[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                  BUILDING AN ACCOUNTABLE VA: APPLYING
                    LESSONS TO DRIVE FUTURE SUCCESS

=======================================================================

                                 HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                       TUESDAY, FEBRUARY 28, 2023

                               __________

                            Serial No. 118-1

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]       


                    Available via http://govinfo.gov
                    
                              __________

                                
                    U.S. GOVERNMENT PUBLISHING OFFICE                    
51-535                       WASHINGTON : 2023                    
          
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                     COMMITTEE ON VETERANS' AFFAIRS

                     MIKE BOST, Illinois, Chairman

AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking 
    American Samoa, Vice-Chairwoman      Member
JACK BERGMAN, Michigan               JULIA BROWNLEY, California
NANCY MACE, South Carolina           MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana   CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa       FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina    SHEILA CHERFILUS-MCCORMICK, 
C. SCOTT FRANKLIN, Florida               Florida
DERRICK VAN ORDEN, Wisconsin         CHRISTOPHER R. DELUZIO, 
MORGAN LUTTRELL, Texas                   Pennsylvania
JUAN CISCOMANI, Arizona              MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona                DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas                    GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

                       Jon Clark, Staff Director
                  Matt Reel, Democratic Staff Director

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                         
                         C  O  N  T  E  N  T  S

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                       TUESDAY, FEBRUARY 28, 2023

                                                                   Page

                           OPENING STATEMENTS

The Honorable Mike Bost, Chairman................................     1
The Honorable Mark Takano, Ranking Member........................     2

                               WITNESSES

The Honorable Michael Missal, Inspector General, Office of the 
  Inspector General, Department of Veterans Affairs..............     3

The Honorable Gene Dodaro, Comptroller General of the United 
  States, Government Accountability Office.......................     5

The Honorable Shereef Elnahal, M.D., Under Secretary for Health, 
  Department of Veterans Affairs.................................     6

        Accompanied by:

    Mr. Michael Frueh, Principal Deputy Under Secretary for 
        Benefits, Department of Veterans Affairs

    The Honorable Matthew Quinn, Under Secretary for Memorial 
        Affairs, Department of Veterans Affairs

                                APPENDIX
                    Prepared Statements Of Witnesses

The Honorable Michael Missal Prepared Statement..................    37
The Honorable Gene Dodaro Prepared Statement.....................    47
The Honorable Shereef Elnahal, M.D. Prepared Statement...........    81

                       Statements For The Record

Concerned Veterans for America...................................    93
America's Warrior Partnership....................................    97
American Federation of Government Employees......................    99
Student Veterans of America......................................   107

 
                  BUILDING AN ACCOUNTABLE VA: APPLYING
                    LESSONS TO DRIVE FUTURE SUCCESS

                              ----------                              


                       TUESDAY, FEBRUARY 28, 2023

                     Committee on Veterans' Affairs
                              U.S. House of Representatives
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 2:24 p.m., in 
room 360, Cannon House Office Building, Hon. Mike Bost 
(chairman of the committee) presiding.
    Present: Representatives Bost, Radewagen, Bergman, 
Rosendale, Miller-Meeks, Murphy, Franklin, Van Orden, 
Ciscomani, Self, Kiggans, Takano, Brownley, Levin, Pappas, 
Mrvan, Cherfilus-McCormick, Deluzio, McGarvey, Landsman, and 
Budzinski.

            OPENING STATEMENT OF MIKE BOST, CHAIRMAN

    The Chairman. If we can get our witnesses to come forward. 
If we can have our witnesses come to the witness table, that 
would be fine.
    Good afternoon and thank you all for being here. Welcome to 
the House Committee on Veterans Affairs' first Oversight 
Hearing of the 118th Congress. I am honored to be the chairman 
of this important committee and leading a group of great 
members. Every one of these members, Republican and Democrat, 
is here because they believe in President Lincoln's promise. We 
all have the responsibility, every man and woman who has served 
in our armed forces, to craft laws that deliver veterans the 
care and benefits they have earned.
    This starts by overseeing VA to make sure that those laws 
are carried out as intended. Unfortunately, VA at times has 
fallen short of that promise to the veterans. And last year 
Inspector General Michael Missal, who is here with us today, 
put it plainly. While discussing the tragic incidents of the VA 
medical centers in Arkansas and West Virginia, Mr. Missal 
stated these failures were the consequences of ``disengaged 
leadership and dangerous culture that is fostered when leaders 
are not attentive to or invested in their staff and the 
veterans they serve.'' Mr. Missal, those were powerful words. 
They ring in my ears. They echo in this room. I hope they keep 
those failed leaders up at night.
    Sadly, they are not the only instances of failed 
leadership. Recently, we have seen veterans denied access to 
community care in direct defiance of the Mission Act 
guidelines, poor care coordination, and delayed diagnoses, 
resulting in low quality care for veterans. VA improperly 
rejecting 31,000 disability claims submitted through its own 
website, senior leaders ignoring disciplinary recommendations, 
and failing to hold management accountable. The Electronic 
Health Record (EHR) Modernization Program is on its fourth 
director in 5 years and continues to burn money and distribute 
care and disrupt care. The VA prioritizing employee 
productivity at the expense of veterans receiving compensation 
and pension benefits.
    Strong, engaged, and thoughtful leadership is the single 
most important factor needed to successfully run an 
organization of any size, be it a family owned trucking company 
like the one I used to run, or one of the largest departments 
of the Federal Government. I am confident that every member of 
this committee agrees with me. All of the examples I just 
listed are areas where leadership failed.
    However, they are not the end of the story. We can and we 
must learn from these failures to deliver a VA that is worthy 
of veterans' service to our great country. This is how we will 
drive VA toward success. Like medical facilities' empowered 
employees to identify and address issues without fear of 
punishment. Helping over 2 million veterans secure housing with 
a VA home loan over the last 2 years, saving over 200,000 
veterans from having their houses foreclosed on during record 
high inflation caused by the Biden administration, and ensuring 
that veterans receive a dignified burial.
    There are all these successes that we can be proud of, but 
unfortunately, they are not yet the norm. VA is simply not 
where it should be. Bringing VA into the 21st Century for 
veterans is my No. 1 priority. With engaged and accountable 
leadership on every level, VA can get to where our veterans 
need it to be. That starts today. We can get there with tough 
but fair oversight, common sense legislation, a commitment from 
VA leadership to always put veterans at the forefront of their 
decisionmaking process. With that, I thank our witnesses for 
being here today. I now recognize ranking member Takano for his 
opening comments.

        OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER

    Mr. Takano. Well, thank you, Mr. Chairman. You and I have 
served together on this committee for more than 8 years now. 
While we may have our differences from time to time, and while 
there are certain issues on which we will never see eye to eye, 
one thing I have appreciated about working with you is that 
whenever possible, we have done our best to find common ground. 
I think one of the most fundamental things we agree on is our 
obligation to hold VA accountable for achieving its sacred 
mission of caring for and honoring our Nation's veterans and 
their families, caregivers, and survivors.
    The last 4 years were busy and productive ones for this 
committee. We saw 36 bills enacted into law, including 
legislation that will address the effects of toxic exposure, 
improve veterans mental health, and reduce suicide, strengthen 
delivery of health care and benefits to women veterans, support 
veterans experiencing housing insecurity, and strengthening 
VA's IT modernization efforts and cybersecurity.
    Dr. Elnahal, Mr. Frueh, and Ms. Quinn, you hold a 
tremendous amount of responsibility. We know you and Secretary 
McDonough are facing many challenges as VA strives to meet its 
mission. One such challenge, a substantial one to be sure, will 
be implementing the Honoring our PACT Act, the landmark 
legislation I championed that finally recognizes the effects of 
toxic exposure as a cost of war. Because of the PACT Act, more 
than 3.5 million veterans are newly eligible for VA health care 
and disability benefits, the most significant VA eligibility 
expansion in decades.
    Like the witnesses, this committee also holds a tremendous 
amount of responsibility. We must conduct rigorous oversight to 
ensure the Department faithfully implements new legislation 
like the PACT Act, while also holding VA accountable for 
efficiently and effectively delivering all other health care 
and benefits veterans have earned.
    Fortunately, we have with us today two of our Nation's 
foremost experts in accountability. VA's Inspector General, Mr. 
Michael Missal and Comptroller General Gene Dodaro of the 
Government Accountability Office. Together, they bring to the 
witness table at least 80 years of collective experience in 
conducting independent, nonpartisan oversight, and 
investigations. As such, they will be able to speak extremely 
knowledgeably about what it takes to ensure accountability at 
VA, the extent to which the Department is successfully meeting 
its mission, and what, if anything, Congress can do to support 
improved accountability across VA.
    It is clear from their testimony that both Inspector 
General Missal and Controller General Dodaro believe strong, 
stable leadership is the foundation upon which accountability 
is built. Having served on this committee since my first year 
in Congress, I could not agree more. Mr. Missal and Mr. Dodaro, 
Chairman Bost, and I have all been in our current roles since 
the Obama administration and have witnessed numerous transition 
in VA leadership during our tenure.
    I am sure today's hearing will provide many opportunities 
for us to examine the negative effects of leadership 
instability on VA's programs. In addition, I anticipate today's 
hearing will also provide an opportunity to examine other major 
management challenges at VA, including persistent staffing 
shortages, antiquated information technology, an aging 
infrastructure, and the extent to which VA is equipped to 
address them.
    I look forward to engaging with our witnesses this 
afternoon and to beginning the work ahead of our committee, 
this Congress. Thank you, Chairman Bost, and I yield back.
    The Chairman. Thank you, Ranking Member Takano. We will now 
turn to our witnesses' testimony. Testifying before us today, 
we have Hon. Michael Missal, Inspector General of the 
Department of Veterans Affairs, Hon. Gene Dodaro, Comptroller 
General of the United States, and Hon. Shereef Elnahal, 
Undersecretary for Health and VA. Now, he is joined by Mr. 
Michael Frueh, Principal Deputy Undersecretary for Benefits at 
the VA, and Hon. Matthew Quinn, Undersecretary for the Memorial 
Affairs at VA. Mr. Missal, you are recognized for 5 minutes.

                  STATEMENT OF MICHAEL MISSAL

    Mr. Missal. Thank you, Chairman Bost, Ranking Member 
Takano, members of the committee, I appreciate the opportunity 
to discuss how the Office of Inspector General's (OIG) work 
enhances VA's accountability. The OIG shares this Committee's 
goal to conduct effective oversight of VA so that it can better 
serve our veterans, their families, and caregivers. Our 
dedicated staff is passionate about their work and committed to 
our mission of meaningful independent oversight.
    In Fiscal Year 2022, our office released more than 250 
oversight publications with 894 recommendations to VA. We made 
over 230 arrests and more than 180 convictions. We had a 
monetary impact of more than $4.5 billion, in addition to the 
invaluable work of our healthcare inspectors that enhance 
patient care and safety. These efforts to improve benefits and 
services for veterans and their families would not be possible 
without the funding and support we receive from Congress.
    Our office appreciates the work VA does every day on behalf 
of veterans. We have regular interactions that we have--we 
value the regular interactions that we have with Secretary 
McDonough and other senior leaders to discuss their concerns 
and priorities. We generally get very good cooperation from the 
Department.
    In addition, we have a strong and collaborative 
relationship with Comptroller General Dodaro and his staff. We 
coordinate efforts with the Government Accountability Office 
(GAO), which promotes more consequential oversight. Our 
oversight work has identified at least five principles that are 
foundational to accountability, and there are examples of each 
in my written testimony.
    They are, first, strong governance and clarity of roles and 
responsibilities. We have found tension between VA offices that 
have policy and oversight functions and leaders in the field 
who are not accountable to those offices. In other cases, staff 
do not understand their roles and responsibilities, or there is 
outdated or conflicting guidance.
    Second, adequate and qualified staffing to carry out those 
duties. VA faces high staff vacancy rates across its programs 
and operations, especially within Veterans Health 
Administration (VHA). These long-standing shortages make it 
challenging for VA to carry out its many programs and 
functions.
    Third, updated IT systems and effective business processes. 
VA is in the process of modernizing a number of significant 
systems that are critical to its operations. We have been 
proactively overseeing VA's implementation of these systems. 
This includes publishing 14 reports on the transformation of 
VA's electronic health record system alone.
    Fourth, effective quality assurance and monitoring to 
detect and resolve issues. VA often lacks controls that 
effectively and consistently ensure that quality standards are 
met. Breakdowns in routine monitoring and workarounds undermine 
efforts to ensure eligible veterans and their families receive 
timely services and benefits.
    Fifth, stable and effective leadership. Frequent turnover, 
vacancies, and long-term use of leaders in acting positions 
have significant negative consequences. Stable and dedicated 
leadership fosters open communication, collaboration, 
psychological safety, and responsibility among all staff.
    I would like to emphasize that OIG report findings and 
recommendations directed to a singular facility, system, or 
program are typically a roadmap to help prevent or correct 
similar problems. These problems are often undetected or 
unaddressed in other facilities or offices across VA. I hope 
that this committee will join me in encouraging leaders at 
every level of VA to review our work proactively to determine 
if findings and recommendations are applicable to their areas 
of responsibility.
    We recognize that VA is working to develop these 
foundations of accountability. We routinely observe personnel 
committed to providing the highest quality care, benefits, and 
services to veterans and their families, despite obstacles. The 
OIG will continue to provide practical and meaningful 
recommendations to help VA remove these obstacles and to 
improve its programs and operations.
    Chairman Bost, and members of the committee, this concludes 
my statement. I look forward to answering any questions that 
you may have.

    [The Prepared Statement Of Michael Missal Appears In The 
Appendix]

    The Chairman. Thank you, Mr. Missal. Mr. Dodaro, you are 
now recognized for 5 minutes.

                    STATEMENT OF GENE DODARO

    Mr. Dodaro. Good afternoon, Mr. Chairman, Representative 
Takano, ranking member, and members of the committee. I am very 
pleased to be here today to talk about GAO's work regarding the 
Veterans Administration. The VA is filled with talented people 
dedicated to their noble mission of serving our veterans. 
However, they work in an unwieldy, highly decentralized 
organization where efforts to bring about positive change are 
extremely difficult to happen. In fact, many initiatives to 
make improvements result in little, if any, meaningful change 
within the Department.
    As a result of observing this over a number of years, I 
added a number of VA areas to a list we keep for the Congress 
of what we consider to be high risk programs and activities. 
These are programs where there is waste, mismanagement, or in 
need of broad-based transformation. We have added veterans' 
healthcare, the acquisition management area, and disability 
exams to this area.
    Now, in the healthcare area, there are a number of things 
we pointed out. First, there is a need for better standards and 
measures to ensure timely access of veterans to the care that 
they need. Also, in the mental health and behavioral health 
area, more analysis to provide services targeted to veterans in 
need of intensive medical health services could be improved, 
particularly for rural veterans. Also, efforts to integrate 
behavioral healthcare into primary health services, which is 
one of VA's strategies, has been hampered by a lack of staff 
shortages, and more attention needs to be put in that area. 
Also, oversight of long-term care facilities needs to be 
improved, both in the oversight of State nursing homes that VA 
provides funds to, as well as VA's own community living 
centers.
    There also needs to be greater attention to ensure there 
are enough providers in the networks to provide care, and also 
that ineligible providers are rooted out, and not allowed to 
provide care in the system, and that employees really pass the 
background screening investigations that they must pass in 
order to ensure the care of veterans and protect our veterans. 
Also, as Mr. Mitchell mentioned, there is a need for much more 
disciplined management practices to ensure the effective 
implementation of the electronic healthcare record system.
    Now, in the acquisition management area, this area, there 
needs to be better strategies to purchase medical and surgical 
supplies in a much more efficient manner than there has been. 
There needs to be attention to supply chain management, so not 
only what is purchased, but how it is managed to get to the 
right places at the right time. Also, to make sure you have an 
adequate workforce in the acquisition area that is trained and 
competent to carry out their responsibilities, to provide the 
support necessary to give medical care to our veterans.
    In the disability exams area, this is one of long-standing 
concerns. You know, we are still using the Veterans Department, 
you know, medical criteria and earnings loss information based 
on a 1940's model. This needs to be improved. VA has been 
working on it. They are 8 years behind schedule. While there 
have been studies, there have not been improvements to this 
system. Also, there is a big backlog. There is about 80,000 
cases from their legacy appeals process, which on average is 
taking 7 years to render an appeal. There is a 380,000 backlog 
in appeals under the new five option appeals process that they 
have.
    As a result of these legacy issues, they are not as well 
positioned as I believe they need to be and could be in order 
to implement the PACT Act. Now that is going to be a heavy lift 
for them and they need to learn from some of these past areas 
where they are not applying best management practices to 
effectuate a good, efficient disability system that ensures 
timely processing of original claims, as well as the appeals 
process going forward.
    We are dedicated at GAO to working with the Inspector 
General with the Veterans Department. I have noticed some 
improvement lately in our efforts to get agreement of what 
needs to be done with the Department. I see some glimmers of 
progress, but that is only the beginning, and there is a long 
way necessary to really bring about the type of change that our 
veterans deserve. I would be happy to answer questions at the 
appropriate point.

    [The Prepared Statement Of Gene Dodaro Appears In The 
Appendix]

    The Chairman. Thank you, Mr. Dodaro. Dr. Elnahal, you are 
recognized for 5 minutes.

                  STATEMENT OF SHEREEF ELNAHAL

    Mr. Elnahal. Thank you, Mr. Chairman, Ranking Member 
Takano, members of the committee for this opportunity to appear 
before you today to discuss the Department of Veterans Affairs 
and our accountability efforts. I am joined today by my 
colleagues from the National Cemetery Administration, Mr. 
Matthew Quinn, Undersecretary for Memorial Affairs, and Mr. 
Michael Frueh, Principal Deputy Undersecretary for Benefits.
    The three of us have had the pleasure to lead a workforce 
that goes above and beyond to serve our Nation's veterans. 
Linda Nair, a licensed practical nurse in Lewistown, Montana, 
demonstrated that dedication when she traveled through two feet 
of snow to ensure veterans receive care during inclement 
weather recently. She does not believe she did anything 
special, but I believe that she demonstrates our employees' 
dedication at every level of the organization. I am sure Mr. 
Quinn and Mr. Frueh can provide similar examples of staff who 
go the extra mile for veterans.
    I want to express gratitude for the PACT Act, the largest 
expansion of benefits and care to veterans in a generation, and 
the Consolidated Appropriations Act of 2023, which provided 
additional authorities and funding to advance our mission. VA 
is also grateful for the partnership with independent 
investigators that improve the way that we serve veterans. Our 
transparency and accountability efforts are significantly 
enhanced by the Government Accountability Office, Office of the 
Inspector General, Office of the Special Counsel, and 
accreditation organizations.
    Thus, I have made it a practice to meet regularly with OIG, 
and I have met directly with GAO officials like Mr. Dodaro and 
his healthcare team multiple times to proactively identify 
opportunities for improvement. As a high reliability 
organization, or HRO, our goal is to enhance the overall 
culture of safety and decrease patient harm events across the 
organization. The HRO accountability framework involves 
instituting a just culture which balances individual 
accountability with systems thinking.
    Patient safety literature has shown that system 
vulnerabilities account for the vast majority of patient safety 
events and lapses in care, and it is incumbent upon staff and 
leadership alike to report and respond to systems issues. 
However, the framework also allows for individual culpability 
in cases of malfeasance, neglect, or instances where leaders 
fail to learn from or respond to patterns of problems when they 
arise.
    Accountability is also a culture and not a specific 
instance of wrongdoing. At VHA, our healthcare operations 
center has established a system to track implementation of our 
priorities. Review of key performance indicators in every 
facility and Veterans Integrated Service Network (VISN) allow 
us to understand which regions are exceeding expectations, 
which have made significant improvements, and which could 
benefit from additional support to ensure every veteran 
receives the care they deserve, regardless of where they live.
    Recently, the Office of Accountability and Whistleblower 
Protection, or OAWP, has undertaken a significant outreach in 
education strategy that involves onsite visits by OAWP senior 
leaders, and more widespread, tailored training. All three VA 
administrations have embraced these efforts and are working 
with OAWP to extend their reach.
    My colleague, Mr. Quinn, is ensuring that our national 
cemeteries are held to a standard befitting of a national 
shrine. Each year, cemetery directors conduct self-assessments 
of their cemeteries to ensure compliance with established 
standards. National Cemetery Administration (NCA) teams also 
conduct meticulous onsite reviews of selected cemeteries, and 
sites are required to develop plans to address any areas noted 
for improvement.
    Recently, NCA achieved an index score of 97 on the American 
Customer Satisfaction Index, the highest score ever achieved by 
any organization, public or private. My colleagues, Mr. Frueh 
and Mr. Josh Jacobs, are ensuring that veterans receive 
appropriate and timely benefits. I am proud to say, as their 
colleague, due to the efforts of dedicated Veterans Benefits 
Administration (VBA) employees, VBA processed a record number 
of claims in fiscal years 2021 and 2022. We have already 
processed more claims so far in Fiscal Year 2023 than we have 
at the same point last year.
    In addition to increasing total production, VBA employees 
also increased productivity in fiscal years 2021 and 2022, 
completing more rating claims per Full Time Equivalent (FTE) 
than ever before. Further, of the more than 320,000 PACT Act 
related claims received since the PACT Act was signed into law, 
nearly 140,000 claims have been processed, and 1,500 terminally 
ill veterans have been granted presumptive service connection.
    VA continues to conduct compliance and quality reviews to 
ensure leaders are accountable for quickly and accurately 
providing veterans the benefits they have earned. The Legacy 
Appeals Inventory has been reduced to just over 25,000 cases, 
representing a 92 percent reduction. Caring for our country's 
veterans and their families is a mission that unites us all. I 
am honored to work with this committee, Congress as a whole, 
and our many other partners to embrace our collective 
responsibility to serve veterans.
    Chairman Bost and Ranking Member Takano, thank you for the 
opportunity to appear before you today, and we look forward to 
your questions.

