45 minutes. Chairman tester i am going i want to thank secretary mcdonough and her friends and partners for joining us today. For those of you joining us on television, you will hear a great opening and questioning of the secretary of the v. A. We have three people who were going to do a combined statement , which will be particularly entertaining. So we have something to look forward to. Chairman tester we do. We are here to take a closer look to the president s 2024 budget request for the department of Veterans Affairs. We have to ensure the department is wellequipped to care for our veterans. The v. A. Completed more than 1. 7 million disability claims. They served over 6. 3 million veteran patients, more than 150 million employments. Demand is only increasing. This law created a fund to cover the new cost of delivering. I have serious concerns to got the fund. Gut the fund. It is all bad news. We send people off to war, we put it on the credit card. They come back and we make excuses not to fund their benefits. After finally making good on our overdue pledge to address the costs of war for veterans, our next step cannot be to renege on that pledge. Lets not forget even if house colleagues make good on their promise to not gut v. A. Care [indiscernible] make no mistake, by tying cuts to the debt ceiling, they are putting veterans livelihoods at risk. Each month treasury makes payments on behalf of the v. A. Nearly half as for benefits payments for more than 7 million veterans and their families. The rest pays for medical clinics and reimburses private providers for people who receive care in the community. If the debt limit is reached all these payments could be delayed or stopped, creating uncertainty for this nation and for the veterans that serve this country. Lets get past the political posturing and ensure our veterans are not harmed. With that said, i look forward to hearing directly from secretary mcdonough on the fy 24 budget. Sen moran i appreciate all of you being with us today and i look forward to hearing your testimony about the v. A. s budget request. There has been some big changes since the last time we met for this purpose, namely the enactment of the honor in our packed act. Pact act. I am committed to protecting support for veterans in the ongoing budget talks and i know my colleagues share that commitment. 70 of the federal spending is on autopilot or on mandatory programs. This is what got us in this deficit mess. Veterans are not insulated from rising inflation and slowed Economic Growth caused by outofcontrol spending. As a longtime member and now Ranking Member of this committee, my party will be to make certain the v. A. Has the funding it needs to provide highquality Health Care Benefits and services to the men and women who served our nation. I believe this and every v. A. Budget request could be judged through a single lens of what will it deliver for veterans. This years budget request is the largest yet for the v. A. , totaling 325. 1 billion. That is a big number and it should lead to big improvements for veterans. We should not brag about the amount of money we spend, but if bigger numbers were all that was needed to deliver, we would have better results. So it is what we can deliver. With bigger numbers, and better results, we still would not have higher veteran suicide rates, hundreds of thousands of veterans waiting for their earned benefits, new Electronic Health records, meaningful decline in access to care, scores of recent reports from the Inspector General detailing serious and fatal failures, persistent problems getting the v. A. To provide timely responses to basic requests for information. I am interested in hearing from the secretary this afternoon on how this budget request will produce different results from past years. I am also interested in hearing the secretary justify budget increases for v. A. Health care. The veterans help administration is requesting a little an 11 increase. This is the first budget request that includes the Toxic Exposure Fund. When the fund was established nine months ago it was not projected to reach 20 billion until 2030, six years from now. Given that the v. A. Does not have a way to track the number of veterans who are enrolling, and has not raise this concern, this request needs explaining. Delivering more money for veterans is not the solution, but delivering that her outcomes is. I have no doubt about what the secretary shares. Ive no doubt we disagree that there is any disagreement about the need for better results. For these reasons it is critical that congress put Veterans First by remaining engaged in the budget process. It is time to get it right for our veterans, their loved ones and i thank you for all being here. Chairman tester i agree with the point you made on the money. It is how the money is spent that is important here. That includes every budget we put our hands on. Todays hearing is just the two panels. We have the great honor to have the secretary of the v. A. , secretary Denis Mcdonough to talk about the v. A. 2024 budget. In your testimony that you have written, you highlighted the v. A. Has delivered more care to more veterans over the last two years than any time in the nations history. Put more of that in perspective for us. Thank you very much sec. Mcdonough thank, mr. Chairman. We are not big on just measuring what we put into, what you give us to put into veterans care, but we measure what it means for veterans and their families. Just last thursday, there was a release of a report, consolidation of 40 separate reports looking at care provided by the v. A. , including throughout the pandemic. That report found that v. A. Provided care is at least as good as and overwhelmingly better than care provided in other settings, including private health care settings. So we are very proud of that, but if you just consider clinical appointments we have had with veterans in the last year, 115 million clinical encounters, 40 million inpatient encounters at v. A. Facilities, 31 million telehealth appointments, 38 Million Community care appointments. You are ready talk through the benefits side of this at the claims we processed last year. We are 15 ahead of that number year on year. These dollars mean real