know, we certainly will do that
any way we can.
So thank you, Mr. Chairman.
Senator Heinrich. No, thank you. And thanks to Secretary
McDonough, and Mr. Rychalski, and all of our senators for
participating in today's hearing. I think we all look forward
to working together to make sure we provide the resources for
the VA to be able to do its job, and do its job at the best
possible quality.
Finally, I will keep the hearing record open for a week.
Any committee members who would like to submit written
questions for the record should do so by 5:00 p.m., Wednesday,
June the 30th. And we very much appreciate the Department
responding to them in a reasonable period of time.
Secretary McDonough. Thank you very much.
ADDITIONAL COMMITTEE QUESTIONS
Questions Submitted by Senator Martin Heinrich
Question. The Department, and particularly the Veterans Health
Administration, has struggled to address workforce vacancies. VA used
administrative flexibilities and supplemental appropriations to hire
staff, which VHA plans to maintain through FY 2023 with base funding.
What is VA's personnel strategy to address clinical vacancies?
Answer.As the Nation's largest integrated health care delivery
system, the Veterans Health Administration's (VHA) workforce challenges
mirror those of the private health care industry. Demand for clinical
staff in all health care sectors exceeds the supply of appropriately-
trained health care professionals to meet projected Nation-wide health
care needs. VHA's strategy is to prioritize clinical vacancies as they
arise and use all the flexibilities authorized for recruitment and
retention to attract top talent, including direct and non-competitive
hiring authorities, competitive pay-setting, recruitment and retention
incentives, and education loan repayment and scholarships. VA also
utilizes a host of marketing efforts, including participation in
recruiting events, award-winning digital and social media marketing
campaigns and trainee recruitment events to transition VA Health
Professions Trainees to permanent employment.
At the end of fiscal year (FY) 2020, VA conducted a position
validation review resulting in a reduction of vacant positions by more
than 41%. As of March 31, 2021, there were 32,647 vacant total Full
Time Equivalents (FTE).\1\ Of those, 16,965 were clinical vacancies in
VHA. It is important to note that these vacancies do not represent
staffing gaps or shortages, nor do they represent the true unfunded
need of the organization or the number of positions that could possibly
be filled at any given time; instead, they reflect the constantly-
occurring turnover of employees in the organization and funded levels
of growth in FTE. For example, in response to the Coronavirus Disease
2019 (COVID-19) pandemic, clinical occupations in VHA grew by 4.2% in
FY 2020 and have continued to grow by another 1.2% in FY 2021 through
March 31, 2021, reflecting a total net increase of more than 12,600
additional clinical staff since the end of FY 2019.
---------------------------------------------------------------------------
\1\ This count does not include more than 20,000 FTEs that are
undergoing a position validation review.
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Question. How does VA plan to recruit, retain, and train staff in
regions where they are needed the most, including rural areas?
Answer. VA has taken great steps to increase access to care for
rural Veterans. The workforce shortage occupations for rural VA
facilities are comparable to those of non-rural VA facilities. The 2019
All Employee Survey found no difference in responses for job
satisfaction and burnout between employees at rural and non-rural
facilities. The Office of Rural Health (ORH) and its partners in
clinical program offices, Workforce Management and Consulting Office
and the Office of Academic Affiliations (OAA) have created a number of
initiatives designed to expand the rural workforce and to provide
training to keep providers in rural health care. These initiatives
include:
--Rural Health Training Initiative provides rural clinical training
sites for health professions students and clinical residents.
Trainees include social workers, nurse practitioners,
pharmacists, psychiatrists, optometry students and dental and
family medicine residents. The focus is on training
professionals at rural sites with the goal of recruiting
graduates to rural-serving VA facilities.
--Rural Interprofessional Faculty Development Initiative provides
training for residency proctors, enabling them to train, mentor
and monitor residents serving rural areas. Participants who
become professional faculty for academic partners have highly
regarded this professional development program. This evidence-
based program impacts job satisfaction for participants,
educates trainees in the nuances of rural health care and
expands the workforce in participating VA medical centers. In
all, this program has provided training for more than 256 new
faculty to date. ORH and OAA are working on expanding the
program, creating a new cohort in FY 2022.
--ORH Rural Scholars Fellowship Program provides professional
development opportunities for rural VA providers to develop the
skills and knowledge needed to lead innovation in rural health
care delivery, and ultimately improve recruitment and retention
of VA providers in rural facilities serving primary care. This
program allows providers to stay onsite in their rural
facilities and conduct research and process improvement
projects while receiving virtual mentoring from recognized
experts.
--Rural Health Career Development Award Program supports early
investigators in developing a research program focused on
issues of relevance to rural Veterans and their health care.
This award provides protected time, research funding and
methodologic guidance to help recipients develop an innovative
program of research in rural Veterans' health and help support
their overall career development as an independently-funded
investigator.
--Geriatric Scholars Program addresses the shortage of specialized
geriatric skills and knowledge in rural VA clinical settings by
training VA general clinicians in the treatment of older rural
Veterans.
--Simulation Learning, Education and Research Network Rural
Coordinators develop simulation-based training infrastructure
to improve rural clinicians' technical skills without leaving
their home clinic.
--Geriatric Research Education and Clinical Center Connect Program
trains VA providers to manage medically-complex cases through
case-based conferences, electronic consultations, virtual
meetings and clinical video telehealth.
--Extension for Community Health Outcomes (ECHO) programs provide
training to VA and some non-VA rural providers in a variety of
different areas. Rural participant satisfaction data indicate
that this professional exchange of knowledge results in greater
job satisfaction among participants. ORH currently partners on
three ECHO programs across VHA, including:
--VA-ECHO Expansion in Specialty Care uses telehealth to train
providers in a wide variety of specialties, including
treatment for chronic kidney disease, hepatitis C and pain
management.
--National Mental Health and Suicide Prevention ECHO connects rural
providers to national mental specialists for regular
discussion of clinical cases and targeted skill-building
training on suicide prevention and substance use disorder
treatment.
--COVID-19 VA ECHO focuses on COVID-19 care for patient care
providers from all disciplines in inpatient, outpatient and
residential care settings (also open to community
providers).
Question. After making tremendous progress in reducing the claims
backlog, it increased significantly over the past year due to the
pandemic, including challenges in completing medical exams and
accessing service records, and the inclusion of presumptive eligibility
for three conditions related to Agent Orange Exposures. The Budget
requests funding for an additional 429 FTE to address the increase in
claims.
What lessons from addressing the Blue Water Navy claims is VA
applying to the current workload?
Answer. VA recognizes the criticality of a robust and timely
evidence supply chain to support qualifying service review, which is
evident in the reviews of Blue Water Navy claims. VA has aggressive
plans to digitize personnel and medical records supporting benefits
determinations before a Veteran or survivor even files a claim.
Congress provided VA with $150 million in the American Rescue Plan
(ARP) Act of 2021 to proactively scan National Personnel Records Center
records. VA and the National Archives and Records Administration (NARA)
are collaborating to build an on-site scanning capability for this
effort. VA will provide digital copies of all scanned records to NARA
to help expedite future requests for records.
Question. How long will it take VA to work through the backlog and
return to a normal claims workload?
Answer. The disability compensation claims backlog is impacted by
two large claim groups. In April 2021, VA established more than 60,000
claims for review pursuant to the Nehmer court order and claims
remaining in the inventory from this group aged into backlog status,
resulting in more than 42,000 claims entering the backlog in August
2021. In June 2021, VA also established approximately 70,000 claims for
review for three new disabilities presumptively linked to Agent Orange
Exposure by the National Defense Authorization Act, and any unprocessed
claims from this group were added to the current backlog as of the end
of October 2021. As of November 4, 2021, there were 260,510 rating
claims in the backlog.
Increased receipts, fueled by the expansion of presumptive benefits
for Gulf War Veterans (which VA began processing in August 2021) and
typical annual receipt growth, will further impact backlog reduction.
To mitigate backlog growth, VA is leveraging ARP grants to fund
overtime to ensure timely claims processing, as well as aggressively
hiring nearly 2,000 claims processors during FY 2022. Assuming
continued improvement of the Veterans Benefits Administration's (VBA)
evidence supply chain (Compensation & Pension examinations and Federal
records), VA plans to reduce the current claims backlog to 100,000
claims by mid-FY 2024.
