Transcripts For CSPAN Veterans 20240703

Veterans Affairs Secretary Denis Mcdonough testified on this departments annual budget request focusing on Veterans Health care and the pact act. A 2022 law that expands benefits for veterans exposed to burn pits and other toxic substances. The subcommittee hearing is one hour and 25 minutes. Good morning. This hearing of the military Construction Veterans Affairs and related agencies subcommittee will please come to order. I would like to begin by welcoming Ranking Member bozeman and Denis Mcdonough. We appreciate the effort of the v. A. s dedicated staff to provide benefits and support to veterans and families and their communities every day. We are here to discuss the department of Veterans Affairs fiscal year 2025 budget and 2026 advanced appropriations request. This committee take seriously the obligation to make sure and provide for the men and women who have fought and sacrificed to keep our country safe and ensure they have the medical care and benefits have earned. Over 210 billion and the discretionary probation of 120 9 billion in fy 25. The v. A. Has access to 24 billion from the Toxic Exposure Fund. These resources are extremely important in providing funding to carry out the expansion of medical care and benefits of the pact act. Without these resources the v. A. Would not be able to keep up with the processing of new claims or expediting Health Care Benefits to veterans exposed to environmental hazards. The budget also requested appropriations for fy 26. Discretionary accounts 23 billion for medical care and 222 billion in mandatory resources for Veterans Benefits programs. Despite this robust request i am concerned about medical care levels in this budget. The request for medical care is lower than the fy 23. When including mandatory medical care spending it represents a cut from fy 24. This committee has an obligation to provide for the men and women who protect this country and i will need your commitment that. This budget does just that. A higher reliance for medical care and greater resolution that in prior years. In part pact act due to the success of the pact act. Veterans are relying on the v. A. More now than ever before. The v. A. Must do more with less. This is impacting Staffing Levels at medical facilities and there are programs that will not be expanded as a result of these levels. There are a few initiatives i would like to highlight. The budget continues to request robust funding for its telehealth program. An estimated 6. 4 billion for fy 25. Even with expanded hiring veterans in rural areas struggle to Access Health care including due to challenges of transportation and internet access. I encouraged to look for costeffective ways to close these gaps. At the end of last year v. A. Signed an agreement that allows v. A. To reimburse for Additional Health Care Services including longterm care, Home Health Services and medical equipment. I encourage v. A. To establish agreements with Tribal Health programs to further eliminate barriers to care for native americans who have served their country. Women are the Fastest Growing demographic entering the military and represent 20 of Service Members. The Women Veteran population is the Fastest Growing demographic in the v. A. Caring for these veterans should be an area of bipartisan support. This budget request a historic 13. 7 billion for women Veterans Health care including 1. 1 billion in gender specific care. I hope we can include that funding in this appropriations bill. The Electronic Monitoring Program continues to be in a strategic pause for issues. The v. A. Recently deployed the new system to a federal Health Care Center in chicago. It is too early to determine if the climate was a success. The budget request shows a substantial cut to the hr program. No new deployments will happen this year. Patient safety is the number one priority but we need to commit to getting this program back on track. Last year v. A. Surpassed its goal of helping 38,000 homeless veterans. This is significant but there is still more to be done. The most recent point in time count numbers show a seven point 4 increase over 2022 in veterans experiencing homelessness. 3. 2 billion dollars is requested to make sure v. A. Has the resources. Secretary, it is clear much is expected from the department. Providing health care requires facilities and quickly providing benefits requires staff and technology support. For the department to succeed you must be resourced appropriately. I look forward to working together to provide veterans with the services and benefits they have earned and deserved. Now i will turn it over to Ranking Member boozman. Sen. Boozman thank you, madam chair mr. Secretary, it is good to have you here. Thank you for coming to discuss v. A. s fiscal year 25 and 26 budget request. For the department of Veterans Affairs including medical care collections, Transformation Fund , toxic exposures funds, representing a 9. 8 percent increase over the fiscal year 24 enacted levels. This includes 129. 1 billion in discretionary funds, and 4. 2 increase from fiscal year 2024. It includes more than 200 billion in minotaur refunds within this amount of 24. 5 billion, 4. 2 billion increase over fiscal year 24. The budget also requested a total of 131. 5 billion in medical care advanced appropriations for fiscal year 26. 118 billion more than fiscal year 2025 advanced appropriation and 22. 8 billion in advance. 222 billion in advance funding for Veterans Benefits. Mr. Secretary, i think we could agree the budget request can reasonably characterize as tight and that is not your fault. It is just the circumstances we are in. In more than 20 years working on Veterans Issues i cannot recall a single year when the budget request for Veterans Health care went down. I recognize the v. A. Has more funding streams than ever before but nevertheless this request stands as an outlier. In recent years i have asked about the amount of risk v. A. Takes in crafting its Community Care request but they sure about to know more about the level of risk v. A. Is taking across this whole enterprise. In your testimony you refer to the fiscal year 2025 planned obligations which will grow by more than 5 even though the base request is lower than last year. I will want to hear from you about what risk this may open the v. A. Up to. I understand this is not about you. We are in a situation where money is tight. The pact act has been a dramatic change for veterans. I also think the v. A. Has a very good story to tell. New veterans enrolling in the number of pact actrelated claims received and processed. I know that you and your staff throughout the v. A. Have worked so hard to make that a success. It also gave the v. A. New tools to recruit and retain its workforce. I look forward to hearing about your plans to ensure you have the right people in the right places to take care of our veterans. I want to know it has been more than a year since you announced the reset of the Electronic Medical records program. As this reset continues i would like to hear more about the timeline to bring the deployed sites up to standard, when we can expect deployments to resume. Dod stumbled out of the gate in its efforts but after pauses i hope the v. A. Has learned from that and will be able to get this Program Moving Forward again soon. More than 11 billion of taxpayer money invested, it is time to start seeing a return. In addition to those updates we look forward to hearing details about the departments request for Mental Health services, including efforts to prevent veteran suicide, initiatives