    [The Prepared Statement Of Shereef Elnahal Appears In The 
Appendix]

    The Chairman. Thank you, Dr. Elnahal. We are going to now 
go to questions, and I would like to recognize myself first for 
5 minutes.
    Dr. Elnahal, on January 31 of this year, Dr. Miller-Meeks 
and I sent a joint letter to you asking regarding data 
regarding abortion provided by the VA. We requested that you 
would provide us that data by February 10, 2023. However, my 
office is still waiting for your response. Can we get a 
commitment from you that we can get that response by March 3?
    Mr. Elnahal. Chairman, we will certainly respond to the 
letter. We have to make sure that our response respects the 
safety and privacy of the veterans we serve.
    The Chairman. Right. Believe me, in the letter, we were not 
asking for names. We are asking for numbers. That is what we 
are asking for. Also, with that, we are asking the procedures 
and at what point these were done.
    No private information. We are not wanting any private 
information. We are looking at this as a whole. Also, we are 
needed to ask also if you could respond to the quarterly 
request for data starting on March 31, because we know there is 
pending suits over this. We are just wanting to know where we 
are at as far as your mission and the procedures that you are 
doing without names.
    Mr. Elnahal. I understand, Mr. Chairman. We are committed 
to getting you a response to that letter.
    The Chairman. All right, thank you. Also, I need to applaud 
VHA for their efforts to create an environment where any 
employee can raise their hand and report a problem. We 
appreciate that. However, too often I hear from employees who 
have reported harassment and hostile work environments, but 
nothing happens. We are losing good employees because we are 
not removing bad ones. How do we turn that around? That is for 
you, doctor.
    Mr. Elnahal. Mr. Chairman, I think the initiative that we 
are undertaking around high reliability speaks exactly to what 
you are asking about. We want every single employee in our 
healthcare system and beyond to understand that they have the 
right to raise a voice and in fact, that they should be 
encouraged to raise issues when they see them without fear of 
retaliation and in a manner that protects whistleblowers so 
that we can respond effectively to improve the system on behalf 
of veterans. That is the core of the high reliability effort, 
which started years ago and is now in place at every single 
facility as of September of last year.
    The Chairman. I really do believe that you as an 
administration and the Secretary are trying to do that. I do 
believe that there are certain administrators at different 
facilities that maybe do not encourage that as much. We want to 
work with you to make sure that when we get those reports, that 
we make sure that the employees understand we want them to come 
forward, because it is about the veterans. It is not about the 
management of any one facility.
    Mr. Missal, you have been the Inspector General since 2016. 
Your statement about disengaged leadership is very powerful. Do 
you believe VA leadership is up to the task of running the one 
of the largest departments in the Federal Government?
    Mr. Missal. We have found that the very senior leadership 
at VA is very engaged, and they understand the importance of 
oversight. They work with us very closely. However, all levels 
of leadership need to be engaged to have the highest 
functioning operation. What we have found in our reports is 
that a root cause toward many of the problems is due to some 
failure of leadership at some level.
    Getting back to your last question about what can be done. 
If VA does not hold people accountable for issues that they 
have, it is really hard to improve the culture, and it is 
really hard to improve leadership.
    The Chairman. I understand. Mr. Frueh, VBA is faced with a 
growing backlog of disability claims. How are you working to 
build trust with veterans that VA will decide their claim 
correctly the first time?
    Mr. Frueh. Excuse me?
    The Chairman. Yes.
    Mr. Frueh. We take our mission very seriously to provide 
benefits to veterans, to all veterans, and we do not want any 
veteran to wait to access the benefits they have earned. We 
have positioned ourselves in the last several years with a 
series of people, process, technology changes throughout our 
organization. In terms of people, hiring more people in the 
last several years. In terms of technology, providing more 
enabling technology so we can quickly gather information and 
reach a decision, whether it is for a compensation claim, or an 
education claim, or a certificate of eligibility for a loan 
guarantee. Through processes trying to find a way to get 
feedback from our people to the people that design the 
processes to say that is not working as well as we can.
    We have been changing dramatically over the last several 
years, and the results have shown that we have been able to 
increase our production and deliver more quickly, more benefits 
to more veterans, more equitably than we ever have in the past 
before. I hope veterans judge us by what they see through the 
service we deliver.
    The Chairman. Thank you for those answers. With that, I 
will yield back and now recognize the ranking member, Ranking 
Member Takano.
    Mr. Takano. Thank you, Mr. Chairman. Dr. Elnahal, House 
Republican leaders recently announced their intent to cap 
Fiscal Year 2024 discretionary spending at the Fiscal Year 2022 
enacted level. For VA, this would mean a cut of at least $31 
billion in funding for veterans health care because Congress 
approves funding levels for VA medical programs one Fiscal Year 
in advance.
    I expect this committee will have a much more robust 
discussion about this at our annual budget hearing later this 
spring. Since the topic of today's hearing is applying lessons 
learned to drive future success, please tell us what a $31 
billion cut would mean for VA's future success.
    Mr. Elnahal. Well, if that were to happen, Mr. Ranking 
Member, I would be deeply concerned about resourcing the health 
care needed, not only for our existing base of veterans, but 
for veterans who are expected to increase their reliance on 
healthcare within the VA, including the aging veterans already 
enrolled in VA Healthcare, but also the veterans who are 
standing to benefit from the PACT Act, both new enrollees and 
veterans currently enrolled who stand to increase our priority 
group after they apply for additional benefits from VBA.
    On top of that, we have a situation where we expect demand 
to grow significantly year to year. We need more funding and 
more support, not less. I would be very concerned about 
resourcing the care needed for veterans.
    Mr. Takano. Well, thank you. Beyond the fact--thank you for 
that response--beyond the fact that this would destroy your 
ability to prepare for the up to 3.5 million PACT Act eligible 
veterans to enter the VA health care system, and I mention that 
because Inspector General Missal just cited in one of his five 
concerns about the success of VA is the understaffing, the 
chronic understaffing. VA is already chronically understaffed. 
Can you comment about what this $31 billion cut would mean for 
VA's ability to staff up just in the professional arena? The 
professional providers or medical providers what this would 
mean to be able to staff up for the 3.5 million veterans we 
anticipate entering into the system?
    Mr. Elnahal. I think it is a very good question, Mr. 
Ranking Member. Certainty to at least to the greatest extent 
possible on funding in the out years is really important when 
it comes to the hiring mission. Of course, we need the funding 
to start paying for new employees now as we bring them on. We 
brought on a record of 18,500 additional employees within the 
healthcare system in the first quarter of this fiscal year. If 
you ask our operational leaders in the field, as I do every 
time we meet in our governing board about concerns they have 
for funding into the future, this is an FTE base that we hope 
continues into the out years. The need to be able to pay these 
employees to meet the veteran mission will continue into the 
out years. We do hope that we continue to see the generous 
funding that Congress has been able to provide VA.
    Mr. Takano. Well, you know, what programs or operations 
could withstand a cut of this magnitude? Are there any at VHA?
    Mr. Elnahal. I can not think of one, Mr. Ranking Member.
    Mr. Takano. Thank you. Dr. Elnahal, I am sure you are aware 
the Drug Enforcement Administration (DEA) proposed two rules 
relating to prescribing controlled substances via telemedicine. 
These rules are urgently needed because we are rapidly nearing 
the end of the COVID-19 public health emergency, which for 
almost 3 years now, has waived requirements for patients to 
have in person evaluations with their prescribers prior to 
receiving controlled substance prescriptions. Very quickly, I 
do not have much time, will VA commit to providing a bipartisan 
briefing for committee staff no later than this Friday so we 
can better understand the potential effect of this rule for our 
veterans?
    Mr. Elnahal. We will definitely brief you, Mr. Chairman, 
when it comes to the implication for veterans. I am very 
pleased to see that DEA put this rule out. We were very 
concerned about the ability to initiate new prescriptions for 
controlled substances, which not only include pain medications 
like opioids, but also immunosuppressants, for example, 
critical medications for conditions that veterans commonly 
face. We do hope this rule comes into effect, of course, before 
the public health emergency ends, so that we do not see any 
lapses in care for veterans getting care through telehealth.
    Mr. Takano. Yes, well, thank you for that. We only have 30 
days to comment on the rule, as you know. We are already 
hearing from some stakeholders that DEA's rules are still too 
strict and could present unnecessary barriers for patients who 
need these medications to treat pain, substance use disorder, 
and other mental health conditions. You just mentioned 
immunosuppressants. It is not just about controlling opioids. 
We got to make sure that our patients in rural areas remain 
capable of being able to get these medications without undue 
burdens. I yield back, Mr. Chairman.
    The Chairman. Thank you, Ranking Member. I now recognize 
General Bergman for 5 minutes.
    Mr. Bergman. Thank you, Mr. Chairman. We will get right to 
it, folks. Mr. Frueh, I would like to ask you about the current 
flaws in the VA accreditation system for agents who are 
assisting veterans in obtaining disability benefits. Under the 
current model, accredited agents cannot charge fees for 
assisting in an initial claim, but instead collect on the back 
pay after the process is complete. Do you agree that this 
creates a financial incentive for those accredited agents to 
drag out the process as long as possible instead of getting 
things right initially?
    Mr. Frueh. As I said before, I do not want any veteran to 
wait to receive their benefit. In terms of accredited agents, 
agents are not allowed to charge a veteran for submission of a 
claim before VA. They are able to charge for an appeal, but not 
for an initial claim.
    Mr. Bergman. The agent benefits if there is an appeal.
    Mr. Frueh. We always recommend to veterans to look for----
    Mr. Bergman. Let me cut to the point here. I guess the goal 
is, when do the veterans benefit, because we can talk about 
things like efficiency and effectiveness. You can be very 
efficient. You can answer 1,000 emails today. What was the 
effectiveness to the, if you will, the end game in this case, 
benefiting the veteran if none of those emails resulted in a 
positive outcome for them?
    Remember, last time I checked, we are all on this earth on 
a timeline. It is God's timeline. It is not anybody else's. The 
point is, a moment lost is lost forever. I would suggest to you 
that when you think about the requirement in the mission 
statement and the culture at the VA, and I applaud all of you, 
I applaud all of you for doing what is right for the veterans 
because they did what is right for our country through their 
service.
    We need to understand that to delay outcomes for the wrong 
reason is then hurting the veterans in the long term. I will 
just, you know, I could probably talk about that for a long 
time and give examples, but time is of the essence for any 
veteran.
    Dr. Elnahal, we continue to receive reports from veterans 
and providers alike that VHA referrals for community care are 
still taking excessive time to be approved and processed. Why 
is this? What is the Agency doing to alleviate this, and better 
adhere to Mission Act guidelines for providing veterans care as 
timely as possible? Remember, time is of the essence. Sir.
    Mr. Elnahal. Thank you, General, for the question. It 
speaks to my priority around ensuring veterans the soonest and 
best care possible, including in the community. Frankly, the 
time it takes on average for our system to schedule 
appointments in the community, as you mentioned, is much too 
long. It is an average of about 28 days. From the time that a 
veteran knows they need an appointment to the time that they 
receive a confirmed appointment in the community, we have to 
reduce that timeframe.
    That is why it is one of our True-North metrics that we are 
monitoring across the system, facility by facility, VISN by 
VISN, and tracking over time to reward the high performers and 
top improvers in improving their processes, but also to 
recognize the folks that need help and have the system come to 
their assistance.
    We are also making sure that we look at new scheduling 
systems to assist our offices of community care across the 
system. In fact, we have a request for information for a 
commercial off the shelf solution that should help with 
scheduling.
    Finally, we are also introducing an initiative to have 
veterans schedule their own appointments as an option should 
they choose to do so, as we have seen in pilots across the 
country, that it dramatically improves the time it takes for a 
veteran to receive a confirmed appointment, after which the 
veteran circles back to us so that we can ensure that care is 
coordinated. I want to make sure this is an option available 
across the country, General.
    Mr. Bergman. Thank you. I know my time is about to run out, 
but that is an example of giving the veterans control of their 
future outcomes, just like giving them control of who they can 
work with for disability claims, for getting care in the 
community, for anything. Enable the veterans, and they are 
going to get into it, and the VA will be better. Thank you, Mr. 
Chairman. I yield back.
    The Chairman. Thank you, Mr. Bergman. Ms. Brownley, you are 
recognized for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chairman. First, Dr. Elnahal, 
I just wanted to express my strong support for the interim 
final rule around reproductive healthcare and your department's 
efforts to ensure access to a full complement of healthcare. I 
really want to compliment the team that you have put on. We 
have had several meetings with them to follow up, and I just 
appreciate your diligence on that, your team's diligence. I 
just want to say, for the record, abortion is healthcare. Thank 
you. Thank you very much.
    You know, this is a broad hearing. I am going to ask a 
broad question. Dr. Elnahal, what do you think VA is doing well 
with regards to serving women veterans? This is a broad 
question, but I want to know what the answer is with regard 
throughout the entire enterprise. I am not really interested in 
that, you know, perfect pilot program that is out there that is 
doing really well or a certain area that is just providing 
outstanding healthcare to our women. You know, what is VA doing 
well with regards to serving women? What do you think VA has 
the most opportunity for improvement?
    Mr. Elnahal. Well, I share your prioritization, 
Congresswoman, of better serving women veterans every day in 
this organization. The fastest growing demographic of veterans 
by far, accounting for 30 percent of new enrollees in our 
healthcare system every year. We are seeing some positive 
signs, certainly with the capacity building we have been doing.
    We have women's health program coordinators now at every 
major medical center within the system. We have women's health 
mini residency programs to be able to train every primary care 
provider that we can in comprehensive women's health. Some of 
these providers have been seeing mostly men for many years. We 
want to make sure they have that updated education about how to 
treat women veterans with the full scope of care. Of course, we 
are working as hard as we can to hire more gynecologists and 
specialists on women's health.
    I think where we have some room to grow is the trust among 
women veterans. That has everything to do with making sure our 
space is accommodating. We provide more and more dedicated 
entrances to women veterans in facilities. That is an 
infrastructure challenge. Making sure our programming across 
the board is meeting women veterans' needs.
    Ms. Brownley. Thank you for that. Just to follow up, I 
think with the Inspector General here, I know that one issue 
that he has pointed out are Military Sexual Trauma (MST) 
coordinators across the enterprise. I guess, you know, I should 
ask you or ask the Inspector General, you know, what is it 
going to take to get--the intention of an MST coordinator is to 
have a full-time MST coordinator in all of those areas where 
the demand is. I know that there can be some exceptions to that 
out in a rural area somewhere where they are just not servicing 
women veterans. I get that. What is it going to take to get to 
a, you know, full FTE MST coordinator throughout the VA? Is it 
going to require the fact that we mandate that so the local 
medical centers do not have control over their resources with 
regards to deciding if it is going to be 1/10 of an FTE or 50 
percent of an FTE, et cetera?
    Mr. Missal. Well, certainly our reports on MST, we have got 
multiple reports on MST certainly show that more can be done in 
this area. I know we have had discussions with Dr. Elnahal and 
his staff about this. I think they recognize a need. As you 
pointed out, it could very well just be a resource issue. We 
agree that more attention needs to be given to this area. 
Hearings like this and the previous hearing that we had, I 
think, really shine the proper spotlight on it.
    Ms. Brownley. Dr. Elnahal, in the last women's veterans 
task force that we had, we had a roundtable to look at the 
implementation of Deborah Sampson. It was really pointed out to 
us by women veterans representing lots of different agencies, 
and Veterans Service Organizations (VSOs), and, you know, 
across the country as well, really stating that this issue 
around sexual harassment and assault within the VA is still 
problematic, that it is implemented in some places, and not in 
others, and it is slow moving. That they cited examples of 
women being really retraumatized for reporting these incidences 
and coming to the VA to report them.
    I will just say I do not have any time left, but, you know, 
we have got to be vigilant across the entire enterprise to make 
sure that if any woman walks into the VA that they will be free 
from any kind of harassment or sexual assault. Thank you, Mr. 
Chairman. I yield back.
    The Chairman. Thank you, Ms. Brownley. Mr. Franklin, you 
are recognized for 5 minutes.
    Mr. Franklin. Thank you, Mr. Chairman. Mr. Frueh, my first 
question would be for you. In the last Congress, I served on 
the Oversight and Reform Committee. Part of that oversight 
involved the National Personnel Records Center. One of the big 
concerns we had at that time was with those employees working 
remotely and so many of the medical records not being 
digitized, we had a huge backlog of veterans unable to verify 
eligibility for VA benefits and that sort of thing. Wondering 
what the impact is currently on you, what is the backlog, and 
what do you see coming down the pike? How can we fix that 
problem faster?
    Mr. Frueh. The backlog today is just over 200,000, 201,000 
out of 750,000 claims. It is about 26 percent, which is a 
fairly standard amount. In terms of National Personnel Record 
Center (NPRC), that is actually a very good story where 
National Archives and Records Administration (NARA) personnel 
came to us for vaccination through VHA several years ago. We 
placed three different shifts of VBA personnel in the Personnel 
Record Center so that we could pull files.
    After the first few months of the pandemic, that led to a 
backlog in their records retrieval, which hurt us in terms of 
operations.
    Within a few months, we returned to two-to-three-day 
responsiveness in retrieving records from the NPRC. I would say 
that is no longer an impact in our operations. What we see now 
is the impact in the number of claims that are ready for 
decision, where they were in gather evidence mode before, now 
we see a lot more claims in the ready for decision, which is 
the last stage before we complete a claim.
    The production of records from NPRC is no longer an issue. 
We are actually scanning every PACT veteran's records into NPRC 
and eventually every veteran's records, living and dead. When 
someone files a claim, they will not have to wait a second for 
us to get access to their information. We provide those files 
to NPRC or NARA so they can access them as well to deliver to 
their customers.
    Mr. Franklin. I have a company in my district, a private 
company, that is been contracted to digitize those. What I do 
not know, I am not sure the timeline. When do you anticipate 
all those records being fully digitized?
    Mr. Frueh. We are talking about 46 million or so records. 
That will be many, many years. The PACT records, the veterans 
that we believe fall in the PACT cohort I think it is about a 
year and a half is when we expect to have all of them 
digitized.
    Mr. Franklin. All right, thank you. Dr. Elnahal, as the 
greater veteran population continues to age, the importance of 
noninstitutional or home and community-based services becomes 
more important. What are you all doing to ensure that veterans 
get the care and support that they need, whether it is through 
the VA or the community, especially for veterans living in 
rural areas?
    Mr. Elnahal. It is a big priority for us, Congressman, 
especially as we see the veteran population aging and more in 
need of homebased care where we can. We in fact have an 
initiative called the Aging In Place Initiative to see the full 
scope of options available to vets and to extend all of them 
where we can. We, of course, have our community care-based home 
services. We also have our Caregiver Support program, which we 
are investing in more and more, and we are reevaluating our 
eligibility criteria for that, while we have a 3-year 
moratorium on legacy participants in the caregiver support 
program, particularly the Parent Child Assistance Program 
(PCAP) program.
    Then finally, we are expanding the Veteran Directed Care 
initiative to every single facility within 2 years, which is an 
acceleration of the original 5-year timeframe. Because we know 
that so many veterans have been able to benefit from this by 
basically asking a loved one or close, someone close to them to 
be their caregiver and allow them to have that financial 
support. We are pushing hard on expanding that capacity, and we 
share your prioritization of this important issue.
    Mr. Franklin. Very good. Thank you, Mr. Chairman. I go 
back.
    The Chairman. Thank you, Mr. Franklin. Mr. Levin, you are 
recognized for 5 minutes.
    Mr. Levin. Thank you, Mr. Chairman. Mr. Frueh, I appreciate 
that VA's testimony addressed the Veterans Rapid Retraining 
Assistance Program, or VRRAP program, which was established to 
help retrain veterans who were unemployed due to the pandemic. 
You may remember I was pretty vocal last year about using as 
much of the $386 million appropriated for the program to 
benefit veterans before the program expired.
    In early September 2022, which was 16 months into the 
program, VA had only allocated around 56 percent of the funds. 
I was surprised, pleasantly surprised, that VA was ultimately 
able to obligate 98 percent of these funds by mid-December. My 
question for you, Mr. Frueh, is how was VA able to drastically 
accelerate veteran participation in the span of 3 months?
    Mr. Frueh. I think a lot of that went to consummate 
awareness. Not to use the word advertising in the traditional 
sense but getting the word out to veterans and getting the word 
out to schools, because two of the issues we had with VRRAP 
were supply and demand. The number of programs that were 
willing to say, I want to operate under this payment structure 
of VRRAP was hard to get off the--to get off the ground at the 
beginning, but by the end, we had 1,300 programs enrolled in 
the VRRAP program.
    Then awareness to veterans because the restriction on who 
is eligible to be certified for enrollment where you had to be 
unemployed due to a COVID related circumstance and have not 
received any Federal or State aid, and not have any remaining 
Vocational Rehabilitation and Employment (VRE) or education 
entitlement, it made it difficult at first to get the wheels 
rolling. As we got the word out, as people started to go 
through the programs, we got a lot more. I think eventually we 
had 30,000 applicants almost for the program, of which 4,300 
graduated through the program, and we are very happy that we 
got more through.
    Mr. Levin. That is a good segue to my next question, which 
is about the data. I understand that the data on all the 
outcomes is not available, as lots of veterans are still 
enrolled in programs or within the 180-day mark for certifying 
employment.
    We do have some data. To the best of my knowledge, as of 
January 3, VA had verified that 818 veterans who participated 
in VRRAP had secured employment. By comparison, 2,744 veterans 
had not secured employment. Mr. Frueh, to what factors does VBA 
attribute this relatively low success rate? What is VA doing to 
improve outcomes for veterans who are still participating in 
VRRAP?
    Mr. Frueh. Well, one, we have a lot of experience in VRE in 
terms of working with employers and future employers, and the 
Vet Tech program is a good analog to this in a different 
sector, in Science, Technology, Engineering and Mathematics 
(STEM) related or cyber related things. We have an employer 
consortium in that area which we work with to find suitable 
employment as quickly as we can afterwards.
    One of the tenets of VRRAP that I like, that I think we are 
starting to see some benefit from is the payment to the program 
upon employment. Programs are getting better at recruiting for 
their students. As of now, we are at, I think, 1,000 employees. 
We have gone up a few hundred in the last several weeks. We 
will see as we get through the next four to 6 months after more 
of the people in the program complete the program. I think a 
lot of it is relying upon the programs themselves to push for a 
positive outcome at the end.
    Mr. Levin. What are any other important lessons that you 
might have learned as a result of this program, and 
specifically, how will you incorporate the lessons that you 
have learned in similar programs in coming months and years?
    Mr. Frueh. I think the pay for performance is a nice 
feature of it from the terms of make sure people do not just go 
through the program. Our programs just do not apply to get 
Federal aid without any positive outcomes at the end. I think 
that feature is something that was a deterrent at the 
beginning, but as we worked our way through it, we got a lot 
more programs involved.
    I think starting earlier, getting the word out a whole lot 
earlier would have enabled us to get more programs involved 
earlier, which would, of course, then enable more enrollment by 
veterans in those different programs.
    Mr. Levin. Mr. Missal and Mr. Dodaro, do you have anything 
you would like to add to anything that has been said?
    Mr. Missal. No, I mean, we looked just very broadly at that 
program, but not in any detail. Obviously, you know, we looked 
very closely at all the VBA programs to see whether or not we 
should be doing projects in them, and we are always open to 
looking even more.
    Mr. Dodaro. I do not have anything to add.
    Mr. Levin. Well, I am out of time. I would just hope that 
the next time we stand up a program, that it does not take so 
long to really get things rolling, and that you have hopefully 
learned some lessons from that initial year where very little 
was happening. I am sure it will be talking about it, although 
I hope it is nothing like a pandemic or anything like that. I 
know we will be having new programs in the years to come, so I 
appreciate the work you are doing, and I will yield back.
    The Chairman. Thank you, Mr. Levin. Mr. Rosendale, you are 
recognized for 5 minutes.
    Mr. Rosendale. Thanks so much, Mr. Chair. General Quinn, it 
is so good to see you.
    Mr. Quinn. Congressman, good seeing you.
    Mr. Rosendale. Dr. Elnahal, I have got a couple of 
questions for you. On September the 9th 2022, the VA published 
an interim final rule titled Reproductive Health Services to 
immediately amend its regulations to remove the exclusions on 
abortion and abortion counseling. As you well know, I was 
deeply disturbed by that. I was proud to co-sponsor a 
resolution of disapproval being led by Congressman Cloud and 
Chairman Bost.
    This rule is in clear violation of Section 106 of the 
Veterans Healthcare Act of 1992, which restricts abortions. The 
administration's explicit decision to violate the law is a slap 
in the face to Congress and the separation of powers. 
Specifically, the rule would direct the VA to provide abortions 
when health of the mother would be endangered. This rule also 
directs the VA to provide abortion counseling. While you and I 
may disagree on this issue, the taxpayers deserve to know how 
their dollars are being spent. With that being said, how many 
abortions has the VA provided since September 2022?
    Mr. Elnahal. Congressman, I appreciate the question. It is 
actually a number that is small enough to possibly allow for 
triangulation and identification of veterans and clinicians 
involved. I think in this public forum, it would be quite risky 
to communicate that information. We are happy to work with you. 
Of course, the Chairman's letter response will be important in 
getting feedback back to this committee.
    Mr. Rosendale. We certainly want to make sure that we do 
get that information. How many dollars has the VA spent 
providing abortions since 2022?
    Mr. Elnahal. What I can say, Congressman, is that we 
projected in the impact analysis of the interim final rule that 
we are talking about less than 1,000 veterans per year based on 
how we restricted the ultimate abortion service latitude in 
cases of the life of the veteran, the health of the veteran, 
rape, and incest. It was really the impetus was around veteran 
safety in the wake of the Supreme Court decision that no longer 
made abortion a constitutional right.
    Mr. Rosendale. Dr. Elnahal, I understand our differences of 
opinion and what may or may not happen and the definition which 
provides for this to be allowable. What is the dollar amount 
spent providing these abortions?
    Mr. Elnahal. All of that is to say that the number of 
veterans is quite small. The dollar amount is compared to, of 
course, our total appropriation a very small number.
    Mr. Rosendale. I see you will not answer the first two 
questions. How many veterans have received abortion counseling 
since September 2022? Can we answer that one?
    Mr. Elnahal. For the same reasons I mentioned before, 
Congressman, with all due respect, I think we would have to 
look at the implications of veteran safety before communicating 
that in the public forum.
    Mr. Rosendale. Okay, well, we will look forward to getting 
that information in a more private setting. Even more 
egregious, there are no conscious protections for VA medical 
staff. A VA nurse practitioner, army veteran Stephanie Carter, 
asked the VA for religious accommodations, but allegedly was 
told by the Department that there is no process that exists to 
review such requests. The Department says that it does allow 
employees to opt out of providing certain services based on 
their religious beliefs. Yes or no? Can the VA medical employee 
opt out of providing abortions or abortion care?
    Mr. Elnahal. Yes, Congressman. In fact, we have made that 
policy clear very shortly after the release of the interim 
final rule through an all-employee message. As of earlier this 
year, we put out specific, clear guidance on how staff and 
physicians alike can opt out of doing these types of services. 
We want to respect points of view on this and personal values 
and religious beliefs. That is a core principle that we are 
following.
    Mr. Rosendale. Thank you. I would like to see that actually 
placed into the rule to avoid any confusion. If we could make 
sure that that happens as we go forward. I want to jump to 
another subject real quick.
    I am glad to see literally everyone here in the room today 
with no facial coverings. We can actually see what you look 
like. I wrote the VA a letter last week regarding a veteran who 
contacted my office in regards to being denied service at a 
Montana VA clinic for refusing to wear a mask. It is outrageous 
to deny anyone, particularly a veteran, medical care over a 
personal decision. The Biden administration announced that the 
public health and national emergencies would terminate on May 
the 11th 2023. While the date is very arbitrary, even the 
President recognizes he can no longer hold the public hostage 
with these executive powers. Do you support denying veterans 
care over their unwillingness to wear a mask?
    Mr. Elnahal. Well, Congressman, I will say that we have 
looked at this recently as the pandemic has evolved into a much 
better place. Just as of this week, we have taken the 
opportunity to maximally relax the masking restrictions in our 
facilities according to Centers for Disease Control and 
Prevention (CDC) guidelines based on transmission levels 
locally. We are bound to follow CDC guidelines. We think it is 
important to be consistent with those guidelines, but we are 
trying to be as open as possible to veteran, and clinician, and 
staff preferences alike on this.
    Mr. Rosendale. When do you anticipate lifting these masking 
requirements, period?
    Mr. Elnahal. Well, again, Congressman, we work with the CDC 
on this. We not only follow their guidelines, we partner with 
them regularly. As the pandemic evolves, we will see what comes 
next.
    Mr. Rosendale. Thank you, Mr. Chair. I yield back.
    The Chairman. Thank you, Mr. Rosendale. Mr. Pappas, you are 
recognized for 5 minutes.
    Mr. Pappas. Thanks very much, Mr. Chairman. I want to 
direct my first question to Mr. Frueh. There has been a little 
bit of a conversation here about claims backlogs, and I just 
want to draw your attention to one specific issue. The 
committee has received several inquiries regarding delays in 
processing aid and attendance pension claims, and I am 
wondering if you can shed any light on those backlogs and what 
steps are being taken to address it.
    Mr. Frueh. It is almost like I am on my computer. Aid and 
attendance backlog, there is a slight backlog in aid and 
attendance. There are several thousand claims, and I now 
actually have numbers here, which probably easier if I get to 
you there. Our average days to complete aid and attendance is 
hovering around 110 days, I think, now. The reasons for 
backlogs are varied, you know, in the claims portfolio. It is 
because of the large volume of claims and the lack of ability 
to produce documents back in time in aid and attendance. It is 
a smaller volume of work, but in a commensurately smaller 
organization. I do not know how large the backlog is. I would 
be happy to dig into that with you further, but anything we can 
do. As I said before, I do not want any veteran to wait for a 
benefit.
    Mr. Pappas. That is helpful. Maybe we can dig into the 
specific issues that we have been hearing about and see if 
there is anything that is materially changed around that and 
just see what attention can be drawn to it.
    I am wondering if you could answer an additional question. 
Last Congress, the Disability Assistance and Memorial Affairs 
Subcommittee, of which I am now the ranking member, had a 
hearing regarding VA's outreach to survivors and dependents. I 
think everyone was surprised at the lack of personnel and 
resources that has been dedicated to important tasks, including 
the proactive communication with new survivors. I am wondering 
if you can talk about what action has been taken since that 
hearing to bolster outreach and any steps that have been taken 
to address this issue for survivors' independence and make them 
aware of benefits that are available through VA.
    Mr. Frueh. Awareness is one of the most key elements of 
enabling veterans to access their benefits. For survivors, we 
have an Office of Survivor Assistance that is, you know, within 
VBA, but it is for the entire department. We also have an 
Office of Outreach and the Office of Outreach and Office of 
Survivor Assistants work together with Public and 
Intergovernmental Affairs and others to get word out. For 
example, with the new PACT Act, we reached out to every former 
Dependency and Indemnity Compensation (DIC) applicant who was 
denied to say, please apply again. There is new rules. There is 
a new legislation you might be able to apply for.
    We work with the branches of the military casualty 
assistance officers, and we work through county VSOs, State 
VSOs, and big national VSOs to amplify our message to 
eventually get to the people who need the information. I can 
say as a son of a deceased veteran whose mother, my mother did 
not know about benefits were eligible she was eligible for. I 
hated not knowing what was eligible for her and I worked at VA. 
I am more educated now in the benefits. And I want to make sure 
that there is no survivors like my mother that are unaware of 
the benefits that can help them with their lives.
    Mr. Pappas. Well, thank you for that commitment. One final 
question for you. Last year, the Department announced that it 
is closing a gap in survivor benefits for certain LGBTQ-plus 
veterans, specifically those who are unable to get married 
before the 2015 Obergefell decision. I am wondering if you can 
provide a status update on VA's benefits for these same sex 
surviving spouses and how many survivors have applied for 
benefits through VA so far.
    Mr. Frueh. That is something I will definitely have to talk 
to you offline. I do not have the numbers on veterans who have 
applied for those benefits, but our goal for that was to act as 
if those survivors were in the same if they were in a State 
that did not allow a marriage between a same sex couple, we 
wanted them to have access to the same benefits as if they 
were. The opening of that was geared around equity to veterans 
in different groups. The numbers I will have to work with you 
offline for.
    Mr. Pappas. Okay, thank you. We will follow up on that. I 
yield back, Mr. Chair.
    The Chairman. Thank you. I now recognize Representative Van 
Orden for 5 minutes.
    Mr. Van Orden. Thank you, Mr. Chairman. Thank you all for 
coming here today. I appreciate it greatly. I am a 100 percent 
service-connected disabled veteran, and I get all of my 
healthcare through the VA. I want to share with you and preface 
these comments, my comments that the vast majority of my 
experiences at the VA have been overwhelmingly positive. I am 
very grateful for the staff throughout Western Wisconsin, 
including La Crosse and the medical center in Tomah. I am very 
proud of them.
    However, we can all do better. That is what we do as 
Americans. We continuously seek improvement. In that spirit, 
Dr. Elnahal, I want to share with you how I spent my first day 
in Congress. I got sworn in and I received an email, and I am 
going to read it to you. Right now. My wife and I tonight 
attended my brother's visitation, and I will be attending 
tomorrow his funeral. He passed away on Wednesday before 
Thanksgiving. He is a Wisconsin born, recently retired from the 
army after 22 years, currently residing in North Carolina. He 
leaves behind a beautiful wife and three beautiful young 
children. He went to the VA for help for mental health issues 
and was turned away. He took his life the Wednesday before 
