Veterans Affairs Sec. Denis McDonough testifies before the Senate Appropriations Committee.
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NewsTranscript
00:00:00of Veterans Affairs. We appreciate the effort of VA's dedicated staff to provide medical
00:00:05care, benefits, and support to veterans, their families, and their communities every day.
00:00:11We're here today to discuss the Department of Veterans Affairs fiscal year's 2025 budget
00:00:16and 2026 advance appropriations requests. This committee takes very seriously the obligation
00:00:22to make sure we provide for the men and women who have fought and sacrificed to keep our
00:00:26country safe and ensure they have the medical care and benefits they've earned. This budget
00:00:31strives to do just that and requests a mandatory appropriation of over $210 billion and a discretionary
00:00:38appropriation of $129 billion in FY25. VA also has access to over $24 billion from the
00:00:46Toxic Exposures Fund that was provided in the Fiscal Responsibility Act. These resources
00:00:51are extremely important in providing funding to carry out the expansion of medical care
00:00:55and benefits in the PACT Act. Without these resources, VA simply would not be able to
00:01:00keep up with the processing of new claims or expediting health care benefits to veterans
00:01:05who are exposed to toxins and environmental hazards. The budget also requests advance
00:01:10appropriations for FY26, including $131 billion in medical care discretionary accounts, $23
00:01:18billion in mandatory resources for medical care funded by the TEF, and $222 billion in
00:01:23mandatory resources for veterans' benefits programs.
00:01:28Despite this robust request, I am concerned about medical care levels in this budget.
00:01:32The discretionary funding request for medical care is lower than the FY23 enacted level,
00:01:37and when including mandatory medical care spending, this still represents a cut from
00:01:41FY24. As I stated earlier, this committee has an obligation to provide for the men and
00:01:46women who protect this country, and I'll need your commitment that this budget does just
00:01:50that. VA is seeing a higher reliance on the Department for Medical Care and greater utilization
00:01:55of benefits and services than prior years, in part due to the success of the PACT Act.
00:02:01Veterans are relying on the VA for more care today than ever before, but the FRA top line
00:02:06is forcing cuts across government. So the VA must do more with less. We know this is
00:02:11impacting staffing level at medical facilities, and that there are programs that will not
00:02:14be expanded as a result of these levels. There are a few initiatives within the budget requests
00:02:19that I'd like to highlight. The budget continues to request robust funding for its telehealth
00:02:24program, with an estimated $6.4 billion for FY25. However, even with expanded hiring and
00:02:31telehealth capacity, veterans in rural areas often struggle to access health care, including
00:02:37due to challenges with transportation and lack of Internet access. I continue to encourage
00:02:41the VA to look for innovative and cost-effective ways to close these access gaps.
00:02:47At the end of last year, VA signed an updated agreement with the Indian Health Services.
00:02:51The new agreement allows VA to reimburse IHS for additional health care services, including
00:02:55long-term care, home health services, and durable medical equipment. I encourage VA
00:03:01to continue establishing agreements with individual tribal health programs to further eliminate
00:03:06barriers to care for American Indian and Native Alaskans who serve their country.
00:03:11Women are the fastest-growing demographic entering the military and now represent nearly
00:03:1620% of service members. The women veteran population is also the fastest-growing demographic
00:03:21within the VA. This population is only anticipated to grow, and caring for these veterans should
00:03:26be an area of bipartisan support. This budget requests a historic $13.7 billion for women
00:03:33veterans' health care, including $1.1 billion in gender-specific care. I hope we can include
00:03:39that level of funding in this year's appropriations bill.
00:03:43The Electronic Health Record Modernization Program continues to be in a strategic pause
00:03:48to assess and address issues discovered during the first five site deployments. VA recently
00:03:53deployed the new system to the Lovell Federal Health Care Center in Chicago. However, it
00:03:57is still too early to determine if this deployment was a success. The budget request shows a
00:04:03substantial cut to the EHR program, and the request assumes no new deployments will happen
00:04:08this year. While patient safety is our number one priority, VA needs to commit to getting
00:04:12this program back on track to deliver a safe and secure health record.
00:04:17Last year, VA surpassed its goal of housing 38,000 homeless veterans. This is significant,
00:04:23but there is still more to be done. The most recent point-in-time count numbers show a
00:04:287.4% increase over 2022 in veterans experiencing homelessness. The budget requests $3.2 billion
00:04:35to continue to ensure VA has the resources to secure housing and case management support
00:04:40for this veteran population.
00:04:42Secretary, it's clear that much is expected from the Department. Providing health care
00:04:46requires facilities, technology, and clinicians, and quickly providing benefits requires staff
00:04:51and technology support. For the Department to succeed in these efforts, you must be resourced
00:04:57appropriately. I look forward to working together to provide veterans with the services and
00:05:01benefits they've earned and deserve. Thank you. And now I'll turn it over to Ranking
00:05:06Member Bozeman.
00:05:15Thank you, Madam Chair, and Mr. Secretary, it's good to have you here today. Thank you
00:05:20for coming to discuss VA's fiscal year 2025 and 2026 budget requests. The budget request
00:05:27of $369.2 billion in fiscal year 2020-2025 for the Department of Veterans Affairs, including
00:05:37medical care collections, the transformation fund, the toxic exposure funds, representing
00:05:43a 9.8% increase over the fiscal year 2024 enacted levels. This includes $129.1 billion
00:05:51in discretionary funds of $5.7 billion or 4.2% decrease from fiscal year 2024. The request
00:06:00includes $235 billion in mandatory funds of $41.8 billion or 21.6% increase over fiscal
00:06:09year 2024. Within this amount of $24.5 billion in the TEF, $4.2 billion increase over fiscal
00:06:18year 2024. The budget also requests a total of $131.5 billion in medical care advance
00:06:26appropriations for fiscal year 2026, $118.9 billion more than the fiscal year 2025 advance
00:06:35appropriation, and $22.8 billion in advance for the TEF. Finally, the request includes
00:06:40$222 billion in advance funding for veterans' benefits.
00:06:46Mr. Secretary, I think we could agree that the budget request can reasonably be characterized
00:06:53as tight. That is not your fault. It is just the circumstances that we are in. In my more
00:06:58than 20 years working on veterans' issues in both the House and the Senate, I can't
00:07:02recall a single year when the budget request for veterans' health care went down. I recognize
00:07:08that VA has more funding streams than ever before, including the TEF, but nevertheless,
00:07:14this request stands as an outlier. In recent years, I have asked you about the amount of
00:07:18risk VA takes in crafting its community care request, but this year I will want to know
00:07:24more about the level of risk VA is taking across its whole enterprise. In your testimony,
00:07:30you referred to fiscal year 2025 planned obligations, which will grow by more than 5%, even though
00:07:37the base request is lower than last year. I want to hear from you about what risk this
00:07:42may open the VA up to. I understand this is not about you. Again, we are just in a situation
00:07:50where money is tight.
00:07:53The PACT Act has certainly been a dramatic change for veterans. I also think VA has a
00:07:58very good story to tell about its implementation, the new veterans enrolling, and the number
00:08:03of PACT Act-related claims received and processed. Again, I know that you and your staff throughout
00:08:11the VA have worked so hard to make that a success. It also gave VA new tools to recruit
00:08:17and retain its workforce, and I look forward to hearing about your plans to ensure you
00:08:21have the right people in the right places to take care of our veterans.
00:08:24I also want to note that it has been a little more than a year since you announced the reset
00:08:29of the electronic medical records program. As this reset continues, I hope to hear more
00:08:35about the timeline to bring the deployed sites up to standard when we can expect deployments
00:08:41to resume. DOD stumbled out of the gate in its efforts, but after a pause, it successfully
00:08:46completed deployments through the country and abroad. I hope the VA has learned from
00:08:51that and will be able to get this program moving forward again soon.