to prevent veterans homelessness, resources dedicated to care for womens veterans and efforts to improve care for our rural veterans. We look forward to discussing these other issues and very much appreciate you being here. Thank you, madam chair. Sen. Baldwin mr. Secretary, we will proceed with your opening statement. Sec. Mcdonough thank you very much. Congratulations on the new assignment, senator boozman, thank you. I am willing to put my prepared remarks into the record and get straight to your questions if you are all amenable to that. We can go straight to questions. Sen. Baldwin thank you. I really appreciate that. We will start with a round of fiveminute questions from the panel. Stay within the five minutes. I will start with the first round of questions. Your models project that utilization of v. A. Health care relies but the discretionary funding for v. A. Health care is below the levels from fy 23 even including mandatory health core funding is 4 billion below fy 24. One are the current spend rates in fy 24 . Do you expect to be on target for fy 25 . Sec. Mcdonough we anticipate spending about 140 billion on health care out of that account in fy 24. All in fy 25 the budget is 150 billion when you count are various funding streams, collection, carryover currently about 12. 7 billion. The Toxic Exposure Fund which has an increase of 7 . There is no doubt as we have talked about a number of times in the last week that money is tight. That is a function of the budget agreement. We think we have the money that we need and most importantly we have the people that we need to implement this increased access to care. Sen. Baldwin secretary, how could you make sure you are able to pay for the care that veterans receive in the community while also ensuring the v. A. Is an option for veterans . Sec. Mcdonough really good question. The budget takes a lot of unique steps this year as it relates to Community Care. We have already notified you all that we are taking the 1. 9 billion in rescission from other than Community Care accounts in the v. A. We also ask that we reprogram in the advance 7 billion into Community Care. That reflects what is a very robust set of referrals. Over the second half of fy 23. But also reflects what has been basically 15 year on year growth going back to the initial meant enactment of the mission act. This is one reason we make these big moves that we make. Notwithstanding those moves, we think that because of the year that we have had and our ability to continue to strategically hire where we needed that we can also meet our demands for care in the direct care system. We do not ask for a second bite. On the advance. But if we find out over the course of these next several months that because of our outreach efforts we have 550 outreach events because of our outreach events that we are getting more veterans enrolled, just sent march 5 we have had 12,500 veterans uniquely from the pact act cohort having enrolled in v. A. If we see that continued trend of growth, my hunch is we may be coming back to you to ask for a second bite if we need to. Margins are tight. We feel like we have the investments we need. If we begin to run into problems , we will definitely come to the committee. Lastly, we are tracking this very closely. We have implemented a series of budget execution tools. It is our intention to share these tools with this committee, with your team. We are working through all that before we do that. You as a team will be able to follow along closely on the execution of those goals. Sen. Baldwin thank you. The fy 25 budget request includes a lower level of spending for rural Health Programs than was appropriated in fy 24. Can you ensure made the v. A. Will direct the full amount of funding toward rural Health Programs . Sec. Mcdonough you have my assurance. Sen. Baldwin thank you. The next question would be whether innovations to increase access for rural veterans to address the fact there is a reduced proposed reduction in spending for fy 25 . Sec. Mcdonough we are among among the more innovative things we are doing is enhancing our cooperation with the department of defense over the course of the last two months with the department of agriculture to increase Access Points in rural settings so we can get care closer to veterans. That is one innovative solution. Second, things like access to Cancer Treatment, we announced a new program last week where we deploy v. A. Professionals closer to veterans so they can get their Cancer Treatments closer to their homes rather than having to drive all the way to phoenix, for example, they can go locally. Supported by the family, not having to drive longer distances. We can do that within the confines of our budget because Cancer Treatment drugs are 30 cheaper for v. A. Than they are for our private sector partners. Third, we are deploying v. A. Professionals i saw this in the Upper Peninsula of michigan to Community Hospitals including federally designated Health Clinics so that we can identify vets who are coming into treatment not enrolled in the v. A. We can then get them enrolled and get them support in those facilities. Ultimately that have crossed over the life of the program for the v. A. But no cost upfront. Lastly, the office of rural health has been basically flat at 337 million for the last three or four years for the simple reason that we finance our clinical resource hubs principally through the office of rural health. That means we will continue to rely on telehealth, as you said in your opening statement. The rest of the investments out of that office are for enterprisewide and ovations innovations. That can be funded out of the 337 million effort. Our homebased primary care is where we are sending providers into rural settings like maine, arizona, wisconsin and arkansas so we are taking care to the veterans. That is the idea. Not that we continue to fund those through the rural care account but the Rural Health Care office but rather we transfer those to being funded through the standard medical care account. Sen. Baldwin thank you, secretary. Senator collins, you are recognized. Sen. Collins thank you very much. I think the vice chair for his graciousness in allowing me to proceed him. Mr. Secretary, let me start with two facts. One is that maine has one of the highest percentages based on population in the country of veterans. That is something i am always product. Mainers have stepped up to serve. Second, maine is the oldest date in the nation by median age. When you combine those two factors, you can easily see why our state veterans homes are so important. In fact, both of my parents had the benefit of Compassionate Care at our states veterans homes at the end of their lives. In 2020 two, despite the Strong Demand for these services, maine considered closing two of its veterans homes. One in my shyest and one in my hometown of caribou. Fortunately that was averted but it would have caused tremendous hardship to veterans and their families. Maine is not unique in this regard. A recent report indicates other veterans homes across the country have notified the v. A. Of potential closures. 