Thanksgiving. Two days later, a letter from the VA came in the 
mail accepting him. It was too late. His name is Retired Major. 
I will not read that publicly.
    It should be illegal for the VA to refuse a soldier who is 
retired or active duty trying to get help from getting 
admitted. I am requesting for you to work with your 
counterparts in North Carolina on some kind of legislation to 
prevent this from happening to another soldier or veteran 
again.
    I spent my first day as a United States Congressman calling 
the brother of this dead soldier, calling the father of this 
dead soldier, calling the widow of this dead soldier, and 
apologizing profusely for the Federal Government's inability to 
schedule a medical appointment. It sits on my desk with this 
sticky pad and it said, this is why I am here.
    I know you have got a tough job. I know that sometimes we 
can be distracted by the events, especially when you are 
leading a huge bureaucracy like the VA. I prepared this for 
you. Will you bring that to him, please? Will you bring that to 
the doctor? This is a copy of this letter, sir. You can put 
that on your desk or you can hang that on your wall. There is a 
blank sticky pad there. I think it would do us all well if you 
wrote on there why you are here, and to never forget that.
    Things are going to be dark some days. People are going to 
get on you. I understand that. Every day when you wake up in 
the morning, me and my fellow millions of veterans throughout 
the United States of America would be deeply grateful for you 
if you remember why you are here. With that, I yield back.
    The Chairman. Cherfilus-McCormick, Congresswoman Cherfilus-
McCormick, you are recognized. I am sorry.
    Ms. Cherfilus-McCormick. Thank you, Mr. Chair. My first 
question is for Mr. Dodaro. In 2008, the National Defense 
Authorization Act directed VA and the Department of Defense 
(DoD) to develop and implement systems that would allow for 
interoperable electronic patient healthcare information 
exchange between the Department. After numerous starts, stops, 
and failure attempts, that requirement has not been achieved. 
Now, both departments are working in deploying Cerner 
Corporation's EHR platform across the respective healthcare 
systems.
    Mr. Dodaro, does GAO have an estimate of the VA's 
expenditures on failed EHR modernization efforts before the 
current Cerner EHR project? We are very concerned that the 
total cost for the Electronic Health Record Modernization 
(EHRM) project remains to be seen. It would be helpful for the 
committee to know the running total for taxpayer spending on 
past EHR modernization efforts.
    Mr. Dodaro. The cost that we estimate is over $1.7 billion 
for failed predecessor electronic healthcare record systems 
that either failed or did not come to fruition.
    Ms. Cherfilus-McCormick. Thank you so much. My next 
question is for Dr. Elnahal. Dr. Elnahal, the EHRM program is 
in the midst of another pause, presumably to address some of 
the system's long standing technical and design issues. What 
has your office's participation been in this evaluation, and do 
you think this pause is going to positively impact the 
direction of the program? If so, how?
    Mr. Elnahal. Well, Congresswoman, that was the exact intent 
of doing the pause. We called it the assess and address period, 
because that is exactly what we have been engaged in diligently 
since we announced it. We are looking specifically at the 
system configuration issues, but also people and process 
matters that led to our need to disclose to tens of thousands 
of veterans that their care may have been delayed or affected 
by the implementation of this system. We took that 
responsibility very seriously.
    In the coming weeks, we are going to be releasing the 
results of that work to include not only Oracle Cerner's 
responsibility to fix the configuration of the system, but also 
our own and making sure our people and process matters continue 
to improve. We are very dedicated to that.
    Ms. Cherfilus-McCormick. Thank you. My last question for 
you. The total number of veterans enrolled in the VA's health 
system increased from 7.9 million in 2006 to about 9.2 million 
in 2022. This increase in beneficiaries needs to be matched 
with an increase in providers to meet the need of every 
veteran. What steps has the VA taken to ensure that there are 
enough healthcare providers to care for our veterans and ensure 
that the veterans of Color receive cultural competence and 
trusted care from providers that look like them and understand 
their healthcare needs?
    Mr. Elnahal. I absolutely agree, Congresswoman. It is why 
the first and most important priority that I have set for the 
healthcare system is hiring faster and more competitively. We 
absolutely need to be staffing our hospitals and clinics, but 
also our support personnel to the greatest extent possible, not 
only to serve our existing base of veterans, but to, for 
example, meet the need of all the new enrollees we expect to 
see from the PACT Act. That includes the staff that you are 
talking about, and we have already hired more than 18,500 staff 
in the first quarter of this year. We have also seen a higher 
retention rate compared to January of last year when we had a 4 
percent loss rate. We only had a 2 percent loss rate just last 
month. The combination of greater retention and greater hiring 
has led to 388,000 employees on board. That is an end strength 
that we think will continue to get better throughout the year 
because of our attempts to improve hiring.
    Ms. Cherfilus-McCormick. Thank you so much. My next 
question is for Inspector General Missal. One of the final 
hearings the committee held while Democrats were still in the 
majority in December 2022, was an oversight hearing on the VA's 
progress in implementing the PACT Act. This hearing provides a 
significant opportunity to get updates on the VA's progress, 
meeting major milestones outlined in the law.
    VA has processed PACT Act claims on January 1, 2023, 
according to the data committee received from the VA this week, 
since the law's enactment in August 2022. More than 309,000 
veterans and survivors have submitted PACT Act related claims. 
In your role as the Inspector General, what oversight do you 
have in processing the PACT Act claims? How can we ensure 
veterans are having a streamlined process while awaiting 
confirmation of benefits?
    Mr. Missal. Well, as previously noted, the PACT Act was one 
of the most significant increases in VA benefits in its 
history. We recognize the importance of it. They are just 
starting to process those claims at this point. We have already 
put together a team of people to address it from a number of 
different areas, including the people, the staff that they are 
needing to hire, the processes, how they are processing the 
claims, and the technology, what they are doing along 
technology lines as well. We expect to have a vibrant 
oversight, just given the importance and the amount of money at 
issue.
    Ms. Cherfilus-McCormick. Thank you so much for your 
responses, Mr. Chairman. I will yield back.
    The Chairman. Thank you. The gentlelady yields back. 
Representative Ciscomani, you are recognized for 5 minutes.
    Mr. Ciscomani. Thank you, Mr. Chair. I serve a community in 
Southern Arizona in the Tucson area where the VA hospital there 
serves two military bases, Davis-Monthan (DM) Air Force Base 
and Fort Huachuca Army Base in Sierra Vista. Therefore, I serve 
a large veteran community. I do hear constant good feedback and 
a lot of improvement, and specifically the VA hospital. I, like 
my good friend Congressman Van Orden, also believe that there 
is room for improvement, like, in anything.
    My question is also in the same vein as my colleague. Dr. 
Elnahal, Chairman Bost sent a letter to the Secretary weeks ago 
asking the Agency to expand on its methodology for counting 
veteran suicide deaths. An issue that concerns me is that a 
large number of these deaths are ruled accidental or 
undetermined by our coroners, and as opposed to suicide or 
homicide. Many of these undetermined veteran deaths are drug 
overdose deaths as well.
    Does the VA have any intention of examining these deaths 
due to overdose or risky behavior within the context of suicide 
prevention? Could the VA include this type of data in its 
suicide report? This is a real issue that we see on the rise 
more and more, unfortunately, among our veteran population, and 
one that I hear from my community constant, and specifically 
after this example from the Congressman, I think it deserves 
weighted attention on this.
    Mr. Elnahal. I agree, Congressman, and we are always open 
to feedback and input about how we calculate veteran suicide 
information. Every year, we work with the CDC closely on this, 
medical examiners across the country, our methodology is 
published online. I want to say that we are not only focused on 
veteran suicide, which is my top clinical priority and has been 
for the Agency for years, but also the various different inputs 
into deaths that some folks may be trying to categorize, or are 
giving us feedback, saying that we should categorize or 
consider doing so for suicide.
    For example, substance use disorder. We have extensive 
programming to include residential treatment, medication 
assisted treatment, and various programming for veterans 
suffering from that. Also, the broad scope of our mental 
healthcare services continue to expand. We are doing more 
telemental health care than we have ever done before. We have 
more than 17,000 providers across the system providing these 
services.
    We are, of course, dedicated to expanding that capacity as 
much as possible. To Congressman Van Orden's request of me, I 
will keep this on my desk, and I will always remember that 
story. I will make sure that we continue to try and do better 
and better to prevent this scourge and to deal with this 
pressing, pressing public health issue.
    Mr. Ciscomani. Thank you. I yield back.
    The Chairman. Mr. McGarvey, you are recognized for 5 
minutes.
    Mr. McGarvey. Thank you, Mr. Chairman. I appreciate it. 
Thank you, gentlemen, for being here today. I echo the comments 
of some of my colleagues, Mr. Ciscomani, Mr. Van Orden. I also 
suggest that cutting $31 billion in the VA budget is not the 
way to best address some of those problems in the next year.
    I want to switch to something going on in my district, 
specifically. In August 2022, the VA OIG issued a report about 
issues with Camp Lejeune processing, the claims processing, a 
topic of which I hear about a lot from my veterans at home. Mr. 
Missal, this one is going to be for you. It was in a report 
that the VA OIG recommended that the VBA consider centralizing 
all Camp Lejeune related processing claims in the VBA's 
Louisville Regional Office.
    As you are likely aware, compared to other regional 
offices, the Louisville Regional Office actually had a much 
lower error rate. They processed a lot of claims. They only had 
an 8 percent error rate. That is compared to a 40 percent error 
rate of all the other offices combined. 40 percent for all the 
others, 8 percent for Louisville. In response to those 
recommendations, the VBA said it would assess all of the 
regional office's accuracy of processing Camp Lejeune related 
claims over time. If the accuracy has not shown consistent 
improvement, that VBA would consider further centralization. My 
question is, what progress has the VBA made on determining the 
need for centralizing the processing of Camp Lejeune claims 
since the report was published?
    Mr. Missal. As you correctly pointed out, there were 
significant problems with the processing of the Camp Lejeune 
claims. We projected out of the 37,000 during a 4-year period, 
21,000 were not processed properly, 17,000 of those, 21,000 
were prematurely denied because they did not have enough 
information. One of our recommendations involved the 
centralization of the claims. My understanding is that VBA is 
going to centralize it, but before we close out that 
recommendation, we want to see that it is actually done and how 
it is working. Then there is a second recommendation from that 
report that remains open as well.
    Mr. McGarvey. I appreciate that because it does seem like 
there is some hesitancy in moving forward with that 
recommendation on centralization. I guess for maybe Mr. Frueh, 
what I would say is we do have spaces in the VA that deal with 
this already. We have teams at VBA that currently specialize in 
processing certain types of claims such as military, sexual 
assault, trauma. Why is there a hesitancy in going ahead and 
centralizing those claims in the Louisville office?
    Mr. Frueh. I would say that the issue with specialization 
versus generalization is there is a lot of different 
disabilities and there is a finite capacity to centralize into 
different areas. It is not a lack of desire to get better. It 
is not a lack of desire to find that the answer of 
centralization will answer this because if we did that with all 
of the disabilities, we would run out of offices to do the 
centralization.
    Our goal and what I consider a quality organization is a 
veteran that applies from any State through any modality, 
through any external help, whether it is a VSO accredited 
representative or us has access to the same outcome. 
Centralizing makes that more likely because you are looking at 
one place to enforce outcomes. We do have a distributed 
workforce and we do do a lot of work around the Nation, and our 
goal is to make that as high quality as we possibly can across 
the Nation.
    Mr. McGarvey. Well, you know, I am not saying 
centralization is necessarily the answer. I think the numbers 
that Mr. Missal gave illustrate the real problem that 
potentially tens of thousands of Camp Lejeune related 
disability claims have been subject to processing errors. The 
most important thing here are the men and women who served who 
are not potentially getting the care, the treatment, the 
resources they need. Mr. Frueh, what is the VBA doing to 
proactively identify those claims that were processed 
incorrectly, to notify the veterans of the error, and to allow 
them to update their claims accordingly?
    Mr. Frueh. I would have to go back to the report. The last 
time I looked at it was a few months ago. When we got the 
identification of claims that the IG said were processing 
error, we did reach out to everyone. We did relook at every 
single claim. When we found a claim that we did find an 
erroneous answer. Some that were process and error that were 
prematurely decided, when we looked at them again, they came to 
the same conclusion. The answer was still the same answer that 
we got before. When we get to a claim that we readjudicate and 
we get a different answer, then we reach out to that veteran 
and reopen the claim and work with them to the ultimate 
conclusion.
    Mr. McGarvey. I am out of time, so I yield back.
    The Chairman. Thank you. Representative Self, you are 
recognized for 5 minutes.
    Mr. Self. Thank you, Mr. Chairman. My issue is the director 
of the Dallas VA Center. You are free to select your senior 
leadership any way you will. I believe that you have damaged 
your relationship with your stakeholders. The Dallas VA Center 
is not in my district, but the Metroplex is a large place, and 
that VA Center is the second largest in the country I 
understand. You are free to select your director, but the 
deputy was not considered for the job. Highly qualified. He had 
been the deputy for the second largest center in the Nation for 
a number of years. The man that was selected to be the director 
came from a very small center, and the deputy was not 
considered at all.
    If I go through the other, central Texas conducted a full 
and open interview process. Amarillo was full and open. El Paso 
was full and open. You did not even post the position in the 
second largest center in the Nation. Again, I believe that you 
have damaged your relationship with the stakeholders, with the 
veterans in the area. Believe you me, there are a lot of 
veterans in the Dallas Metroplex and in North Texas. My 
questions are, did Mr. Jones, is it Dr. Jones, the H.R. 
director? Mr. Jones, Dr. Jones, your H.R. director, did he 
follow proper protocol when considering the new executive 
director of the North Texas Dallas VA? Then the real question I 
have is, does it make sense that he would select a candidate 
from a clinic of 17,000, move him to the second largest in the 
country, with a budget of roughly 20 billion?
    Mr. Elnahal. Congressman, I had a chance to visit the 
Dallas VA Medical Center. I met the individuals that you are 
talking about. Wendell Jones is the network director across 
VISN 17 for Texas. I think it is an extraordinary asset for the 
veterans and the community.
    Personnel decisions are always very difficult. Before I 
signed off on this action, I checked with our Office of General 
Counsel, and they determined that the process was within the 
scope of the law. What I can tell you is we have a commitment 
to ensuring that the entire team there is supported to meet the 
mission on behalf of veterans in the Dallas area.
    Mr. Self. In your mind, you signed off of it. You just gave 
me a legal process. How about the personnel process? Did you 
hire the best man for the job or woman for the job? We are not 
discussing names here. Did you hire the best person for the 
job----
    Mr. Elnahal. In my discussion----
    Mr. Self [continuing]. realizing that the deputy had been 
there for a number of years in this second largest VA center in 
the Nation?
    Mr. Elnahal. Well, candidly, Congressman, there are a lot 
of inputs that go into these very difficult decisions about 
picking our leaders in the organization. After I consulted with 
Mr. Jones on this, we came to the determination that we did. 
That is not a disparagement at all of anybody else who wanted 
that job. What I am committed to doing is making sure that we 
are meeting the mission on behalf of veterans in every 
performance indicator we can in the Dallas VA.
    Mr. Self. Understand, the deputy was not considered, as far 
as anyone knows. I think that you have some work to do to 
regain the trust of the stakeholders and the veterans in the 
Metroplex area, in the North Texas area.
    With that, I would like to move to a different issue. Mr. 
Quinn. In 2021, the VA IG reported that NCA could better ensure 
that VA grant funded State veterans cemeteries were maintained 
according to national shrine standards. How has the NCA 
improved the oversight over those State veterans cemeteries?
    Mr. Quinn. Congressman, thanks for the question. I will 
make sure I have a voice through this hearing. We have looked 
very closely at that State in particular that was mentioned in 
the IG report. We have gone back for additional assistance 
visits with that State, and we have done an additional 
inspection of that State, and we do that with all states. We 
want to make sure that this partnership between the Federal 
Government and the State, Tribal, territorial, grant funded 
cemeteries are out there, that we maintain national shrine 
standards. The veterans deserve that. The family members 
deserve that. We will take every step necessary to make sure 
that those are national shrines.
    Mr. Self. You are assuring me that it is meeting the 
traditional national shrine standards today?
    Mr. Quinn. Congressman, we are still working with that 
State to ensure that they meet national shrine standards. Yes, 
sir.
    Mr. Self. Thank you, sir. I yield back, Chairman.
    The Chairman. Thank you, Mr. Mrvan.
    Mr. Mrvan. Thank you, Chairman Bost. This week, I am 
introducing the VHA Leadership Transformation Act, a bill I 
believe will help address some of the leadership and governance 
challenges that are described in the Inspector General Missal's 
and Comptroller General's Dodaro's testimony. First, my bill 
will establish a 5-year term for the Undersecretary for Health 
in order to provide greater leadership, stability, continuity 
within the Veterans Health Administration. Second, my bill will 
remove existing statutory limitations on the number of 
Assistant Undersecretaries for Health that VHA can have, as 
well as the requirement that nearly all of them be doctors.
    This will give VA greater flexibility to determine its 
organizational structure and expand the pool of healthcare 
executives who can be considered for these senior leadership 
positions. Mr. Missal and Mr. Dodaro, what are your thoughts on 
the idea of depoliticizing the appointment of the 
Undersecretary for Health? What would be the potential benefits 
of greater leadership, stability, and continuity at VHA? Third, 
and could VHA benefit from having greater flexibility to design 
its organizational structure?
    Mr. Dodaro. First, I think there are tremendous benefits to 
be gained of sustained leadership and stability over a period 
of time, provided it is the right person in the leadership job. 
In fact, the criteria that we have for getting off GAO's high 
risk list, the very first criteria is sustained leadership. 
That is pivotal. Without that, you are not going to make 
progress.
    There are a number of other positions across government 
with 5-year terms. The Internal Revenue Service (IRS) 
Commissioner within the Treasury Department. The FAA Administer 
in the Department of Transportation, Small Business, or excuse 
me, Social Security Administration has a 5-year term. 
Unfortunately, two of those, all three are vacant right now, so 
they are trying to be filled.
    I believe that with the right person, sustained leadership 
is important, particularly at VA, where if you want to have 
change of the magnitude that is needed there, you need to have 
stability over time to guide it to a successful conclusion. I 
also think it is important to consider people who have 
management skills, as well as medical skills in order to 
effectuate the type of change that is needed over at the VHA. I 
would submit to you, although you did not ask me, that the same 
thing should be true for VBA and the Benefits Administration to 
have that stable leadership over a period of time when you have 
such important functions that we have and these are functions 
that need to be performed. To be successful, you need to have 
continuity over time.
    Mr. Missal. I would just add second what Mr. Dodaro said 
about leadership. Effective leadership and stable leadership is 
so critical, particularly for an organization as large, 
complex, and decentralized at VHA. I have been the IG for a 
little more than six and a half years. In my time at VA, there 
have been six people who have sat in the undersecretary's chair 
at VHA, either an acting basis or as a Senate confirmed 
position. I know that the Commission on Care in 2016 
recommended 5-year terms for the VHA. I think they called it 
the executive director, with the possibility of being 
renominated for it. I agree with Mr. Dodaro that anything that 
gets stability within these very important positions would be 
very helpful.
    Mr. Mrvan. Then, Dr. Elnahal, do you have any views to add? 
Do you think by making the statue less restrictive, VHA could 
recruit the kind of senior healthcare executives it needs?
    Mr. Dodaro. Yes. I think you--oh, I am sorry. Was it to me 
or to the doctor?
    Mr. Mrvan. To the doctor.
    Mr. Dodaro. Okay, I am sorry.
    Mr. Mrvan. No, problem, sir.
    Mr. Elnahal. Thank you. I am glad we agree.
    Mr. Mrvan. I am just going to direct all my questions to 
you.
    Mr. Dodaro. No, I am sorry. I am sorry.
    Mr. Mrvan. Thank you, sir, very much.
    Mr. Elnahal. Thank you, Congressman. Of course, as we do 
with proposed legislation analyzing the implications of such a 
bill, we have not had a chance to come to a position yet as an 
agency or administration. I would just concur in principle with 
my colleagues that continuous leadership is really important. I 
am very focused, for example, on filling our medical center 
directors and VISN directors with permanent folks and making 
sure we utilize every single PACT Act authority, and hiring 
authority, and retention authority that we have to sustain that 
leadership.
    I am very sensitive to the oversight of my colleagues, the 
colleagues to my right in various reports about the risks of, 
you know, continuously transitioning leadership. It is hard to 
sustain initiatives. It is hard to hold folks accountable. It 
really sets a path for continuous improvement that is 
consistent with our high reliability effort to have continuous 
leadership.
    Mr. Mrvan. With that, I yield back my time. I thank you 
very much.
    The Chairman. Dr. Murphy, you are recognized for 5 minutes.
    Mr. Murphy. Thank you, Mr. Chairman, gentlemen, thank you 
for coming today. I represent North Carolina's 3rd 
congressional District. One-seventh of my constituents are 
veterans or active-duty military. It is a heavily populated 
military district. Our veterans issues are, very, very 
important to me. I have also been a physician for 30 years plus 
now. The trials and tribulations that go on in the VA are not 
lost on me. To your point of stability, trying to fill doctors 
in, I get it, because we in the civilian world are facing a 
cataclysmic fall in physicians, even more so with surgeons. I 
know sometimes recruiting is very difficult in rural areas and 
especially in VA areas. Any help that we can do in that regard, 
you have to let us know because that is a big deal for our 
veterans. They signed on the dotted line to serve and sacrifice 
for us. As far as I am concerned, the day they come home is the 
time for us to turn our attention on the second part of that 
contract.
    Veteran suicide is a big problem. Dr. Elnahal, I wish you 
could speak to that and what improvements, where you see this 
going, because we are at now, what, 22, 24 a day? Absolutely 
unacceptable. What are we doing? What are we doing in the VA to 
change that? How can we help or what fires do we need to light 
to make a difference?
    Mr. Elnahal. Well, Congressman, I share your priority 
around preventing veteran suicide. It is my top clinical 
priority for the healthcare system and it has been so for the 
Agency for years. We will simply not be satisfied until we 
bring that number to zero.
    Every veteran suicide is a tragedy. We are focused with a 
comprehensive public health approach, everything from ensuring 
access to crisis care, both through our veteran crisis line and 
urgent care through our emergency settings, to lethal means 
safety, to ensuring same day access to care and continuous 
mental healthcare. Very importantly, community-based 
organizations need to be our partners in this to include, of 
course, our veteran service organizations. We have put in more 
than $50 million in this Sergeant Parker Gordon Fox grant 
program to fund community-based organizations in partnership 
with us.
    We just announced $20 million in funding to innovative 
organizations, startups, community-based organizations alike 
through our Mission Daybreak program. We are simply not going 
to stop until we get to zero.
    Mr. Murphy. Thank you. I appreciate that. That said, we are 
not bending the needle. We are not changing things. I 
appreciate the work. It is a hard-to crack. I am not belaying 
that whatsoever, especially in today's society when you wake up 
and you do not know who you are, which whatever you pick these 
days, and there is so much pressure by society to be something 
different. I get it. No wonder suicide rate is up, actually 
across all age groups, primarily with young girls. That is a 
different issue.
    I will tell you this, and I need your help with this, and I 
need your opinion on this I have, as a surgeon, I have worked 
with wound care for over 30 years, wounds that will not heal. I 
have found absolute and repeatable excess with hyperbaric 
oxygen. I will tell you, I have studied the literature. It is 
somewhat controversial. I will readily admit, being an 
objective scientist. I will tell you, I have known many well, 
several veterans who I know, who have undergone hyperbaric 
oxygen at their last thread, and it has saved their life. I 
want your opinion, and I really want a commitment that the VA 
is going to really put some effort into this for a last thread. 
If we are going to really do everything, if we are not going to 
leave anything on the table, we have to explore this option.
    Mr. Elnahal. The first thing I will say is I fully respect 
your perspective, Congressman, as a surgeon and a physician 
yourself, and appreciate that you have seen the benefits of 
this yourself. We do allow for referrals for hyperbaric oxygen 
therapy in the community. That is a patient by patient, 
physician by physician, or provider determination at the point 
of care.
    Mr. Murphy. Does the VA pay for this?
    Mr. Elnahal. Yes, the VA does pay for that therapy in the 
community. If the referral is made at the front line and the 
clinical determination is made.
    Mr. Murphy. Okay, that is news to me, because that is not 
the word that I am getting back. I will take you for what you 
said, and that is in the record, and we will go from there. Mr. 
Chairman, I am done. Thank you all for what you do for our 
veterans. It is critical. I just say this, we do not go to bed 
without something worrying about what the next thing is. I 
expect you guys to not go to bed every night not worrying about 
that next veteran. Thank you, sir. I will yield back.
    The Chairman. Ms. Ramirez, you are recognized for 5 
minutes.
    Ms. Ramirez. Thank you, Chairman. Before I went into the 
State legislature, for a very long time, I was the executive 
director of a social service agency. We worked primarily with 
people experiencing homelessness. Many of them were men 
experiencing homelessness, and about 20 percent of them were 
veterans. Being on this committee is first an honor and a 
privilege, and certainly, there is a lot of work to be done as 
we talk about housing insecurity and the connections between 
mental health and housing insecurity.
    Mr. Frueh, as we have thought about access to permanent 
stable housing and particularly even as we think about 
homeownership, I know that recently the VA, in coordination 
with a broader White House initiative, announced it was 
enhancing its oversight procedures to better identify and act 
against discriminatory bias in VA home loan appraisals. VA is 
also recommending that all VA fee panel appraisals and all 
lenders staff appraisal reviewers take training on appraisal 
bias, fair housing, and fair lending. Can you tell me how VA--
can you tell me if the VA has already removed any appraisers 
under its newly enhanced oversight process for detecting bias 
and discrimination?
    Mr. Frueh. First, I would say thank you so much for 
focusing on housing and housing America's most vulnerable 
population. From our perspective, every benefit, every veteran 
deserves access to their benefits, not some veterans. We want 
to make sure we root out discrimination wherever it is from the 
loan guarantee program and the new focus on finding bias in 
appraisals, I do not think that it is yet identified bias. I 
think it is a new program that is still being implemented. I 
would be happy to talk with your staff and you about this as we 
go forward with it. I do not yet have any results from that 
work.
    Ms. Ramirez. You are still in the process of putting 
together the program and the training itself, is that correct?
    Mr. Frueh. I believe so. I know it is in its infancy.
    Ms. Ramirez. Okay. For the record, I would like to be able 
to work with you and closely learn how the training program is 
being designed and then how we are going to be enforcing it. I 
think the last thing I would say is I started as a case worker, 
actually as a mail lady, when I worked at the Social Service 
Agency. I started at the age of 17. I remember I was a senior 
in high school, and I would run right after school to the 
shelter to help distribute mail to people that did not have a 
permanent mailing address. As young, as naive as I was, I sat 
in a room and I heard people who have dedicated their life, who 
died in service, who nearly died in service, talk to me about 
the traumas they had experienced, trauma that I could not 
connect with. I kept asking myself, how could you have fought 
for our country and now be in a church basement with no access 
to supports?
    I would say to you that I have been honored to work on some 
of the affordable housing initiatives on veteran housing in the 
State of Illinois. I really want to put on record how 
incredibly important it is, as you have said, that we continue 
to prioritize housing as we see the housing crisis across this 
country, veterans, both women and men, are struggling between 
paying for their rent and paying, in some cases, for either 
utility bills or rising costs of other things.
    I am grateful that the healthcare system within the VA 
continues to improve, but we still have a long way to go. I 
just want to make sure that as we talk about mental health, as 
we talk about trauma, that we understand that there is an 
intersection between housing, employment, supports for family, 
and that we continue to work to make housing a top priority for 
veterans. I look forward to working with all of you to make 
that happen. Thank you. I yield back, chairman.
    The Chairman. Thank you. Ms. Budzinski, you are recognized 
for 5 minutes.
    Ms. Budzinski. Thank you, Mr. Chairman. Good afternoon. My 
name is Nikki Budzinski. I have the honor and privilege of 
representing Illinois 13th congressional District, which is in 
central and southern Illinois, a little further south of 
Congresswoman Ramirez. I have two VA clinics, one in Decatur, 
one in Springfield, that I have the honor of getting to work 
with and represent. I also have a lot of constituents that are 
serviced by a VA hospital in St. Louis, as the district is 
quite long and reaches over there.
    I am really excited. I am the granddaughter of two World 
War II veterans to get to serve on the Veterans Affairs 
Committee and help my constituents, including many of those 
that are servicemen and women. As a new member and as a part of 
the Veterans Affairs Health Subcommittee, I look forward to 
helping to ensure our veterans have access to the highest 
quality and affordable healthcare. This includes, for me, 
really prioritizing issues around expanding access to 
telehealth, supporting, and helping to recruit the workforce of 
the VA. I know a number of members have spoken to shortages and 
looking at how I can be helpful in that area and ensuring that 
Americans have--our veterans--excuse me, have access to 
behavioral health services, something that I know a number of 
other members on the committee have also spoken to. Because my 
district is predominantly rural, as you know, there are a lot 
of specific challenges that rural communities face when trying 
to tackle some of these priorities.
    I believe our veterans have sacrificed so much for our 
country, and it is our duty as a member, as Members of 
Congress, to work together to find the best solutions. Another 
point I would make is I am honored to serve on this committee, 
which has a long history of bipartisan working together to 
service our men and women that are veterans. I am committed to 
working with my colleagues to do just that.
    I just want to say a thank you to all of your honor being a 
part of this panel. This was very informative, and I am sorry, 
with our schedules, that we have to kind of come back and 
forth, in and out of our committee hearing. I did want to ask 
specifically to Dr. Elnahal, you know, with the ongoing work of 
the PACT Act, which is, I think, very exciting for our veterans 
in this country, I am very specifically interested in how 
specialized care can be expanded through the work of the 
implementation of the PACT Act. Then as a second part of that 
same kind of question around the PACT Act is how you are 
looking at the unique challenges that implementation in rural 
communities, how you are going to be tackling those.
    Mr. Elnahal. Well, thank you, Congresswoman. We share your 
dedication, of course, to providing the highest quality, best 
care we can, including to rural veterans. I think the most 
enabling thing we have to do to fully implement the PACT Act to 
its fullest extent is to hire enough talented, quality 
providers to be able to do so. The PACT Act actually affords us 
the requirement, frankly, to do a study on making sure we 
maximize all of the tools we have to be able to recruit 
specific staff to be able to meet the needs of rural veterans. 
We have already commenced with that important work. We are, of 
course, also trying to maximize, as you mentioned, the use of 
telehealth, because that just makes care more accessible, 
especially to rural veterans.
    We have a partnership with the Federal Communications 
Commission, the FCC, to be able to extend wireless and 
broadband access. We are handing out tablets as well, and 
devices for folks in rural areas to be able to receive that 
care. We are making sure they are trained to be able to do so, 
including training and supporting caregivers. Across the 
spectrum, hiring the number of providers we need to hire, 
making sure we are as productive as we can be with our clinics, 
with various initiatives to be able to improve productivity, 
but also extending connectivity and telehealth to meet rural 
veterans' needs.
    Ms. Budzinski. Thank you, Mr. Chairman. I will yield back 
my time. Thank you.
    The Chairman. Thank you. That concludes all of the people 
who are having questions. Ranking Member Takano, do you have 
closing remarks?
    Mr. Takano. Yes, just briefly, Mr. Chairman, thank you for 
putting this hearing together and calling all the witnesses. I 
want to extend my deep sympathy and condolences to 
Representative Van Orden for the tragic loss of it was your 
brother. Unfortunately, this event occurred at a time when VA 
had not implemented the recent COMPACT Act. I want to use this 
opportunity because I think we might want to get this message 
out to folks that the COMPACT Act was implemented on December 
17--January 17, January 17 of this year. It was a bill that I 
introduced and carried and very proud of it. What that bill 
does is it says that a veteran can call 988, the crisis 
hotline, and be evaluated and be immediately referred, 
immediately referred to a mental health practitioner. It could 
be inpatient or outpatient, and it could be in VA or out of VA, 
wherever it is, whatever is the pathway. This eligibility 
extends to anyone who wore the uniform. Even if you are not 
eligible for VA and you are going through an emergency health 
mental health crisis, you can call 988 and press 1 and be 
connected.
    I wish it had been implemented earlier, but I am very 
grateful Dr. Elnahal, that we have it implemented now. I just 
want to take this moment to make sure that people know about it 
and all our offices can be involved, making sure our veterans 
know about it. Since I took over the chairmanship in 2017, 
suicide prevention has been my No. 1 priority.
    I want to thank you. Many of the new Members of Congress 
coming in, new people coming onto the committee have made it 
their top priority. I agree with Dr. Elnahal, we will not rest 
until that number is zero. Thank you.
    The Chairman. I want to thank the ranking member for 
bringing that up, because it is vitally important that all of 
our members know and understand what that is. The outreach can 
be quick and that no one would be denied.
    I do want to thank all of our witnesses for being here 
today. I think it is clear that VA has a lot of work to do. We 
can get VA to where it needs to be by going back to the basics 
and conducting thorough oversight of VA and the Biden 
administration and where fixes are needed to be made. We will 
work hard to enact thoughtful, necessary legislation that puts 
veterans first and fiscally responsible. We will propel VA into 
the future, force it to keep pace with the modern healthcare 
systems for this generation of veterans and the next. Our 
veterans deserve no less than that but the best in exchange for 
their service. The VA, they use day in and day out should 
reflect that. I look forward to working with the honorable 
members of this committee and our stakeholders to accomplish 
these objectives.
    Again, I want to thank you for being here today. Now, I ask 
unanimous consent that all members shall have 5 legislative 
days in which to revise and extend their remarks and include 
extending their material. Hearing no objections, so ordered. 
With that we are adjourned.
    [Whereupon, at 4:16 p.m., the committee was adjourned.]     
=======================================================================