engagements. These engagements mean Better Outcomes for veterans and i stand by the assertion that we are now providing more benefits and more care to veterans than at any time in the v. A. s history. Who are they . The Fastest Growing veterans are Women Veterans. Just everest as a result of the pact act, we have 77,000 new enrollees in v. A. Health care. The Fastest Growing cohort is Women Veterans. The beauty of the pact act that you gave us last year is that it allows us to restart a conversation with the younger and more diverse veterans at the same time weird opening our engagement with vietnam veterans. We are seeing younger veterans, more diverse veterans, including more gender diverse veterans, meaning more women, in our care. There has been debate about the bill the house passed that cut programs. Most of the debate revolved around veteran benefits. Senator moran address stated in his opening statement. Addressed it in his opening statement. As i look at the bill, they attempt to rescind 1. 8 billion for v. A. Veterans services. The question for me becomes if we did not cut any veteran benefits, this is not called benefits because it has to do with administration . I guess that is the way they look at it. You had a chance to look at that bill and the proposal put out by your agency. Tell me what you see that comes out of that and what impacts it would have . A bill that would by the way the speaker said did not cut benefits, but call the president a liar, when effect the president was telling the truth. Sec. Mcdonough the bill itself is vague for the reasons you talked about. We have looked at this a lot of different ways. We have been talking with members on all sides of this debate is january when this debate really got engaged. If you just apply the 22 budget cut to v. A. , which may not be what ends up happening, maybe it is less, but if you take the top lines of the bill and recognize that v. A. Is not held harmless. The way for example dod is held harmless then we are going to be confronted with significant challenges. We think that if that 22 cut is applied to v. A. Health care, that would mean outpatient visits of the type i talked through that we had last year. Those are outpatient visits in the Community Care system. Alternatively, if you look at it from the benefits administration , talked about the fact that claims filed are 30 above where they were a year ago. We are fulfilling 15 more claims year on year than we did a year ago. We are able to do that because of efficiency we found and hiring we carried out. If you apply 22 reduction, that would mean 6000 fewer staff there. We have 20,000 staff there for the first time. We talked this committee through how our staffing model works. But if there are 6000 fewer personnel to process claims, that will be an extension of a timeline that is already too long. The v. A. Inspector general found a substantial commingling between the 14. 4 billion in simple mental funding the v. A. Received under covid19 and the v. A. s regular appropriations. He seems to me that would be separate accounts, but that is not with the inspector found. The intent of the supplemental was to support urgent timelimited needs, one period of time circumstances, not to create an artificial increasing of the budget. What steps did the v. A. Take to make sure cost projections were not based upon those supposing onetime amounts of money . Sec. Mcdonough this has been a historic challenge for the v. A. , how does it account for supplemental funding. This goes back many years. It has to do with the age of our infrastructure, how we track the stuff and it also has to do with where we push the money for our operators to execute it. The important thing we have done, as we have now taken responsibility for that. And put it in the hands of the cfo here at headquarters. We are making sure that he and i are directly responsible, ultimately. The covid funds those funds being the medical care funds. Rather than making every individual facility have to account and try to figure out where this money comes from, we are going to make sure that we do it at headquarters. We worked that out with omb, we have been brief your staff about this because we think this is an important change. Secondly, we have regularly updated the committee on how it is that we are spending these funds and that is why we can have the confidence that we have now and we will use the overages that we have had today, remember those overages were for what we expected to be a surge of care as people come back to us the end of the pandemic, we have had that conversation. We have great confidence we will use that money this year. And partially into next year. Our regular updates to you guys help us do that. But the ig has routinely raised this issue of supplemental funds, we are trying to figure out a good way to do it. We think bringing responsibility of this to the ceo cfo level is the way to do it. But none of this obviates the need to continue to stay in close touch with the committee and make sure that the Committee Sees clearly how we spend the money. I understand the v. A. Plans to track expenditures from the toxic exposure fun to make sure they are justified. How will the v. A. Define and track which health care is associated with exposure to environmental hazards in which care is not pursuant to the law that created the fund . We have had a handful of discussions with your teams here in the committee and with others among the appropriators and the house as well about our methodology. We are comfortable with our methodology, we have worked this through with omb, we are working it through with your team. All of them will characterize to you their degree of comfort, if we have to change that methodology we will do that. The base case is that we are in a position to ensure that as the law envisioned, talking exposure funds, will be spent only for toxic exposure requirements. And we have made sure that weve given clear guidance to the field. Again operating as we do with the cfo and meet responsible to make sure that we can execute. So the lack of accounting from the money from covid, which you are now trying to address by bringing it to the central office, that is not anything that would suggest the same problem