00:08:57With well more than $11 billion of taxpayer money invested, it is time to start seeing
00:09:01a return. In addition to updates on those big picture items, we also look forward to
00:09:06hearing details about the Department's request for mental health services, including efforts
00:09:12to prevent veteran suicide, initiatives to prevent veterans' homelessness, resources
00:09:18dedicated to care for women veterans, and efforts to improve care for our rural veterans.
00:09:24We look forward to discussing these other issues, and again, very much appreciate you
00:09:29being here. Thank you, Madam Chair.
00:09:32Thank you, Ranking Member. Mr. Secretary, we'll now proceed with your opening statement.
00:09:35You have five minutes.
00:09:37Madam Chair, thank you very much. Congratulations on the new assignment. Senator Bozeman, other
00:09:42members of the committee, thank you, Senator Baldwin, for the opportunity to be here today.
00:09:45I'm willing to just put my prepared remarks into the record and get straight to your questions
00:09:50if you are amenable to that. I'm happy to go straight to questions.
00:09:58Thank you. I really appreciate that. We'll start with a round of five-minute questions
00:10:03of our panel. I ask all my colleagues to keep track of your clock and stay within those
00:10:06five minutes. I'll start with the first round of questions. Secretary, your models project
00:10:12that utilization of VA health care will rise, but the discretionary funding request for
00:10:16VA health care is below the levels from FY23, and even including mandatory health care funding,
00:10:23it's $4 billion below FY24. What are the current spend rates for the medical care accounts
00:10:29in FY24, and based on these trends, do you expect to be on target for FY25?
00:10:35Thanks so much. We anticipate spending about $140 billion on health care out of that account
00:10:43in FY24. All in FY25 in the budget is $150 billion when you count our various funding
00:10:52streams, medical care collections, carryover, importantly, about $12.7 billion in carryover,
00:10:58and then as you said, the toxic exposure fund, which is an increase of about 7% in total
00:11:03health care spending. There's no doubt, as we've talked about a number of times in the
00:11:09course of the last week, that money is tight, and that is a function of the budget agreement,
00:11:14but we think that we have the money that we need here, and we have, most importantly,
00:11:18the people that we need to implement this increased access to care.
00:11:25And Secretary, at these levels, how can you make sure that you're able to pay for the
00:11:29care that veterans receive in the community while also investing to ensure that the VA
00:11:34is an available option for veterans?
00:11:35That's a really good question, and this is one that we spend a lot of time worrying about.
00:11:38The budget takes a lot of unique steps this year as it relates to community care. Perhaps,
00:11:47we've already notified to you all that we are taking the $1.9 billion in rescission
00:11:54from other than community care accounts in the VA. We also ask that we reprogram, in
00:12:01the advance, $7 billion into community care. That reflects what is a very robust set of
00:12:10referrals over the second half of FY23, but also reflects what has been basically 15%
00:12:21year-on-year growth going back to the enactment of the Mission Act. This is higher than CBO
00:12:26would have anticipated, and that's one of the reasons that we make these big moves
00:12:31that we make here. Notwithstanding those moves, we think that because of the hiring year that
00:12:37we have had and our ability to continue to strategically hire where we need it, that
00:12:43we can also meet our demands for care in the direct care system. We do not ask for a second
00:12:51bite on the advance, but if we find out over the course of these next several months that
00:13:01because of our outreach efforts, we have 550 outreach events this year, because of our
00:13:05outreach events, that we're getting more veterans enrolled. Just since March 5th, we've had
00:13:1312,500 veterans uniquely from the PACT Act cohort having enrolled in our outreach efforts.
00:13:20If we see that continued kind of growth, my hunch is we may be coming back to you after
00:13:27working with OMB to ask for a second bite if we need to. But again, margins are tight.
00:13:33We feel like we have the investments we need. If we begin to run into problems, we'll definitely
00:13:41come to the committee. Lastly, we are tracking this very, very closely. We've implemented
00:13:47a series of budget execution tools. It is our intention to share those tools with this
00:13:54committee, with your team. We're working through all that paperwork on our end of the street
00:13:59before we do that. So you all, as a team, will be able to follow along closely with
00:14:03us on the execution of those goals.
00:14:05Thank you, Secretary. The FY25 budget request, as I mentioned in my opening remarks, includes
00:14:10a lower level of spending for rural health programs than was appropriated for FY24. First,
00:14:17can you assure me that the VA will direct the full amount of funding towards rural health
00:14:20programs in 24?
00:14:22You have my assurance.
00:14:23Thank you. The second question would be, what are innovative initiatives that you're developing
00:14:27to increase access for rural veterans to address the fact that there is a proposed reduction
00:14:34in spending for FY25?
00:14:36Thanks very much. Among the more innovative things we're doing right now is we're enhancing
00:14:42our cooperation with the Department of Defense and, over the course of the last two months,
00:14:47with the Department of Agriculture to increase access points in rural settings so we can
00:14:54get care closer to veterans. That's one innovative solution.
00:14:58Second, things like access to cancer treatment. We announced a new program last week, Close
00:15:05to Me, where we forward-deploy VA professionals to CBOCs, closer to veterans, so if they can
00:15:12get their cancer treatments closer to their homes, rather than having to drive all the
00:15:16way to Phoenix, for example, they'll be able to go to their local CBOC, supported by their
00:15:21family, not having to drive those longer distances. We can do that within the confines
00:15:28of our budget because cancer treatment drugs are 30 percent cheaper for VA than they are
00:15:34for our private sector partners.
00:15:38Third, we are forward-deploying VA professionals, I saw this in the Upper Peninsula of Michigan,
00:15:45to community hospitals, including federally designated health clinics, so that we can
00:15:53identify vets who are coming in to treatment, not enrolled with VA. We can then get them
00:15:57enrolled and get them support in those facilities. Ultimately, that has cost over the life of
00:16:04the program for VA, but no cost up front.
00:16:08Lastly, the Office of Rural Health has been basically flat at $337 million for the last
00:16:15three, four years, for the simple reason that we finance our clinical resource hubs principally
00:16:22through the Office of Rural Health. That means we're going to continue to rely on telehealth,
00:16:27as you said in your opening statement. Then the rest of the investments out of that office
00:16:32are for enterprise-wide innovations. Among those innovations that have come from that
00:16:39office that can be funded at that $337 million effort are home-based primary care. This is
00:16:51where we are sending providers into rural settings like Maine and Arizona and Montana
00:16:58and Wisconsin and Arkansas, so that we are taking the care to the veterans. That's the
00:17:05idea. Not that we continue to fund those through the rural health care office, but
00:17:14rather we then transfer those to being funded through the standard medical care account.
00:17:19Thank you, Secretary. Senator Collins, you're recognized.
00:17:23Thank you very much, Madam Chair. Again, I thank the Vice Chair for his graciousness
00:17:29and allowing me to precede him. Mr. Secretary, let me start with two facts. One is that Maine
00:17:39has one of the highest percentages based on population in the country of veterans. That's
00:17:47something I'm very proud of. Mainers have always stepped forward to serve. Second, Maine
00:17:55is the oldest state in the nation by median age. So when you combine those two factors,
00:18:04you can easily see why our state veterans' homes are so important. In fact, both of my
00:18:11parents had the benefit of compassionate care at our state's veterans' homes at the end
00:18:19of their lives. In 2022, however, despite the strong demand for these services, Maine
00:18:29considered closing two of its veterans' homes, one in Machias and one in my hometown of Caribou.