                         A  P  P  E  N  D  I  X

=======================================================================


                    Prepared Statements of Witnesses

                              ----------                              


                  Prepared Statement of Michael Missal

    Chairman Bost, Ranking Member Takano, and Committee Members, thank 
you for the opportunity to discuss how the Office of Inspector 
General's (OIG) work enhances VA's accountability and continuous 
improvement efforts for its services, programs, and operations. The 
OIG's mission is to serve veterans and the public by conducting 
meaningful independent oversight of VA. Our more than 1,100 staff 
conduct and support accurate, fair, and impactful audits, reviews, 
healthcare inspections, and investigations across the Nation. In just 
this past fiscal year, the OIG produced 250 oversight publications with 
894 recommendations for corrective action. Our personnel have made over 
200 arrests, fielded more than 36,000 contacts to our hotline, and 
testified before congressional committees on 14 occasions, including 10 
before this committee or its subcommittees. Our work has resulted in a 
monetary impact of more than $4.5 billion for VA. This would not be 
possible without the funding and other support we receive from 
Congress.
    The OIG appreciates the work VA does every day on behalf of 
veterans. Secretary McDonough, other VA leaders, and the vast majority 
of personnel with whom the OIG staff engages recognize the benefits of 
meaningful, independent oversight and have been very responsive to our 
requests for information. We also value the regular interactions we 
have with senior leaders to understand their concerns and priorities. 
In addition, we have a strong and collaborative relationship with 
Comptroller General Dodaro and his staff and our work often complements 
and builds on their oversight.

FOUNDATIONS OF ACCOUNTABILITY

    The OIG's oversight reports reveal recurring themes and 
deficiencies that often center around key elements of accountability. 
They are routinely shared with VA leaders across the enterprise to 
encourage positive change and efficiencies within their respective 
programs and operations. OIG recommendations that focus on even a 
single medical facility or benefits process are often a road map for 
other facilities and offices across VA to help prevent or correct 
similar problems that have gone undetected or unaddressed.

    The OIG's work often focuses on five components of accountability:

        1. Strong governance and clarity of roles and responsibilities

        2. Adequate and qualified staffing to carry out those duties

        3. Updated information technology (IT) systems and effectual 
        business processes to support quality healthcare delivery, 
        accurate and timely benefits, and efficient operations

        4. Effective quality assurance and monitoring to detect and 
        resolve issues

        5. Stable leadership that fosters responsibility for actions 
        and continuous improvement

    The OIG reports referenced below help illustrate how weaknesses in 
any of these areas of accountability can negatively affect veterans, 
their families, and caregivers and can waste or misuse taxpayer 
dollars.

Strong Governance and Clarity of Roles and Responsibilities

    Misconduct, failures to take appropriate action, and persistent 
problems are often the result of VA personnel or contractors not 
understanding their roles and responsibilities. In other cases, they 
understand their duties, but simply do not or cannot fulfill them. This 
may be due to outdated policies and procedures, conflicting guidance, 
or a lack of clear decisionmaking--often with those best positioned to 
act lacking the authority to do so.
    Some oversight reports reveal the tension between program offices 
that may have the policy and oversight functions but lack the authority 
to direct staff in the field. OIG reports have noted this, for example, 
in the governance structure for VA police.\1\ An OIG audit conducted in 
response to concerns about accountability found VA did not have 
adequate and coordinated governance over its police program, due in 
part to confusion about police program roles and authority and lack of 
centralized management. Governance of the police program has been 
divided between the Veterans Health Administration (VHA), whose medical 
facility directors directly supervise police assigned to their 
facilities, and the Office of Security and Law Enforcement (OSLE) that 
oversees police policy and inspections. In this structure, OSLE had the 
authority to inspect medical facility police programs but no authority 
to ensure the problems they detected were promptly fixed.
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    \1\ VA OIG, Inadequate Governance of the VA Police Program at 
Medical Facilities, December 13, 2018; VA OIG, VA Police Information 
Management System Needs Improvement, June 17, 2020.
---------------------------------------------------------------------------
    An OIG healthcare inspection described concerns with the oversight 
and supervision structure for military sexual trauma (MST) 
coordinators.\2\ The VHA Office of Mental Health and Suicide Prevention 
oversaw and provided funding for the national MST Support Team that was 
tasked with facilitating communications among regional staff, MST 
coordinators, and other VA staff. Yet funding for MST programs at the 
facility level was allocated by facility leaders, resulting in MST 
coordinators having to compete against other medical facility needs for 
support. The OIG found that inadequately protected administrative time, 
insufficient support staff, and deficient funding were among the 
problems that challenged MST coordinators' ability to fulfill their 
responsibilities to patients. The OIG made one recommendation to the 
under secretary for health to evaluate the guidance and operational 
status and take necessary actions.
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    \2\ VA OIG, Challenges for Military Sexual Trauma Coordinators and 
Culture of Safety Considerations, August 5, 2021.
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    A review of the Intimate Partner Violence Assistance Program 
(IPVAP) revealed personnel at both the Veterans Integrated Service 
Network (VISN) and facility levels were confused about their roles and 
responsibilities, impeding the progress of this program.\3\ In 
interviews, VISN champions expressed the need to clarify their 
responsibilities and those of VISN lead coordinators. Almost half of 
the IPVAP facility coordinators described inadequate resources to 
fulfill their responsibilities. Fourteen percent of IPVAP facility 
coordinators reported that their facilities did not implement routine 
screening to help detect and offer services and supports to patients 
who might be subjected to intimate partner violence. Although IPVAP 
facility coordinators are identified as responsible for program 
evaluation, the OIG found that VHA had not established standardized 
program evaluation methods or measures.
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    \3\ VA OIG, Intimate Partner Violence Assistance Program 
Implementation Status and Barriers to Compliance, September 28, 2022. 
VA has divided the country into 18 regional systems of care referred to 
as Veterans Integrated Services Networks. See www.va.gov/HEALTH/
visns.asp.
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    Confusion over roles and decisionmaking that is not fully informed 
can affect patient care and business operations on even the most 
routine operations. The OIG review on the cause of a backlog of mail at 
the Atlanta VA Health Care System (HCS) in Decatur, Georgia, revealed 
that the HCS and VHA's Payment Operations and Management (POM) office 
mismanaged incoming mail from November 2020 to September 2021, causing 
a backlog of more than 17,000 mailed items.\4\ The mail included 
veterans' medical records, claims for payment from veterans and 
community care providers, and checks totaling nearly $207,000. The 
cause was traced to a verbal agreement that transferred POM's 
responsibility for mail management to HCS personnel, without engaging 
HCS staff expected to take on this work. HCS leaders lacked a clear 
understanding of the additional workload they assumed and did not 
ensure enough staff were adequately prepared for managing the influx of 
mail. POM officials were later reluctant to help, citing the transfer 
of their responsibilities in a verbal agreement. VA concurred with the 
OIG's five recommendations, including one recommendation focused on 
addressing all negative consequences, but that recommendation remains 
open.
---------------------------------------------------------------------------
    \4\ VA OIG, Atlanta VA Health Care System's Unopened Mail Backlog 
with Patient Health Information and Community Care Provider Claims, 
April 27, 2022.
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    Similarly, OIG reports on Veteran Benefits Administration (VBA) 
claims-processing deficiencies identified the tension and disconnect 
between VBA's Office of Field Operations (OFO) and Compensation Service 
office. OFO manages the employees who process veterans' claims, sets 
production goals, and oversees personnel management. Compensation 
Service provides the ``how to'' guidance, training, and quality 
assurance checks. The disconnect between the two offices is illustrated 
through the deficiencies involving MST-related claims processing. The 
OIG issued two reports on the processing of MST claims, one in 2018 and 
a follow-up in 2021, which actually showed an increase in incorrect 
claims processing following the ineffective implementation of OIG 
recommendations.\5\ In the follow-up report, the OIG found that the 
Compensation Service and OFO did not communicate effectively to resolve 
claims-processing problems identified in 2018 and managers and claims 
processors were not being held accountable for adhering to updated VBA 
policies and procedures. Communication and cooperation between these 
offices is crucial to successfully overseeing the processing of claims, 
and the OIG recommended that VBA develop, implement, and monitor a 
written plan that requires these two offices to strengthen 
communication, oversight, and accountability.
---------------------------------------------------------------------------
    \5\ VA OIG, Denied Posttraumatic Stress Disorder Claims Related to 
Military Sexual Trauma, August 21, 2018; VA OIG,Improvements Still 
Needed in Processing Military Sexual Trauma Claims, August 5, 2021.
---------------------------------------------------------------------------
    The OIG report, Improvements Needed to Ensure Final Disposition of 
Unclaimed Veterans' Remains, demonstrates the repercussions of having 
27 program offices with responsibilities related to unclaimed 
remains.\6\ This led to inadequate and ineffective administration and 
oversight of benefits and services by VHA, VBA, and the National 
Cemetery Administration. The OIG team obtained more than 9,000 records 
from a Department of Justice database and found more than 400 matches 
of individuals whose remains were unclaimed that appeared to be 
veterans based on a search of full names and dates of birth and 
death.\7\ Additionally, the team identified multiple instances of 
individuals who may be veterans interred in mass graves as well as 
those with final interments delayed as long as 44 years. There were 
three key areas in which VA governance of benefits and services for 
deceased veterans whose remains are unclaimed was not effective: (1) 
insufficient outreach to funeral homes and other custodians of 
unclaimed remains and collaboration with external entities to locate 
deceased veterans and facilitate their burials; (2) a financial 
oversight structure that did not support cross-administration or VA-
wide reconciliation of payments made for these deceased veterans; and 
(3) inadequate oversight across and within VA's three administrations.
---------------------------------------------------------------------------
    \6\ VA OIG, Improvements Needed to Ensure Final Disposition of 
Unclaimed Veterans' Remains, December 15, 2021.
    \7\ The National Missing and Unidentified Persons System (NamUs) is 
the Department of Justice data base used. The review team referred all 
NamUs-matched records to VA for follow-up to conclusively identify 
veterans and eligible dependents, which may require coordination with 
the medical examiner, coroner, or law enforcement agency that has 
custody of the remains.
---------------------------------------------------------------------------
    The problematic decentralized nature of governance is also seen in 
VA's financial management structure. Under the Chief Financial Officer 
(CFO) Act, the VA CFO has the responsibility for establishing financial 
policy, systems, and operating procedures for all VA financial 
entities. VA administrations and other offices are responsible for 
implementing those policies and producing financial information, but 
they are not under the supervision of the VA CFO. This fragmented 
structure has been a consistent concern and finding in the audit of 
VA's consolidated financial statements.\8\ Without active involvement 
from VA's senior leaders to overcome organizational silos and ensure 
collaboration, problems at the administration level may not be elevated 
for resolution.
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    \8\ VA OIG, Audit of VA's Financial Statement for Fiscal Years 2022 
and 2021, December 7, 2022.