Any additional expansion in presumptive benefits, without
commensurate resource increases in FTE, technology and other process
improvement funding, as well as time to implement such changes, will
increase the current claims backlog further and reduce timely claims
decisions for all Veterans.
Question. How many claims raters will be needed if toxic exposure
legislation currently under consideration in the Senate is passed?
Answer. As part of VA's enhanced technical assistance for the
Comprehensive and Overdue Support for Troops (COST) of War Act of 2021,
VBA has identified a need for 9,871 FTE in the first year and an
average of approximately 8,000 FTE over 10 years, after passage. VA
provided this estimate to the United States Senate on July 30, 2021.
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, including coordination of care
with non-VA providers?
Answer. VA operates the Indian Health Service/Tribal Health
Programs (IHS/THP) Reimbursement Agreements Program (RAP) which
improves access to care by reimbursing IHS/THP facilities for direct
care provided to Veterans. To improve care coordination for Veterans
who need services beyond what IHS/THP facilities directly provide and
are referred back to VA, VA established the Healthcare Coordination
Advisory Board to assist in developing a standardized care coordination
process. Details of the approach can be found on the IHS/THP RAP
website under the Care Coordination section. VA has made progress in
implementing key elements of this effort. VA successfully partnered
with IHS and THP facilities to expand reimbursement coverage to include
telehealth through a modification signed by IHS and distributed to
tribes in late September/early October 2020. VA is currently developing
and implementing the Community Provider Orders/Standardized Request for
Service Process, a Nation-wide effort to improve care coordination
between community providers (including IHS/THP providers) and VA. This
process and accompanying tools allow for community providers to
electronically send referrals back to VA. Upon receipt of referrals, VA
staff will then be able to coordinate the care needed by the Veteran--
either in a VA facility or by a community provider through VA's
Community Care Network. VA is sharing information about this process
during training sessions with IHS/THP held as of July 2021 to
understand their interest in using this approach.
Question. About half of the States have veterans living in highly
rural areas, and main obstacles to veterans in these areas obtaining VA
health care is distance and transportation. VA's Highly Rural
Transportation Grant Program, which was funded at less than $3.0
million in FY 2021, is one tool to improve these Veterans access to
care. How does VA determine the demand for this program, and whether
the Department is meeting the demand?
Answer. VA establishes Highly-Rural Transportation Grant Program
demand through a grant request process by issuing an annual Notice of
Funding Availability (NOFA) letter. Eligible Veterans Service
Organizations and state Veterans agencies are responsible for
submitting grant requests. Demand for the program is gauged by the
number of requests received in response to the annual NOFA, and future
budget funding levels are informed by previous years' program demand
balanced against total funds available for competing priorities.
______
Questions Submitted by Senator Brian Schatz
va telehealth
Question. Does VA's ability to make permanent any of the telehealth
policies that it adopted during the COVID-19 pandemic rely on the
current federal public health declaration?
Answer. During the Coronavirus Disease 2019-declared public health
emergency, VA providers are authorized to prescribe controlled
substances following an audio-visual assessment of a Veteran using
telehealth technologies in the home. Once the public health declaration
is rescinded, VA will lose this authority. VA has advocated for this
authority to become permanent through a special registration for
telemedicine from the Drug Enforcement Administration. A special
registration for telemedicine is already authorized under Federal law
in the Controlled Substances Act but has not yet been established (21
U.S.C. Sec. 831(h)).
Question. What structural changes does VA need to make so that it
can institutionalize and expand on the telehealth policies and services
that it adopted during the COVID-19 pandemic, including with respect to
the following:
--Changes to the policies related to VA's electronic medical record
and appointment referral system;
--Changes to the way VA contracts for community care;
--Changes to the way VA contracts for internal medical care;
--Changes to the way that VA provides pay retention or other
incentives to internal health care physicians and staff;
--Changes to the way VA establishes standard of care models for its
patients;
--Changes to the equipment and training that VA providers need to
deliver care through telehealth; and
--Changes to the way VA ensures veterans have the ability to acquire
tablets or other devices to access telehealth care.
Answer. The Veterans Health Administration's (VHA) Connected Care
Strategic Vision builds on VA's strong foundation in virtual care
delivery and will contribute significantly to enhancing the exceptional
care that VHA already delivers. Solidifying connected care foundations
is one of three goals in the strategic vision.
Connected care foundations are the policies, legal authorities,
technical infrastructure, equipment and processes on top of which
connected care services operate. Key foundational goals have already
been achieved as part of VA's ongoing Anywhere to Anywhere telehealth
initiative, begun in 2017. These include license portability under
Federal law for VA health care professionals (VA Maintaining Internal
Systems and Strengthening Integrated Outside Networks Act of 2018, P.L.
115-182) and for health professions trainees and other qualified health
care professionals (National Defense Authorization Act of 2021, P.L.
116-283). These also include modernization of bandwidth infrastructure
at community-based outpatient clinics, development of a standard
platform for telehealth delivery to Veteran homes (i.e., VA Video
Connect), a system to efficiently grant providers access to one or
multiple facility medical records, a systematic process to help
Veterans overcome the digital divide and publication of VA policy for
cross-facility clinical resource sharing and telework-telehealth.
As part of its next phase of solidifying connected care
foundations, VA is focused on:
--Integrating VA Video Connect scheduling into its front-line
Veterans Health Information Systems and Technology Architecture
scheduling application and increasing appointment flexibility;
--Establishing policy authorizing national health care professional
telehealth privileging;
--Enhancing cross-facility scheduling applications to facilitate
additional clinical resource sharing from telehealth hubs;
--Resolving legal barriers to controlled substance prescribing
including for substance abuse treatment;
--Developing a certification program for telehealth support staff
inside and outside VA;
--Enhancing accessibility options in telehealth applications;
--Integrating required components of VA connected care into Cerner;
--Developing systems to support provider collaboration across
facilities;
--Adding options to assist Veterans with overcoming the digital
divide; and
--Modernizing and simplifying telehealth equipment.
As part of its efforts to modernize care delivery, all options to
enhance VA's connected care foundations, and therefore VA services, are
being considered. While VA has not yet identified the need for specific
changes to community care policy, provider pay incentives, standards of
care or changes to the way Veterans obtain tablets from VA, these could
become future focus areas.
Question. Does VA require any new statutory authority to make any
of the structural changes identified above?
Answer. Legislative changes are needed to resolve barriers to
controlled substance prescribing, including for substance abuse
treatment. VA would appreciate engagement with Congress regarding
authorities for prescribing controlled substance(s) via telehealth.
______
Questions Submitted by Senator John Boozman
Question. Since Congress passed the 21st Century IDEA [Integrated
Digital Experience Act], the nature of how individuals engage with
government has fundamentally changed-in large part because of the
coronavirus pandemic. These changes underscore an even stronger need to
implement the 21st Century IDEA and allow federal agencies to deliver
an excellent customer experience from anywhere, to anyone, on any
device.
Has the Department of Veterans Affairs fully implemented the 21st
Century IDEA Act (Public Law No: 115-336)?
Answer. The breadth of services, transactions and content available
to Veterans on VA.gov is extremely large, and despite not fully
implementing the 21st Century Integrated Digital Experience Act (IDEA),
we have made great progress. VA has been working to modernize and
consolidate various tools into an enterprise-wide self-service platform
accessible from a single place: VA.gov. The new VA.gov launched in
November 2018, and it now serves as the primary front door to VA.
The site-wide navigation, on VA.gov web pages, allows users to sign
in or search VA.gov, and just below that on the homepage are the top
tasks Veterans told VA are the most important to them--representing
over 80% of the tasks users visited VA.gov to accomplish. The
modernized pages are all compliant with section 508 of the Americans
with Disabilities Act. Since relaunch, the Customer Satisfaction Score
for all VA.gov websites (including both modernized and legacy pages)
rose from 52.9% to 67.9 % (a 28% increase).