15 have reduced their bed capacity, another four have closed permanently. The v. A. Raised its per diem rates in 2023 but frankly that increase has not kept pace with rising medical costs. The veterans homes in maine, as is true across the country, are struggling financially. What is the v. A. Doing to support financially troubled state veterans homes and what more can be done at the federal level to prevent closures or reductions in beds . Sec. Mcdonough senator, thank you for the question. I could not agree more strongly with you about the importance of state veterans homes. That is why the bias in funding streams more so than the commercially run veterans homes and longterm care facilities. Among the things we are doing is up to 65 of the cost of facility construction, remodeling grants and nursery grants i will come back to that in a second medical sharing arrangements with considerable cost sharing when we can get our personnel into those facilities to care for vets and continued Clinical Care education. As you pointed out, the per diem has increased 7 in 2023 and another 7 in 2024. Higher than our increases for other similarly situated programs. Nevertheless, i agree with you that there are big challenges especially in two areas. One reason we are hearing from other states they are closing if they do not have the staff. Because of veterans they are getting are requiring more complex care. The greater funding for staff who can provide more complex care for those veterans is important and that is something we will be more than happy to work with you and maine with. Secondly the cost of pharmaceuticals for those veterans who end up in state run veterans homes. By tradition, the states take on the cost of most pharmaceutical treatment patterns. They also do not have access to our more price competitive formularies. We would also like to work with you on that, to figure out, how is it that we address these significant costs associated with pharmaceutical treatments because our veterans are living longer with more complex health care systems. Those are two areas we would like to enhance our support to states like maine. One, how do we make sure we can afford the staff for complex care . How can we ensure that we are not just passing on a very unmanageable pharmaceutical treatment regiment that the states cannot afford but the veterans need. Thank you. I only have 19 seconds left. Just to put on the record, there is also a problem with transporting veterans from rural areas to the one va hospital that we have in the state of maine. I hope that is something we can also Work Together on. Sec. Mcdonough count on that. We have a legislative proposal. We have some ideas. Thank you. Sen. Baldwin thank you, vice chair collins. Sen. Baldwin mr. Secretary, there has been a steady and significant decline in the number of veterans being described opioids for Pain Management since 2014. The implementation of the comprehensive addiction and recovery act in july of 2016, which included the jason memorial and promise act, have contributed to this trend. Sec. Mcdonough very much. Sen. Collins from a nationwide high of more than 878,000 veterans prescribed opioids in the last quarter of 2013, the number decreased to fewer than 300,000 at the beginning of this year. That 67 decline in prescription rates over the last decade is extraordinary and a testament to the progress we can achieve if we work diligently and resource the v. A. Appropriately. This decrease in opioid prescription rates does not mean the v. A. Is not treating pain. Rather it means the v. A. Is treating pain responsibly. For example, a Medical Center spearheaded the Pain University initiative to achieve improved Pain Management through comprehensive solutions without the use of opioids. Mr. Secretary, how else can congress enable the v. A. To provide these Integrative Health options for our veterans and what does this committee need to do to support and continue the efforts to responsibly manage pain and pain care for our veterans . Sec. Mcdonough i think the tools you pointed out are really important and i think you for making sure we got them and i think the family for the dedication since jasons death. We asked for 254 million for Pain Management and opioid safety drug monitoring in the budget. We think that is an appropriate improved investment. Secondly, we need to continue to staff. We are not yet at 100 of facilities with paying Pain Management teams. We are north of 90 but not yet at 100 . Continued investment to allow us to build out the Pain Management teams. Third, the whole Health Initiative allows us toma is also a flagship effort but allows us to deploy clinically improved Pain Management techniques that are nonpharmacy based. Those range from acupuncture, yoga, meditation, all of these things that are really important to making sure we can manage holistically that veterans pain. We are proud of the progress we have made on opioid prescription. That is directly a result of your law of investments and alternatives. And of accountability for those alternatives. I think this budget gives us a long way to could to doing the process. Sen. Baldwin great. Mr. Secretary, i have heard you say and i know you feel this deeply, even one veteran suicide is too many. I know you are working to reduce this troubling epidemic. I share your concerns and i was proud to lead the Bipartisan Legislation the transition the v. A. Crisis line to the National Suicide prevention hotline 988 number. During the first year in operation the Veterans Crisis line fielded nearly one million contacts. The implementation of this line has not been without difficulty and it will take commitment to oversee and commitment to oversight to get this right for our veterans. Can you please provide both your assessment of the contribution the Veterans Crisis line has made in addressing suicide among veterans and inform the committee of what Additional Resources would help rectify some of the problems and issues with the crisis land that have been identified . Sec. Mcdonough thank you so much. I am very proud of our Veterans Crisis line team and our operators, i have met with them many times. Their work has proven time and again to be timely and effective. Not to say it is without faults. We have had tough, hardhitting investigations on that that relate to training. We have the funding for training and staffing. There is an issue on the continued funding of the crisis line itself, the 988. This is not an issue for us but it is an issue at the states. The standup of the line envisioned a federal role at the start, handing out to the states making the investments thereafter. Remember the way it works for us, as a veteran you call 988 and then you press 1. At that point you exit the general crisis line and then you are into the v. A. Managed veteran crisis line. Notwithstanding the substantial increase in number of calls in the first year, time to answer shrunk. Abandonment rate shrunk. An followup assessments with the veterans in terms of survey results demonstrate satisfaction. We think the execution is going well. Not to say it is without fault. You will recall many of us many of you held us publicly accountable for a report out of one of our veteran crisis lion teams and we are taking that crisis line teams. We have the funding we need and the training capacity that we need. I hope we can ensure continuity of the overall effort through funding from the states. V. A. , thanks to your generosity, is in a very good spot to continue our part of the veteran crisis line. One last thing. We also begin executing a year ago the compact act. If a veteran does not just want to call 988 and press 1, that veteran can go into any hospital , irrespective of enrollment status of the v. A. , and get care today and we will pay for that. There are growing pains in the program, it is not perfect but almost 48,000 vets took advantage of it in the first year. We think it is an Important Program and it is reflected in these numbers. Sen. Baldwin thank you, secretary. Sen. Boozman thank you, mr. Secretary for