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Adequate and Qualified Staff

    VA faces high vacancy rates across its programs and operations, 
especially within VHA. These long-standing shortages of qualified 
personnel make it difficult for VA to carry out its many goals and 
functions, impeding its ability to serve the Nation's veterans. Having 
the right people in the right positions committed to doing the right 
thing is essential to building a culture of accountability.
    To address these staffing shortages, VA has engaged in surge hiring 
and other recruitment strategies under their expanded authority. While 
expedient hiring is critical, VA cannot lower its standards for 
suitability and expertise. A report released last week focuses on 
suitability (background) checks. It was prompted in part by the 
recognition that nursing assistant Reta Mays, convicted for murdering 
seven patients in a West Virginia VA medical center, had not undergone 
a timely background check that might have prevented her from attaining 
her position.\9\ In the course of auditing the personnel suitability 
process across all VA medical facilities, the OIG detected problems 
with how this process was being conducted at the VA medical center in 
Beckley, West Virginia. In addition to finding that suitability 
personnel support was significantly understaffed at Beckley, the review 
of the facility revealed a need to tighten controls for ensuring 
individuals are suited for their positions. Thankfully, no patient harm 
was detected and all affected personnel had either left VA or were 
successfully cleared. Making certain that staff are and remain 
competent to do their jobs is central to the quality assurance issues 
discussed below as well.
---------------------------------------------------------------------------
    \9\ VA OIG, Personnel Suitability Process Concerns at the Beckley 
VA Medical Center in West Virginia, February 23, 2023.
---------------------------------------------------------------------------
    As for persistent shortages, VA is not alone. Medical systems 
across the country are facing challenges in finding and retaining 
qualified personnel. The OIG is required by law to conduct an annual 
review to identify clinical and nonclinical VHA occupations with the 
largest staffing shortages within each VHA medical center.\10\ In the 
Fiscal Year 2022 review, the OIG found that all 139 VHA facilities that 
were surveyed reported at least one severe occupational staffing 
shortage.\11\ The total number of their reported severe shortages was 
2,622. Twenty-two occupations were identified as a severe occupational 
staffing shortage by at least one in five facilities, including the 
medical officer and nurse occupations, which have been reported as 
severe shortages every year since 2014. Practical nurse positions were 
the most frequently identified ``clinical severe occupational staffing 
shortage'' in Fiscal Year 2022 (62 percent of facilities), with 
custodial worker and medical support assistance positions being the 
most frequently reported nonclinical and ``Hybrid Title 38'' shortages, 
respectively.\12\ The total number of severe occupational staffing 
shortages increased by 22 percent from the prior year. This was also 
the first Fiscal Year that facilities identified more than 90 
occupations as severe shortages.
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    \10\ VA Choice and Quality Employment Act, Pub. L. No. 115-46, 131 
Stat. 958 (2017).
    \11\ VA OIG, OIG Determination of Veterans Health Administration's 
Occupational Staffing Shortages Fiscal Year 2022, July 7, 2022.
    \12\ In 2003, Public Law 108-170 provided for 21 Title 5 
occupations to be converted to ``Hybrid'' 38 positions, including 
psychologists, respiratory and physical therapists, and medical 
technologists. This conversion provided greater benefits related to 
appointment, advancement, and some pay matters, while retaining some 
traditional Title 5 employment provisions, including performance 
appraisals, leave, work schedule, and retirement benefits. See 38 
U.S.C. Sec. Sec.  7403 and 7405.
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    In a recent inspection, the OIG found that inadequate staffing 
within the Martinsburg, West Virginia, VA medical center's Care in the 
Community (CITC) Service led to delays in scheduling community consults 
(referrals).\13\ Sixty-two percent of the COVID Priority 1 cardiology 
consults during a one-year period were scheduled more than 30 days 
beyond the clinically indicated date, which is the date the patient 
needs to be seen based on their clinical status. To meet workload 
demands, the CITC Service at the facility needed a minimum of 23 
schedulers and 11 clinical employees. At the time of the inspection, 
they had only 10 scheduling and four clinical staff, with facility 
leaders reporting significant staff turnover and a lack of training as 
contributing factors.
---------------------------------------------------------------------------
    \13\ VA OIG, Care in the Community Consult Management During the 
COVID-19 Pandemic at the Martinsburg VA Medical Center in West 
Virginia, February 16, 2022.
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    In another recent report, the OIG team focused on VA's 
accountability for the physical security of its medical facilities.\14\ 
The report identified multiple security vulnerabilities and 
deficiencies at the time of the review, most notably staffing shortages 
that contributed to the lack of a visible and active police 
presence.\15\ To meet VA's established security requirements, 
facilities need to fill police officer vacancies to correct security 
weaknesses. Other measures facilities can take to improve campus 
security include increasing security personnel resources, such as 
suitable police operations rooms; operable surveillance cameras with 
consistent monitoring; and adequate equipment. Moreover, the report 
found that facilities need to do a better job securing doors and 
restricting public access to high-risk areas. VA concurred with the 
OIG's six recommendations, which included delegating a responsible 
official to monitor and report monthly on facilities' security-related 
vacancies; authorizing sufficient staff to inspect VA police forces; 
and ensuring medical facility directors appropriately assess VA police 
staffing needs, authorize associated positions, and leverage available 
mechanisms to fill vacancies.
---------------------------------------------------------------------------
    \14\ VA OIG, Security and Incident Preparedness at VA Medical 
Facilities, February 22, 2023.
    \15\ Police staffing shortages have remained in the top 10 most 
frequently reported positions with severe shortages annually in the 
OIG's annual survey of occupational shortages. VA OIG, OIG 
Determination of Veterans Health Administration's Occupational Staffing 
Shortages Fiscal Year 2022.
---------------------------------------------------------------------------
    In addition to addressing staffing shortages, VA should also make 
sure that its existing personnel are equipped and prepared to do their 
jobs. The OIG recently reviewed whether staff at VBA were correctly 
following procedures when requesting medical opinions, a process that 
is vital to ensuring veterans receive the benefits to which they are 
entitled.\16\ The review found that claims processors did not 
consistently identify relevant medical evidence for the examiner's 
review, did not always use clear and accurate language, did not 
regularly request all warranted medical opinions, and sometimes 
requested unnecessary medical opinions. One contributing factor to 
these issues was inadequate training. The mandatory training for claims 
processers on making medical opinion requests did not explain how to 
correctly complete the requests using VBA's electronic systems, 
including what information to input in particular fields. The training 
also did not describe what constitutes relevant evidence for a medical 
examiner's review or provide examples of what language should be used 
to ensure requests are adequate and well written. These failings can 
lead to inaccurate medical opinions, incorrect decisions on veterans' 
claims, delayed decisions for veterans, as well as an inefficient use 
of resources (such as when the medical opinion requires rework).
---------------------------------------------------------------------------
    \16\ VA OIG, VBA Could Improve the Accuracy and Completeness of 
Medical Opinion Requests for Veterans' Disability Benefits Claims, 
September 7, 2022.

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Modernizing IT Systems and Business Processes

    VA is in the process of modernizing a number of significant systems 
that are critical to its operations. The OIG has been proactively 
overseeing VA's implementation of these crucial systems. However, as 
the OIG has detailed in multiple reports, VA has had significant 
troubles with upgrading or replacing key systems that support patient 
care, supply management, benefits to veterans and their families, and 
the stewardship of taxpayer dollars. These issues must be resolved for 
VA to remain accountable for the care, services, and benefits it 
provides. VA's process for replacing crucial IT systems, however, faces 
significant ongoing challenges. Major plans to modernize electronic 
health records, supply chain management, claims processing, and 
financial management systems have been marked by critical missteps. 
These have typically included weaknesses in planning, lack of stability 
in leadership positions, insufficient stakeholder engagement, failures 
to promptly fix known issues, and program management or coordination 
deficiencies. The OIG recognizes the tremendous complexity and cost of 
these efforts and continues to provide recommendations that are as 
practical and actionable as possible to support VA personnel working 
tirelessly to ensure patient safety and to deliver benefits and 
services to eligible veterans.
    Perhaps the largest contract in VA history, and one that affects 
patient care, is VA's Electronic Health Record Modernization (EHRM) 
program. Key objectives of the new system include achieving 
interoperability of VA and DoD systems to provide complete health 
records for veterans and enhancing the ability to exchange records with 
external healthcare providers.\17\ Essential to implementing and 
budgeting this multibillion-dollar effort, VA needs a high-quality, 
reliable, integrated master schedule to ensure all tasks are properly 
and fully completed and accounted. An OIG audit found, however, that 
this foundational master schedule had significant reliability 
weaknesses, including missing tasks, no baseline schedule, and no risk 
analyses.\18\ Without remediation, VA cannot offer reliable assurances 
on timelines and costs. Further, the OIG has estimated that any delay 
in the program's completion would cost about $1.95 billion a year.
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    \17\ VA OIG and DoD OIG, Joint Audit of the Department of Defense 
and the Department of Veterans Affairs Efforts to Achieve Electronic 
Health Record System Interoperability, May 5, 2022.
    \18\ VA OIG, The Electronic Health Record Modernization Program Did 
Not Fully Meet the Standards for a High-Quality, Reliable Schedule, 
April 25, 2022.
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    Overall, the OIG has released 14 reports on VA's rollout of the new 
electronic health record system that identify critical missteps and 
lack of remediation. Of the 68 recommendations issued to date, 24 have 
not yet been implemented--with 12 open for more than a year and two 
open nearly three years. The open recommendations include VA minimizing 
the number of required mitigation strategies healthcare providers must 
use when the system goes live, determining if veterans' appointments 
are being scheduled correctly, and addressing unresolved issues related 
to medication management and care coordination. These reports have also 
been highlighted in seven congressional hearings in which the OIG 
testified.\19\ Unless VA more effectively engages and coordinates all 
affected offices and contractors, IT solutions will continue to be 
delayed, more cost overruns will occur, and the risk to patients and VA 
operations will increase.
---------------------------------------------------------------------------
    \19\ Prior EHRM congressional statements can be found at 
www.va.gov/oig/publications/statements.asp.
---------------------------------------------------------------------------
    Although VA paused its EHRM rollout in June 2022, users of the new 
system continue to raise troubling complaints that the system hinders 
the delivery of prompt, high-quality patient care. The effects on 
staff, workload, and the risks for errors are also concerning. The OIG 
is continuing its oversight, including an examination of system 
degradations and outages.
    Similarly, there are other key systems essential to maintaining 
effective and efficient VA operations in other areas that are also in 
critical need of updates or replacement. In March 2019, VA decided to 
modernize and standardize its supply chain management, replacing up to 
12 legacy systems with a system already in use at DoD--the Defense 
Medical Logistics Standard Support (DMLSS) system. The OIG reviewed 
VA's oversight and coordination of the system's implementation at the 
pilot site to identify challenges that could affect supplies getting to 
where and when they are needed and to inform future deployments.\20\ 
The OIG found that the system did not meet more than 40 percent of the 
high-priority essential business requirements identified by VA medical 
facility staff at the pilot site. This occurred because the VA 
Logistics Redesign (VALOR) program manager did not follow VA's 
acquisition framework as required. After months of trying to determine 
the way ahead, VA announced in December 2022 that it will not deploy 
the DMLSS multibillion-dollar supply chain management system across the 
department's health and medical services.\21\ In considering next 
steps, supply chain modernization is not just about the system; it is 
about the people, processes, and technology limitations. Without clear 
roles and responsibilities, business requirements, and effective tools, 
VA will struggle to achieve accountability for its multibillion-dollar 
logistics portfolio.
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    \20\ VA OIG, DMLSS Supply Chain Management System Deployed with 
Operations Gaps That Risk National Delays, November 10, 2021.
    \21\ Edward Graham, ``VA Cancels Future Deployments of New Supply 
Chain Management System,'' Nextgov, December, 13, 2022, https://
www.nextgov.com/technology-news/2022/12/va-cancels-future-deployments-
new-supply chain-management-system/380841/. The article states that the 
decision to abandon DMLSS deployment followed the OIG report findings.
---------------------------------------------------------------------------
    Making sure veterans are promptly and accurately provided benefits 
is one of VA's most important responsibilities, yet it is often 
hindered by outdated IT systems and unclear or complex business 
processes. For example, VA improperly created debts in veterans' 
accounts when reducing disability levels. In a national review of the 
issue, the OIG found instances in which VA employees retroactively 
reduced disability levels and erroneously created debts without always 
informing veterans--in part due to system limitations. Based on the 
review of a statistical sample, the OIG estimated errors resulting in 
incorrectly created veteran debts totaling about $13.4 million.\22\
---------------------------------------------------------------------------
    \22\ VA OIG, VBA Improperly Created Debts When Reducing Veterans' 
Disability Levels, July 28, 2022.
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    The OIG has also released a series of reports on GI bill benefits 
in response to concerns that eligible beneficiaries were not getting 
payments owed to them or were being underpaid.\23\ Starting with an 
issue statement in 2019, the OIG identified delays in system 
modifications needed to satisfy the statutory requirements, in part due 
to the lack of an accountable official to oversee the project.\24\ The 
OIG team found that approximately 10 months passed from the time 
Congress enacted the Forever GI Bill until VA received the initial 
software development release and began testing the system 
modifications. VA's testing of the software development release 
identified defects, prompting the development of additional versions. 
Based on interviews, when user testing occurred, there were failures 
related to scenarios that VBA did not account for when personnel 
developed the business requirements. In a recent report on the Post-9/
11 GI Bill, the OIG found errors in VBA's processing of school vacation 
breaks due to the process being entirely manual, resulting in about 
$624,000 in underpayments to beneficiaries for monthly housing 
allowances and college funds.\25\
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    \23\ VA OIG, Forever GI Bill: Early Implementation Challenges, 
March 20, 2019; VA OIG, Controls Appear to Have Addressed Prior 
Overpayments of Post-9/11 GI Bill Monthly Housing Allowance, June 23, 
2020; VA OIG Management Advisory Memorandum, Post-9/11 GI Bill Non-
College Degree Entitlement Calculations Lead to Differences in Housing 
Allowance Payments, January 19, 2021; VA OIG, Processing of Post-9/11 
GI Bill School Vacation Breaks Affects Beneficiary Payments and 
Entitlement, May 3, 2022.
    \24\ VA OIG, Forever GI Bill: Early Implementation Challenges.
    \25\ VA OIG, Processing of Post-9/11 GI Bill School Vacation Breaks 
Affects Beneficiary Payments and Entitlement.
---------------------------------------------------------------------------
    Another report indicated improper payments were being made to 
veterans who were deceased because VA needed to better monitor its 
death match records automated process, and VBA missed opportunities to 
discontinue payments by not coordinating with and obtaining data from 
VHA.\26\ In one case, payments continued to be improperly paid to a 
veteran who was deceased for a total of about $99,000.\27\ An automated 
system also was to blame for improper processing of pension reductions 
as detailed in a 2021 report, leading to veterans not being notified 
that their benefits were being reduced or given the information 
necessary to appeal those reductions. All of the estimated 13,100 cases 
contained notification errors that made it difficult for beneficiaries 
to determine what action they should take, such as submitting evidence 
that the benefit should not be reduced or requesting a hearing. Errors 
identified were the result of inadequate planning and implementation of 
the automated pension reduction process.\28\
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    \26\ VA OIG, Additional Actions Can Help Prevent Benefits Payments 
from Being Sent to Deceased Veterans, April 21, 2022.
    \27\ In a recent OIG criminal investigation, the daughter of a 
deceased widow who had been receiving VA survivors benefits continued 
to receive those benefits even after her mother passed by forging her 
mother's signature and fraudulently filing VA paperwork to make it 
appear as if her mother was still alive. The daughter was ordered to 
pay restitution of almost $462,000. VA OIG, Monthly Highlights, January 
2023.
    \28\ VA OIG, Improper Processing of Automated Pension Reductions 
Based on Social Security Cost of Living Adjustments, October 28, 2021.
---------------------------------------------------------------------------
    VA has also been struggling since the early 2000's to replace its 
financial management system. After several failed attempts in 2004 and 
2010, VA used the lessons learned and established the Financial 
Management Business Transformation (FMBT) program. The program's 
mission is to increase the transparency, accuracy, timeliness, and 
reliability of financial information across VA, ultimately resulting in 
improved care and services for veterans and accountability to 
taxpayers. Central to the FMBT program's modernization efforts is the 
multiyear, phased deployment of the Integrated Financial and 
Acquisition Management System (iFAMS) beginning with NCA. In September 
2021, the OIG issued a management advisory memorandum on inadequate 
business intelligence reporting capabilities in iFAMS that hindered 
NCA's ability to easily monitor its budget and operations.\29\ In June 
2022, the OIG issued another memorandum on the results of a consulting 
engagement related to financial reporting controls for iFAMS at 
NCA.\30\ This memorandum identified risks that could lead to inaccurate 
financial reporting, including interface errors, more manual data 
entry, and the lack of automated controls. VA is currently reviewing a 
draft report related to the deployment of iFAMS at NCA that discusses 
issues that should be addressed as VA moves forward with further 
deployment of iFAMS.
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    \29\  VA OIG, Inadequate Business Intelligence Reporting 
Capabilities in the Integrated Financial and Acquisition Management 
System, September 8, 2021.
    \30\ VA OIG, Results of Consulting Engagement Related to Selected 
Financial Reporting Controls for the Integrated Financial and 
Acquisition Management System at the National Cemetery Administration, 
June 15, 2022.

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Quality Assurance, Monitoring, and Reviews

    VA often lacks controls that effectively and consistently ensure 
quality standards are met. Routine monitoring breakdowns and 
workarounds undermine efforts to ensure eligible veterans and their 
families receive timely quality services and benefits. Failures in 
quality assurance and monitoring relate not just to systems and 
processes, but to personnel as well--particularly in areas such as 
credentialing, privileging, and monitoring of healthcare personnel 
entrusted with veterans' care.
    VBA and VHA programs have various types of quality assurance 
programs; however, they are not consistently and effectively 
implemented and the results are not always clearly communicated or 
resolved. Among the many reports the OIG has published, a series of 
four focused reports and a roll-up report have been released on VBA's 
multifaceted quality assurance program.\31\ The program is managed by 
VBA's Compensation Service but VBA's OFO is responsible for ensuring 
regional office employees adequately address claims-processing 
deficiencies routinely identified by the quality assurance program. The 
individual reports on elements of the quality assurance program 
identified weaknesses in the program, and the summary report identified 
systemic weaknesses in OFO's oversight and accountability. Two aspects 
of the quality assurance program are the STAR Program and the Quality 
Review Team Program. However, OIG staff have observed those programs 
focus on an overall statistical sample of completed disability 
compensation claims. That means that complex claims, such as claims for 
military sexual trauma and ALS (Lou Gehrig's disease), are not the 
focus of the sample. Processing deficiencies related specifically to 
these complex claims may go undetected if they are simply grouped with 
claims at lower risk for error. Without more focused sampling, quality 
assurance results provide incomplete information to VBA on how well 
staff are processing claims more vulnerable to error.
---------------------------------------------------------------------------
    \31\ VA OIG, The STAR Program Has Not Adequately Identified and 
Corrected Claims-Processing Deficiencies, July 22, 2020; VA OIG, 
Deficiencies in the Quality Review Team Program, July 22, 2020; VA OIG, 
Site Visit Program Can Do More to Improve nationwide Claims Processing, 
August 18, 2020; VA OIG, Greater Consistency Study Participation and 
Use of Results Could Improve Claims Processing nationwide, September 
29, 2020; VA OIG, The Office of Field Operations Did Not Adequately 
Oversee Quality Assurance Program Findings, May 18, 2021.
---------------------------------------------------------------------------
    One of the OIG's reports on VBA's quality assurance program 
examined VBA's site visit program of regional benefits offices, which 
is designed to not only correct deficiencies at individual regional 
offices, but also to identify error trends across multiple regions that 
could be used to drive nationwide improvements in claims processing. 
The OIG reviewed the site visit reports for 47 regional offices and 
found that almost 50 percent had deficient workload management plans, 
36 percent had no plans at all to clear the backlog of errors pending 
correction identified by quality review teams, and 23 percent were 
deficient in MST claims processing.\32\ While the site visit program 
identified these and other frequently recurring deficiencies, OFO did 
not require all offices across the country to apply the information to 
ensure widespread improvements. As a result, VBA missed opportunities 
to provide impactful oversight and drive positive change, which could 
ultimately improve the accuracy and consistency of veterans' disability 
benefit decisions. Until VBA leaders ensure improvements are made, 
veterans may not get the benefits to which they are entitled.
---------------------------------------------------------------------------
    \32\ VA OIG, Site Visit Program Can Do More to Improve nationwide 
Claims Processing.
---------------------------------------------------------------------------
    VA has identified patient safety as a top priority.\33\ Healthcare 
facilities committed to patient safety routinely follow protocols that 
prioritize high-quality care and have a structured and proactive 
quality and safety management oversight team. OIG reports, however, 
routinely identify instances in which staff fail to adhere to policy or 
to take actions that ensure a culture of patient safety. For example, a 
recent OIG report found that the Tuscaloosa VA Medical Center and VISN 
7 had insufficient oversight of the facility's Patient Safety 
Program.\34\ The OIG received a VHA Issue Brief identifying concerns 
with the program's management not completing the required patient 
safety root cause analyses and risk assessments, and the former Patient 
Safety Manager (PSM) not attending meetings with facility and VISN 
committees. These concerns followed the extended leave and abrupt 
retirement of the former PSM. The OIG substantiated the concerns and 
identified other issues with program oversight and the facility's 
culture of safety. According to the report, the facility and VISN 
leaders did not take appropriate action. Facility leaders failed to 
fully engage with Patient Safety Program staff and did not sufficiently 
use available tools to assess and evaluate reported concerns related to 
patient safety, putting patients at unnecessary risk.
---------------------------------------------------------------------------
    \33\ See, e.g., VA, ``Patient safety a primary concern at VA,'' 
March 15, 2021, https://news.va.gov/85809/patient-safety-primary-
concern-va/, and ``VHA National Center for Patient Safety'' (web page), 
VA, https://www.patientsafety.va.gov/about/approach.asp.
    \34\ VA OIG, Deficiencies in the Patient Safety Program and 
Oversight Provided by Facility and VISN Leaders at the Tuscaloosa VA 
Medical Center in Alabama, February 27, 2023.
---------------------------------------------------------------------------
    Ensuring high-quality patient care was also identified in a report 
on the Columbia VA Health Care System in South Carolina.\35\ That 
report focused on adverse clinical outcomes for three patients. While 
reviewing the allegations related to those patients, the OIG found 
weaknesses in the peer review and quality management processes. The 
peer reviews and the peer review committee practices were inefficient 
and there was a delay in the initiation of an institutional disclosure 
to the patient's family and completion of a root cause analysis of the 
problem. All seven of the report's recommendations remain open, 
including three focused on the facility's quality management program.
---------------------------------------------------------------------------
    \35\ VA OIG, Surgical Adverse Clinical Outcomes and Leaders' 
Responses at the Columbia VA Health Care System in South Carolina, 
September 27, 2022.
---------------------------------------------------------------------------
    Proper documentation practices are an important aspect of 
accountability in both benefits and healthcare settings. Those 
practices help VA and oversight entities ensure that policies and 
requirements are being met. In healthcare settings, proper 
documentation is especially critical as it communicates to members of 
an integrated healthcare team critical data that are necessary to 
ensure coordination and collaboration. For example, in an inspection of 
the VA Pittsburgh Healthcare System, the OIG found that failures in 
completing a thorough assessment and documentation may have contributed 
to a lack of appropriate intervention and ultimately an adverse 
clinical outcome for a patient.\36\ A behavioral health nurse 
practitioner did not document a comprehensive suicide risk assessment 
for eight patients, even though this was required based on their 
positive screen for suicidal ideation. The nurse practitioner also 
failed to consistently document intent, risk and protective factors, 
and a mitigation plan for the patients. The OIG also found that a nurse 
manager who was responsible for conducting ongoing professional 
practice evaluations (OPPE) had given this nurse practitioner a 
``satisfactory'' rating for the ``safety plan completion for high risk 
for suicide patients'' and ``copy and paste use'' elements--even though 
the nurse manager admitted to not reviewing these elements of 
documentation. In fact, the inspection team found that the nurse 
practitioner not only failed to complete a safety plan for eight 
patients, but also inappropriately copied and pasted significant 
sections of notes from prior documented clinical encounters. The OIG's 
recommendations centered on the improvement of assessment and 
documentation practices, verification of the review of performance 
elements in OPPEs, and manager oversight of those OPPEs.
---------------------------------------------------------------------------
    \36\ VA OIG, Deficiencies in a Behavioral Health Provider's 
Documentation and Assessments, and Oversight of Nurse Practitioners at 
the VA Pittsburgh Healthcare System in Pennsylvania, May 3, 2022.
---------------------------------------------------------------------------
    Quality controls and process monitoring must be coupled with 
ensuring the competency of personnel to meet the requirements of their 
position and their commitment to serving veterans. Delayed responses to 
concerns related to the competency of healthcare providers cannot only 
put patients at risk and compromise the trust of staff, but can 
negatively affect the skills and practices of the providers in 
question. A report on the Richard L. Roudebush medical center in 
Indiana highlights this issue.\37\ The cardiology nursing staff had 
expressed multiple concerns to facility leaders regarding the skills of 
a newly trained interventional cardiologist. As a result, the 
cardiologist's cardiac catheterization laboratory privileges were 
suspended and a factfinding investigation was initiated. However, these 
actions were not completed in a timely manner. The factfinding 
investigation was finalized more than 3 months after the cardiologist's 
suspension, and it took almost another three months for the 
cardiologist's privileges to be reinstated so that leaders could 
initiate a second observed evaluation of the cardiologist's performance 
in the catheterization laboratory. After 6 months out of practice, the 
cardiologist refused to participate in a practice review and resigned. 
Ultimately, the OIG did not substantiate that the interventional 
cardiologist provided poor quality of care to patients at the facility.
---------------------------------------------------------------------------
    \37\ VA OIG, Deficiencies in Credentialing, Privileging, and 
Evaluating a Cardiologist at the Richard L. Roudebush VA Medical Center 
in Indianapolis, Indiana, January 17, 2023.