In order to continue to align VA's digital experience with our
users' expectations--and to meet the goals put forth by the 21st
Century IDEA--VA has placed a major focus on modernizing our digital
experience. Our Agency digital strategy has three primary goals: 1)
increase the use of self-service tools; 2) enable faster access to care
and more timely delivery of services; and 3) improve customer
experience and reliability on VA's online services. VA has continued to
make progress on these goals throughout 2021, even as we continue to
create new digital experience capabilities to support VA's Coronavirus
Disease 2019 pandemic response that began in March 2020.
Question. What barriers has the VA faced in implementing this law
and modernizing its digital services?
Answer. The process to modernize VA's inventory of forms and
digital services is driven by the demands and priorities of the Office
of Information and Technology's business partners. The Department
provides hundreds of benefits, with forms to enable Veterans to apply
for each and in many cases, online tools to help track and manage both
the application as well as the benefit itself.
Question. The final FY21 MilConVA Appropriations bill included
report language and funding direction for the VA to implement Section 4
of PL 115-336 ``21st Century IDEA,'' which required that no later than
two years after the date of enactment, each executive agency was
required to digitize and ensure any paper-based form was made available
to the public in a fully usable mobile friendly option.
Who is responsible inside VA for ensuring the agency fully
implements PL 115-336?
Answer. The Digital Experience product line, within the Office of
the Chief Technology Officer, is charged with executing VA's Digital
Modernization Strategy. This includes initial and ongoing efforts to
implement the 21st Century IDEA.
Question. Where does the VA stand in ensuring its forms can be
filled out and submitted electronically on all common, digital devices?
Answer. Currently, there are approximately 500 public-facing forms
available on VA's web properties. This number varies as forms are
added, removed or expire. Additionally, many VA medical centers create
and manage their own forms in a decentralized fashion, adding to and/or
subtracting from that overall total. All public-facing customer VA
forms are currently accessible online as fillable Portable Document
File forms. Those can be completed digitally, printed and then
submitted to VA by mail, fax or in-person. Approximately 20 of VA's
most used forms can be completed and submitted through an online
wizard. These comprise about 350,000 submissions per month. All of VA's
digital online experiences are compliant with section 508 and conform
to both the Privacy Act and the Paperwork Reduction Act. VA is working
to ensure that all digitized forms meet these standards.
VA is also working to identify and prioritize the digitization of
paper forms and non-digital services that are highly utilized by
Veterans. On VA.gov today, over 40% of traffic comes from mobile users,
so introducing new forms and services that are secure and mobile-
responsive will not only allow us to better connect with our users and
have a greater impact on their lives, but it will also help VA achieve
cost savings and workflow efficiencies.
Question. For more than ten years, VA has successfully provided
timely access to high quality dialysis services through community
providers under the Nationwide Dialysis Services contracts when VA
cannot directly provide such care. What factors have changed to trigger
consideration of changing contracts which has been successful in
providing care to these vulnerable veterans?
Answer. VA's Office of Community Care implemented the next
generation of Veteran Community Care in fiscal year 2020 with the
Community Care Network (CCN) roll out. As of today, CCN is operational
across the United States and will soon be operational in the Outer
Pacific Islands. With this implementation, previous Community Care
contracts began to sunset. The National Dialysis Services Contract
(NDSC), which had been VA's previous community Dialysis Program, also
began the sunset process for some contracts. However, nine NDSC
contracts will be renewed for another year. NDSC was a successful
program, but it did not encompass the full spectrum of dialysis care--
for example, nephrologist oversight and Acute Kidney Injury (AKI) were
not covered. Under the new CCN contracts, End Stage Renal Disease,
nephrologist oversight and AKI can be managed by the same Contractor's
in-network provider base.
______
Questions Submitted by Questions Senator Mitch McConnell
louisville va medical center (vamc)
Question. As you know, Kentucky veterans have been waiting for a
new VA medical facility in Louisville since 2006. Please provide an
update on the new Robley Rex Louisville VAMC, including the expected
timeline for construction and when the hospital will begin serving the
region's veterans.
Answer. On August 17, 2021, the United States Army Corps of
Engineers awarded the base construction contract to Walsh Turner Joint
Venture II (located in Chicago, Illinois) for construction of the new
Robley Rex Louisville VA Medical Center. At this time, construction
completion is scheduled for winter 2025, with the Beneficial Occupancy
Date of winter 2026.
Question. The VA's budget includes an additional $93 million for
this project to address increased costs stemming from project delays.
Please provide an explanation of these costs, as well as the potential
for additional funding needed to complete the project.
Answer. Of the budgeted $93 million requested for fiscal year (FY)
2022, $51 million is for cost escalation associated with a 2-year
solicitation delay (at approximately 3.8% per year) due to the lawsuit
by the Crossgate community over VA's compliance with the National
Environmental Policy Act. VA prevailed in spring 2021. The remaining
$42 million of the $93 million is for cost escalation and additional
contingency funds associated with executing contract options that will
not be awarded for 12-18 months after the base contract award.
Question. Can you please detail how the new Louisville VAMC will be
specifically equipped to provide state-of-the-art health services to
female veterans?
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,
PharmD 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 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
specifically assigned to the Women's Health Clinic, all other PACT
modules include gynecology examination rooms with private restrooms.
rural health
Question. Will you provide information on the VA's plans to improve
access to health care for Kentucky's rural veterans?
Answer. The Office of Rural Health, in collaboration with other VA
program offices, plans to maximize high-quality virtual care options
for Kentucky's rural Veterans by continuing its efforts to increase
access to health care by providing opportunities for the delivery of
health care services to rural Veterans through funding the following
initiatives: Telehealth Clinical Resource Hubs, Pharmacist Providers
for Rural Veterans with Opioid Use Disorder, VA Maintaining Internal
Systems and Strengthening Integrated Outside Networks Act Emergency
Room Specialty Care Scribe Program, Women Veteran Care Coordination and
Management Program, Veteran Transportation Services and Telehealth
Equipment Modernization efforts, all delivered via telehealth, in-home
or in-clinic. VA will continue to expand our telehealth partnerships
with community partners and create strong partnerships to utilize
available facilities and resources to better serve rural Veterans,
their families and the communities where they live. Additionally, VA's
Community Care Network will provide a direct link with community
providers when needed that will ensure VA provides the right care, at
the right time, to Veterans.
Question. What are the VA's plans to expand telehealth options for
rural veterans who lack reliable access to the internet?
Answer. VA has established a 5-year strategic vision for connected
care which 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
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 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.
As part of its vision to deliver trusted VA care, anytime and
anywhere, VA will continue efforts to bridge the digital divide for
Veterans who lack the technology or broadband internet connectivity
required to participate in VA telehealth services irrespective of their
location in the country. Central to this effort, VA has implemented a
national digital divide consult process in the electronic medical
record. Through this process, qualifying Veterans can obtain an
internet-connected device from VA or assistance in applying for Federal
Communications Commission (FCC)-administered internet subsidies. The
FCC subsidies are available through the Lifeline and Emergency
Broadband Benefit (EBB) programs. The Lifeline and EBB programs can
combine to provide many qualifying Veterans up to $59.25 per month for
their internet services. Veterans on tribal lands can receive up to
$109.25 through these programs. VA has completed over 49,500 digital
divide consultations since the beginning of FY 2021 and has distributed
more than 84,000 internet connected tablets since the start of the
pandemic. Additionally, VA has worked with major wireless carriers such
as Verizon, T-Mobile, SafeLink by Tracfone and AT&T to support
Veterans' access to VA telehealth services through Zero Rating the
telehealth platform VA uses to deliver telehealth to the home. Zero
Rating this platform allows Veterans, their families and caregivers to
use VA Video Connect with fewer worries about data fees.
VA will also continue enhancing existing telehealth infrastructure
at community-based clinics serving rural and highly-rural parts of the
country. Clinical video telehealth visits, with full remote examination
capabilities, allow Veterans to receive specialty care services at
their closest clinic, even if the specialist is elsewhere in the VA
system. This supports care in rural areas, even where affordable
broadband is not readily available in the community.