being here. As i said earlier, i have had the opportunity in the house and assented to be on the v. A. Committee for quite a while. We do have a situation where we have a decrease in Veterans Health care. I guess the question is i have all the figures and we do not need to go through this, you and your staff know those butter than anybody the question is how much risk are we taking, assuming with this budget im sorry how much risk we are taking and what options we have if those assumptions are not correct . What do we do . Sec. Mcdonough the highest variability item in this multivariate equation is Community Care. I think it is generous to call it variable because it is variable in one direction, and that is up. There are a lot of reasons for that. Frankly, we do not know them all yet. We are looking at that. If there is elevated risk, it would be in there. But our options to manage that are our ability to come back to you to ask for some authority to transfer among different accounts in the medical care account. We are not taking substantial risk. At some point, we will take risk on maintenance of the personnel we need at v. A. To carry out the care the veterans expect because you cannot have a high variability Purchase Care Program that is increasing every year and maintain a high cost care system with big fixed costs for personnel. That is the tradeoff we will confront at some point. I think we begin to confront it in this budget which is why we prudently, especially by last years very productive hiring year, make some decisions to downsize vha and vba, as i promised you we would do, by the end of 25. When you consider those numbers, 10,000 over 4000 employees, that is not much greater than traditional attrition at vha. We are a little under traditional attrition because you were so generous to us with funding for staffing increases, pay increases and things like the Critical Skills incentive. This might be a little bit harder, might be slightly more risk because retention is up, quit rates are down but i consider that a highclass problem, not a risky problem. Sen. Boozman one thing i would like to get on the table, just being out and about in various facilities and talking to providers is more pact act claims are processed, many veterans will see an increase in ratings. You will see people at 70 go to 100 . The problem then is a number will become ineligible for dental in particular. I had not heard a lot about. The question is, the number of veterans eligible rising prior to the pact act grew 8 . Last year it grew by nearly 12 . Given the v. A. Dental is operating near capacity, this growth will likely be addressed by Community Care. I want to put that on the table and see if you have a response. There is a number of things this is probably the biggest one not unintended consequences but consequences we need to take care of that is a good thing for veterans but that will cost some money. Sec. Mcdonough you are right. This is a consequence of pact. Frankly, it is among the things veterans are most excited about because of pact because there is so much demand for dental. People who wish they qualified. Just to give you some numbers, 17 more 100 Service Connected veterans today than before the pact act was signed. A substantial number. If you consider fy 23, 690,000 eligible veterans for dental. 567,000 got that care 100 onsite. 123,000 got that in the community. Our dental staff increase in 2023 with about 4. 8 . They saw a similar bump. We should be able to continue to grow with dental this year but the big number out there, the big bogey here is 2. 7 8 million eligible veterans for dental by 2028. Up from 690,000 in 23. Our budget gets us going on that process but you are right, there is this transition period until we have dentists, hygienists and shares in our facilities, there will be a transition period where we will rely on the community. Sen. Boozman a great opportunity for veterans. The police that would be bad sec. Mcdonough cannot let them down. Sen. Boozman exactly. Sen. Baldwin thank you. Thank you. I appreciate you having this hearing. It is always great to see you, secretary mcdonough. Did you sleep here last night . Sec. Mcdonough i did not sleep much last night. The only thing i would add to the dental care thing for the veterans longterm, this could help reduce health care costs. If you have dental problems, you have health problems. Sec. Mcdonough heart problems. Every day i get visited by folks and they bring up issues that potentially impact veterans. You know how many native americans serve. I met with some urban native americans today. They told me two things i want to ask you about. The first thing they said was, is the v. A. Uses us, the urban Indian Health care, they use us. The reimbursement is less than adequate. That is number one. I just want you to respond to that. The second thing they said is that use us because i will give you the community if you want because the community is not fully staffed with doctors. You put a freeze on it, you have 14,000 new nurses and it is time to take a breath and see what youve got i do not disagree with that. We are talking about Community Care, v. A. Care, if we do not have Proper Staffing as was pointed out, it forces more folks into the community and those inflated prices go up. The other question is treated differently when it comes to the try west in montana . Sec. Mcdonough thank you so much. I spent time with them the day before yesterday, they are great partners. I would with senator moran in wichita my first trip after i left montana. We want our data veterans to get the care that is culturally competent for them where they needed, when they needed. That means at a v. A. Facility, at a uio for ihs facility or through the Community Care program. You know this better than i do. The number of data veterans living in urban settings, away from their families and their tribes, is extraordinary. We negotiated a new agreement with that you i o uios. We have had zero requests against the new arrangement since i went to the facilities in 2021. We have to do a better job. We also have a new reimbursement arrangement with ihs. We are working really aggressively on that. The chairwoman mentioned this in her opening remarks. We have a new reimbursement arrangement with them. We are finalizing that plan. It is with ihs now. Im excited about the opportunity not only for veterans to get care but we have committed to our tribal advisory committee, which you put into law, that we will begin having exams at ihs facilities, closer to veterans. We have the tools, we had to figure out why people are not taking advantage. Talk to me a little bit about staffing and the impacts that has on Community Care, which you say is doing nothing but going up. Sec. Mcdonough it is a really tough question because you have the chicken and the egg. At what point are we not providing care because we do not have people . At what point are we providing care in the community because it is easier to do . That is why we have made aggressive effort over the last three years to staff as aggressively as we did, 1. 