Stable Leadership That Fosters Responsibility and Continuous 
---------------------------------------------------------------------------
    Improvement

    VA leaders at every level often do not get the information they 
need to make effective decisions; some fail to take necessary and 
prompt action, while others struggle to create a culture where every 
employee feels empowered to report problems. The frequent turnover in 
key positions or the long-term use of acting positions exacerbates 
these challenges.
    The OIG's recent report on the mistreatment of a patient admitted 
to the Miles City Community Living Center (CLC), part of the VA Montana 
Healthcare System in Fort Harrison, describes failures in leadership 
that led to several incidents of patient abuse.\38\ The OIG learned 
that nurses and a physical therapist forced a critically ill patient to 
walk after the patient verbally refused and lowered to the floor to 
further refuse participation. Staff reported the physical therapist, 
and a nurse forcefully lifted the patient by the arm to stand and then 
pulled the patient's walker forward and out of reach, compelling the 
patient to walk. A VA police report documented bruises to the patient's 
arms, and staff told the OIG that the patient sustained skin tears 
during this session. The OIG concluded that the physical therapist and 
nurses violated VHA policy by failing to respect the patient's right to 
refuse treatment and subjecting the patient to mistreatment during two 
physical therapy sessions. The OIG also determined that there were 
three previous investigations with confirmed findings of mistreatment 
or abuse in the CLC. Two nurses involved in the mistreatment of this 
patient were also involved in two of the other incidents, one in a 2018 
incident and both in an August 2020 incident. The OIG determined that 
facility leaders did not complete oversight processes for the CLC, 
including intervening in prior findings of CLC patient mistreatment in 
2018 and 2020. Facility leaders also failed to oversee the sole 
physician responsible for the CLC patients. The lack of oversight 
repeatedly placed patients at risk. With a distance of over 350 miles 
to the Fort Harrison facility, staff easily escaped accountability.
---------------------------------------------------------------------------
    \38\ VA OIG, Mistreatment and Care Concerns for a Patient at the VA 
Montana Healthcare System in Miles City and Fort Harrison, January 26, 
2023.
---------------------------------------------------------------------------
    The Montana case is an example of a culture the OIG has found in 
other facilities that did not foster the prompt and candid reporting of 
concerns. Leaders' failures to create a culture in which personnel feel 
safe in reporting clinical personnel's incompetency or errors can lead 
to tragic outcomes. For example, in a 2021 report, the OIG detailed how 
Dr. Robert M. Levy, the former pathologist at the VA Health Care System 
of the Ozarks in Fayetteville, Arkansas, was found to have been working 
while impaired by substance use and misdiagnosed thousands of patients' 
pathological specimens. His errors resulted in some veterans not being 
diagnosed with cancers for which they needed prompt and tailored 
treatments and others undergoing interventions they did not need--some 
with significant side effects. In addition, in his position as chief of 
pathology, he was able to alter quality management documents to conceal 
his errors.\39\ Dr. Levy was sentenced to 20 years in federal prison 
(including one count of involuntary manslaughter), followed by three 
years of supervised release, and ordered to pay $497,745 in 
restitution.\40\ Like the Reta Mays serial murder case mentioned 
earlier, personnel had concerns regarding the circumstances surrounding 
the hypoglycemic events, but not all personnel promptly reported 
concerns and there were insufficient follow-up actions taken.
---------------------------------------------------------------------------
    \39\ VA OIG, Pathology Oversight Failures at the Veterans Health 
Care System of the Ozarks in Fayetteville, Arkansas, June 2, 2021.
    \40\ US Department of Justice, ``Fayetteville Doctor Sentenced to 
20 Years in Federal Prison for Mail Fraud and Involuntary 
Manslaughter,'' January 22, 2021, www.justice.gov/usao-wdar/pr/
fayetteville-doctor-sentenced-20-years-Federal-prison-mail-fraud-and-
involuntary.
---------------------------------------------------------------------------
    In a number of OIG reports, leaders' stated commitment to 
improvement is not reflected in closing, sustaining, or fully 
implementing recommendations for corrective action.\41\ As stated 
earlier, the OIG has reviewed VBA's processing of posttraumatic stress 
disorder (PTSD) claims related to MST several times due to delays in 
implementing recommendations for improvement or sustaining those 
corrective actions. In August 2018, the OIG found that claims 
processors did not follow the proper procedures for about half of 
denied claims to veterans, resulting in premature denials. The OIG made 
six recommendations including calling for VBA to have MST claims 
handled by a specialized group of claims processors. In response, VBA 
identified a list of designated claims processors and in January 2019 
established a procedure requiring that only designated employees 
process MST claims.\42\
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    \41\ See, e.g., VA OIG, Follow-Up Review of the Accuracy of Special 
Monthly Compensation Housebound Benefits, December 15, 2021.
    \42\ VA OIG, Denied Posttraumatic Stress Disorder Claims Related to 
Military Sexual Trauma.
---------------------------------------------------------------------------
    However, in August 2021, the OIG concluded in a followup to the 
2018 report that VBA leaders had not sustained the corrective 
actions.\43\ About 80 percent of claims denied from October 1 through 
December 31, 2019, were processed by one or more VBA employees who were 
not designated MST claims processors. Based on a sample of claims 
processed after VBA acted on the prior OIG recommendations, the review 
team estimated about 620 of 1,100 denied claims (57 percent) were 
incorrectly processed, which was not an improvement from the previous 
error rate.
---------------------------------------------------------------------------
    \43\ VAOIG, Improvements Still Needed in Processing Military Sexual 
Trauma Claims.
---------------------------------------------------------------------------
    VA has a special obligation to provide veterans who are claiming 
benefits every opportunity to support their claims. Leadership duties 
do not end when the OIG closes a recommendation based on VA-provided 
documentation that demonstrates sufficient plans and steps have been 
taken to address identified issues. Leaders must instill in all VA 
personnel a commitment to continuous improvement, including fully 
addressing and sustaining corrective actions taken in response to OIG 
recommendations.
    A lack of commitment to full transparency in reporting operational 
problems can also hinder OIG and other oversight. In reviewing VA's new 
EHR system at the Mann-Grandstaff VA Medical Center in Spokane, 
Washington, the OIG found that leaders in what was then the VA Office 
of Electronic Health Record Modernization (OEHRM) showed a careless 
disregard for the accuracy and completeness of the information they 
provided, and that those leaders' lack of due care and diligence 
resulted in misinformation being submitted to OIG staff.\44\ The OIG 
recommended that the program's leaders clarify to their personnel that 
all staff have a right to speak directly and openly with OIG staff and 
ensure that direct communication with OIG staff is not impeded when 
needed to clarify requests or responses.\45\
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    \44\ VA OIG, Training Deficiencies with VA's New Electronic Health 
Record System at the Mann-Grandstaff VA Medical Center in Spokane, 
Washington, July 8, 2021. In December 2021, OEHRM was restructured to 
form the Electronic Health Record Modernization Integration Office 
(EHRM IO).
    \45\ VA OIG, Senior Staff Gave Inaccurate Information to OIG 
Reviewers of Electronic Health Record Training, July 14, 2022.

---------------------------------------------------------------------------
Conclusion

    There is no question that the overwhelming number of VA leaders and 
personnel are committed to serving veterans, their families, and 
caregivers, as well as answering the call for assistance from their 
local communities in times of crisis. They often have to navigate 
obstacles and overcome challenges to make certain that patients receive 
prompt high-quality care and that veterans and other eligible 
beneficiaries receive the compensation and services they are owed. 
Unfortunately, the OIG has found that VA has struggled with the 
foundations of accountability, including strong governance and clarity 
of roles and responsibilities; adequate and qualified staffing; updated 
IT systems and effectual business processes; effective quality 
assurance and monitoring; and stable leadership that fosters 
responsibility for actions and continuous improvement. Without a 
greater emphasis on these areas of accountability, VA will not always 
provide the highest-quality care, benefits, and services to veterans 
and their families.
                               __________

                   Prepared Statement of Gene Dodaro
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                               __________

                 Prepared Statement of Shereef Elnahal

    Our Nation's most sacred obligation is to prepare and equip the 
troops we send into harm's way, and to care for them and their families 
when they return home. VA is honored to fulfill the promise made to 
care for our brave Service members and we will stop at nothing to serve 
Veterans, their families, caregivers, and survivors every bit as well 
as they have served us.
    VA has provided more care, more benefits, and more services to more 
Veterans than ever before. Across the enterprise, VA has achieved 
record-breaking numbers in providing benefits and care. In 2022 alone, 
the Veterans Benefits Administration (VBA) completed more than 1.7 
million disability compensation and pension claims for Veterans, an 
all-time VA record that broke the previous year's record by 12 percent. 
Continued focus on claims processing fundamentals, such as expanded C&P 
examination capacity, digitization of federal records, and ensuring a 
robust hiring and onboarding process, contributed to the agency's 
ability to meet these goals. This resulted in Veterans and survivors 
receiving over $128 billion in disability compensation and pension 
benefits in 2022, including nearly $10 billion in retroactive awards.
    During this same period, the Veterans Health Administration (VHA) 
also provided more than 115 million clinical encounters, with VA 
serving over 6.4 million patients. This included roughly 40 million in-
person appointments and more than 31 million tele-health and telephone 
appointments and approximately 38 million community care appointments 
in 2022 alone.
    In addition, the National Cemetery Administration (NCA) interred 
nearly 150,000 Veterans and eligible family members in our national 
cemeteries during Fiscal Year 2022--the highest number of annual 
interments VA has recorded. NCA also provided more than 350,000 
headstones, markers and columbarium niche covers around the world. We 
also provided nearly 12,000 medallions in 2022 to mark the privately 
purchased headstones of Veterans. In 2023, VA will continue to deliver 
more care and more benefits to more Veterans than ever before, and 
continue to fight for all Veterans, their families, caregivers, and 
survivors.
    To continue this momentum, VA has a threefold approach. First, VA 
is focused on increasing access to world class health care and earned 
benefits by improving customer service and ensuring that Veterans and 
their families trust VA by expanding outreach to underserved Veterans 
and implementing new authorities (such as the Sergeant First Class 
Heath Robinson Honoring our Promise to Address Comprehensive Toxics 
(PACT) Act to expand services, programs, and benefits.
    Second, VA is investing in its people. This means VA is hiring more 
staff across the Department to ensure that care and benefits are 
delivered in a timely manner. VA is also focused on improving employee 
experience to help improve outcomes for Veterans, their families, 
caregivers, and survivors which makes sure that we keep the Veteran at 
the center of everything we do. Additionally, VA is implementing new 
hiring authorities and new retention authorities to grow and maintain a 
diverse, talented workforce with a shared mission to provide more care 
and more benefits to more Veterans. For example, using the recently 
approved Direct Hire Authority for mission critical occupations, VBA 
was able to increase its total workforce by more than 5 percent (more 
than 1,300 employees) in the first four months of Fiscal Year 23, 
compared to less than 1 percent growth in the workforce over the same 
time period in Fiscal Year 22.
    Third, VA is transforming systems, processes, and infrastructure in 
order to achieve operational excellence, increase productivity, and 
ensure that systems and processes are easy to use by both the staff and 
the Veterans we serve. Outcomes for Veterans drive everything we do - 
because Veterans, not us, are the ultimate judges of our success. The 
proof of VA's ability to deliver on this promise is evident in NCA's 
recent top score in the prestigious American Customer Satisfaction 
Index (ACSI) \1\ ratings. For the second time, NCA has scored 97 (out 
of 100) on the index, which is the highest score ever achieved by any 
organization rated by the ACSI, public or private, including the best-
known companies in our country. The ACSI survey describes itself as 
``the only national cross-industry measure of customer satisfaction 
available in the United States.''
---------------------------------------------------------------------------
    \1\ In 1999, the federal government selected the ACSI to be a 
standard metric for measuring citizen satisfaction. The ACSI measures 
citizen satisfaction with over 100 services, programs, and websites of 
federal government agencies. The objective of the survey is to measure 
customer satisfaction with a score of 0-100.
---------------------------------------------------------------------------
    This is the seventh time NCA has been ranked first in customer 
satisfaction by ACSI. This remarkable achievement is testament to the 
extraordinary hard work that every member of the NCA team puts in every 
day. They are motivated every day to ensure that Veterans receive the 
final honor they have earned from our grateful Nation - a place of 
eternal rest in a National shrine. NCA's impressive customer 
satisfaction scores are an inspiration for all of us in VA. Every 
employee in VA shares that dedication and motivation to serve our 
Nation's Veterans every day.

Increasing Access

    Across VA, VHA, VBA, and NCA have focused on increasing access to 
world class health care and earned benefits to all Veterans, their 
families, caregivers, and survivors. We will continue to do so by 
facilitating timely access, focusing on women's health care, and 
expanding mental health care and suicide prevention.

Access to the Soonest and Best Care

    Providing Veterans access to the best care in a timely way is at 
the core of our mission. Over the last 2 years, VA has delivered more 
care to more Veterans through both VA and community care providers than 
during any time in our Nation's history. Veterans completed more than 
73 million outpatient appointments in VA and another 38 million 
community care outpatient appointments in calendar year 2022. While 
enrolled Veterans continue to receive the majority of their outpatient 
care in VA, more than 3.5 million Veterans have completed at least one 
outpatient appointment with a community care provider since we 
implemented the VA MISSION Act of 2018. As such, more than 1/3 of all 
Veterans enrolled in VA health care have been eligible for and chosen 
to elect to receive at least one community care appointment at some 
point in the last five years.
    Veterans today have more options for care than ever. VA has more 
than 1,100 medical centers and community-based outpatient clinics for 
Veterans to receive their care. VA offers care in-person, over the 
phone or through video appointments as clinically appropriate. VA's 
community care network has more than 1.3 million community care 
providers across all 50 States and U.S. Territories. Enrolled Veterans 
also have access to community urgent care, and all Veterans have access 
to emergent suicide care.
    Veterans' trust levels for VA health care exceed 90 percent 
nationally, whether care is received in VA or through a community 
provider. Veterans believe VA health care is getting better, according 
to studies by the Veterans of Foreign Wars, more than 90 percent of 
Veterans surveyed say they would recommend VA care to other Veterans. 
VA is seeing more patients than ever before and studies show VA 
compares favorably to the private sector for access \2\ as well as 
quality of care \3\ - and in many cases exceeds the private sector.
---------------------------------------------------------------------------
    \2\ Comparison of Wait Times for New Patients Between the Private 
Sector and United States Department of Veterans Affairs Medical Centers 
: Health Care Quality : JAMA Network Open : JAMA Network
    \3\ VA Health System Generally Delivers Higher-Quality Care Than 
Other Health Providers : RAND

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Women's Health Care

    VA remains committed to providing high-quality, equitable care to 
women Veterans at all sites of care. More women are choosing VA for 
their health care than ever before, with women accounting for over 30 
percent of the increase in Veterans served over the past 5 years. The 
number of women Veterans using VHA services has more than tripled since 
2001, growing from 159,810 to more than 600,000 today.
    To provide the highest quality of care to women Veterans, VA offers 
women Veterans trained and experienced designated Women's Health 
Primary Care Providers (WH-PCP). National VA satisfaction and quality 
data indicate women who are assigned to WH-PCPs have higher 
satisfaction and higher quality of gender-specific care than those 
assigned to other providers. Importantly, we also find women assigned 
to WH-PCPs are twice as likely to choose to stay in VA health care over 
time. Designated WH-PCPs are available across all VA health care 
systems. VA tracks sites with fewer than two WH-PCPs to enhance 
national training and local hiring initiatives in rural areas and in 
additional areas where we have gaps in capacity to treat women.
    While maternity care is not provided in VA facilities, a 
significant number of Veterans use maternity services provided through 
VA-authorized care in the community. Pregnant and postpartum Veterans 
continue to receive care in VA for other conditions and may also need 
primary care, emergency care and require coordination of Community Care 
services. To support pregnant and postpartum Veterans, VA has developed 
a Maternity Care Coordination (MCC) program in all VA health care 
systems to ensure coordination of care both in VA and in the community. 
To further support our Veteran population and in response to Public Law 
(P.L.)116-79, Protecting Moms Who Served Act of 2021, VA is expanding 
the maternity care coordination program to follow pregnant Veterans for 
one year postpartum, a particularly vulnerable time for families. VA 
MCCs support pregnant Veterans through every stage of pregnancy and 
postpartum. MCCs help pregnant Veterans navigate health care services 
both inside and outside of VA, connect to community resources, cope 
with pregnancy loss, connect to needed care after delivery and answer 
questions about billing. MCCs screen Veterans for intimate partner 
violence, perinatal mental health conditions, substance use disorders, 
homelessness and food insecurity and ensure Veterans are connected to 
appropriate resources and needed services.
    VA is focusing on enhancing care coordination for preventive care, 
such as breast and cervical cancer screening. VA is actively 
implementing the Dr. Kate Hendricks Thomas Supported Expanded Review 
for Veterans In Combat Environments (SERVICE) Act. Beginning in March 
2023, VA will be providing breast cancer risk assessments, including 
toxic exposure risk assessments, to Veterans eligible under the SERVICE 
Act with referral for mammography as clinically indicated. Breast and 
cervical cancer screening programs require meticulous tracking to 
ensure that all eligible Veterans receive appropriate screening and 
receive results of screening tests, and that followup care is arranged 
as needed. To ensure accuracy, timeliness and reliability, VA tracks 
the provision of breast and cervical cancer screening and the 
availability of breast and cervical cancer care coordinators across the 
system.

Preventing Suicide

    Preventing Veteran suicide is a top priority, and VA has 
implemented a comprehensive public health approach to reach all 
Veterans. This approach is in full alignment with the President's 
national strategy, Reducing Military and Veteran Suicide \4\, advancing 
a comprehensive, cross-sector, evidence-informed public health approach 
with focal areas in lethal means safety, crisis care, and care 
transition enhancements, increased access to effective care, addressing 
upstream risk and protective factors, and enhanced research 
coordination, data sharing, and program evaluation efforts.
---------------------------------------------------------------------------
    \4\ Military-and-Veteran-Suicide-Prevention-Strategy.pdf 
(whitehouse.gov)
---------------------------------------------------------------------------
    With the goal to reach Veterans both inside and outside VA care, VA 
launched Suicide Prevention 2.0 (SP 2.0). SP 2.0 is a population-based, 
public health model of intervention. SP 2.0 includes community-based 
prevention strategies and evidence-based clinical strategies that 
empower action at National, regional, and local levels. To accomplish 
the goal of working toward ending suicide among all 20 million U.S. 
Veterans, a comprehensive approach to suicide prevention that blends 
community-based prevention and clinically based interventions is 
needed. The model works to reach Veterans in the community and those we 
currently serve in VA with evidence-informed community-based prevention 
strategies combined with strategies with known outcomes for reducing 
suicide and suicide attempts based upon the VA-Department of Defense 
(DoD) Clinical Practice Guidelines.
    Another tool VA actively uses to combat suicide is the Veterans 
Crisis Line (VCL), which offers support to Veterans who reach out for 
help. Since July 16, 2022, the VCL has been easily accessible via 988, 
and pressing 1. The new, shorter number, implemented thanks to the 
National Suicide Hotline Designation Act of 2020, directly addressed 
the need for ease of access and clarity in times of crisis, both for 
Veterans and non-Veterans alike. Between 2007 and October 2022, VCL has 
taken more than 6.4 million calls, 269,000 texts, 772,000 chats and 
provided more than 1.2 million referrals. Since the official launch of 
988 through February 5, 2023, VCL has seen a 12.35 percent increase in 
call volume and 25.46 percent increase in text volume compared with 
last year. Average calls per day exceeded 2000 between July 15, 2022, 
and February 5, 2023. Additionally, VCL campaigns are designed to raise 
awareness of call, chat, and text supports for Veterans in crisis. The 
campaign also provides social media, web, print and video resources 
that can be broadly shared through the Spread the Word Initiative .
    In partnership with the Department of Health and Human Services' 
Substance Abuse and Mental Health Services Administration, VA is 
facilitating State-level efforts to prevent Veteran suicide with the 
Governor's Challenge to all States and territories. The Governor's 
Challenge advances a public health approach to suicide prevention by 
bringing together key State leaders to develop strategic action plans 
focused on Veteran suicide prevention. As the President announced in 
the State of the Union address, VA is working with the Departments of 
Health and Human Services and Defense to work with the States and 
territories through the Governor's Challenge. VA is launching a new $10 
million program to further bolster these efforts. We appreciate 
Congress' support in this regard. Additionally, with the launch of 
Mission Daybreak, VA invited innovators across the country to 
participate in a $20 million challenge to help VA develop suicide 
prevention strategies for Veterans. VA received over 1,300 submissions 
and recently announced 2 Grand Prize Winners as well as second and 
third place prize winners. The prize winners have at least one element 
in common: they each reflect various innovative approaches to clinical 
and community-level suicide prevention and intervention and they each 
are well-positioned to be deployed across a variety of settings and 
communities as part of our collective suicide prevention efforts.
    VA is expanding outreach to Veterans like never before. To reach 
Veterans wherever they are, VA has emphasized paid media campaigns to 
facilitate suicide prevention awareness. These include: 1) Don't wait. 
Reach out; 2) Keep it Secure; and 3) the Veterans Crisis Line. To 
develop the ``Don't Wait. Reach Out'' campaign, VA entered into an 
agreement with the Ad Council, a national non-profit organization that 
uses donated communication industry resources to elevate messaging. The 
campaign strategy was informed by extensive research with Veterans and 
portrays real Veterans in all videos. For the Don't Wait, Reach Out 
Campaign, from October 2021-July 2022, we have had over 1 billion 
impressions with over $10 million in donated media value.
    The Keep it Secure campaign is a national public health campaign, 
launched in September 2021, focused on safe storage for firearms during 
times of distress. From launch through January 2023, the campaign has 
garnered over 1.8 billion impressions, and over 20 million website 
visits to access resources and support for safe storage. As part of the 
White House Strategy to Reduce Military and Veteran Suicide, VA will 
continue expansion of this lethal means safety campaign this year with 
new communication endeavors also focused on providers, caregivers, and 
family members of Veterans, encouraging secure storage of firearms and 
medication.
    Finally, the VCL campaign works to reach Veterans and those who 
love them to support them 24/7 during times of crisis. Since the launch 
of the VCL campaign in February 2020 until July 2022, there have been 
nearly 2 billion impressions. When developing these and other 
campaigns, VA strives to represent the demographic and cultural 
diversity of Veterans. Together with ongoing campaigns like AboutFace 
and Make the Connection, VA hopes every Veteran will see themselves 
represented and know VA is here to serve them. VA is also making it 
easier for customers to connect with us with VA.gov and VA's Health and 
Benefits mobile app as our digital front door and 1-800-MyVA411 as our 
telephonic front door.
    With the enactment of the Commander John Scott Hannon Veterans 
Mental Health Care Improvement Act of 2019 (Hannon Act , P.L. 116-171) 
, VA is using new authorities that improve Veterans' mental health and 
substance use disorder care and services through the expansion of 
mental health care options. This includes the Staff Sergeant Parker 
Gordon Fox Suicide Prevention Grant Program (SSG Fox SPGP), which 
awards grants to eligible entities to provide or coordinate suicide 
prevention services to eligible individuals and their families. This 
grant program is the first-of-its-kind effort by VA to provide funding 
for local suicide prevention programs through outreach, suicide 
prevention services, and connection to VA and community resources.
    Through this new program, VA awarded $52.5 million to 80 grantees 
in 43 States, the District of Columbia and American Samoa. Twenty-one 
grantees serve Tribal lands including Navajo Nation, Cherokee Nation, 
Choctaw Nation, Alaskan Native Tribes and others. Funding decisions 
reflect VA's authority to prioritize the distribution of grants to 
rural communities, Tribal lands, Territories of the United States, 
medically underserved areas, areas with a high number or percentage of 
minority Veterans or women Veterans, and areas with a high number or 
percentage of calls to the Veterans Crisis Line.
    In addition to implementation of the authorities in the Hannon Act, 
VA continues to implement several other statutory requirements related 
to mental health care. As of January 17, 2023, as part of the COMPACT 
Act, eligible individuals (including Veterans) in suicidal crisis are 
eligible to receive covered emergency care - including transportation 
costs, inpatient or crisis residential care--from any health care 
facility, whether at VA or in the community. Inpatient care is 
available for up to 30 days, and outpatient care is available for up to 
90 days.