00:18:37Fortunately, that was averted, but it would have caused tremendous hardship to veterans
00:18:44and their families. Maine is not unique in this regard. A recent report indicates that
00:18:50other veterans' homes across the country have notified the VA of potential closures. Fifteen
00:18:57have reduced their bed capacity. Another four have already closed permanently. The VA raised
00:19:05its per diem rates in 2023, but frankly, that increase has not kept pace with rising
00:19:13medical costs. And the veterans' homes in Maine, as is true across the country, are
00:19:21struggling financially. What is the VA doing to support financially troubled state veterans'
00:19:30homes, and what more can be done at the federal level to prevent closures or reductions in
00:19:38beds? Yeah. Senator, thank you very much for the question, and I couldn't agree more strongly
00:19:45with you about the importance of state veterans' homes. That's why we bias in VA funding streams
00:19:52for bigger investments in the state-run veterans' homes than we do in the commercially-run veterans'
00:19:58homes and long-term care facilities. Among the things that we are doing, obviously, is up to 65%
00:20:05of the cost of facility construction, remodeling grants, importantly, nurse recruitment grants,
00:20:12and I'll come back to that in a second, medical sharing arrangements with considerable cost
00:20:16sharings when we can get our personnel into those facilities to care for vets, and then
00:20:21continued clinical care education. Notwithstanding that, and as you pointed out, the per diem has
00:20:28increased 7% in 23, and again another 7% in 24, higher than our increases for other similarly
00:20:37situated programs. Nevertheless, I agree with you that there are big challenges out there,
00:20:43especially in two areas. One, and one of the reasons we're hearing from other states, not in
00:20:48Maine, but from other states that they're closing, is they don't have the staff because the veterans
00:20:54that they're getting are requiring more complex care. So, greater funding for staff who can
00:21:02provide more complex care for those veterans is important, and this is something that we're
00:21:06working, we'll be more than happy to work with you in Maine on and work with the committee on.
00:21:11Secondly, the cost of pharmaceuticals for those veterans who end up in state-run veterans' homes.
00:21:18They, by tradition, the states take on the cost of those pharmaceutical
00:21:24treatment patterns. They also don't have access to our more price competitive formularies. So,
00:21:31we'd like to also work with you on that to figure out how is it that we address these significant
00:21:38costs associated with pharmaceutical treatments, because our veterans are living longer with more
00:21:44complex healthcare systems. So, those are two areas where we'd like to try to enhance our
00:21:49support to states like Maine. One, how do we make sure that we can afford the staff that we need for
00:21:57the complex care they get? Two, how can we ensure that we are not just passing on a very unmanageable
00:22:04pharmaceutical treatment regimen that the states can't afford, but the veterans need?
00:22:11Thank you. I only have 19 seconds left, but just to put on the record, there's also a problem with
00:22:19transporting veterans from rural areas to the one VA hospital that we have in the state of Maine,
00:22:29and I hope that that's something that we can also work together on.
00:22:34Count on that, and we have a legislative proposal on that. I've been studying up on this since you
00:22:39and I discussed, so we have some ideas on that. We'd like to work with you on those.
00:22:43Terrific. Thanks so much.
00:22:45Thank you, Vice Chair Collins. I recognize Senator Baldwin.
00:22:49Thank you, Madam Chair. Mr. Secretary, there has been a steady and significant decline in the
00:22:56number of veterans being prescribed opioids for pain management since 2014. The implementation
00:23:04of the Comprehensive Addiction and Recovery Act in July of 2016, which included the Jason
00:23:11Simkoski Memorial and Promise Act, has contributed to this trend.
00:23:16Very much.
00:23:17From a nationwide high of more than 878,000 veterans prescribed opioids in the last quarter
00:23:25of 2013, the number decreased to fewer than 300,000 at the beginning of this year.
00:23:32That 67 percent decline in prescription rates over the last decade is extraordinary and is
00:23:39really a testament to the progress we can achieve if we work diligently and resource the VA
00:23:45appropriately. This decrease in opioid prescription rates does not mean that the VA isn't treating
00:23:52pain. Rather, it means that the VA is treating pain responsibly. For example, the Tomah VA
00:23:59Medical Center spearheaded the Pain University Initiative to achieve improved pain management
00:24:06through comprehensive solutions without the use of opioids.
00:24:11Mr. Secretary, how else can Congress enable the VA to provide these integrative health
00:24:18options for our veterans? What does this committee need to do to support and continue
00:24:23the efforts to responsibly manage pain and that pain care for our veterans?
00:24:30Yeah, Senator, thanks very much. I think the tools that you pointed out are really important,
00:24:34and I thank you for making sure that we got them, and I thank
00:24:40Marv Simkoski and the Simkoski family for the dedication that they've
00:24:45manifested since Jason's death. We asked for $254 million for pain management and opioid safety
00:24:56on prescription drug monitoring in the budget. We think that's an appropriate and prudent
00:25:04investment. That's the first thing we would ask. Secondly, we need to continue to staff up. We're
00:25:10not yet at 100% of facilities with pain management teams that's required in your law. We're north of
00:25:2090%, but we're not yet at 100%. So continued investment to allow us to build out those pain
00:25:26management teams. Third, the whole health initiative allows us, Tomah is also a flagship
00:25:34effort here, that allows us to deploy new clinically proven pain management techniques
00:25:41that are non-pharmacy based. So those range from acupuncture, battlefield acupuncture,
00:25:48yoga, meditation. All of these things are really important to making sure that we can manage
00:25:56holistically that veteran's pain. We're very proud of the progress we've made on opioid prescription.
00:26:03That's directly a result of your law, of investments in alternatives, and of accountability
00:26:12for those alternatives. I think this budget gets us a long way to continuing that process.
00:26:21Mr. Secretary, I've heard you say, and I know you feel this deeply, even one veteran suicide
00:26:27is too many. And I know you are working to reduce this troubling epidemic. I share your concerns,
00:26:35and I was proud to lead the bipartisan legislation that transitioned the VA crisis line to the
00:26:41National Suicide Prevention Hotline 988 number. During the first year in operation, the veteran's
00:26:49crisis line fielded nearly 1 million contacts. The implementation of this line has not been
00:26:56without difficulty, and it will take a commitment to oversight to get this right for
00:27:04our veterans. So can you please provide both your assessment of the contribution the veteran's crisis
00:27:11line has made in addressing suicide among veterans, and inform the committee of what
00:27:16additional resources would help rectify some of the problems and issues with the crisis line that
00:27:22have been identified? Yeah, thanks so much. So I'm very proud of our veteran crisis line team.
00:27:30I've met with our operators there many times. Their work is proven time and again to be timely
00:27:36and effective. It's not to say that's without faults. We've had really tough, hard-hitting IG
00:27:43investigations on that that relate to training. That's on us. We have the funding for training,
00:27:47we have the funding for staffing. There is an issue on the continued funding of the crisis
00:27:54line itself, the 988. This is not an issue for us, but this is for VA, but this is an issue at the
00:28:00states. The stand-up of the line envisioned a federal role at the start, handing off to the
00:28:09states making the investments thereafter. Remember, the way it works for us is as a veteran, you call
00:28:14988, then you press 1. At that point, you exit the general crisis line, and then you're into the VA
00:28:21managed veteran crisis line. Notwithstanding the substantial increase in a number of calls
00:28:29in the first year, time to answer shrunk, abandonment rate shrunk, and follow-up assessments
00:28:39with the veterans in terms of survey results demonstrate increased satisfaction. We think
00:28:45that the execution is going well. That's not to say, again, it's without faults. You'll recall that
00:28:51many of you held us publicly accountable for an IG report out of one of our veteran crisis line
00:29:00teams, and we're taking that very, very seriously. We have the funding we need. We have the training
00:29:05capacity that we need. I really hope that we can ensure continuity of the overall effort
00:29:12through funding from the states, but VA, thanks to your all's generosity, is in a very good spot
00:29:19to continue our part of that veteran crisis line. I'll say one last thing. We also began executing
00:29:25a year ago the Compact Act, so if a veteran doesn't want to just call 988 and press 1,
00:29:32that veteran can go into a hospital, any hospital, irrespective of enrollment status with VA,
00:29:40and get care today, and we will pay for that. Again, there's growing pains in that program.