2, that is why we ran an access sprint, to test the proposition. We proved that in 25,000 cases, they are. But we have to get better on productivity. We have to show every time a veteran has a choice, we make a referral for that veteran to go to the community. We said this is where you qualify, you should do that if you want but we would like you to stay with us. But they cannot stay with you unless you have the staff. Sec. Mcdonough correct. Which is why we have this period under the access sprint that we are seeing 11 more clinical visits in that period. We have to extend that and keep those vets in. The system by the way, we will keep adding vets. As we do that if we need more money, we will come back and ask for that second bite. I want to do that because there is more vets demanding more access, not because we cannot manage our workforce. Here is the point i want to make. As you go into this hiring freeze, do not forget to look at the hospitals that are short on pas, docs, rns, all of the above. If we do not do that we cannot expect Community Care to level off. Hopefully your directors and the director in v. A. Montana, which is doing pretty damn good, will take a look and put pressure to get more docs in because we did them otherwise the Community Care issue will continue to grow. Thank you. Sec. Mcdonough could not agree more. Sen. Baldwin thank you. Senator murkowski . Sen. Murkowski you know you are welcome anytime. The snow is melting and the weather is getting pretty good. One thing i wanted to raise with you is the palmer pioneer veterans home. Made it through the winter without losing that roof. As you know, this is something we have been watching for a long time. This is something where just last march, we got the v. A. Engineering office to issue a memo stating the threat of a roof collapse does constitute a life safety issue. It has been reclassified. That is great. It now goes to what i understand is the top of the sub priority group. We made it through the winter and we had a lot of snow. I am not certain that this roof is safe moving forward. The sooner, the faster we can attend to this, i would just put that before you in terms of prioritization. Sec. Mcdonough the good news is our engineers have came to the stem conclusion you have so it does get to the top of the list. I will stay on top of this and make sure we stay in close touch with you. Sen. Murkowski i know all of our veterans at the palmer home appreciated. I had a meeting a month ago with a group in fairbanks that had been working, the fairbanks Veterans Cemetery for a long time, probably 20 years now. I appreciate the v. A. Has placed the vet cemetery there as a high priority to establish a new cemetery. But the way the list is stacked, as you well know, it puts the expansion of existing facilities, there are multiples ahead of any of the efforts to bring on a new facility. I think you have heard the benefits that a Veterans Cemetery in this region, it would serve about 65 of the states veteran population. We have one small tribal cemetery. We have a Second National cemetery that serves southeast. We have one that is difficult to access. This is a very significant region of the state with a significant population of veterans. They have been working aggressively on this. I am hoping the community can fully fund this account for fy 25 and in future years. What we are trying to do is figure out if there is a way maybe it is splitting the Grant Funding so you have a certain extent certain percent for expanding programs and a certain percent for new construction. It will be years and years before a new construction of a cemetery will be allowed to proceed. Maybe you have a better idea of a timeline that we might be able to report back to folks. I would like you to take a look at that list. We will try to do our best. I will put my shoulder into it on the committee to see if we can get that number up. Even if we get it up it will be a long time before you get to any new construction. Sec. Mcdonough i have asked our team to look at this particular fairbanks option in the context of our overall strategic call to have 95 for stash strategic goal to have 95 of veterans within seven miles of a hospital. Sen. Murkowski you definitely need this one. Sec. Mcdonough analytically, that might be important. I have asked for that review. Sen. Murkowski 350 miles away from the closest one. Sec. Mcdonough exactly. I have asked for that review. We will stay in touch with you. Sen. Murkowski i appreciate that. Sec. Mcdonough the importance of this is coming through strongly. Sen. Murkowski i am running close on time. Im curious to where we are with the claims inventory and the backlog. Im told following the pact act we have seen that increased dramatically. We have also seen the claims accuracy backlog im told the accuracy rate has dropped to just over 83 , the lowest it has been in the last 10 years. I do not know if that is directly related to the claims backlog and the increase but this is an issue that our veterans are raising in alaska. I am sure they are in other states, as well. Sec. Mcdonough thank you for the question. The backlog as of this morning was just over 300,000 claims. Sen. Murkowski how does that sec. Mcdonough inventory is about 930,000 claims. I think, if i remember that right. I will get to a number by the close of business today. We are at about a 31 backlog rating of the overall inventory. That is generally in the zone of what we have considered healthy for backlog. We will not rush to get a no to a veteran if more development will get us to a yes. That is first. Second we have been anticipating much on the low end of what we anticipated and frankly what our model told us the backlog would be by now. It could be that we are on the downside of the backlog. It is too soon to definitively state that. The main input is people. We have hired we have basically increase the workforce by about 25 in the last three years, anticipating this influx of claims. Sen. Murkowski has that impacted the accuracy because you are bringing new people on . Sec. Mcdonough correct. Im not sure were 83 comes from. I got an update yesterday we are at 93 . We have a dispute with their ig, too. He scores are accuracy differently. There are quality concerns, which we anticipated because of so many new people and training requirements. We have throughout the course of the summer a quality stand up, which will increase enhanced training and an update of the Training Program to review these quality questions. Because, again, this traditional we worry about the backlog when it grows so we over index on the backlog number so then quality comes down. We have to toggle back and forth between these two things. We have anticipated this. I hope this addresses that. That is a training issue. That is an oversight and management issue. Again, because we are seeing the same thing in vba, enhanced retention of our personnel, i feel pretty good about our ability to address that. Sen. Baldwin thank you. Senator peters . Sen. Peters it is good to see you again. Thank you for being here. As Service Members transition into civilian life it is absolutely critical they have the tools and the job training they need to be successful in that transition. In 2020, my bipartisan bill, the support for veterans with apprenticeships act was signed into law. It increases veterans access to Financial Assistance they can use in connection with an Apprenticeship Program and requires apprenticeships to factor in the skills and experiences they gain through military service which is often extensive and helps the veteran get placed in those apprenticeships. The fact remains that for veterans to use their g. I. Bill benefits on these programs they have to actually be aware of apprenticeships in the first place and how those g. I. Funds can be used to help them get that training to transition. This committee is part of the fy 23 v. A. Funding legislation which attracted directed the v. A. Utilization of apprenticeships among veterans. My question for you is what is the v8 doing to ensure veterans are aware of the opportunity to