VA is also evaluating the opportunity to leverage community-based
telehealth access points through its Accessing Telehealth through Local
Area Stations (ATLAS) pilot program. ATLAS is a pilot designed to
bridge the digital divide and reach rural and underserved Veterans in
areas with limited access to broadband and health care. Through this
initiative, VA is teaming up with Philips, Walmart, Veterans of Foreign
Wars and The American Legion to provide convenient locations within
Veterans' communities equipped with the broadband and telehealth
technology necessary to access VA health care. Walmart has provided
space within their health services room as well as equipment, while
Philips designed unique and private spaces equipped with state-of-the-
art telehealth equipment within Veterans Service Organizations. VA
currently has 12 ATLAS locations nationally that are open and available
for scheduling. By the end of 2021, it is anticipated that a total of
13 ATLAS sites will offer clinical services by telehealth from VA
providers.
mental health
Question. Will you provide an update on the VA's efforts to improve
veterans' access to mental health care services, including through the
implementation of the President's Roadmap to Empower Veterans and End a
National Tragedy of Suicide (PREVENTS) and the Commander John Scott
Hannon Veterans Mental Health Care Improvement Act (P.L. 116-171)?
Answer. The Veteran Wellness, Empowerment and Suicide Prevention
Task Force under the President's Roadmap to Empower Veterans and End a
National Tragedy of Suicide (PREVENTS) Task Force was formed as a
result of Executive Order 13861, signed on March 5, 2019, with a call
to action to amplify and accelerate the progress in addressing Veteran
suicide in the United States. On June 17, 2020, the Task Force released
PREVENTS, which contains recommendations for a federally-coordinated
national public health strategy to address Veteran suicide.
In FY 2021, the PREVENTS national public health campaign called
Reach, Engage, Attend, Connect, Help (REACH), has garnered
approximately 5.7 billion impressions since it was launched in July
2020. The REACH website, https://www.reach.gov, has been visited more
than 12 million times and PREVENTS-produced public service
announcements have had nearly 1.3 million views. In March 2021,
PREVENTS launched the How We R.E.A.C.H. Coaching Tool to teach people
how to ``reach out'' to help someone in need. In 1 month, the Coaching
Tool was downloaded more than 1,600 times and its accompanying
application nearly 900 times. More than 16,000 individuals signed an
online pledge to help increase awareness of mental health challenges
and suicide prevention practices. These efforts demonstrate the
efficacy of PREVENTS contributions to VA's collective efforts to
improve Veterans' access to mental health care services.
Paid media is a critical component of any national public health
campaign. In FY 2021, paid media was implemented through a variety of
media platforms, including social media, television, radio, digital
content (such as news websites) and online media streaming services
(e.g., Pandora and Spotify). Paid media also included running public
service announcements in communities that have had high rates of
Veteran suicide, and during programming that is watched, listened to or
visited by targeted audiences as well as during events or activities
attended by Veterans (e.g., the Army/Navy football game). In FY 2022,
PREVENTS communications will continue to target Veterans at risk for
suicide and people in their communities to get them the resources they
need to prevent suicide with a goal of decreasing risk factors and
increasing prevention factors, particularly lethal means safety. VA
will also be evaluating the campaign to see what is effective in
driving exposure, awareness and engagement, and we will adjust efforts
as needed. All of this will be done in coordination with other VA
suicide prevention initiatives and programs to ensure public health
campaign communications are appropriately aligned and research is
informed. VA will also collaborate with others to carry the public
health campaign message forward when the PREVENTS Task Force terminates
on June 17, 2022.
Implementation of the Commander John Scott Hannon Veterans Mental
Health Care Improvement Act (P.L. 116-171) continues to move forward.
Prior to the President signing the legislation into law, VA established
a team within the Office of Mental Health and Suicide Prevention to
oversee implementation. Each section was assigned a primary Point of
Contact who is responsible for ensuring all actions in that section are
completed. All Congressionally-mandated reports due to date have been
submitted on time. A series of White Papers on each section, along with
responses to any questions or concerns needing clarification from
Congress, have been provided to the staff of the House Committee on
Veterans' Affairs (HVAC) and Senate Committee on Veterans' Affairs
(SVAC). VA continues to brief HVAC and SVAC on a regular basis (last
briefings were completed July 1 and July 6, respectively). Development
and implementation of the Staff Sergeant Parker Gordon Fox Suicide
Grant Program (section 201) and the Readjustment Counseling Service
Scholarship Program (section 502) continue to make exceptional
progress. Regarding section 502, the proposed regulation has been
reviewed and approved by VA's Office of General Counsel (OGC). The
Office Management and Budget (OMB) has determined that the Secretary
can sign the proposed rule for publication in the Federal Register
without full OMB review, which is anticipated to result in expediting
the scholarship award cycle.
toxic exposures
Question. I have heard from Kentucky veterans who were exposed to
contaminated water while stationed at Marine Corps Base Camp Lejeune
between 1953 and 1987. What steps has the VA taken to provide resources
and information on benefit eligibility to veterans and their family
members who may suffer from medical conditions caused by toxic exposure
at Camp Lejeune?
Answer. On March 14, 2017, VA effectuated 38 C.F.R.
Sec. 3.307(a)(7) to address the presumption of service connection for
certain conditions associated with exposure to contaminants in the
water supply at Camp Lejeune. The rule allows Service members with
records demonstrating no less than 30 days of service (either
consecutive or cumulative) at Camp Lejeune during the specified
timeframe, and who have been diagnosed with any of the eight
presumptive diseases, to be presumed to have a service-connected
disability for purposes of entitlement to VA benefits. The rule applies
to all military Active Duty, Reserve and National Guard personnel who
meet the requirements of the regulation. To address community concerns
and provide information, VA has held joint community meetings,
partnering with the Department of Defense (DoD), on Camp Lejeune.
Further, VA provides resources and information to the public regarding
benefit eligibility through its website at Camp Lejeune water
contamination health issues. Veterans and survivors may also call the
benefits toll-free hotline at 1-800-827-1000 to speak directly with a
VA employee, who may assist with benefit eligibility questions.
The Agency for Toxic Substances and Disease Registry held Community
Assistance Panel (CAP) meetings for 15 years. These quarterly meetings
included large public meetings and CAP board member meetings, and VA
attended these meetings. These meetings were online and in person, as
they were held before the onset of the Coronavirus Disease 2019 (COVID-
19) pandemic. VA discussed the programs available for both Veterans and
family members. VA answered an average of 200 individual questions for
these meetings. VA placed posters (electronic and/or paper when
available) in VA medical centers and clinics. VA prepared and conducted
training regarding Camp Lejeune exposures for its health care providers
and Compensation and Pension examiners. This was also available to
civilian providers via a platform called the TrainingFinder Real-time
Affiliate Integrated Network, or better known as TRAIN. VA newsletters
have featured articles about Camp Lejeune and benefits available to
Veterans and family members.
If one searches the term Camp Lejeune programs online, the first
items to appear are VA's Public Health website at https://
www.publichealth.va.gov/exposures/camp-lejeune/index.asp, which covers
Camp Lejeune questions and offers resources. VA's Community Care
website also offers information regarding Camp Lejeune at: https://
www.va.gov/COMMUNITYCARE/programs/dependents/CLFMP.asp. There are many
civilian, advocacy and law firm websites that reiterate VA benefits
when searched. VA coordinates with DoD mailings to those on the DoD
Camp Lejeune rosters about VA benefits. DoD has also placed full-page
advertisements in newspapers across the country to discuss the benefits
available.
Question. What statutory limitations, if any, prevent the VA from
efficiently accessing the Department of Defense records needed to
provide benefits or establish service connections for diseases related
to toxic exposures, both at Camp Lejeune and elsewhere?
Answer. 38 U.S.C. Sec. 320 codified the VA-DoD Joint Executive
Committee, which is, in part, tasked with providing recommendations to
both Secretaries about the strategic direction for the joint
coordination and sharing efforts between and within the two
Departments.
DoD and VA have worked together extensively since at least 2011 on
exposure-related issues. Regarding Camp Lejeune drinking water
contamination, the United States Marine Corps supported VA by providing
computerization of millions of personnel and housing records of
Veterans. Other efforts include the development of the Individual
Longitudinal Exposure Record (ILER), a web-based application that will
reference multiple data sources to create the exposure record for
Service members. ILER will provide medical providers with an available
exposure record, support VA clams processing for claims due to in-
service environmental exposures and have other functions and benefits.
Question. Veterans dealing with health conditions due to service-
related toxic exposures need timely access to life-saving VA benefits.