00:29:45It's not perfect, but 47,000, almost 48,000 vets took advantage of it in the first year.
00:29:51We think it's a really important program. That's reflected in these community care numbers,
00:29:55too, by the way. Thank you, Mr. Secretary.
00:29:58Ranking Member Bozeman.
00:30:01Thank you, Madam Chair, and again, thank you, Mr. Secretary, for being here.
00:30:07As I said earlier, I've really had the opportunity in the House and now in the Senate to be on the
00:30:12VA committee for quite a while. We do have a situation where we have a decrease in veterans'
00:30:20health care, so I guess the question is, and I've got all the figures and we don't need to
00:30:26go through that, you know those, your staff know those better than anybody, but the question is,
00:30:30how much risk are we taking, assuming with this budget and what opinions,
00:30:38what, I'm sorry, how much risk we're taking and then what options we have
00:30:43if those assumptions aren't correct? What do we do?
00:30:47Well, I think the highest variability item in this multivariate equation here is community care,
00:30:58and I think it's generous to call it variable because it's variable in one direction,
00:31:03and that's up, and there's a lot of reasons for that, and frankly, we don't know them all yet,
00:31:11and we're looking at that. So, if there is elevated risk, it would be in there,
00:31:20but our options to manage that are our ability to come back to you to ask for some
00:31:30authority to transfer among different accounts in the medical care account,
00:31:35so that we're not taking substantial risk on the provision of care there.
00:31:39At some point, we will take risk on maintenance of the personnel that we need at VA to carry out
00:31:48the full suite of care that veterans expect because you can't have a high variability
00:31:54purchase care program that's increasing every year and maintain a high-cost direct care system
00:32:00with big fixed costs for personnel. That's the tradeoff that we're going to confront at some
00:32:06point. I think we begin to confront it in this budget, which is why we, I think prudently,
00:32:12especially informed by last year's very productive hiring year, make some decisions to
00:32:19downsize VHA and VBA, by the way, as I've promised you we would do, by the end of 25,
00:32:26but frankly, when you consider those numbers, 10,000 over a denominator of about 400,000 employees,
00:32:34that's not much greater than traditional attrition at VHA. Now, we're a little under
00:32:41traditional attrition right now. Why? Well, because you were so generous to us with funding for
00:32:48our staffing increases, pay increases, and things like the critical skills incentive.
00:32:56So, this might be a little bit harder, might be slightly more risk because retention is up,
00:33:02quit rates are down, but I consider that a high-class problem, not a risky problem.
00:33:07Right. One thing I'd like to get on the table, you know, just being out about, you know,
00:33:14visiting in various facilities, again, just talking to providers. As more PACT Act claims
00:33:21are processed, many veterans will see an increase in their disability rating. So,
00:33:25you're going to have people at 70 percent because of the PACT go to 100 percent, and then the
00:33:31problem then is, as a result, a number of them will become newly eligible for things like dental
00:33:37benefits, dental in particular, which I hadn't heard a lot about. I guess the question is, you
00:33:45know, this is rising, the number of veterans eligible prior to the PACT Act grew by more than
00:33:518 percent a year. Last year, it grew by nearly 12 percent. Given that VA dental clinics operate
00:33:58at near capacity, this growth will likely be addressed by community care. So, I want to put
00:34:05that on the table and, you know, see if you have a response, but there's just, I think, a number of
00:34:10things, and this is probably the biggest one of not unintended consequences, but consequences that
00:34:18are out there that we need to take care of. It's a good thing for veterans, but that's going to
00:34:22cost some money. Yeah, I think you're right that this is a consequence of PACT. I think, frankly,
00:34:32it's among the things that veterans are most excited about because of PACT, because there's
00:34:37so much, you know this better than I do, so much demand for dental, and so many people who wish
00:34:41they qualified. So, just to give you some numbers, 17 percent more 100 percent service-connected
00:34:48veterans today than before the PACT Act was signed. It's a substantial number. If you consider
00:34:56FY23, we had 690,000 eligible veterans for dental. 567,000 got that care 100 percent on-site.
00:35:09123,000 got that in the community, right? Our dental staff increase in 23 was about 4.8 percent,
00:35:21so they saw a similar bump. So, we should be able to continue to grow
00:35:28with dental this year, but the big number out there, the big number, the big bogey here is
00:35:362.78 million eligible veterans for dental by 2028, up from 690,000 in 23. So, our budget
00:35:47gets us going on that process, but you're right that there's this transition period.
00:35:55Until we have dentists, hygienists, and chairs in our facilities, there is this transition period
00:36:00where we're going to be relying on the community. Great opportunity for veterans. The only thing
00:36:07that would be bad is if we couldn't, you know, once we've said benefit is there.
00:36:12Can't let them know. Exactly. Thank you, Madam Chair.
00:36:17Thank you. Senator Tester. Yeah, thank you, Madam Chair and Ranking Member. Appreciate you having
00:36:22this hearing, and it's always good to see you, Secretary McDonough. Sir. Did you sleep here last
00:36:27night, or no? I didn't sleep much last night. That's good. The only thing I would add to the
00:36:34dental care thing is I think for the veterans long-term, this could actually help reduce
00:36:39health care costs moving forward, because you got dental problems, you got health problems.
00:36:42Heart problems, mental health problems. There's just no question about it.
00:36:47You know, every day I get visited by folks, and they bring up issues that potentially impact
00:36:53veterans. You know how many Native Americans serve higher than any other minority,
00:36:59and I met with some urban Native Americans today. They told me two things that I want to ask you
00:37:06about. The first thing they said was, is that the VA uses us, the urban Indian health care,
00:37:15they use us, but the reimbursement is less than adequate. That's number one. I just want you to
00:37:21respond to that, and the second thing they said is, is that they use us, because, and I'll give
00:37:28you the community if you want, because the community where the VA CBOC is, is not fully
00:37:33staffed with doctors, so they have to have us. You guys put a freeze on. I get it. You hired
00:37:3814,000 new nurses. It's time to take a breath, take a look, see what you got, and then move
00:37:42forward. I don't disagree with that, but the question becomes, we're talking about community
00:37:47care. We're talking about VA care. If we don't have proper staffing, as Shane Lehrman pointed
00:37:53out yesterday from the DAV, it forces more folks into the community. Those inflated prices go up.
00:37:59That's one question. The other question is, is IHS treated differently when it comes to the
00:38:05Tri-West, in my case, in Montana? Yeah, thanks so much. So, the UIOs, I spent time with them
00:38:12the day before yesterday. They're really great partners. No secretary had ever been to a UIO,
00:38:17but I went with Senator Moran in Wichita on my first trip right after I left Montana.
00:38:23We want our Native veterans to get the care that's culturally competent for them where they
00:38:31need it, when they need it. That means at a VA facility, at a UIO, or at an IHS facility, or by
00:38:39the way, in the community through the community care program. You know this better than I do,
00:38:44the number of Native veterans who are living in urban settings away from their families and their
00:38:50tribes is extraordinary. So, we negotiated a new reimbursement agreement with the UIOs,
00:38:56but I challenged them when I was with them on Tuesday. We've had zero
00:39:03requests against the new arrangement since I went to the facilities in 2021.
00:39:09We got to do a better job, right? Now, we also have a new reimbursement arrangement with IHS,
00:39:17and Rosalynn Soh and I are, I think, working really aggressively on that.