use how does your fy 23 budget request support further outreach to these individuals . Sec. Mcdonough both the general Education Program at vba and the veteran readiness and employment programming at vba because of the committees requirements have enhanced and have specific targets to increase enhancement of communication around apprenticeship options. The budget fully funds those because it fully funds programming for both. We will begin to see data on the uptick of that. We will accumulate that data and share with you over the course of the coming year. I want to ask you a couple questions lidded to v. A. Inspector general investigations. You and i have spoken repeatedly about my concerns regarding a case. Ian is a native michigander who tragically passed away following a decline in his Mental Health as he and his family and friends worked very hard to try to gain admittance to a v. A. Medical facility. I was pleased when the v. A. Opened. An Inspector General investigation into his case last summer following our conversations. My question for you is i know the investigation is ongoing but i want to get your commitment today that once the investigation concludes you will implement the ig recommendations across the v. A. As they become aware . Sec. Mcdonough yes. He was also a national hero. You have my commitment to implement the recommendations. I had been in close touch with the ig on this and have every expectation he is wrapping up his work and that will be public soon. I think the ig does really important work, really good work. My guess is it will be really tough for us but that is the most important stuff we have to get right and we will. Sen. Peters i appreciate your commitment and attention to this from the getgo. I also want to touch on the a detroit v. A. Issue. Senator stabenow and i were alarmed to learn about a crisis of care and leadership at a Medical Center in downtown detroit. In response, the senator and i called on the v. A. s Inspector General to conduct an independent investigation into the facility that was launched shortly thereafter. Last summer the Inspector General released its report which include recommendations to remedy issues found at the facility. One recommendation related to removing conflicts of interest within the peer review process. I have introduced legislation with Ranking Member boozman to the v. A. Peer review act to act on the recommendations from that v. A. System. My question for you is can you provide an update today on the detroit v. A. s implementation of the recommendations contained within the Inspector General report . Sec. Mcdonough i spoke to our director this morning and she had her Monthly Update with the director in detroit yesterday. On your question, recommendations 1, 2 and 8 are still open. 1 and 2 regard oversight of the surgery department. The next meeting with the ig is on june 10. I hope we can close those out or get closer to closing those out by then. Recommendation 8 relates to the demand from the ig that we get a permanent executive Leadership Team in place. He has a numeric goal or a timelapse goal that we just need time on that. That is not yet closed but i hope it will be because our permanent executive med Center Director is doing a really good job. They have reopened 30 inpatient beds in the hospital in the middle of detroit. We had 30 inpatient beds closed. Those are opened. Care as measured by relative value units, unique visits and clinical encounters are all up right now. This year over last. Again, an indication of the seriousness of that Leadership Team and staffs interest in getting that group functioning that team functioning again. They are also helping with management in saginaw, battle creek in a way that we long expected them to but they have not done. Similar to the way ann arbor helps manage caseloads for veterans functioning at the highlevel facility they should be. Nothing is permanent. We have to stay on top of that but that is indications we are making progress. Sen. Peters thank you. Secretary, thank you for being here and for your work on behalf of veterans. I want to pick up on something that senator murkowski was talking about but a little bit different twist on it. About making sure our great veterans have access to cemeteries and their families have access to cemeteries. As you are aware, because we have talked about it, in fargo we have established a cemetery and expanded it from five to 35 acres. It was initiated under the Rural Cemetery initiative. It was the first one established. That was five acres. To show the need, we were going through that so fast that recently we work with the v. A. And expanded that to 35 acres. Now the key is to enhance the facilities. Senator murkowski discussed that it is a challenge fundingwise. We are willing to step forward and actually fund and build a Visitor Center on the cemetery and we are working to do that. We worked very closely with assistant secretary macklin who has been good to work with, i want to commend him. I understand he will be leaving on may 23. I want to thank him and commend him for the great work he has done. It is important that we have somebody in that slot that will continue this work with us on a project that is really fantastic for veterans, keeping in mind it was interesting it was senator murkowski because the v. A. National cemetery, it serves an area you are familiar with, all of western minnesota. A lot of folks that need access, it is a long way to minneapolis. All of north dakota because this is the only federal cemetery we have and a lot of south dakota because they have to go all the way to spearfish which is on the very western edge so this is situated where he will serve a big population and we are willing to step up and cover the whole cost in essence and then donate it. But we obviously have to work through the bureaucratic challenges that go with that so i really need your commitment particularly as we are losing the secretary and he has done such a good job. The new replacement, we are going to need somebody who will work with us and i need your commitment on that. He is fine. Well, he is from montana. Exactly. I was going to commend our leaders on the full v. A. Authorization committee, too. Both senators have been working with us for closely. Youve got my commitment on this. I made it in private and im happy to make in public. I think we demonstrated that he is routinely out there, meeting with your vets, meeting with local Community Leaders and we will stay on top of the commitment to that. They are really awesome. That is a beautiful area. But you know that when i lay that out for you, because he come from the area, the need is there and this is important so thank you for that commitment. The second thing i wanted to talk to you about is veterans access to health care and nonv. A. Longterm care facilities, one of the challenges is that because of the if i get that right, the office of Contract Compliance Office of federal contract compliance programs, they dont have a permanent rule that allows these Nursing Homes to accept v. A. Reimbursement. Without a separate exam, separate from cms. I think it was the pack act and we provided authorization for the v. A. To exempt these facilities from all fcc p separate compliance exams if they were meeting the cms requirements for medicare and medicaid because it just makes sense that they dont go through this duplicate study which was keeping a huge number of them from accepting veterans on v. A. Coverage. So v. A. Insurance payments, to cover their stay. Now, you put in place a two year rule. We really appreciate that. That