Access to Burial Benefits

    VA is focused on increasing access to burial benefits as well by 
developing new National cemeteries, developing additional gravesites at 
existing National cemeteries, and establishing and expanding Veterans 
cemeteries through grants to States, territories, counties and Tribal 
organizations. VA has been steadily managing the largest expansion of 
the cemetery system since the Civil War. VA has opened 13 new 
cemeteries in the last decade with one more planned this year. We also 
plan to open one new cemetery in each of the next two years. These 
National cemeteries will provide new or enhanced burial access to over 
3.8 million Veterans and their families.
    VA is also working with States and Tribal authorities to encourage 
the development and placement of VA grant-funded cemeteries in 
locations where Veterans do not have reasonable access to a burial 
option, either in a VA National or VA grant--funded Veterans' cemetery. 
Tribal access is a particular focus for VA. Within the last year, VA 
has engaged directly with the Crow Tribe in Montana, the Pascua Yaqui 
tribe in Arizona and the Sisseton Wahpeton Oyate tribe in South Dakota 
to address challenges and identify potential solutions regarding 
utilization of their grant-funded cemeteries. Similar sessions with 
leaders from the remaining eleven tribes with grant-funded Veterans 
cemeteries are planned.
    In Fiscal Year 2022, VA interred nearly 150,000 Veterans and 
eligible family members in our National cemeteries--the highest number 
of annual interments VA has recorded. Also in Fiscal Year 2022, VA also 
provided more than 350,000 headstones, markers and columbarium niche 
covers around the world, as well as nearly 12,000 medallions to mark 
the privately purchased headstones of Veterans. But these statistics 
reveal a key challenge for VA: ensuring Veterans know about and take 
advantage of interment in a VA national cemetery, or a VA-funded State, 
territorial or tribal cemetery.
    Approximately half of all Veterans are eligible for benefits and 
services, about one third of all Veterans actively use VA health care, 
and 85 percent of eligible Veterans use their GI Bill benefits (either 
themselves or by transferring those benefits to a family member). 
However, only 15 percent of all Veterans who die each year are interred 
in a VA National cemetery, with another 5 percent interred in a VA-
funded State, territorial or Tribal cemetery. That's why we are 
embarking on a campaign to ensure that Veterans know they have the 
option to Choose VA for their final resting places. To ensure they know 
that VA stands ready to fulfill our solemn obligation to them: to care 
for them and their loved ones in a manner that mirrors their own 
dedicated service and devotion to our Nation - in perpetuity.

Serving Veterans with Environmental Exposures

    Passage and enactment of the PACT Act marked the largest and most 
significant expansion of Veterans' care and benefits in decades, 
empowering VA to deliver additional care and benefits to millions of 
Veterans and their survivors. VA issued sub-regulatory guidance and 
provided training before going live with nationwide claims processing 
on January 1, 2023. Prior to implementation of the law, the VA used its 
authority under sections 403, 404, and 406 of the PACT Act to treat all 
presumptive conditions newly added as part of the PACT Act as 
applicable as of August 10, 2022, instead of future phased-in dates as 
prescribed by the law, to allow VA to deliver much-needed benefits and 
access to care to Veterans, family members, caregivers, and survivors 
as soon as the law was signed. As of February 4, 2023, VA has received 
nearly 300,000 PACT Act-related claims and completed over 110,000 
claims. Using the new PACT Act authorities, VA has granted presumptive 
service connection for over 1,200 terminally ill Veterans.
    VA immediately began executing a comprehensive, targeted outreach 
effort to encourage Veterans and survivors to apply now for PACT Act-
related care and benefits. VA hosted 127 PACT Act ``Week of Action'' 
events between December 10th and 17th in all 50 States, the District of 
Columbia, and Puerto Rico. Each event was open to Veterans, their 
families, caregivers, survivors, and advocates as well as the press. 
Invitations were also extended to Members of Congress, State Directors 
of Veterans Services, and local officials and stakeholders. More than 
50,000 attendees participated in person or online, VA completed 5,600 
exposure screenings, and received 2,600 claims for benefits, and more 
than 800 applications to enroll for health care. Over the coming weeks 
and months, VA will continue targeted outreach efforts to include 
public service announcements (PSA), advertisements such as the video 
billboard in Times Square, social media posts, and radio, TV, and audio 
streaming.
    One of the biggest challenges VA faces is identifying and 
contacting survivors, even more so now that many more may now be 
eligible for benefits under the PACT Act. We have mailed nearly 300,000 
letters to potentially eligible survivors and are working with Veterans 
Service Organizations and survivor organizations such as the Tragedy 
Assistance Program for Survivors (TAPS) and Gold Star Wives to amplify 
and streamline messaging. VA is also leveraging social media and 
posting YouTube videos to provide easy to read information on PACT Act. 
VA's goal is to provide information on the PACT Act not just to 
survivors themselves, but to anyone who may know a survivor so that 
VA's message can reach as many impacted individuals as possible.

Toxic Exposure Screenings

    As of February 8, 2023, VA has screened more than 1.78 million 
Veterans for toxic exposure. Of the 1.78 million Veterans screened, 43 
percent required follow-up. This includes both Veterans who reported 
possible exposure, and Veterans who were unsure of potential exposure 
concerns and had additional questions. When the screening is initiated 
by physicians (MD), osteopathic doctors (DO), advanced practice 
registered nurses (APRN), and physician assistants (PA) with 
privileges, 90 percent of followup screenings occur on the same day as 
the initial screening. If a screening is initiated by a staff member 
without clinical privileges (such as the facility Toxic Exposure 
Screening, or TES Navigator), the followup screening is then referred 
to and completed by a clinical provider. This ensures all Veterans with 
health concerns receive appropriate clinical assessment in a timely 
manner.

Toxic Exposure Research and Registry

    VA has completed a review of the Airborne Hazards and Open Burn Pit 
Registry in light of the 2022 National Academy of Sciences Engineering 
and Medicine (NASEM) 5-year review of the Registry, VA's internal 
Office of Inspector General review and our partnership with DoD to 
better address a Service member's (soon to be a Veteran's) health 
through the separation health assessment done at separation or 
retirement from military service.
    Title V of the PACT Act elevates the timely progress of exposure 
science through a whole-of-government approach. VA, in collaboration 
with the heads of other Federal entities, will establish an 
interagency, mission-aligned toxic exposure research working group with 
the goal of collaboratively developing and executing a 5-year strategic 
research plan on the health consequences of toxic exposures experienced 
during active military, naval, air, or space service, as required by 
section 501 of the PACT Act. VHA's Office of Research and Development 
met with other Federal agencies on February 2, 2023, to address section 
501 of the PACT Act, and establish an interagency Toxic Exposure 
Research Working Group, which will, in part, identify collaborative 
research activities and resources available among entities represented 
by members of the Working Group to conduct collaborative research 
activities and develop a 5-year strategic plan for such entities to 
carry out collaborative research activities.

Ending Veteran Homelessness

    VA has made significant progress in preventing and ending Veteran 
homelessness and VA remains focused on ending homelessness for all 
Veterans. Since 2010, the number of Veterans experiencing homelessness 
in the United States has declined by more than 55 percent. More than 
1,000,000 Veterans and their family members have been permanently 
housed, rapidly rehoused, or prevented from falling into homelessness 
through VA's homeless assistance programs. VA housed over 40,000 
homeless Veterans in 2022. This accomplishment along with VA's ongoing 
collaborative efforts with the Departments of Housing and Urban 
Development and Labor and the U.S. Interagency Council on Homelessness, 
are anticipated to further reduce the overall number of Veterans 
experiencing homelessness.

Supporting Transitioning Service Members

    VA is charged with ensuring that every Veteran is aware of and 
understands the benefits they have earned as they transition from 
military service. In Fiscal Year 2022, VA conducted 6,467 Transition 
Assistance Program (TAP) briefings to over 164,000 Service members and 
provided 58,356 one-on-one counseling sessions.
    The VA Solid Start program which launched in December 2019 has 
successfully connected with 315,604 (66.4 percent) eligible Veterans 
and provided information about, and access to, the benefits and 
services they have earned. Additionally, to reduce the Veteran suicide 
risk and to ensure continuity of care, VA Solid Start provided priority 
contact to those Veterans who met certain risk criteria. Since the 
program launched, VA Solid Start has successfully connected with 53,220 
(78.9 percent) priority Veterans supporting a successful transition to 
VA mental health care treatment.
    VA has begun work with DoD on a TAP Military Life Cycle (MLC) 
module with Other than Honorable (OTH) discharge as the topic focus. 
Further, VA will look to update OTH information in the VA TAP Benefits 
and Service Participant Guide beginning in March 2023. VA has found 
Veterans with an OTH character of discharge did not receive adequate 
information or support to connect with the VA benefits and services for 
which they are eligible, which may have detrimental downstream effects 
on a population already prone to crisis situations (mental health 
emergencies, joblessness, suicidality, homelessness, etc.).
    VA has a special commitment to understanding and supporting the 
unique needs of women Veterans. The Women's Health Transition Training 
Program is a critical resource tool that provides a comprehensive 
holistic approach to help transitioning Service women and recently 
separated women Veterans understand their VA health care benefits and 
services. In concert with our TAP interagency partners, VA has worked 
diligently to promote the Women's Health Transition Training Program 
through TAP and other means to make sure every Service woman is aware 
of this specialized course and is able to participate in this effective 
learning opportunity through five modules.

Improving Economic Opportunity

    VA is dedicated to improving the economic opportunity of 
Servicemember, Veterans and their families. VA has undertaken a number 
of improvements with the Veteran Readiness and Employment (VR&E) 
Program, Education Program, Home Loan Guaranty Program and Insurance 
Service to ensure that Veterans have an opportunity to achieve suitable 
employment, attain an education, obtain affordable housing, and 
maintain life insurance for themselves and their families.
    In Fiscal Year 2022, VA implemented a six-point plan to improve 
outcomes for Veterans participating in the Veteran Readiness & 
Employment (VR&E) Program. This plan includes implementing a new 
comprehensive data management system (RES), formerly known as the Case 
Management System (CMS); implementation of e-VA, electronic document 
signing, and other system enhancements; enhancements to the Veteran 
Success on Campus (VSOC) program; Employment Services; Quality Review 
Teams; and increased Vocational Rehabilitation Counselor (VRC) 
recruitment and retention.
    VA continues its efforts in realigning the services provided by the 
VSOC program. VSOC counselors have taken on increased workload allowing 
for more Veterans to be served in a counseling capacity at the school 
to which they are assigned. Therefore, an updated position description 
has been classified, removing the positive education requirement, which 
ultimately expands the population of individuals who can qualify to 
work as a VSOC counselor.
    Through the Digital GI Bill (DGIB), the VA is also transforming how 
GI Education Benefit Claims are submitted, reviewed, and processed 
using a multi-prong strategy - with the intent of enhancing the Veteran 
and beneficiary education experience. In August 2022, for the first 
time, Veterans were able to submit original Post-9/11 GI Bill 
applications could through an automated system. Applicants receive a 
head start by having pre-filled service history information which leads 
to quicker eligibility decisions, including as soon as the same day 
instead of more than 10 days on average.
    In support of the DGIB, the Office of Information and Technology 
(OIT) has worked with its VBA partners to successfully deploy ``My 
Education Benefits'' through va.gov, allowing the automated processing 
of original claims for the first time ever. The DGIB team has also 
moved the DGIB Application to production, saving the government 
millions in infrastructure costs for cloud computing and storage. DGIB 
is ready to deploy the ``Enrollment Manager'' and Chatbot to over 
45,000 school certifying officials around the world, which will improve 
the user experience for schools and increase automation of claims. This 
allows for the decommissioning of the VA-Once legacy application. In 
addition, VA has refined the rules so that Supplemental Automation has 
consistently been above 50 percent and as high as 62 percent. Last, the 
DGIB team deployed text messaging (with opt-in rates above 90 percent) 
and email services, enabling faster communication with VA that allows 
Veterans and beneficiaries to easily verify their enrollment in college 
courses.
    The Veterans Rapid Retraining Assistance Program (VRRAP) was 
enacted on March 11, 2021, under the American Rescue Plan to support 
Veterans seeking retraining and economic opportunities in response to 
the effects of the COVID-19 pandemic. VA worked on a highly effective 
PSA campaign with over 29 million impressions on television and radio, 
as well as a robust social media campaign to increase Veteran and 
eligible schools' awareness and participation in VRRAP. VA processed 
over 5,600 enrollments in less than 90 days. These actions were vital 
in allowing VA to obligate 98 percent of the $386 million available for 
Veterans to train and find suitable employment.
    The Veteran Employment Through Technology Education Courses (VET 
TEC) is a 5-year pilot program for eligible Veterans to help them 
secure meaningful employment in the technology sector. VET TEC pairs 
eligible Veterans with market-leading training providers offering 
sought after high-tech training and skills development. Since the 
program started, over 93,000 Veterans have applied for VET TEC with 
64,463 receiving Certificates of Eligibility. 9,075 Veterans have 
graduated from a VET TEC training program and 4,089 have found 
meaningful employment with an average salary of $65,118. The VET TEC 
Employer Consortium helps Veterans bridge the gap between program 
completion and meaningful employment, it also fosters a network of 
employers and training providers for graduates to leverage at the 
beginning of, and throughout, their careers.
    VA is dedicated to protecting Veterans as they pursue higher 
education. The Department of Education (ED) recently announced final 
rules that will better protect Veterans and Service members from 
predatory recruitment practices. These regulations implement an 
important change made by the American Rescue Plan, closing a 
longstanding loophole in the Higher Education Act of 1965 that allowed 
for-profit colleges to aggressively recruit Veterans and Service 
members because they could count money from Veteran and Service member 
benefits toward their 10 percent revenue requirement (other than 
Federal assistance). VA worked with ED on this effort and is assisting 
schools in maintaining compliance with ED's 90/10 rule, by providing 
training on how to obtain reports from VA detailing GI Bill payments.
    Since 1944, VA's home loan program has helped almost 28 million 
Veterans achieve the dream of home ownership. This program continues to 
maximize opportunities for Veterans, Service members, and surviving 
spouses to obtain, retain and adapt their homes. Veteran households 
have higher homeownership rates than the general population and, for 
many Veterans, VA's home loan program is the most advantageous mortgage 
option. Veterans make up approximately 6 percent of the U.S. 
population, but VA home loans account for 13 percent of the current 
mortgage market. VA's home loan program is popular because Veterans 
receive competitive interest rates, pay limited closing costs, and 
avoid private mortgage insurance requirements--usually without having 
to make a down-payment. Due to efforts of the Loan Guaranty Service to 
improve the program, even in today's higher interest rate environment, 
rates for 30-year, fixed-rate VA home loans currently average nearly 
one-half of 1 percent (or 50 basis points) lower than rates on 
conventional loans. Another specialized feature of the home loan 
program is the individualized service VA loan technicians provide to 
Veteran borrowers facing financial difficulty.
    VA continues to look for opportunities to improve the homebuying 
process for Veterans and their families. Through people, process, and 
technology enhancements, 76 percent of home loan certificates of 
eligibility (COE) are issued instantaneously. Appraisal timeliness has 
shown steady improvement, with average business days to completion 
decreasing from 10.4 business days in October 2021 to 6.7 business days 
in January 2023. As a member of the Property Appraisal and Valuation 
Equity (PAVE) Task Force, supporting Veterans' ability to utilize their 
home loan benefit without bias or racial impacts is of utmost 
importance. VA's commitment is further augmented by the fact that VA is 
the only agency that maintains and oversees an independent appraisal 
panel. VA recently announced advanced oversight procedures to improve 
methods of screening for potential appraisal bias and discrimination.
    VA remains committed to expanding opportunities for homeownership 
to Native American Veterans residing on trust land. VA is providing 
expansion through increased outreach to and collaboration with the 574 
federally Recognized Tribes. VA has signed 111 memoranda of 
understanding allowing the signatory Tribes to participate in the 
Native American Direct Loan (NADL) program. We continue to work with 
stakeholders in the State of Alaska to expand this vital direct loan 
program for Native American Veterans residing in Alaska.
    At the start of the COVID-19 pandemic, VA proactively announced 
numerous flexibilities in servicing guidelines to help Veterans with VA 
home loans. Since the start of the pandemic, VA's loss mitigation 
options have helped more than 200,000 Veterans remain in their homes, 
with more than 30,000 Veterans assisted through VA's temporary home 
retention options, the COVID-19 Veterans Assistance Partial Claim 
Payment, and the COVID-19 Refund Modification programs. As the COVID-19 
national emergency nears an end, VA continues to explore changes in 
servicing policies and home retention options to assist Veteran 
borrowers.
    As VA celebrates the 75th anniversary of the Specially Adapted 
Housing (SAH) grant program this year, it is worth reflecting on the 
nearly 50,000 grants that have been awarded under this program since 
inception. Each SAH grant represents VA's enduring commitment to 
assisting the Nation's most severely disabled Veterans live 
independently in their homes. The enactment of the Ryan Kules and Paul 
Benne Specially Adaptive Housing Improvement Act of 2019 led to 
expanded SAH assistance, with nearly $250 million in grant approvals in 
fiscal years 2021 and 2022.
    VA Insurance Service provides 5.7 million Veterans, Service 
members, military families and survivors insurance coverage totaling 
over $1.45 trillion with Servicemembers Group Life Insurance (SGLI) 
coverage increasing to $500,000, the highest level ever. This makes VA 
the Nation's 12th largest American life insurer. Additionally, on 
January 1, 2023, VA launched VALife, a whole life policy which 
eliminates time barriers and medical underwriting for all service-
connected Veterans with any rating (0-100 percent) aged 80 and under. 
VALife offers automated online applications and instant approvals even 
through a smart phone and at the most competitive rates which will 
never increase.

Supporting Family Caregivers

    VA expanded its Program of Comprehensive Assistance for Family 
Caregivers (PCAFC) to eligible family members and Veterans of all eras 
on October 1, 2022, and has received over 44,300 applications as of 
February 8, 2023. Previously, PCAFC was only available to eligible 
Veterans who served on or after September 11, 2001. On October 1, 2020, 
VA expanded the program to eligible Veterans who served on or before 
May 7, 1975, or on or after September 11, 2001. Currently, there are 
over 44,800 Veterans participating in the PCAFC across the country, 
including territories. As of February 8, 2023, 98 percent of PCAFC 
applications are dispositioned in under 90 days.
    VA is not only adding to the services and supports that we offer 
our caregivers but focusing on how VA offers it. Additionally, VA is 
enhancing and expanding the types of resources provided to caregivers, 
including enhanced respite, mental health services, and the caregiver 
and Veteran experience. The Caregiver Support Program has partnered 
with the Office of Mental Health and Suicide Prevention to fund 54 
mental health clinicians who will be dedicated to providing mental 
health services for our Family Caregivers through clinical resource 
hubs. In addition, VA is funding 14 respite liaisons to assist 
caregivers in experiencing a smooth and seamless respite experience.
    VA has trained over 120 staff at 54 sites to be health and well-
being coaches for Caregivers. These coaches focus on providing 
individualized personal care plans on areas that matter most to 
caregivers. By the end of this fiscal year. VA will have staff trained 
at every VA medical center in this model. VA has also trained over 
7,271 staff through the Campaign for Inclusive Care, which seeks to 
move from caregiver support to caregiver integration, making the 
caregiver an integral part of the Veteran's treatment team.
    In addition, caregivers participating in PCAFC will have access to 
services such as household budget planning, debt management, retirement 
planning review and education, and assistance with advanced directives, 
power of attorney, simple wills, and guardianship.

Investing in Our People

    Providing Veterans, their families, caregivers, and survivors 
access to world class health care, timely access to earned benefits, 
and when the time comes, a final resting place is only possible with an 
enterprise-wide team of the best and brightest in their respective 
fields. VA is investing in our people by dramatically increasing 
hiring, holding onboarding surge events to onboard staff more quickly, 
increasing the use of incentives for recruitment and retention, 
maximizing pay authorities and scheduling flexibilities, expanding 
scholarship opportunities, and providing more education loan repayment 
awards than ever before.

Veterans' Health Administration

    In Fiscal Year 2022, VHA nearly doubled the number of scholarships 
for clinical education offered to employees and increased the number of 
Education Debt Reduction Program (EDRP) awards to over 3,000. 
Additionally, the percentage of staff receiving recruitment, retention, 
and relocation incentives (3Rs) more than doubled from 5.9 percent to 
12.2 percent. At rural facilities, the use of 3Rs increased from 4.3 
percent to 18.9 percent. And for some critical shortage occupations, 
such as housekeeping aides (10.5 percent to 35 percent) and food 
service workers (2.1 percent to 18.7 percent), the use of 3Rs increased 
even more dramatically. These incentives assisted with the reduction of 
loss rates for critical shortage occupations in those areas to address 
increased competition for health care and entry level staff.
    The nationwide onboarding surge event that occurred in November 
2022 resulted in onboarding more new staff in VHA in the first quarter 
of Fiscal Year 2023 (12,900 staff) than first quarter onboarding in any 
previous year, this was 86 percent higher than the typical number 
onboarded in the first quarter. Onboarding continued to be high in 
January 2023 (5,603 new staff onboard, approximately 600 more than last 
January). VHA's emphasis on hiring has also resulted in a net increase 
in onboard staff of 2.1 percent as of January 31, 2023. This is already 
two-thirds of our end strength goal of 3 percent growth just 4 months 
into the fiscal year.

Veterans Benefit Administration

    Through the implementation of the PACT Act, VA has actively engaged 
the workforce through a variety of avenues and solicited feedback. 
Since the enactment of the PACT Act, VA has hosted open townhalls with 
VA leaders, hosted local townhalls led by the Regional Office Directors 
and engaged with both labor partners and claim processors to ensure the 
workforce is equipped with the necessary information to process PACT 
claims and to resolve concerns. VA created a PACT Act inquiry tool to 
allow regional offices direct access to policy experts for questions 
about process and policy. In response to feedback on training, VA 
hosted additional live training sessions and created additional tools 
to aid processors in understanding how to implement the law.
    These investments in employee engagement are critical as we look to 
hire more employees than ever before. Under the initial Toxic Exposure 
Funding (TEF) spend plan approved on October 6, 2022, VA allocated 
1,871 positions toward claims processors and supporting staff. As of 
February 21, 2023, VA has hired 1,257 of the 1,871 positions (67.2 
percent).
    Currently, VA is hosting in Salt Lake City the 7th in-person PACT 
Act Career and Hiring Fair of the month. These events have been a 
resounding success with thousands of candidates coming in-person to 
learn about available jobs, participate in onsite interviews, conduct 
suitability assessments, and complete fingerprinting, resulting in 
hundreds of candidates receiving tentative job offers the same day. VA 
is leveraging all available hiring options to ensure we meet our PACT 
Act hiring goals - including the use of expanded hiring authorities 
provided in Title IX of the PACT Act.
    VA continues to partner with military installations to recruit 
military spouses and transitioning Service members. The Secretary 
visited the VA Intake Center at Fort Hood and discussed the total 
rewards of a VA career directly with Service members. Additionally, 
during the Waco hiring fair, the Secretary spoke directly to candidates 
interested in career opportunities with VA. Fiscal Year 2022 was a 
record year for VA hiring and by the second quarter of Fiscal Year 
2023, we are pleased to report that we have already surpassed 60 
percent of Fiscal Year 2022 total hires.

National Cemetery Administration

    Developing our staff is a critical investment for all of VA. The 
Cemetery Director Development Program trains the next generation of 
leaders at NCA by teaching them how to lead, manage burials, conduct 
maintenance, and manage administrative operations at a national 
cemetery. The Cemetery Caretaker/Representative is the face of VA to 
grieving families at our National cemeteries and VA has recently 
upgraded the position to increase recruitment and retention of these 
important staff and to provide them with advancement opportunities.

Transforming Systems, Processes, and Infrastructure

    VA has strengthened its capital construction project change 
management processes for Major Construction, Major Lease, and CHIP In 
Act (Community Helping Invest through Property and Improvements Needed 
for Veterans Act of 2016) projects. This has been accomplished through 
regular engagement on projects at both the local and national levels, 
collaborative review of decision event documents, and synchronization 
of the VA change management processes for these programs. Over time, 
this will improve VA's ability to deliver large projects within budget 
and on schedule, and to be good stewards of taxpayer investments while 
bringing modernized health care infrastructure to support care for the 
Nation's Veterans.
    Authorities in Title VII of the PACT Act have already helped 
further our infrastructure further improvement in our infrastructure 
All 31 leases authorized by the PACT Act are in development, with some 
already in the solicitation phase. The revised approval and budget 
authorities for leases allow VA much greater flexibility than in the 
past, particularly accelerating timelines for leases that fall below 
the new Major Lease threshold but above the previous threshold. VA is 
in active discussion with multiple academic affiliates and multiple DoD 
entities on opportunities enabled by new authorities in the PACT Act, 
and both are already informing our Fiscal Year 2025 Strategic Capital 
Investment Process currently underway.
    VA is making progress in upgrading its facility infrastructure to 
correct deficient building systems, such as horizontal cabling and 
electrical upgrades, that will support modernized technologies such as 
the electronic health record, financial management, and supply chain 
management systems. This needed investment in facility infrastructure 
will allow timely and efficient future deployments of these modernized 
systems. The increase in non-recurring maintenance funding in recent 
fiscal years has allowed VA to make bigger investments per project and 
allowed many more projects to be funded. These improvements will help 
VHA address more of the Facility Condition Assessment backlog than has 
been possible previously.
    The modernization of VA's electronic health record (EHR) system is 
a highly complex clinical and business transformation endeavor, with 
the opportunity to standardize and optimize clinical operations for VA 
health care personnel, support delivery of consistent, high-quality 
care for Veterans, and ensure interoperability with the DoD and the 
broader health care community. In October 2022, VA delayed upcoming 
deployments until June 2023 to address challenges with the system. VA 
has been focusing on assessing and remediating identified issues at the 
five current sites where the system has been implemented and has been 
planning for future sites. VA is committed to continuous improvement of 
the electronic health record and associated health information 
technologies, even while executing ongoing deployments across the 
health care system in the years to come. VA continues to develop and 
finalize a new deployment schedule and remains fully committed to 
implementing a modernized electronic health records system, in service 
of providing the best possible care for our Veterans.
    Our national cemeteries are also transforming and evolving with the 
rest of the agency to meet Veterans' expectations in the modern, cyber-
driven world. Beyond merely establishing the physical burial locations, 
NCA has embraced technology and made significant improvements to its 
digital landscape to better serve Veterans and their families. The 
Veterans Legacy Memorial (VLM) continues to expand its reach among 
Veterans, their families, and friends. Loved ones and others can upload 
tributes, photos, and other items to a Veteran's VLM page, hosted on 
NCA's public-facing webpage. The number of VLM pages, for those 
individuals buried in National and VA grant-funded cemeteries, 
increased to 4.4 million pages in 2022. This year VA is planning to add 
VLM pages for those interred in 28 DoD-managed cemeteries, including 
Arlington National Cemetery, 18 Army post cemeteries, 5 Navy 
cemeteries, and 4 Air Force cemeteries. VLM was awarded three industry 
awards last year, further highlighting its unique position in honoring 
the lives and legacies of Veterans.
    NCA is also preparing to meet the changing needs and preferences of 
Veterans and their families in the 21st century. With the enactment of 
the National Cemeteries Preservation and Protection Act of 2022 (P.L. 
117-355), NCA will soon begin piloting green burials at the Pikes Peak 
National Cemetery with potential expansion to other locations. Green 
burial sections will include a natural appearance of the grounds, with 
a design and grounds maintenance plan based on the cemetery's 
geographic location, which may include use of natural prairie and 
meadow grasses and wildflower mixes.