00:39:23The chairwoman mentioned this in her opening remarks. We have a new reimbursement arrangement
00:39:27with them. We're finalizing that plan. It's with IHS now. I'm really excited about the opportunity,
00:39:34not only for veterans to get care there, but we've also committed to our Tribal Advisory
00:39:39Committee, which you put into law, that we'll begin having CMP exams at IHS facilities,
00:39:46closer to veterans. But again, we have the tools there. We just have to figure out why are people
00:39:51not taking advantage of them. Okay. And then talk to me a little bit about staffing and the impacts
00:39:57that that has on community care, which you say is doing nothing but going up. Yep. It's whatever,
00:40:04a Gordian knot. It's a really tough question because you got the chicken and the egg.
00:40:09At what point are we not providing care in-house because we don't have people? This is what you've
00:40:14challenged me to do since I got here. And at what point are we providing care in the community
00:40:19because it's easier to do? That's why we've made the very aggressive effort over the last three
00:40:25years to staff up as aggressively as we did, one. Two, that's why we ran an access sprint
00:40:31to test the proposition. Are these new clinicians seeing veterans? Yep. And we proved that in 25,000
00:40:39cases, they are, but we have to get better on productivity. And then we have to show every time
00:40:48a veteran has a choice, we make a referral for that veteran to go to the community. We say, hey,
00:40:53this is where you qualify in the community. You should do that if you want, but we'd like you to
00:40:56stay with us and here are your options there. But they can't stay with you unless they got the staff.
00:41:00Correct. Which is why we have this period under the access standard. Yep. That access sprint that
00:41:06we just showed. Yeah. That we're seeing 11% more clinical visits. Yeah. In that period. Yep. We have
00:41:14to extend that. Yep. And keep those vets in the system. And by the way, we're going to keep adding
00:41:19vets. So as we do that, if we need more money, we'll come back and ask for that in a second bite.
00:41:26But I want to do that because there's more vets demanding more access, not because we can't manage
00:41:31our workforce. Here's the point I want to make, and I'm going to give it up here in a second.
00:41:35The point is, as you go into this hiring freeze, don't forget to look at the hospitals that are
00:41:41short on PAs, on docs, on RNs, on all the above. Because if we don't do that, you can't expect
00:41:50community care to even begin to level off. It's going to continue to go through. So hopefully
00:41:55your viz and directors and the director in VA Montana, which by the way is doing pretty damn
00:41:59good, will take a look and say, hey, we'll put pressure on you guys to get more docs in here
00:42:04because we need them. Otherwise, the community care issue is going to continue to grow and grow
00:42:08and grow with emergency care and everything else. Thank you, Madam Chair.
00:42:13Thank you, Senator Tester. Senator Murkowski.
00:42:15Thank you, Madam Chair. Mr. Secretary, good to see you. Thank you for your visit to Alaska. You know
00:42:20you're welcome any time. The snow is melting and the weather's getting pretty good.
00:42:27One of the things that I wanted to raise again with you is the Palmer Pioneer Veterans Home.
00:42:33We made it through the winter without losing that roof. But as you know,
00:42:41this is something that we've been watching for a long time. This is something where
00:42:50just last March, we got the VA engineering office to issue this memo stating that the threat of a
00:42:57roof collapse does constitute a life safety issue. It's been reclassified. That's great.
00:43:04It now goes to what I understand is top of the sub-priority group. So we made it through the
00:43:12winter and we had a lot of snow. But I am not certain that this roof is safe moving forward.
00:43:21So the sooner, the faster we can attend to this. I would just put that before you in terms of
00:43:28prioritization. The good news is our engineers have come to the same conclusion you have.
00:43:34So it does get to the top of the list for us. But I'll stay on top of this and make sure that we
00:43:38stay in close touch with you. Thank you. I appreciate that and I know all of our veterans
00:43:42there at the Palmer Home appreciate it. I had a meeting about a month ago with a group in Fairbanks
00:43:49who have been working this Fairbanks Veterans Cemetery for a long time, probably about 20 years
00:43:56now. And I appreciate that the VA has placed that cemetery there as a high priority among the
00:44:04projects to establish new cemeteries. But the way the list is stacked, as you well know, it
00:44:15puts the expansion of existing facilities, there are multiples ahead of any of the efforts to bring
00:44:26on a new facility. I think you've heard the benefits that a veteran's cemetery in this
00:44:35region would be. It would serve about 65 percent of the state's veteran population. We have one
00:44:41small tribal cemetery down in Metla-Ketla. We have a second national cemetery that serves
00:44:51southeast in Sitka. We've got the one at J-Bear, but that's difficult to access. So this is a very
00:45:00significant region of the state with a very significant population of our veterans. And again,
00:45:05they have been working aggressively on this. I'm hoping that the committee is going to be
00:45:10able to fully fund this account for FY25 and in future years. But what we're trying to do is to
00:45:18figure out if there's a way that there can't be, you know, maybe it's splitting the grant funding
00:45:25so that you have a certain percent for expansion projects and reserve a certain percent for new
00:45:30construction. Because as we're looking at this list, it's going to be years and years before
00:45:37a new construction of a cemetery is going to be allowed to proceed. So maybe you have a better
00:45:42idea of a timeline that we might be able to report back to folks. But I'd like you to take a look at
00:45:49that list. We're going to try to do our best. I'm certainly going to put my shoulder into it on the
00:45:53committee here to see if we can't get that number up. But even if we get it up, it's going to be a
00:45:58long time before you get to any new construction. Yeah, so I've asked our team to look at this
00:46:05this particular Fairbanks option in the context of our overall strategic goal to have,
00:46:12you know, 95 percent of veterans within 75 miles of a hospital. And you definitely need this one.
00:46:22That's what I mean. So I think this feels like it probably analytically can, that may be important.
00:46:29So I've asked for that review. Yeah, we're 350 miles away from the closest one. Exactly. So
00:46:36I've asked for that review. We'll stay in close touch with you and with the whole delegation on
00:46:40this. Good, I appreciate that. The importance of this is coming through very strongly. Got it.
00:46:47Thank you. And I'm running close on time, but I'm curious about where we are with the claims
00:46:52backlog and the claims inventory and the backlog. Because I'm told that following the PACT Act,
00:46:57we've seen that increase dramatically. We've also seen the claims accuracy backlog. I'm told that
00:47:09the accuracy rate has dropped to just over 83 percent, the lowest it's been in the last 10
00:47:15years. I don't know if this is directly related to the claims backlog, what we're seeing with
00:47:20the increase, but know that this is an issue that our veterans are raising in Alaska. I'm sure that
00:47:25they are in other states as well. So I don't know if you can give us an update on that. Definitely.
00:47:30Thanks for the question. Backlog as of this morning was just over 300,000 claims. How does
00:47:39that stack? Inventory is about 930,000 claims. So we're at, I think if I remember that right,
00:47:49but I'll get you the specific number by close of business today, but we're at about a 31 percent
00:47:57backlog rating. Sorry, of the overall inventory, about 31 percent of the claims are backlogged.
00:48:04That's generally in the zone of what we have considered healthy for backlog, because we're
00:48:10not going to rush to get a no to a veteran if more development will get us to yes. That's the
00:48:18first thing. Second, we did anticipate, oh by the way, we've been able to manage this. This is kind of
00:48:26much on the low end of what we anticipated and frankly what our model told us the backlog would
00:48:32be by now. And it could be, by the way, that we're on the downside of the backlog, but it's too soon
00:48:40to definitively state that. The main input there is people, and we have hired, we've basically
00:48:48increased the VBA workforce by about 25 percent in the last three years, anticipating this influx
00:48:56of claims. Has that impacted the accuracy because you're bringing new people on? Correct. So that's
00:49:02the last point, and this is where you're, I'm not sure where 83 percent comes. I just got an update
00:49:07yesterday. We're at 93 percent, but there frankly we have a dispute with our IG too about he
00:49:14scores our accuracy differently. So I don't want to over index the number, but there is quality
00:49:21concerns, which we anticipated because of so many new people and because of the training requirements.