takes us to 2025. For tricare, you passed all that just exempts it. And we need Something Like that in order to get these Nursing Homes to change their policy and accept veterans that are on v. A. Reimbursement rather than medicare and medicaid so it is a twoyear but i would really encourage you because you have the authority now. We passed that in law. It would require a permanent rule on your part to do it. You did it with tricare but you can see why on a two year, a lot of them are reluctant to change their policy because they could be right back to dual exams and that might mean another elevator, might mean all these different things, you know, so i would ask you to take a look at that. I am on it. I got it. And then the last one is one you and i talked about, particularly in rural america, access to Mental Health care. Telemedicine has helped but boy, any and all initiatives you have to help getting access to Mental Health care for our vets is really important. When we talk about strategic hiring and that continuing, notwithstanding our net zero growth on ftes, you know, over the course of this year, strategic hiring, you know, front of the line is psychologists, Mental Health professionals, Mental Health social workers, so we will continue to do that. Secondly, you have given us authorities and investments to increase cooperation with tribes and with local communities to make sure that we are investing in them as well. Thirdly, we are also investing we now have 1900 p are specialists in v. A. , basically the way i see it as an Irish American person, they are based on the aa model where we basically have recovering vets helping other vets, you know, earlier in their recovery and that is helping vets and us making those investments in them is a proven help so we are trying to go out in every vector there in the a come apartment the ground, and then a traditional manifestation of Mental Health care providers, and those will remain our priority because our number one clinical priority is suicide prevention, right, and we are going to stay on top of this until there is none. Thank you. Appreciate it. Thank you. First, i want to thank the senator for his comments on Mental Health in particular. That is an incredible challenge, especially in states like mine. Secretary, welcome back. Always good to see you. I want to ask you about the partial claim Payment Program and when that ended relatively abruptly, it was destabilizing for a lot of veterans in new mexico. Obviously, we are in a very different interestrate environment than we were at the beginning of the pandemic. What steps is the v. A. Taking to ensure that folks impacted by that will be included in the purchasing program that has been stood up . Works well, so, we are reaching out to veterans who our data shows are struggling, and we are communicating also as aggressively as we can to veterans to make sure they are aware that we are standing up any support program on the current moratorium, when it expires at the end of this month and the end of may. And you know, we think that, and by the way, as a general manager matter, we are tracking veteran performance on their v. A. Back to mortgages because we have a whole series of programs, not Even Associated with what we call what we will roll out when the moratorium ends that we want to make sure vets can avail themselves through our Debt Management center. So we are trying to communicate to vets individually. We are trying to communicate more generally to vets and the new program, which we kept the committee uptodate on will develop the implementation targets more aggressively over the course of the next four weeks that will allow us to make sure that veterans struggling do not lose their homes and come up with a more manageable debt picture overtime. Great. I know senator collins raised the transportation grant. I was pleased to be able to work to include some additional funding for that in fy 24. Just my understanding, because i was not here when she asked her question, is you may have referenced a legislative proposal in that area. Do you want to expound on it . We would like to, you know, you and i, you are the first person to have raised this with me and that is what i said to the senator when we talked about it privately recently. New mexico and maine are uniquely poorly positioned based on the definition of highly rural as fewer than seven people per square mile. We would like to change that in the statute and we have some proposals on how we would do that. And then you know, we would couple that with an increase a commensurate increase in funding because, you know, its just right now, we have too few counties who can participate. Im certainly not going to speak for senator collins but im sure i suspect we would both look forward to working with you on that. You talked a little bit about Substance Use treatment or Substance Use disorders. One of the challenges we see in new mexico is that folks who want to treat their Substance Use disorder are having real challenges getting access to the medications that they are prescribed by their doctors, particularly in offering even offering bupenorphrine. This is a highly attract these medications are highly tracked but i would love for you to look into that because we want to make sure that our vets who want to get treatment can get the medication they are being prescribed. It is a major priority for us to assist treatment, and so, if there is lets definitely dig into it. There is no reason a veteran who is struggling and wants to get take those steps, lets make sure we are there for them. We have had challenges with the big chain pharmacies just stalking those medications and we did not expand on we will get together and expand on why that is. But we are not going to make headway on this if we cant get folks to treatment. We are really proud of our medically assisted treatment options, so that should not be reliance on any of those big boxes. The question is maybe theres a mail order pharmacy issue for us, but let me dig into that. You have got my attention on this. If there is one guy who is struggling to get that, thats too many. Look forward to working with you on this. Thank you. Senator fischer. Thank you, madam chairman. I just want to start off to thank you for all the great work we are seeing the v. A. Do in nebraska and especially over this last year. Last year during this hearing, we talked about needing to invest in the cemetery grant program. We did and the cemetery is now on its way and in your most recent budget, i was pleased to see that a new Medical Center for omaha is now number two on the skip list so thank you for that. That Medical Center is nearly 75 years old and obviously, renovations are not going to cut it anymore so we are very excited to see that move ahead and i look forward to working with you. I appreciated your comments and our conversation about the Community Care program, and i do remain concerned about the future of that program. We have over 40 of nebraska veterans, they live in rural areas, and many are located hours from the nearest v. A. Facility, so that Community Care program is really vital for those people. In recent months, i have heard some of my colleagues call for tightening or even scaling back on that Community Care program. Of course, i want the v. A. To work on improving the appointment wait times but that doesnt change the reality that we face in rural areas and sparsely Populated Areas, so does the v. A. Have any plans to modify the access standards for that care program, and can you commit to us today that rural veterans will maintain