will occur for the money in the fund for toxic exposure . We wont have the same problem we had with covid money being comingled, the department will be able to determine what is appropriately spent for toxic exposure benefits. We think yes. In the methodology, the basis on which we establish that methodology to track that funding is something we are talking through with your teams in very minute detail. But we are also going to continue to not only talk to you but continue to be subject to oversight to the gaos oversight to ombs oversight, and if there is something we need to change we will change it. But we have great confidence that we will be able to invest the toxic exposure dollars for toxic exposure care. Senator brown . Thank you i appreciate what you said about dod being held harmless in the v. A. Not. Other senators and i fighting for the pack act last summer when it was perilous whether it was going to pass because some said it was too expensive, i do roundtables, im going to do one in every county in the state, i did one on the 31st the other day. There is always money for defense but too many people want to skimp on spending on the v. A. So thank you for your work on that. Secretary, thank you for all you are doing in so many ways. Thank you for taking the right step in stopping the Electronic Health records. I know we have talked many times, i appreciate your attention to that and your understanding their that the staff at chalmers and columbus, their hard work, i visited there as you have. You did the right thing and i want to keep working with you. I want to talk about the pact act. Do you have numbers up to date on how many veterans, i like to say when i do these roundtables that this is government done right. This bill passed in august of 2022, by january 8 are headed up and running and hundreds of thousands of veterans were getting care. That is exactly the way government should run and all of us are proud to be a part of that. You have uptodate numbers on how many have been served . As of may 6, 251,584 total veterans or survivors have had completed pact act related claims. We are granting at about 80 . That is the beauty of the presumption, is that we are able to grant at a much higher rate, it is 79. 7 . This is a troubling number, the average days for completing a pact act related claim right now is 155 days. I think there is a series of reasons, the biggest is that some claims were filed either related to our initial three presumptive claims were filed shortly after the president signed the law and we did not begin to process the pact act claims until january. We should see that average number of days go down. We have about, as i said earlier, about 77,000, a little over new enrollees and vh a health care as a result of that. There are many more existing enrollees who qualify for greater access to care as a result of the pact act as well. I participate as an observer at a screening event in toledo, in northwest ohio in march and it was an illuminating experience to see what veterans go through. You have been more handson than any v. A. Secretary i have seen them going out and seeing the action. I have heard from veterans and advocates who need additional screening, many are prohealth and had to have invasive biopsies in order to complete these. What steps is the v. A. Taking to implement less invasive diagnostic techniques such as advanced technology screenings . The toxic exposure screenings youve talked about are enabled by the law, we have now had about 3. 3 million thats complete those screenings. It is very interesting because somewhere between 35 and 40 , i do not have the most recent number, of cases of those screenings we have veterans about whom we have learned some new exposure that that veteran may have experienced. That is allowing us to get to know the veterans already in our care better. There are technological challenges, one of the things that we think most veterans suffer from which is bronchiolitis, the test for which are so invasive as to make them actually not useful. Potentially harmful to the veteran. So that is why we have stood up in the pact act enabled us to stand up. A special organization focused just on the science of the exposures as well as new techniques to verify the existence of the condition. That team meets on a regular basis, we just met with them late last week. Not only did you set up the presumptive process for us you have also given us additional authorities to make sure that we are testing new technologies to make confirmation of these conditions, including bronchiolitis less invasive. Thank you. Mr. Secretary, your work especially since you have taken office, in cincinnati and columbus and your help for the national v. A. , thank you for all of that. Thank you mr. Chairman secretary, for your opening statement. Congratulations on your daughters graduation. It is a fine institution, 15 minutes from my home. I want to thank you for the great thing you gave me back in my office, most folks know i voted against the pact act in spite of the fact i worked a lot on it. He did not have to do with numbers and had to do with operational challenges that i hoped we could clear up, but you gave me a reason to be optimistic. Can you give me a 62nd cliffs notes version on some of the risk, i did hear the 150 days, but i think you have a plan for that . Can you share that with me . Thank you, what we know now after years of watching the benefits process in particular. The claims filing process. So since that is overwhelmingly the main door that thats enter at the v. A. It is a very human intensive process. We need to make assessments about how many vets we anticipate filing claims and we need to make sure you have trained people ready to handle those claims. Starting in the end of the fiscal year 2021, we began hiring. We now have 28,000 vba professionals, importantly they are not only hired a good chunk of them are now through the training process. Such that they can begin to add to our ability to reduce the backlog of claims that get filed. A good example is yesterday we had the single biggest day claims completion in the history of the v. A. , we completed over 295,000. We are still getting more claims on any given day than that but we are able now to