00:49:28So we have throughout the course of the summer a quality stand down, which will increase enhanced
00:49:35training and an update of the training program to review these quality questions. Because again,
00:49:43this is traditional seesaw in VA. We worry about the backlog when it grows, so we over index on
00:49:50the backlog number. So then all of a sudden quality comes down. So we have to kind of toggle back and
00:49:57forth between these two things. We've anticipated this. I hope the stand down as that we're going
00:50:02to undertake over the course of this summer addresses that. And again, that's a training
00:50:09issue, and then that's an oversight and management issue. And again, because we're seeing the same
00:50:16thing in VBA, enhanced retention of our personnel. I feel pretty good about our ability to address
00:50:23that. Thank you for your attention to this. Thank you, Mr. Secretary. Thank you, Madam Chair.
00:50:26Thank you. Senator Peters. Thank you, Madam Chair. Secretary McDonough, it's good to see you again.
00:50:31Thank you for being here. As service members transition into civilian life, it's absolutely
00:50:39critical that they have the tools and the job training that they need to be successful in that
00:50:44transition. In 2020, my bipartisan bill, the Support for Veterans in Effective Apprenticeships Act,
00:50:51was signed into law. What the law did is it increases veterans access to financial assistance
00:50:56they can use in connection with an apprenticeship program and requires apprenticeships to factor in
00:51:02the skills, the training, and the experiences they gain through military service, which is often
00:51:07extensive and helps the veteran get placed in those apprenticeships. But the fact remains that
00:51:13for veterans to use their GI bill benefits on these programs, they have to actually be aware
00:51:18of apprenticeships in the first place and how those GI funds can be used to help them get that
00:51:24training to transition. This committee, as part of the FY23 VA funding legislation, directed the VA
00:51:31to take additional actions to promote awareness and increased utilization of apprenticeships
00:51:37among veterans. So my question for you, sir, is what is the VA doing to ensure veterans are aware
00:51:42of the opportunity to use GI bill benefits on apprenticeship programs and how does your FY25
00:51:49budget request support further outreach to these individuals? Both education, the general education
00:51:57program at VBA and the VR&E, the Veteran Readiness and Employment Programming at VBA, because of
00:52:07the committee's requirements, have enhanced and have specific targets to increase enhancement
00:52:14of communication around apprenticeship options. So the budget fully funds those because it fully
00:52:21funds our programming for both. And we will begin to see data on the uptake of that.
00:52:29We'll accumulate that data and share that with you over the course of the coming year.
00:52:32Great. I appreciate that. I also want to ask you a couple of questions related to
00:52:38VA Inspector General investigations. First, you and I have spoken repeatedly about my concerns
00:52:44regarding a case of Ian Fishbeck. Yes. Ian is a native Michigander who tragically passed away
00:52:51in 2021 following a decline in his mental health as he and his family and friends worked and worked
00:52:58very hard to try to gain admittance to a VA medical facility. I was pleased when the VA opened
00:53:04an Inspector General investigation into his case last summer following our conversations. But my
00:53:11question for you, sir, is I know the investigation is ongoing. Yes. But I can I want to get your
00:53:16commitment today that once that investigation concludes you will implement the IG recommendations
00:53:22across the VA as you become aware of them. Yeah. Ian Fishbeck was also a national hero.
00:53:31One. Two, you have my commitment to implement those recommendations. Three,
00:53:35I've been in close touch with the IG on this. I have every expectation that he's wrapping up
00:53:41his work and that will be public soon. And I think the IG does really important work,
00:53:51really good work. My guess is it's going to be really tough for us, but that's the most important
00:53:57stuff that we got to get right and we will. I appreciate your commitment and your really
00:54:02your attention to this right from the get go. I also want to touch on the Detroit VA issue.
00:54:10Back in 2022, Senator Stabenow and I were alarmed to learn about a crisis of care and quite frankly,
00:54:17a crisis of leadership at the John Dingell VA Medical Center in downtown Detroit. In response,
00:54:24Senator Stabenow and I called on the VA's inspector general to conduct an independent
00:54:28investigation into that facility, which was launched shortly thereafter. Last summer,
00:54:33the inspector general released its report, which included recommendations to remedy issues found
00:54:38at that facility. One of the recommendations related to removing conflicts of interest
00:54:44within the peer review process, and I've introduced legislation with ranking member Bozeman
00:54:51to the VA Peer Review Neutrality Act to act on the recommendations from that VA system.
00:54:57So my question for you, sir, is can you provide an update today on the Detroit VA's implementation
00:55:03of the recommendations contained within the inspector general? Yeah, thanks so much. I just
00:55:07talked to our visiting director this morning. She just happened to have her monthly update
00:55:13with Chris Colley, the VAMC director in Detroit yesterday. Importantly, on your question,
00:55:21recommendations one, two, and eight are still open. One and two really relate to oversight
00:55:28of the surgery department and data collection in that department. The next meeting with the IG
00:55:35is on the 10th of June. I hope that we can close those out or get closer to closing those out by
00:55:44then. Recommendation eight relates to the demand from the IG that we get a permanent executive
00:55:51leadership team in place, and he has, I think, a numeric goal or a time elapsed goal on that,
00:55:59so we just need time on that. So that's not yet closed, but I hope it will be because our
00:56:06permanent executive med center director, Chris Colley, is doing a really fine job.
00:56:13Importantly, they have reopened 30 inpatient beds in the hospital. Imagine,
00:56:18in the middle of Detroit, we had 30 inpatient beds closed. Those are opened.
00:56:24Care as measured by relative value units, RVUs, unique visits, and clinical encounters
00:56:33are all up right now, this year over last. Again, an indication of the seriousness of
00:56:40that leadership team and the staff's interest in getting that group functioning, that team
00:56:46functioning again, and for the first time in anybody's history, they're also helping with
00:56:52caseload management with Saginaw, with Battle Creek, in a way that we have long expected them
00:56:59to, but they have not done, similar to the way Ann Arbor helps manage caseload for veterans
00:57:07functioning as the high-level facility that they should be. So nothing's permanent. Obviously,
00:57:14we have to stay on top of this, but those are indications, I think, that we're making progress.
00:57:18Right. Well, thank you. Thank you for continuing to work on that. Thank you, Mr. Chair.
00:57:21Thank you, Senator. Thank you, Ranking Member. Secretary, thanks for being here. Thanks for
00:57:26your work on behalf of veterans. Very much appreciate it. I want to pick up on something
00:57:32that Senator Murkowski was talking about, but a little bit different twist on it, but again,
00:57:37about making sure that our great veterans have access to cemeteries and their families have
00:57:43access to cemeteries. And as you're aware, because we've talked about it, in Fargo now, we've
00:57:49established a cemetery and just expanded it from five to 35 acres. And it was initiated under the
00:57:57Rural Cemetery Initiative. I think it was the first one established, but that was five acres.
00:58:03But to show the need, we were going through that so fast that recently we worked with VA and
00:58:09expanded that to 35 acres. So now the key is to really enhance the facilities. As Senator Murkowski
00:58:17discussed, that's a challenge funding-wise. So we're willing to step forward and actually
00:58:24fund and build a visitor center on the cemetery, and we're working to do that. We've worked
00:58:31very closely with Assistant Secretary Matt Quinn, who has really been good to work with. I want to
00:58:36commend him, but I understand he'll be leaving on May 23rd. So first, I want to really thank him
00:58:42and commend him for the great work he's done, but I want to impress how important it is that we have
00:58:46somebody in that slot who will continue this work with us on a project that is really fantastic
00:58:53for veterans, keeping in mind, it was interesting to listen to Senator Murkowski, because the VA
00:58:58National Cemetery, that serves an area you're very familiar with, all of western Minnesota, your home
00:59:04country. Bigger fish are. Exactly. Great lakes. Great area, but a lot of folks that need access.