Once scientific research has identified a connection between a disease
and a toxic exposure, what steps does the VA take to ensure decisions
regarding service connections are made and implemented quickly?
Answer. Once rulemaking is complete, VA will develop procedures and
training curriculum to deploy to claims processors, as well as make any
required system updates to allow for processing of the condition(s).
This will include any needed updates to the Veterans Benefits
Management System. The scope of training will be dependent on the
number of impacted Veterans and scale of expected receipts; therefore,
training may be deployed to a subset of claims processors at a limited
number of sites or to all claims processors. Additionally, for efforts
with larger numbers of expected receipts, VA is likely to request
additional resources in future budgets or supplemental requests to
ensure timely claims processing.
veteran homelessness
Question. Will you provide an update on the permanent supportive
housing project in Lexington, Kentucky, which became operational in
fiscal year 2020? How many veterans are currently being served through
this enhanced-use lease project?
Answer. The Victory Point Apartments and Townhomes supportive
housing enhanced use lease project in Lexington, Kentucky, received its
first Certificate of Occupancy on May 6, 2020. The 50 units of
permanent supportive housing currently have 26 Veteran and 24 non-
Veteran residents.
Question. Will you provide an update on how the VA is meeting the
specific needs of female veterans who are homeless or at risk of
homelessness?
Answer. The national VA Homeless Program Office (HPO) provides a
full spectrum of services designed to meet the unique needs of all
Veterans, including women Veterans who are at-risk of or who are
experiencing homelessness. These services include clinical outreach,
treatment, transitional housing, supportive services and permanent
housing. VA's efforts are enhanced by harnessing the strength of
community providers in coordination with VA health care and benefits.
In FY 2020, including all homeless services provide under HPO, over
32,700 unique women Veterans were served. In 2021, HPO conducted an
analysis to identify potential gaps in services provided by VA homeless
programs for women Veterans experiencing or who are at-risk for
homelessness. Results from this analysis show that there are no
significant gaps in service delivery, outcomes and Veteran
satisfaction, and to the extent possible, VA is meeting the needs of
homeless and at-risk women Veterans.\2\ Additionally, the Johnny
Isakson and David P. Roe, M.D. Veterans Health Care and Benefits
Improvement Act of 2020 (P.L. 116-315) provides VA homeless programs
with flexibilities to address identified gaps, as detailed in the
summary below.
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\2\ A detailed review of data for corresponding findings will be
provided in a Congressionally Mandated Report (CMR) titled ``Gap
Analysis of Department of Veterans Affairs Programs that provide
assistance to women Veterans who are homeless.'' The CMR is currently
in concurrence for clearance and pending submission to Congress.
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Population Comparison: As of FY 2020, women Veterans represented
8.4% of the overall homeless Veteran population and 38.5% of women in
the general homeless population. Since 2017, the number of homeless
women Veterans decreased, while the number of homeless women in the
general homeless population increased. Women were equally represented
among the Veteran population (8.9%) and the homeless Veteran population
(8.7%); however, women Veterans comprised 11.5% of all Veterans served
by VA homeless programs. These data demonstrate that VA homeless
programs successfully reach women Veterans experiencing or who are at-
risk for homelessness and are providing services designed to resolve
their housing needs.
Homeless and At-Risk Veterans Served by VA Homeless Programs: A
demographic overview shows VA homeless programs provide a wide variety
of services to meet the diverse needs of the homeless population. This
analysis identified gender gaps in service engagement, which are
attributed to the often unique service needs and family composition of
women Veterans. Specifically, homeless and at-risk women Veterans are
more likely than men Veterans to have children in their custody and
require additional services and resources to accommodate dependents.
Additionally, many congregate living settings, like VA's residential
treatment programs, are mostly populated by men, with women as the
extreme minority. These congregate settings have limited designated
space available for women, such as separate living and bathroom
facilities. Traditionally, women Veterans are more likely to utilize
services that provide independent housing options such as housing
subsidies for an apartment/house or temporary shelter in a private
hotel. As a result, women Veterans have a higher rate of admission to
the Department of Housing and Urban Development-VA Supportive Housing
(HUD-VASH), Supportive Services for Veteran Families (SSVF) Prevention
and SSVF Rapid Re-housing (RRH) programs than to programs more
congregate in nature. VA's residential treatment Grant and Per Diem
(GPD) program serves approximately 50% less women Veterans than HUD-
VASH, SSVF or RRH. It should be noted that the Johnny Isakson and David
P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020
(P.L. 116-315 Sec. 4204) provides that in cases of a homeless Veteran
who has care of a minor dependent, GPD must pay, in addition to the
daily cost of care of the eligible Veteran, an amount that equals 50%
of the daily cost of care for each minor dependent.
We expect that this ability to pay for care for dependents will
make GPD a more viable option for women Veterans with minor dependents
and should increase the percentage of women served in GPD as time goes
on. Within HUD-VASH, there is a significant difference in service
utilization when comparing rates of program entry among women and men
Veterans with children, with close to 30% more women with children
entering HUD-VASH compared to men with children. In SSVF and RRH, there
are no significant differences in admission rates for this cohort.
Beyond the specified limitations of programs offering congregate living
settings, no significant gender gaps in homeless program service
provision or access were identified in this analysis.
VA Homeless Program Outreach: VA's Health Care for Homeless
Veterans (HCHV) program provides outreach and case management services
to at-risk and homeless Veterans. Women Veterans received more outreach
contacts proportionally than what they represent in the homeless women
Veteran population (10.9% of all outreach contacts were with women
Veterans, compared to the 8.4% of women represented in the homeless
Veteran population). This demonstrates that VA is actively reaching out
to women Veterans experiencing homelessness to ensure equitable access
to services. No significant gender gaps in outreach services were
identified in this analysis.
VA Homeless Program Referrals: VA homeless programs receive
referrals from community partners, self-referrals from Veterans and
other VA services. Self-referrals from Veterans can come through the
National Call Center for Homeless Veterans (NCCHV), which provides a
24-hour/7-day-a-week hotline for Veterans seeking housing services.
There were no significant gaps in referrals generated through NCCHV
when comparing men and women Veteran callers. While men represented
higher numbers of calls to NCCHV, a slightly higher proportion of Women
Veterans had a service provider visit within 90 days of reaching out to
NCCHV. Veterans receiving care across VA health care settings complete
an annual Homeless Screening Clinical Reminder (HSCR), which is a brief
screening to determine if a Veteran needs assistance with housing.
While men represented higher numbers of positive HSCRs, they also had a
slightly higher proportion of subsequent visits with a VA service
provider within 90 days of being screened. No significant gender gaps
in referrals and service provision from these two main referral sources
were identified in this analysis.
SSVF has innovative features that allow its grantees to address the
needs of women and in households where women were head of household.
These features, described below, have allowed SSVF to serve
significantly more women Veterans than would be expected as women
currently represent 8.4% of the homeless Veteran population but 13% of
Veterans served by SSVF in FY 2020.
--SSVF can offer families temporary child-care, thereby providing
opportunity for women Veterans with children to seek employment
and needed medical and mental health care.
--SSVF offers additional assistance to those fleeing domestic
violence. This provision allows the full range of SSVF
services, including financial assistance, to be offered to
victims of domestic violence whether they are Veterans or the
victim of violence in a Veteran's household.
--SSVF is unique in that it can directly serve all household members,
including dependent children, of homeless and at-risk Veterans.
As women are often the primary caretakers for a family's
dependent children, this feature of SSVF is critical to meeting
the needs of these women Veterans.
--SSVF is currently working with communities across the country on a
national initiative that seeks to help at-risk Veteran families
avoid homelessness through family reunification. By training
staff on mediation techniques, supported by limited financial
assistance, SSVF seeks to work with families and friends to
prevent the trauma of homelessness.
--If a Veteran is separated from their family for any reason
(including discord, hospitalization, incarceration or other
forms of institutionalization), services can be maintained and
provided to the Veteran's family members for up to 1 year.