access to care through that Community Care program . Yes, you know, the statute is very clear. Drivetime standards will continue to be impactful for rule veterans rural veterans. The big parts and pointing out our i am pointing out our south carolina, georgia, mississippi. Fully 70 of veterans there are referral qualified by virtue of where they live alone. So because of drivetime. It is an important axis opportunity for veterans in rural areas and will continue to be some of the things we are thinking about is updating the axis standards to reflect the fact that overwhelming amount of care in v. A. And in the private sector is offered through telehealth. We think our axis standards should reflect that. Ideally, that we would be able to get that done fairly quickly but that would be through rulemaking and there would be public comments. We have issues with connectivity though. A lot of these sparsely Populated Areas in my state, that is a big issue. We are not going to get a vet a pig and a poke, knowing that they dont have internet access, telling them to go get internet access, so we have no interest in that. So thats probably the biggest change we are anticipating currently, but you know, its been six years now since the law was enacted and since then, we had the pandemic and now, we have the packed act. Any one of those things would be a seismic impact on v. A. Three of them in a row, i am proud of the way our team has managed and i think it is reasonable for us to take a step back over the course of this year and ask what are the impacts of all of those things . If we anticipate changes out of those, we will come talk to you about them. As we talked about on our call, you have a tight budget, very tight budget, and given the ongoing implementation of the packed act, which i was very proud to support, i believe it is important for the v. A. To ensure that it has staff in place to meet the needs of access to assist that and i know in nebraska, we added over 200 new employees this past year to v. A. Facilities, but with the departments budget request, i think you are envisioning an overall reduction of approximately 10,000 health care workers. Can you talk about the departments plans on how it plans to reduce the workforce, and will the reductions be equally spread across the v. A. Facilities . Thanks so much. We envisioned at the end of 2025, that is september 2025 to be at 10,000 fewer fte. When all is said and done, frankly, if you measure traditional attrition at v. A. , that is not much different than traditional attrition. However, because retention is so high, because we have been so generous for various pay enhancements, we have historically high retention, historically low quit rates and as a result, it might be a little tougher. We are not going to make those decisions from headquarters. These are going to be decisions made by our leaders. This year is going to be a year of strategic hiring. A good example is recently in texas. San antonio has been looking for g. I. Experts, one of the most limited capabilities in health care and the United States right now and they finally found two and hired them both, right . So we will continue our strategic hiring but those are going to be facility based decisions, not me making those decisions from here as a politico or bureaucrat. That is not good for veterans. And we will track this month by month. We are doing this on fte, on dollars spent. We will talk this through with teams. They can follow along with us and watch that. My guess is one of my great strengths is our facility leadership is having the kind of leadership omaha does with year with their delegations. My guess is this is going to be a very public, very well debated effort and that is the way it should be. Good to hear. Thank you, sir. Thank you, senator fischer. I dont have anymore questions but i do want to welcome you to this subcommittee. I had the opportunity of doing that yesterday. But i know you are going to make a tremendous difference. Senator murray did a great job but i have enjoyed working with you on Veterans Issues in the past and we appreciate you. We are both blessed with excellent staff, not good staffs, but excellent staff that make us look better than we are. The secret to success. Thank you, mr. Secretary, so much. We appreciate you and your staff that really are working hard for veterans. Cripes i agree with lisette about your staff. That was wise of you. Thank you so much, senator. Secretary, thank you so much for the work you are doing on behalf of veterans all across our country. Thank you very much, madam chair. We are lucky to have a subcommittee fellow senators who care very deeply about the veterans who served our country so well so i am excited to continue the bipartisan tradition of the subcommittee. That will conclude our hearing today. I would like to say again, thank you to the secretary and our colleagues for participating in todays hearing. I look forward to providing veterans and their families with the benefits and care and support that they need. Finally, i will keep the hearing record open for one week. Commemorate Committee Members who would like to receive written questions should do so by 5 00 p. M. On thursday, may 9. We appreciate the department responding to those questions in a reasonable period of time and with that, we stand adjourned. Thank you. Great job. We appreciate you. [indiscernible chatter] earlier today, Pete Buttigieg testifieon the budget request. He was asked about rebuilding ltimores Francis Scott key bridge which colpsed in march after beinstruck by a ship. Watch the subcommittee heang tonight at 8 00 eastern on cspan. Its also available on can now from our free mole video app, or online at cspan. Org. Cspans washington journal. Our live forum involving your to discuss the latest issues and government, politics, and public policy. From washington and across the country. Coming up friday morning, the National Political reporter, eric, talks about his interview with former President Donald Trump about his vision for a potential second term in office and then shall be talcott talks about the trump campaigns process for vetting and selecting a running mate for the former president and Vanderbilt University law professor and war crimes expert Michael Newton talks about the process of prosecuting war crimes in the International Criminal court in the context of the israelhamas war and russias invasion of ukraine. Cspans washington journal, join in the conversation at 7 00 eastern friday morning on cspan, cspan now, or online at cspan. Org. Sunday on q a, former rhode island democratic congressman Patrick Kennedy talks about americans who struggle with Mental Illness and the role family members play in their care. In my own case with met my father, obviously, who died before they were born, but they got to meet my mom and they got to meet my mom because my brother and sister and i went to court to get guardianship over my mother to keep her from killing herself. She was so happy. At the time, she wasnt happy, but she ended up being so grateful that she was able to make it to the other side because we intervened. Patrick kennedy with his book, profiles in Mental Health courage, sunday night at 8 00 eastern on cspans q a. You can listen to q a and all of our podcasts on our free cspan now app. The house will be in order. This year, cspan celebrates 45 years of covering Congress Like no other. Since 1979, we have been your primary source for capitol hill, providing balanced, unfiltered coverage of government, taking you to where the policy is debated and decided all with th