00:59:11It's a long way for them to Minneapolis. All of North Dakota, because this is the only
00:59:15veteran cemetery, federal cemetery we have, and a lot of South Dakota, because they have to go
00:59:21all the way to Spearfish, which is on the very western edge. So this is situated where it will
00:59:27serve a big population, and we're willing to step up and cover the whole cost, in essence, and then
00:59:33donate it. But we obviously have to work through the bureaucratic challenges that go with that,
00:59:38so I really need your commitment, particularly as we're losing Secretary...
00:59:45Quinn. Right, and he's done such a great job, the Assistant Secretary, I should say, not Quinn,
00:59:51but the new replacement. We're going to need somebody that will work with us,
00:59:54and I need your commitment on that. Yeah, well, first of all, let's not let this go to Quinn's
00:59:58head. I mean, he's fine, but you know... Well, he is from Montana, so I mean, we got to be a little...
01:00:04And I was going to commend our leaders on the full VA authorization committee,
01:00:11too, both Senators Test and Moran. They've been working with us very closely on that. Yeah,
01:00:15so you've got my commitment on this, and I've made that commitment in private, and I'm happy
01:00:18to make it again here in public that we're going to make this work, and I think we've demonstrated
01:00:23that through Matt's commitment on this. He's routinely out there meeting with your vets,
01:00:29meeting with local community leaders, and we'll stay on top of it. You got my commitment on that.
01:00:34And you're right about the lakes. They are really awesome. That's some great, beautiful area,
01:00:38but you know that when I lay that out for you, because you come from the area,
01:00:43that the need is there, and this is important, so thank you for that commitment.
01:00:47The second thing I wanted to talk to you about is veterans' access to healthcare in non-VA
01:00:54long-term care facilities. One of the challenges is that because of the, if I get it right here,
01:00:59the Office of Contract Compliance, Office of Federal Contract Compliance Programs,
01:01:06they don't have a permanent rule that allows these nursing homes to accept VA reimbursement
01:01:14without a separate exam, separate from CMS. Now, we, I think it was the PAC Act, we provided
01:01:22authorization for the VA to exempt these facilities from OFCCP separate compliance exams
01:01:32if they were meeting the CMS requirements for Medicare and Medicaid, because it just makes sense
01:01:38that they don't go through this duplicate study, which was keeping a huge number of them from
01:01:44accepting veterans on VA, you know, coverage. So, VA insurance payments, you know, to cover
01:01:55their stay. Now, you put in place a two-year rule. We really appreciate that. That takes us to 2025,
01:02:02but for TRICARE, you passed a rule that just exempts it, okay? And we need something like
01:02:09that in order to get these nursing homes to change their policy and accept veterans that are
01:02:15on VA reimbursement rather than Medicare and Medicaid. And so, it's a two-year, but I would
01:02:21really encourage you to look, because you have the authority now. We passed that in law, but you
01:02:25have, it would require a permanent rule on your part to do it. You did it with TRICARE, but you
01:02:31can see why, on a two-year basis, a lot of them are reluctant to change their policy because they
01:02:35could be right back to dual exams, and that might mean another elevator. That might mean all these
01:02:41different things, you know. Fair enough. And so, I'd ask you to take a look at that. I'm on it.
01:02:46Okay. I got it. And then, the last one is one you and I talked about, particularly in rural America,
01:02:55access to mental health care. Telemedicine's helped, but boy, any and all initiatives you
01:03:01have to help getting access to mental health care for our vets is really important. Yeah. Well,
01:03:07this is, you know, when we talk about strategic hiring and that continuing, notwithstanding our
01:03:12net zero growth on FTEs over, you know, this year, strategic hiring, you know, front of the line
01:03:20there is psychologists, mental health professionals, mental health social workers. So, we'll continue
01:03:26to do that. Secondly, you've given us authorities and investments to increase cooperation with
01:03:31tribes and with local communities to make sure that we're investing in them as well. Thirdly,
01:03:41we are also investing. We now have 1,900 peer specialists in VA. These are basically, the way
01:03:49I see it as a kind of an Irish American person, they're based on the AA model where we basically
01:03:56have recovering vets helping other vets, you know, earlier in their recovery. Vets helping vets and
01:04:04us making those investments in them is a proven help on substance use disorder, a proven help on
01:04:11mental health care. So, we're trying to go out every vector there. Big VA, partners on the ground,
01:04:19and then a traditional manifestations of mental health care providers. And those will remain our
01:04:27priority because our number one clinical priority is suicide prevention. Right. And we're going to
01:04:32stay on top of this until there's none. Right. Thank you, Secretary. Appreciate it.
01:04:37Thank you. Senator Heinrich. First, I just want to thank Senator Hoeven for his comments on
01:04:43mental health in particular. That's an incredible challenge and especially in big rural states like
01:04:48mine. Secretary, welcome back. It's always good to see you. I want to ask you about the partial
01:04:55claim payment program. And when that ended relatively abruptly, it was really destabilizing
01:05:03for a lot of veterans in New Mexico. Obviously, we're in a very different interest rate environment
01:05:09than we were at the beginning of the pandemic. What steps is the VA taking to ensure that folks
01:05:17impacted by that will be included in the service or purchasing program that's been stood up? Yeah.
01:05:22Well, so we're reaching out to veterans who we, who our data shows are struggling.
01:05:31We're communicating also as aggressively as we can to veterans to make sure that they're aware
01:05:36that we are standing up a new support program when the current moratorium expires at the end of
01:05:49this month, end of May. And, you know, we think that, and by the way, as a general matter,
01:05:57we're tracking veteran performance on their VA-backed mortgages because we have a whole
01:06:04series of programs not even associated with what we call the VASP, which is what will roll out when
01:06:11the moratorium ends, that we want to make sure that vets can avail themselves of through our
01:06:17debt management center. So we're trying to communicate to vets individually. We're trying
01:06:22to communicate more generally to vets. And the new VASP program, which we've kept the committee
01:06:29up to date on and will develop the implementation targets more aggressively over the course of the
01:06:35next four weeks, will allow us to make sure that veterans struggling do not lose their homes and
01:06:41come up with a more manageable debt picture over time. Great. I know Senator Collins raised the
01:06:51highly rural transportation grant. I was pleased to be able to work to include some additional
01:06:57funding for that in FY24. Just my understanding, because I wasn't here when she asked her question,
01:07:04is that you may have referenced a legislative proposal in that area. Do you want to expound on
01:07:10it? Well, we'd like to, you know, it serves, I mean, you and I, you're the first person to have
01:07:17raised this with me, and that's what I said to Senator Collins when we talked about it privately
01:07:21recently. New Mexico and Maine are uniquely poorly positioned based on the definition of
01:07:30highly rural as, you know, fewer than seven people per square mile. We would like to
01:07:38change that in statute. Great. Right. And we have some proposals on how we would do that.
01:07:43And then, you know, we would couple that with an increase, a commensurate increase in funding,
01:07:49because, you know, it's just right now we have too few counties who can participate.
01:07:55And I'm certainly not going to speak for Senator Collins, but I'm sure, I suspect we would both
01:08:01look forward to working with you on that front. You talked a little bit about substance use
01:08:06treatment or substance use disorders. One of the challenges we see in New Mexico is that
01:08:14folks who want to treat their substance use disorder are having real challenges getting
01:08:22access to the medications that they're prescribed by their doctors, particularly buprenorphine.