VA Homeless Programs Outcomes: There were no significant gender
gaps in outcomes for women Veterans served in VA homeless programs, and
overall, women had better outcomes compared to men. Across all
programs, women had higher rates of permanent housing placements and
lower rates of negative program exits. Women were more likely than men
to exit HUD-VASH case management with a voucher at exit. Women Veterans
were also more likely than men to have full or part-time employment at
exit, except in the GPD program, where women and men were equally
likely to have full or part-time employment at exit. Finally, apart
from the Health Care for Homeless Veterans Contract Residential
Services/Low Demand Safe Haven (HCHV CRS/LDSH) programs, women Veterans
had higher rates of income and non-cash benefits at exit than men, with
slightly lower proportions of women exiting HCHV CRS/LDSH having income
and non-cash benefits at exit.
Veteran Satisfaction: VA's two primary satisfaction surveys reveal
that both women and men Veterans reported similarly high levels of
satisfaction with VA services. Over 90% of women and men agreed that
the services they received met their expectations and needs, and over
95% of women and men were satisfied with the overall services they
received. In 2019, three of the top five Veteran-met needs were the
same for homeless women and men Veteran respondents: Medical Services,
Medication Management and Tuberculosis Testing and Treatment. Of the
unmet Veteran needs in 2019, three of the top five were the same for
homeless women and men Veteran respondents: Legal Assistance to Expunge
a Criminal Record, Legal Assistance for Credit Issues/Debt Collection
and Tax Issues. It should be noted that under section 5105 of the
Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits
Improvement Act of 2020, VA must enter into one or more agreements with
public or private entities to provide legal services to women Veterans.
As of this report, HPO has identified communities with the most
pronounced indications of unmet need for legal services among homeless
women Veterans and is conferring with OGC regarding the potential for
new or expanded partnerships with legal service providers in these
communities as a result of this legislation. No significant gender gaps
in reported satisfaction with VA homeless programs and services between
men and women served were identified in this analysis.
Question. Will you provide an update on how the VA is meeting the
specific needs of rural veterans who are homeless or at risk of
homelessness?
Answer. The Veterans Benefits Administration's (VBA) Veterans
Transportation Program (VTP) offers Veterans many travel solutions to
and from their VA health care facilities at little or no cost to
eligible Veterans. VTP provides safe and reliable transportation to
Veterans who require assistance traveling to and from VA health care
facilities and authorized non-VA health care appointments. In addition,
the VHA Office of Connected Care's ATLAS service is part of VA's
Anywhere to Anywhere telehealth initiative, which sets out to better
serve the nearly 9 million Veterans who receive care through VA no
matter where they are. ATLAS has teamed up with public and private
organizations to enhance underserved Veterans' access to VA health care
by offering them convenient locations to receive VA care closer to
home. This new option reduces obstacles such as long travel times to
appointments and poor internet connectivity at home.
HPO provides a full spectrum of services designed to meet the
unique needs of all Veterans, including the needs of rural Veterans who
are homeless or at risk of homelessness. VA's efforts are enhanced by
harnessing the strength of community providers in coordination with VA
health care and benefits.
--Grant and Per Diem: GPD's grant funding decisions consider a
variety of factors including geographic dispersion. When funds
are made available for a grant or per diem award under 38
C.F.R. part 61, VA will publish a Notice of Funding
Availability in the Federal Register. The notice will state any
priorities for or exclusions from funding to meet the statutory
mandate of 38 U.S.C. 2011, to ensure that awards do not result
in the duplication of ongoing services and to reflect to the
maximum extent practicable appropriate geographic dispersion
and an appropriate balance between urban and non-urban
locations. In this way, GPD promotes equity and is responsive
to the needs of communities. GPD continues to work to support
communities in need, such as rural communities, as they work to
end homelessness among Veterans by providing transitional
housing resources for use by Veterans experiencing or at risk
of homelessness.
--Supportive Services for Veteran Families: Through the SSVF program,
generally, grantees may use a maximum of 40% of the temporary
financial assistance to provide homeless prevention assistance
to those most at risk of becoming homeless. However, this
requirement has been waived for the duration of the COVID-19
health emergency. SSVF recognizes that rural areas often lack
the shelter capacity to meet local needs and therefore, rural
Veterans are more likely to be in temporary housing
arrangements that qualify only as prevention. To address this
unique feature of rural communities, SSVF allows rural grantees
to apply for a waiver to this 40% prevention spending limit.
Additionally, when selecting applicants to receive supportive
services grants, VA will, ``[t]o the extent practicable, ensure
that supportive services grants are equitably distributed
across geographic regions, including rural communities and
tribal lands.'' 38 C.F.R. Sec. 62.23(d).
--HUD-VA Supportive Housing: Approximately 9% of Veterans housed with
HUD-VASH vouchers live in rural or highly-rural areas. These
Veterans often require additional or modified case management
services to accommodate their remote locations. Even prior to
the challenges posed by the global COVID-19 pandemic, the
national HUD-VASH program office had encouraged facility-level
programs to adopt telehealth as a means to ensure Veterans were
able to access adequate case management supports.
--Tribal HUD-VASH: Serves American Indian/Alaska Native Veterans (AI/
AN) within the tribe's service area. HUD provides the grant
funding for rental assistance, administered by the tribe or
tribally-designated housing entity grantee, and VA provides the
case management and supportive services to enrolled AI/AN
Veterans. There are currently 26 tribes participating in the
program. Tribal HUD-VASH has case managers who travel to the
grantee's reservation or tribal areas to provide outreach to
homeless Veterans and Veterans at risk of homelessness. The
program has been developed to specifically address the unique
aspects of homelessness in tribal communities. Throughout the
pandemic, some of the tribal grantees have closed their borders
to non-tribal persons but made an exception for VA staff. These
tribes expressed their support for VA tribal HUD-VASH staff as
VA brings services to Veterans, instead of Veterans having to
travel to services. VA staff aided tribal members with
individual contacts, VA Video Connect (VVC) or other virtual
telehealth-type meetings, and through contactless delivery of
goods such as food, clothing and masks. VA was able to lend
smart phones with data plans to Veterans who did not have these
resources and assisted Veterans with use of the devices to
allow them to complete VVC meetings or to at least connect by
telephone if the Veteran was not comfortable using video
technology. Staff provided support and assistance to Veterans
who were experiencing significant losses of family, friends and
cultural connections due to the pandemic.
--Homeless Patient Aligned Care Teams (HPACT): The HPACT program is
committed to addressing the physical, mental health and social
needs of all Veterans experiencing homelessness or at risk of
homelessness including those residing in rural and highly-rural
areas. Work is focused on the expansion of HPACT sites and
services to provide optimal health to rural Veterans through
utilization of extensive outreach, engagement and telehealth to
increase access to care. Many HPACTs offer some form of
outreach and engagement including health assessment, health
education, medication prescriptions and referrals to homeless
programs or other needed VA services. Additionally, telehealth
services, such as VVC, enhance access and allow Veterans to
receive additional services when indicated.
______
Questions Submitted by Senator Lisa Murkowski
Question. I appreciate that the Department is increasing its
request for suicide prevention initiatives to $598 million dollars. A
92% increase is an impressive ask and I believe that it indicates that
you are making a serious commitment to provide support to our nations
veterans who are facing desperate situations, and you have my
wholehearted support in doing so. In 2019 and the wake of a tragic
cluster of suicides, the U.S. Army at Fort Wainwright in Fairbanks,
Alaska completed an in-depth Behavioral Health Epidemiological
Consultation that identified several actions they could take to try and
reduce suicide among active duty service members. Despite the Army's
serious commitment to implementing these changes, we have not seen a
significant decrease in suicides. I am worried that this may happen at
the VA, where we continually appropriate money at the problem but don't
see improvement in the situation.
What is different about this year's suicide prevention portion of
the budget request that will justify such a large ask?
Answer. There are four primary programmatic areas that account for
the suicide prevention budget increase: 1) Veterans Crisis Line's (VCL)
implementation of 988; 2) Suicide Prevention 2.0 (SP 2.0); 3)
President's Roadmap to Empower Veterans and End a National Tragedy of
Suicide (PREVENTS); and 4) the Staff Sergeant Parker Gordon Fox Suicide
Prevention Grant Program (SSG Fox SPGP).