01:08:29And it's been a, you know, like literally people can't get their prescriptions filled. There's a
01:08:35number of reasons for this, because this is a highly tracked, these medications are highly
01:08:40tracked. But I'd love for you to look into that, because we want to make sure that our vets who
01:08:46want to get treatment can get the medications that they're being prescribed. It's a major
01:08:51priority for us to increase medically assisted treatment. And so if there's, let's definitely
01:09:01dig into it. There's no reason a veteran who's struggling and wants to get, take those steps,
01:09:08let's make sure that we're there for them when they do it. Yeah, we've had real challenges with
01:09:12some of the big chain pharmacies just stocking those medications. And we can expand on- That's
01:09:18interesting. And we'll get together and expand on why that is. But we're not going to make headway
01:09:23on this if we can't get folks to treatment. Yeah, well, we're really proud of our medically
01:09:27assisted treatment options. And so that should not be reliant on any of those big boxes. The
01:09:33question is maybe there's a mail order pharmacy issue for us, but let me dig into that. You've
01:09:40got my attention on this. If there's one vet who's struggling to get that, that's too many.
01:09:44Look forward to working with you. Thank you. Thanks, Senator. Senator Fischer.
01:09:49Thank you, Madam Chairman. Thank you, Mr. Secretary for being here today. And I just want to
01:09:54start off with thank you for all the great work we're seeing the VA do in Nebraska and especially
01:10:01over this last year. Thanks. Last year during this hearing, we talked about needing to invest
01:10:07in the cemetery grant program. We did. And the Grand Island Cemetery is now on its way.
01:10:14And in your most recent budget, I was pleased to see that a new medical center for Omaha
01:10:20is now number two on the skip list. So thank you for that. That medical center is nearly 75 years
01:10:29old. And obviously, renovations aren't going to cut it anymore. So we're very excited to see that
01:10:37move ahead. And I look forward to working with you on that. I appreciated your comments in our
01:10:44conversation about the community care program. And I do remain concerned about the future
01:10:50of that program. We have over 40 percent of Nebraska veterans, they live in rural areas,
01:10:57and many are located hours from the nearest VA facility. So that community care program is really
01:11:05vital for those people. In recent months, I've heard some of my colleagues call for tightening
01:11:12or even scaling back on that community care program. Of course, I want the VA to work on
01:11:21improving the employment wait times, but that doesn't change the reality that we face in
01:11:27rural areas and sparsely populated areas. So does the VA have any plans to modify
01:11:37the access standards for that care program? And can you commit to us today that rural veterans
01:11:43will maintain access to care through that community care program? Yeah, you know, the
01:11:51statute is very clear, the Mission Act, that drive time standards will continue to be
01:12:00impactful for rural veterans. We have big parts of Nebraska, big parts of, you know,
01:12:06the one I keep pointing out is VISN 7, which is part of South Carolina, Alabama, Georgia,
01:12:13Mississippi, you know, 70, fully 70 percent of veterans there are referral qualified by virtue
01:12:20of where they live alone. So because of drive time. So it is an important access opportunity
01:12:29for veterans in rural areas. It will continue to be. Some of the things we're thinking about
01:12:35is updating the access standards to reflect the fact that overwhelming amount of care in VA
01:12:44and in the private sector is offered through telehealth. So we think our access standards
01:12:48should reflect that. So ideally that we'd be able to get that done fairly quickly, but that
01:12:54would be through rulemaking and there'd be public comment. Then we have issues with connectivity
01:13:00though, broadband deployment, because a lot of these sparsely populated areas in my state,
01:13:07that's a big issue. Definitely, and we're not gonna give a vet a pig in a poke and say,
01:13:13you should get, you know, knowing that they don't have internet access, tell them to go
01:13:19get internet access. So we have no interest in that. So that's the probably the biggest change
01:13:28we're anticipating currently. But, you know, it's been six years now since the law was enacted.
01:13:34Since then we not only had the Mission Act, but then we had the pandemic and now we have the
01:13:37PACT Act. Any one of those things would be a seismic impact on VA. Three of them in a row. I
01:13:44think I'm really proud of the way our team has managed them. But I think it's reasonable for us
01:13:49to take a step back over the course of this year and ask what are the impacts of all those things.
01:13:53If we anticipate changes out of those, we'll come talk to you about it.
01:13:56You know, as we talked about on our call, you have a tight budget. Very tight budget. And
01:14:03given the ongoing implementation of the PACT Act, which I was very proud to support,
01:14:10I believe it's important for the VA to ensure that it has staff in place to meet the needs
01:14:18of access to assist veterans. And I know in Nebraska we added over 200 employees,
01:14:25new employees, this past year to VA facilities. But with the department's budget request,
01:14:31I think you're envisioning an overall reduction of approximately 10,000 healthcare workers.
01:14:39Can you talk about the department's plans on how it plans to reduce the workforce and will the
01:14:47reductions be equally spread across the business and the VA facilities?
01:14:54So thanks so much. You know, we envisioned at the end of 2025,
01:15:00so that's September 2025, to be at about 10,000 fewer FTE.
01:15:09When all is said and done, frankly, if you measure traditional attrition at VA,
01:15:15that's not much different than traditional attrition. However, because retention is so
01:15:21high, because you've been so generous to us for various pay enhancements, we have historically
01:15:29high retention, historically low quit rates. As a result, it might be a little tougher.
01:15:37We are not going to make those decisions from headquarters. These are going to be decisions
01:15:42made by our VISN leaders. This year is going to be a year of, as we're calling it, strategic hiring,
01:15:48where we need people. A good example is recently in Texas, San Antonio has been looking for GI
01:15:54experts, one of the most limited capabilities in healthcare in the United States right now.
01:16:00They finally found two. They hired them both, right? So we'll continue our strategic hiring,
01:16:06but those are going to be VISN-based and facility-based decisions, not me making those
01:16:11decisions from here as a political or as a bureaucrat. That's not good for veterans.
01:16:18We'll track this month by month. We're doing this on FTE. We're doing it on dollars spent.
01:16:24We'll talk this through with your teams so that they can follow along with us and watch that.
01:16:29My guess is, I think one of our great strengths is our facility leadership having the kind of
01:16:35relationship that Omaha does with you, with their delegations. My guess is this is going to be a
01:16:41very public, very well-debated effort, and that's the way it should be.
01:16:47Good. Good to hear. Thank you, sir.
01:16:49Thank you.
01:16:50Thank you, Senator Fischer.
01:16:54No, I don't have any more questions, but I do want to welcome you to this subcommittee. I had
01:17:00the opportunity of doing that yesterday in MilCon, part of the subcommittee, but I know
01:17:08you're going to make a tremendous difference. Senator Murray did a great job, but I've enjoyed
01:17:13working with you on veterans issues in the past, and we appreciate you. We're both blessed with
01:17:20excellent staffs, not good staffs, but excellent staffs that make us look better than we are.
01:17:27It's the secret to success, Senator.
01:17:28Then again, thank you, Mr. Secretary, so much. We appreciate you and your staff that
01:17:33really are working hard for veterans.
01:17:34Thank you. I agree with what you said about your staff, Senator.
01:17:38That was wise of you.
01:17:39Thank you so much, Senator. Secretary, thank you so much for being here today and for the work
01:17:44that you're doing on behalf of veterans all across our country.
01:17:46Thank you very much, Madam Chair.
01:17:48We're very lucky to have a subcommittee full of senators who care very deeply about veterans
01:17:53and the veterans who have served our country so well. I'm excited to continue
01:17:57the bipartisan tradition of this subcommittee.
01:18:00That will conclude our hearing today. I'd like to say again, thank you to the Secretary and
01:18:03our colleagues for participating in today's hearing. I look forward to working together
01:18:07on this year's appropriations bill to ensure that we're providing veterans
01:18:10and their families with the benefits and care and support that they need.
01:18:13Finally, I will keep the hearing record open for one week.
01:18:16Committee members who'd like to submit written questions for the record should do so by 5 p.m.
01:18:21on Thursday, May 9th. We appreciate the department responding to those questions
01:18:25in a reasonable period of time. With that, we stand adjourned.
01:18:28Thank you.
01:18:29Very good.
01:18:30Thank you.