First, VCL accounts for 50% of the total increase, which is to
support operational readiness in fulfillment of the National Suicide
Hotline Designation Act of 2020, which requires the Federal
Communications Commission (FCC) to designate 9-8-8 as the universal
telephone number for the National Suicide Prevention Lifeline and VCL.
A volume increase of 122% to 154% is anticipated for VCL, and the
transition to 988 must be complete by July 16, 2022. Once activated,
the 988 expansion will directly address the need for ease of access and
clarity in times of crisis, both for Veterans and non-Veterans alike.
By providing a universal, unique 3-digit dialing code, it will also
give VA an opportunity to work in greater collaboration with the
suicide prevention community across the United States and open the door
to engage new individuals in life-saving care.
Second, the increase for SP 2.0, which accounts for 12% of the
total increase, is to further the implementation of our public health
approach to suicide prevention. To accomplish its goal of reducing
suicide among all 20 million U.S. Veterans, and to reach Veterans both
inside and outside VA care, SP 2.0 is moving suicide prevention beyond
a one-size-fits-all model to a blended model combining community
prevention strategies and evidence-based clinical strategies that will
empower action at the national, regional and local levels. This
initiative is informed by the evidence supporting suicide prevention
interventions and public health approaches. The Centers for Disease
Control and Prevention, the Substance Abuse and Mental Health Services
Administration and the National Action Alliance for Suicide Prevention
have all moved toward a public health approach to suicide prevention.
The model works to incorporate reaching both Veterans in the community
as well as those we currently serve in VA with innovative community-
based prevention strategies combined with strategies with known
outcomes for reducing suicide and suicide attempts based upon the 2019
updated VA-DoD Clinical Practice Guideline (CPG) for the Assessment and
Management of Patients at Risk for Suicide.
Third, the increase for PREVENTS, which accounts for 18% of the
total increase, is to support Roadmap implementation and completion to
include an aggressive plan integrating Roadmap recommendation 1 with
Roadmap recommendation 8 across fiscal year (FY) 2022.
Fourth, SSG Fox SPGP accounts for 19% of the total increase. SSG
Fox SPGP supports section 201 of the Commander John Scott Hannon
Veterans Mental Health Care Improvement Act of 2019 (P.L. 116-171) and
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 (2018), 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.
Question. Does this budget request have any points of focus on
Veteran suicide prevention programs that target rural or remote
communities like so many in Alaska?
Answer. The Office of Rural Health (ORH), in collaboration with
other VA program offices and research entities, have funded over 40
mental health and suicide prevention initiatives targeted at rural or
remote Veterans. The following programs have been established and are
delivered in rural and highly-rural communities to Veterans in
locations similar to those in Alaska: Telehealth Clinical Resource
Hubs, Rural Access Network for Growth Enhancement, Pharmacist Providers
for Rural Veterans with Opioid Use Disorder and Clinical Pharmacy
Specialist Providers programs. In addition, ORH funds several
initiatives in other rural communities such as the VA Farming and
Recovery Mental Health Services, National Mental Health and Suicide
Prevention Extension for Community Healthcare Outcomes, Community
Clergy Training to Support Rural Veterans Mental Health and the Rural
Suicide Prevention Program, just to name a few. These mental health and
suicide prevention programs contribute to VA's continuing efforts to
increase access to health care and to expand delivery of health care
services to rural Veterans where they live. Active partnership with the
Tribal Health Organizations in implementing these suicide prevention
programs will be essential in highly-rural Alaska. In addition,
providing postvention support when suicides happen and honoring those
individuals in their communities would help them heal and assist them
in being open to the resources.
The budget includes expansion of our Community-Based Interventions
for Suicide Prevention (CBI-SP) program to all Veterans Integrated
Service Networks (VISN), including VISN 20. This program brings
together the Governor's Challenge initiative (Alaska will be invited to
join in FY 2022), the Together With Veterans peer led rural program and
Veterans Health Administration (VHA) Community Engagement and
Partnership Coordinators to facilitate community-led suicide prevention
efforts. CBI-SP will facilitate the spread of the community suicide
prevention efforts to all communities by deploying trained and
dedicated VA staff who will help community coalitions organize, provide
technical assistance and provide training all within a unifying model.
Question. The VA is running a Native Veteran Suicide Prevention
Project with the goal of addressing risk factors or enhancing known
protective factors of suicide and developing Tribal partnerships. The
program is in the process of establishing, or has already established,
partnerships with 32 Tribes. Is the VA planning to expand this program
to any Alaskan Tribes?
Answer. The Tribal-VHA Partnerships for Suicide Prevention project
is a demonstration project with three VA medical centers: VA Puget
Sound Health Care System, Northern Arizona VA Health Care System and
the Oscar G. Johnson VA Medical Center in Iron Mountain, Michigan. The
tribal partnerships and outreach being conducted as part of this
project are specific to tribes in these health care systems within the
states of Washington, Arizona, Michigan and Wisconsin (which is served
by the facility in Iron Mountain). The goal of this project is to
develop and demonstrate a model for increasing partnership between VA
suicide prevention and rural tribes. This initial project deliverable
is due at the end of FY 2022, after which we expect to propose to roll
the model out further in order to support additional VA health care
systems that serve Native American Veterans.
______
Questions Submitted by Senator John Hoeven
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 its community care providers. These types of contracts are
intended to be used 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 the long-term care they
need, or having to relocate away from family and friends.
What is the current status of Veterans Care Agreements?
Answer. Veterans Care Agreements (VCA) are currently being utilized
to supply providers to support VA's ability to deliver timely care to
Veterans to meet their medical needs. Pursuant to the legal standard
for use of VCAs that is set forth in the VA Maintaining Internal
Systems and Strengthening Integrated Outside Networks Act, a provider
with a VCA is used to serve a Veteran when the hospital care, medical
services and/or extended care services needed for that Veteran is not
feasibly available from VA or through a conventional procurement
contract or a sharing agreement (e.g., health care resource sharing
agreement with the Department of Defense). There are 16,945 active VCAs
as of October 13, 2021, according to the VA Provider Portal Management
System.
Generally, the use of VCAs has been gradually decreasing as the
Community Care Network (CCN) has stabilized, and VA is less reliant on
them as the implementation of the CCN becomes more robust. Some of the
services VA is currently most reliant on utilization of VCAs to acquire
are homemaker/home health, mental health and dental services.
Question. Can you provide examples of where VA is currently using
Veterans Care Agreements?
Answer. A few examples of where VCAs are currently being used
include CCN Regions 4 and 5 (Alaska/California/Arizona), where VA
utilizes VCAs for mental health services, when necessary, to ensure
Veterans have timely access to mental health care. Additionally, VCAs
are currently VA's primary means of procuring family member Bowel and
Bladder coverage.
In many geographic areas, particularly rural areas, VCAs bridge the
gap for providing specialties related to homemaker home health care, as
well as for dental services in those areas where providers are still
being recruited into the CCN. As of October 13, 2021, there are
approximately 2,970 VCAs for Bowel and Bladder care, 3,300 VCAs for
home health care and 8,300 VCAs for dental services.
Question. Since 2019, the Fargo VA has carried out a hyperbaric
oxygen therapy (HBOT) clinical demonstration project. Under the
project, veterans who have yet to experience positive outcomes from two
traditional post-traumatic stress disorder (PTSD) therapies can be
referred for HBOT in the community.
Do you agree that in order to put an end to veteran suicide, we
need to address the problem with every possible option--including
expanding access to innovative, alternative treatment options like
HBOT?
Answer. VA agrees with the importance of providing effective mental
health care to address Veteran suicide and supports the use of
promising practices along with evidence-based treatments for mental
health. The effects of Hyperbaric Oxygen Therapy (HBOT) on suicidal
thoughts and behaviors have not been tested; however, HBOT does not
appear to be an effective treatment for mental health disorders. The
evidence on HBOT for traumatic brain injury (TBI), with or without
posttraumatic stress disorder (PTSD), that is based on the results of
four randomized controlled trials is largely negative, with only one
study showing some short-term benefit for PTSD. VA offers Veterans
access to a range of promising practices through its Whole Health
Program and will continue to monitor the evidence on HBOT and
potentially innovative strategies for addressing Veteran suicide.
Question. Given it is already July and the country is still
recovering from the COVID-19 pandemic, do you anticipate extending the
HBOT demonstration project beyond this fiscal year so that more
veterans can access this treatment option?
Answer. VA does not anticipate extending the HBOT clinical
demonstration project (program evaluation) beyond this fiscal year. VA
clinicians and Fargo VA Health Care System leadership will continue to
make case-by-case, evidence-based determinations on clinical care and
case management, including community care authorizations for HBOT for
any medical indication, consistent with VA policy and with
consideration for the unique needs, health factors and treatment
history of individual Veterans.
The clinical demonstration project was intended to identify
administrative implications of administering this therapy within VA and
has successfully accomplished that goal. It was never intended or
designed to address efficacy of HBOT for these conditions or influence
clinical care decisions, which are made by the provider in
collaboration with the Veteran patient.
On October 22, 2020, the Acting Under Secretary for Health agreed
to increase the total number of Veterans who could enroll in the
program evaluation across all five sites from 215 to 250, which
facilitated consistent opportunity for Veteran participation at each
location. At the end of fiscal year (FY) 2020, leadership at four of
the sites concluded their participation in the program evaluation
following the planned active period of approximately 24 months. Due to
the impact of Coronavirus Disease 2019 and the later start date, VA
leadership supported the continuation of the program evaluation at the
Fargo VA Health Care System for an additional 12 months (through the
end of FY 2021), which would be consistent with the 24-month active
period of the other four program evaluation sites. To maintain
consistency across sites, the program evaluation concluded at the end
of FY 2021.
Background:
--A total of 56 Veterans have been referred across all five sites.
--A total of 51% Veterans either dropped out or canceled before
beginning treatment across all sites.
--As of June 23, 2021, Fargo VA Health Care System remains the only
site that continued to enroll Veterans for FY 2021.
--A total of 23 Veterans have been referred to the Fargo site since
September 2019.
--A total of 45% of all Veterans have either dropped out or canceled
before beginning treatment at Fargo.
--Data indicate that the number of referrals for the first year (12
referrals) is similar to the second year (10 referrals over 10
months).
--HBOT is not recognized as an evidence-based treatment for PTSD or
TBI; is not approved by the Food and Drug Administration (under
guidance by the Undersea and Hyperbaric Medicine Society); and
is not reimbursable by Medicare, Medicaid and insurance.
Question. The National Cemetery Administration (NCA) has determined
that additional infrastructure--such as restrooms, storage sheds, and
wind walls--are necessary at Rural Initiative cemeteries in order to
better serve veterans and their families. Can you provide my office an
update on the pending design and construction of the infrastructure
projects at Fargo National Cemetery?
Answer. The infrastructure improvement project at Fargo National
Cemetery is currently under design. We anticipate the design phase will
be completed this fall. We also anticipate a construction contract will
be awarded over the winter, and the work will be completed in the fall
of next year.
______
Questions Submitted by Senator Susan M. Collins
Question. In December 2020 my legislation, the State Veterans Homes
Domiciliary Care Flexibility Act, was enacted into law. This
legislation requires the VA to implement regulations which allow the
waiver of certain eligibility requirements for domiciliary care per
diem payments when in the best interest of the veteran. This authority
would ensure that vulnerable veterans do not fall through the cracks
and receive the care they need, and I urge the VA to quickly complete
its rulemaking and delegate this waiver authority to local VA hospitals
and regional Veterans Integrated Service Networks (VISN). Can you
please provide the committee with a status update on these efforts?
Answer. The proposed changes to regulation 38 C.F.R. Sec. 51.51 are
currently going through the VA regulatory concurrence process which
follows the Administrative Procedures Act, which typically, though not
always, requires two rulemaking stages. This process takes generally 18
to 24 months and involves VA and the Office of Management and Budget.
Following internal development, review and approval of the regulation,
the Federal Register publishes VA's Notice of Proposed Rulemaking
(NPRM). VA's NPRM invites the public to comment on the proposed
amendments. VA considers and responds to all comments in the final
rulemaking. The proposed regulations will address the new waiver
authority in the Public Law.
Question. A 24-bed Substance Use Disorder Residential
Rehabilitation Treatment Program (SUD RRTP) facility was approved at
the Togus VA in August 2020 as an out-of-cycle Strategic Capital
Investment Plan project. Currently, veterans served by VA Maine are
unable to get these services within the State, and Maine veterans
waiting for admission to a SUD RRTP or unwilling to travel out-of-state
utilize over 500 acute inpatient bed days of care per year at VA Maine.
The establishment of a residential program at Togus would improve
veteran continuity of care and accessibility to vitally important
services for Maine veterans. My understanding is that a design was
internally approved by VA for FY21 funding in December 2020. However,
based on the Department's budget request submission, it does not appear
the VA has adequately prioritized this project. When does the VA plan
to construct this much needed facility?
Answer. The following is the anticipated timeline for the Substance
Use Disorder Residential Rehabilitation Treatment Program facility:
--Design Award--September 28, 2021
--Design Completion--February 2022 to June 2022
--Construction Award--December 2022 to January 2023
--Construction Completion--March 2024
--Activation--April 2024
--Occupancy--May 2024
Question. New International Guidelines for the Prevention and
Treatment of Pressure Injuries were made available in 2019. Hospital
acquired pressure ulcers impact over 2.5 million and cost the health
care system $26.8 billion annually. Following these guidelines could
make significant improvements in wound care for veterans being treated
at VA hospitals. When does VA anticipate adopting these guidelines as
the VA's standard of care and implementing the Standardized Pressure
Injury Prevention Protocol (SPIPP) Checklist to improve pressure injury
prevention?
Answer. VA is aware of the evolving evidence and research related
to Pressure Injury (PI) prevention and wound care. Moreover, VA has
adopted the 2019 International Prevention and Treatment of Pressure
Ulcer/Injury: Clinical Practice Guidelines, as well as areas contained
in the Standardized Pressure Injury Prevention Protocol Checklist,
within the recently-released Veterans Health Administration (VHA)
Directive 1352, Prevention and Management of Pressure Injuries. This
directive provides policy and implementation procedures for the
assessment, prevention and management of PIs across VHA clinical
practice settings. The directive contains practice recommendations and
is consistent with both national and international guidelines for PI
prevention and management. Additionally, the national VA Approved
Enterprise Standard Skin (VAAES) Inspection/Assessment electronic
health record template was developed to ensure staff documentation of
interventions were consistent with evidenced-based recommendations and
guidelines for PI prevention and management. VAAES also includes the
link to the 2019 International Prevention and Treatment of Pressure
Ulcer/Injury: Clinical Practice Guidelines.
______
Questions Submitted by Senator Shelley Moore Capito
Question. I appreciated you meeting with me and my colleagues last
month to update us on the actions that the Department is taking at the
Louis A. Johnson VAMC in Clarksburg, West Virginia, in the wake of the
horrific events that took place at the facility. As I know you observed
during your time at the facility, both staff and patient morale is low.
It is imperative that the VA continues to monitor the progress towards
restoring trust at the medical center.
During our visit, I brought up that there is still staff in
leadership roles at the facility, who were in those positions when the
murders took place. You told me that part of the issue is that the VA
could not begin its internal investigation, until after the OIG and DOJ
investigations concluded. While I understand that the internal
investigation is probably still ongoing, can you provide me with an
update on this and if the VA has found any new issues since our last
meeting, that need to be addressed?
Answer. The internal Administrative Investigation Board was
completed on December 18, 2020. No actions were taken until the Office
of Inspector General (OIG) report was published May 11, 2021. We were
awaiting completion of the OIG report to implement disciplinary actions
regarding this incident, all of which have since been effectuated.
Question. Are there still employees waiting to have disciplinary
action taken against them?
Answer. VA has taken the necessary administrative actions against
all identified employees. The administrative actions ranged from
written counseling to removal. There were several VA staff members
including the Medical Center Director, Chief of Staff and Associate
Chief Nurse who retired from their respective positions before
administrative action could be taken. Additionally, two staff members,
a Hospitalist and a Quality Manager, resigned before administrative
action could be taken.
SUBCOMMITTEE RECESS
Senator Heinrich. And with that, we stand adjourned.
[Whereupon, at 11:02 a.m., Wednesday, June 23, 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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