The Path Forward

    As described throughout this statement, there are many joint 
concerted efforts to address every domain of Veterans, their families, 
caregivers, and survivors' lives. While many of these efforts are still 
in early stages, we commit to a continued partnership of transparency 
and accountability to ensure VA is doing right by those we serve. VA is 
a Veteran-centric, collaborative and transparent organization dedicated 
to serving more Veterans than ever before.

                       Statements for the Record

                              ----------                              


          Prepared Statement of Concerned Veterans for America
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                               __________

          Prepared Statement of America's Warrior Partnership
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                               __________

   Prepared Statement of American Federation of Government Employees

    Chairman Bost, Ranking Member Takano, and Members of the Committee:
    The American Federation of Government Employees, AFL-CIO (AFGE) and 
its National Veterans Affairs Council (NVAC) appreciate the opportunity 
to submit a statement for the record on today's hearing titled 
``Building an Accountable VA: Applying Lessons Learned to Drive Future 
Success.'' AFGE represents more than 750,000 Federal and District of 
Columbia government employees, 291,000 of whom are proud, dedicated 
Department of Veterans Affairs (VA) employees. These include front-line 
providers at the Veterans Health Administration (VHA) who provide 
exemplary specialized medical and mental health care to veterans, 
including those newly eligible for treatment under the Sergeant First 
Class (SFC) Heath Robinson Honoring our Promise to Address 
Comprehensive Toxics (PACT) Act. Furthermore, we represent the Veterans 
Benefits Administration (VBA) workforce responsible for the processing 
veterans' claims, the Board of Veterans' Appeals (Board) employees who 
shepherd veterans' appeals, and the National Cemetery Administration 
Employees (NCA) who honor the memory of the Nation's fallen veterans 
every day.
    With this firsthand and frontline perspective, we offer our 
observations on the problems the VA Employees are facing, many of which 
were created or exacerbated by VA leadership. AFGE provides these 
examples with goal of both urging the VA to address these issues 
administratively and highlight to the House Veterans Affairs Committee 
to use its oversight and legislative authority to better enable VA 
employees, over a third of whom are veterans themselves, to continue 
serving veterans. Specifically, AFGE will identify current issues and 
needed solutions related to:

      Veterans Benefits Administration:

          o Performance Standards, including:

      Counterproductive Frequency of Changes to Processes

      Failure to Award Credit for Each Issue Claimed

      ``Talk Time'' at VBA National Call Centers

          o Addressing the critical need for staffing with the rapid 
        influx of new PACT Act claims.

          o Ensuring the training for VBA employees is adequate, 
        nationally consistent, and beneficial.

      Board of Veterans Appeals

          o Performance Standards

          o Recruitment and Retention

      Veterans Health Administration

          o Monitoring that VHA has the staff it needs to meet the 
        increased demand created by the PACT Act.

          o Ensuring that VHA is using the compensation tools it gained 
        in the PACT Act to benefit lower-grade front line clinicians.

          o Ensuring that VHA compensates its employees what they are 
        owed.

          o Restoring full HR functioning at the facility level through 
        additional hiring, training, and decentralization.

      VA Police

    We hope you find these suggestions constructive, and we stand ready 
to work with the Members of the Committee to make necessary and 
positive improvements to the VA.

Performance Standards for VBA Employees

    For many years prior to the passage of the PACT Act, AFGE has 
highlighted the many problems with the VBA performance standards faced 
by its employees. Standards are often introduced and implemented for 
VBA staff in a haphazard manner and are overly focused on metrics that 
prioritize quantity over quality, providing a disservice to the 
veterans they are intended to benefit. Unfortunately, these problems 
have not been solved by the PACT Act, but instead further highlighted 
with increased demand from the PACT Act. When asking bargaining unit 
employees in the VA's Regional Offices (VARO) to identify the single 
biggest obstacle they face to successfully performing their duties and 
serving veterans, the universal answer is constantly changing 
performance standards.

Counterproductive Frequency of Changes to Processes

    A classic example of VBA's constant change to performance standards 
was the implementation of new performance standards for Veteran Service 
Representatives (VSR) and Rating Veteran Service Representatives 
(RVSRs) on October 1, 2020, with a three-month acclimation period. 
Since the implementation of these standards, VBA made changes to these 
standards in November 2020 and December 2020, and then announced at the 
end of the end of December 2020 that it would make more changes leading 
to another three-month acclimation period. These standards were changed 
again in January 2021, again in March 2021, and were finalized on April 
1, 2021. For context, these standards are incredibly complex and take 
time to learn, requiring acclimation periods to allow the employees to 
fully understand them. Having six changes made in six months was 
severely disruptive and made it difficult for staff to perform their 
duties and effectively serve veterans. Had VBA worked collaboratively 
with AFGE representatives from the beginning when changing these 
standards to gain employee perspectives and input, many of these 
problems could have been avoided and VBA would have been able to 
process claims in a more efficient and timely manner.
    The implementation of the PACT Act is leading to changes in 
performance standards for numerous positions throughout VBA, while the 
manual that states correct procedures and provides technical advice is 
updated weekly. Through AFGE's midterm bargaining, AFGE proposed a 
Memorandum of Understanding to allow for a 180-day adjustment period 
for claims processors to learn these new complex procedures and adjust 
accordingly. The VA refused, and instead stated that the 90-day 
adjustment period was non-negotiable. This unnecessary and self-imposed 
obstacle will only continue to stress and pressure VBA employees, lead 
to additional errors, and inadvertently cause errors to veterans' 
claims.
    Furthermore, since the start of 2023, VBA has imposed new standards 
for Authorization Quality Review Specialists, Rating Quality Review 
Specialists, Fiduciary Program Specialists, and Quality Review 
Specialists in the National Call Center. AFGE attempted to reach a 
memorandum of understanding with VBA on these changes prior to their 
implementation on January 1, 2023, rather than VBA unilaterally 
imposing new standards on the workforce. While AFGE was able to bargain 
issues related to appropriate arrangements and procedures with the VBA, 
the VBA refused to negotiate the metrics themselves. These standards 
will lead to additional employee errors, burnout, higher turnover, and 
decreased service to the veterans they serve. As these standards are 
implemented and other performance standards are updated, AFGE urges VBA 
to work in good faith with AFGE to design fair and attainable standards 
that prioritize quality over quantity, and best serve veterans. 
Specifically, AFGE recommends that the VBA offer a more generous grace 
period to learn the evolving complexities in both PACT Act and older 
claims and give employees additional time between manual updates which 
will allow employees to absorb information prior to adjusting to 
changes. AFGE also urges the committee to perform oversight on the 
developments of new VBA production and quality standards in response to 
both older claims and new PACT Act claims to ensure that these 
standards enable employees to serve the best interests of veterans.

Failure to Award Credit for Each Issue Claimed

    Clearly, every veteran is supposed to be treated equally by the VA, 
but VBA performance standards can cause disparate treatment depending 
on the claim filed. When evaluating claims, VBA does not easily 
distinguish the number of issues or contentions each veteran makes in 
their claim, instead using a complex tier system that unnecessarily 
hurts the ability of VSRs and RVSRs to meet their standards. This is 
arbitrary and punishes employees who get assigned claims with a 
significant number of contentions, but not enough to earn additional 
credit. This can unfairly punish veterans who, through no fault of 
their own for the number of contentions they submit in a given claim, 
realize negative decisions affecting their claims.
    The PACT Act will lead to the filing of many claims with 
significantly more contentions and distinctions. While we have 
advocated repeatedly for a change in employee production standards that 
adequately account for complicated claims, the implementation of the 
PACT Act necessitates a fair and accurate recalibration of standards, 
and new training programs and procedures to factor in the additional 
work and time that will be required to process these new claims and 
urge the committee to monitor the implementation of these performance 
standards.
    We also urge the Committee to monitor the VBA's changes to these 
standards and ensure that they enable employees to best serve veterans, 
instead of meeting arbitrary and self-imposed internal metrics.

``Talk Time'' at VBA National Call Centers

    For years, AFGE has raised concerns to this committee about the 
VBA's measure of the timeliness or ``talk time'' component for Legal 
Administrative Specialists (LAS) who answer veterans' questions at 
VBA's eight national call centers. Each LAS is allotted a certain 
amount of time they can be on the phone with a veteran based upon the 
employee's GS level. This can be as little as eight minutes and thirty 
seconds. This is a one size fits all standard that does not consider 
common issues veterans often call in about including a ``first notice 
of death call'' where a veteran's spouse is calling to inform the VA 
that the veteran has passed away. Such a call may take 20-30 minutes. 
The standard also does not take into account the numerous older 
veterans who have difficulty communicating or veterans who have more 
than one question or issue to resolve. It also does not account for a 
veteran not having their VA ``Pin Number'' available and leaving the 
LAS on the phone while they attempt to locate the information. 
Additionally, the standard effectively disincentivizes an employee from 
suggesting to a veteran about a benefit or program he or she may be 
eligible for but does not know to ask about, because it would take more 
time on the phone.
    With passage of the PACT Act, there has been a predictable surge in 
calls to the national call centers with numerous questions for VBA 
employees. Despite the fact this problem that was easily anticipated by 
VBA leadership, employees, including those in the National Call 
Centers, have not been given any additional time to meet their talk 
time standards, and were only provided with a short generic script to 
respond to a veteran's complex questions.
    An employee whose primary responsibility is to answer a veteran's 
questions should not have their performance measured by how quickly 
they can get a veteran off the phone, and the VA should not prioritize 
a contrived metric over providing valuable customer service to 
veterans, especially in the wake of a massive and complex expansion of 
benefits to millions of veterans. VBA should remove Talk Time as a 
critical component of employee performance.
    Furthermore, it has come to AFGE's attention that on October 20, 
2022, VBA instituted new performance standards for the call centers 
that further restricted the use of ``wrap up time'' at the end of the 
day for LASs to input data, prepare mail to veterans and complete other 
tasks that they could not handle during calls. This change was also 
accompanied by a new availability standard that substituted percentages 
for raw minutes, further increasing stress on workers, and 
unnecessarily increasing the difficulty of the job. These rules, which 
result in unnecessarily limiting bathroom breaks, are pennywise and 
pound foolish, and decrease the quality of service that veterans 
receive.

VBA Staffing and Backlog

    The enactment of the PACT Act has resulted in a need to increase 
the size of the VBA workforce to process the expected surge in claims 
from newly eligible veterans. In a Senate Veterans Affairs Committee 
Hearing on February 16, 2023, Josh Jacobs, the nominee for 
Undersecretary of the VBA stated that VBA expects 700,000 new PACT Act 
claims to be filed in 2023. This in part explains why in a presentation 
made to AFGE representatives, VBA estimated that the current backlog of 
150,000 claims is expected to increase to 450,000 claims in 2023. 
Additionally, according to the data on staff vacancies required by 
Section 505 of the VA MISSION Act, VBA has 2,806 vacancies as of the 
end of the third quarter of Fiscal Year 2022. Despite this, while the 
VA has hired many new claims processors, AFGE has heard reports of slow 
hiring for employees, one example being the Cleveland, Ohio, VARO, 
which is having a delay in hiring candidates who are disabled veterans. 
These delays have taken months, causing some applicants to accept other 
jobs. Additionally, given the months it takes to effectively learn to 
process claims, this delay is worsening the backlog to the detriment of 
veterans. AFGE urges the VBA to continue to quickly ramp up its 
staffing and training of claims processors and allow it to better 
manage the backlog of claims, instead of relying upon mandatory 
overtime, which exacerbates employee burnout.

Training

    The PACT Act mandates several new VA workforce training 
initiatives. However, the information shared with employees since 
enactment has been greatly inadequate. So far, VBA employee have five 
Talent Management System courses, the vast majority of which last 30 
minutes each, courses and given a new Standard Operating Procedure to 
read. To date, no hands-on training or opportunities to ask questions 
of a live instructor have been offered.
    This will foreseeably create inconsistency in the future with 
different VAROs creating different determinations. AFGE urges the VBA 
to increase training, including ample opportunity to ask questions. 
Specifically, for all training to be effective, including PACT Act 
training, it is essential that management solicit input from the labor 
representatives' rank and file members who are actually working claims 
as to what training would enable them to better serve veterans. 
Furthermore, AFGE recommends that VBA create a team of specialized 
instructors to travel to different to regional offices and provide this 
training to employees while using real claims as examples, giving 
employees the opportunity to ask questions in real time. By using this 
model and not having each Regional Office assemble their own team, this 
will ensure consistency in training across the agency, and create less 
variability between Regional Offices.

Board of Veterans Appeals

    AFGE is proud to represent the employees who work at the Board of 
Veteran Appeals (Board). This dedicated workforce plays a critical role 
in the final stage of the claims process for claims that require 
additional review. However, there have been recent decisions made at 
the Board that have created negative consequences for Board attorneys 
and the veterans they serve.

Performance Standards

    Board attorneys, like VBA claims processors, face difficult to meet 
performance standards that cause burnout and harm recruitment and 
retention. Prior to the implementation of the Appeals Modernization Act 
(AMA), Board attorneys were expected to complete 125 cases a year, a 
pace that averaged 2.4 cases per week. Each case, regardless of the 
number of issues decided, carried the same weight toward an attorney's 
production quota. In Fiscal Year 2018, the Board increased its 
production standards from 125 to 169 cases per annum, (or 3.25 cases 
per week), a 35 percent increase in production requirements which was 
overwhelming for Board attorneys. In Fiscal Year 2019, the Board 
created an alternative measure of production for Board attorneys which 
evaluated the total number of issues decided by an attorney, regardless 
of the number of cases completed, setting that number at 510 issues 
decided. AFGE supports the creation of this alternative metric as it 
better accounts for the work required to complete each case. However, 
we caution that measuring the number of issues can also be manipulated 
to create unfair metrics. Unfortunately, this manipulation appeared in 
Fiscal Year 2020, the first full year the AMA was fully implemented, 
because while the case quota remained at 169, the issue quota was 
raised to 566. Finally in Fiscal Year 2021, the quota was changed to a 
more manageable but still difficult 156 cases or 491 issues. 
Unfortunately, AFGE has heard reports that the Board intends to 
increase its production quota for the next Fiscal Year in an attempt 
meet expected appeals as a result of the PACT Act. Simply increasing 
the quota will not increase production and may result in reduced 
quality for veterans who have often waited years to have their appeals 
heard.
    These standards are also harmed by the rule that a Board attorney 
may only receive credit for a case once a judge signs off on the work. 
While this requirement may appear reasonable, delays caused by 
overburdened judges can cause attorneys to miss their quotas through no 
fault of their own. When attorneys are adjudged to be performing poorly 
based on such missed quotas, it violates Article 27, Section 8, 
Subsection E of AFGE's collective bargaining agreement with the VA, 
which states ``When evaluating performance, the Department shall not 
hold employees accountable for factors which affect performance that 
are beyond the control of the employee.'' The VA should adhere to the 
terms of the collective bargaining agreement and not penalize workers 
for no fault of their own. This is especially true since the Board 
recently began the practice of hiring Veteran Law Judges, or Board 
Members, who have no experience in Veterans law, and are simultaneously 
harming employees' performance and slowing down the appeals process for 
veterans who have waited long enough for their claims to be finalized. 
The leadership of the VA and the Board should revert to hiring Board 
Members with significant veteran law expertise and look to current 
Board Attorneys to fill those positions.

Recruitment and Retention

    To further assist with recruitment and retention, the Board of 
Veterans' Appeals is a place where attorneys should have a path to work 
for their entire careers. To accomplish this goal, the Board needs to 
re-establish a standard career ladder for GS-14 Board Attorney 
positions which had until recently existed for new hires. Eliminating 
this level of growth and compensation for attorneys is a direct way of 
dissuading qualified applicants from joining the Board of Veterans 
Appeals or choosing to stay long term. The VA should reverse this 
shortsighted policy and attract the best candidates to the Board's 
ranks.
    Additionally, AFGE strongly supports the creation of a journeyman 
non-supervisory GS- 15 Board Attorney position. Currently, Board 
attorney grades range from GS-11 to GS-14. Of the 871 attorneys 
currently at the Board, 439 attorneys are at the GS-14 level. While not 
all attorneys would qualify or choose to advance to a GS-15 position, 
creating the possibility for 100 to 200 GS-15 attorneys would help with 
long-term recruitment and retention. It is also important to note that 
there are non-supervisory journeyman GS-15 attorneys within the VA 
Office of General Counsel, thus setting a precedent. As Board attorneys 
are in the Excepted Service, it is within the Secretary's discretion to 
create and fill these new positions. AFGE has and continues to 
encourage the Secretary to create this advancement opportunity and has 
asked Congress to voice its support for this change or pass legislation 
establishing its creation.

VHA Staffing, Compensation, and Other Workforce Issues

    As a result of the PACT Act, VHA is facing an unprecedented 
increase in demand for medical care. The hiring and training of 
additional health care personnel will be essential to meet the 
screening and treatment needs of newly eligible veterans in virtually 
every medical center service line, in particular primary care clinics, 
emergency rooms (ER), cardiology, pulmonology, urology, 
gastroenterology and dermatology. Unfortunately, an informal survey of 
our members reveals very limited efforts to hire, train or carry out 
other activities for an effective rollout of new PACT Act health care 
initiatives and increased demand for services.

Staffing

    There is an urgent need for VHA to address the chronic short 
staffing that significantly worsened during the COVID-19 pandemic. 
According to the data on staff vacancies required by Section 505 of the 
VA MISSION Act, VHA had 76,531 vacancies as of the end of the third 
quarter of Fiscal Year 2022. Outpatient clinics are forced to shut 
their doors due to lack of staff.
    Many facilities cannot reopen their hospital beds due to a critical 
nurse staffing shortage, leaving veterans in the ER for up to 48 hours 
waiting to be admitted. AFGE received an encouraging member report from 
a VISN 6 facility that is actively carrying out onboarding events to 
expedite the hiring of more clinical staff, an effort that should be 
replicated across the country. Another VISN 6 provider provided a less 
encouraging report that his facility's management has failed to step up 
recruitment and retention efforts, and in some cases, is actively 
pushing employees to resign.
    AFGE has received very troubling reports from our locals at 
numerous facilities that medical center directors who received 
retention incentive funds provided by the PACT Act have not distributed 
them to front line clinicians even in the face of high vacancy rates. 
Also, the job listings posted by medical centers in many locations 
failed to align with the much higher vacancy rates used to justify 
these retention incentive dollars. More generally, congressional 
oversight of the deeply flawed and unreliable vacancy data that is 
currently collected and published by the VA is badly needed.
    A failed HR modernization effort launched under the Trump 
Administration and continued under the Biden Administration is 
exacerbating staffing shortages. Under this modernization, Human 
Resources (HR) functions traditionally performed by personnel at 
medical centers were centralized at the VISN level. AFGE members across 
VISNs report that lack of coordination between the facilities and the 
VISN are extending the time it takes to hire employees and often leads 
to ``bait and switch'' offers where new employees take jobs based on 
compensation, benefits and duties that change when they begin the job. 
Many qualified candidates lose interest in VA positions or accept a job 
only to quit shortly thereafter when it was not what was agreed upon. 
This situation deteriorates even further for many employees who choose 
to stay, as VA employees also report that HR mistakes create ``debt'' 
for employees whose pay is clawed back retroactively. Employees receive 
inadequate information about how they can have this debt waived.
    For an agency that has claimed it wants to recruit the best 
providers possible and that recruitment and retention of employees is a 
top priority, the counterproductive centralization of HR functions away 
from the medical centers must be reversed. Front line personnel and 
their labor representatives need access to knowledgeable HR specialists 
at the facility level to resolve routine personnel matters.

Compensation

    Compensation that is not competitive with private pay remains a 
major barrier to both recruitment and retention. The pay grades of a 
number of lower-wage VHA positions, including the nursing assistants 
and licensed practical nurses who make up the core of VA community 
living center workforces, are still too low to recruit and retain 
sufficient staff. Similarly, medical support assistants who handle 
patient scheduling and other critical support functions are already 
working at a low grade that causes a lot of attrition and in some cases 
are facing downgrades to even lower positions.
    According to the VA master agreement, the VA should review wages 
offered by non-VA hospitals in a region to determine if VA pay is 
competitive but often fail to fulfill this obligation. As a result, VA 
employees are often paid based on out-of-date information about local 
wages.
    While it is encouraging that the PACT Act may make it easier to 
hire more housekeepers to keep medical facilities clean and safe, this 
position has had a high attrition rate for many years. VA needs to 
raise their pay grades to make them more competitive with the private 
sector.
    The lack of mobility between grades further worsens shortages as 
employees stymied by lack of opportunity for promotion--even after 
years of experience and/or receiving additional training--leave for 
jobs where their advanced skills are rewarded.

Collective Bargaining

    In 1991, Congress amended Title 38 to provide medical professionals 
who work at VA facilities with limited collective bargaining rights 
(which include the rights to use the negotiated grievance procedure and 
arbitration) (P.L. 102-40 Sec. 202). Under 38 USC Sec. 7422, covered 
employees can negotiate, file grievances and arbitrate disputes over 
working conditions except ``any matter or question concerning or 
arising out of'':

      professional conduct or competence (defined as direct 
patient care or clinical competence);

      peer review; or

      the establishment, determination, or adjustment of 
employee compensation.

    This has resulted in VA management interpreting these exceptions 
very broadly and refusing to bargain over virtually every significant 
workplace issue affecting Title 38 medical professionals. It is also 
very problematic that VA managers are increasingly asserting ``7422'' 
themselves, rather than requesting a 7422 ruling from the VA Under 
Secretary for Health (USH) as required by statute. (The statute 
authorizes the VA Secretary to make 7422 rulings. In a 1992 memorandum, 
the VA Secretary delegated this authority to the USH (formerly called 
the Chief Medical Director.).
    When managers refuse to seek a USH 7422 ruling, the union's efforts 
to enforce the rights of Title 38 professionals are hamstrung because 
nothing prevents the VA medical center from belatedly and retroactively 
obtaining a USH 7422 ruling when the Federal Labor Relations Authority 
(FLRA) threatens the VA with ordering remedial relief for the 
professionals. When local management asserts Section 7422 but does not 
seek an USH ruling, the union is forced to file an Unfair Labor 
Practice (ULP). The FLRA Regions generally decline to take any action. 
However, if the FLRA region starts to pursue an action over the ULP 
charge, the management will then seek an USH ruling even though it is 
late in the FLRA litigation process.
    VA Title 38 medical professionals have extremely limited collective 
bargaining rights in comparison to their counterparts in other federal 
agencies, State and local government systems, and the private sector. 
As a result, Registered Nurses (RNs), doctors and other impacted 
employees at the VA are experiencing increased job stress, low morale, 
and burnout. This in turn, exacerbates the VA's recruitment and 
retention problems. AFGE seeks a legislative fix that would restore 
full collective bargaining rights to title 38 employees. But in the 
absence of this reform, VA should be held accountable for its overuse 
of 7422 exceptions to block workers' right to grieve agency wrongdoing.

Contract Care Access Standards

    The MISSION Act required the Department to implement access 
standards to determine when veterans should be referred outside the VA 
health care system for care in the private sector through the Veterans 
Community Care Program (VCCP). These standards consider how long 
veterans wait to access VA in-house care and how long it takes for the 
veteran to drive to the closest VA medical facility in order to 
determine if the veteran should be referred to a VCCP provider. If a 
veteran must wait more than 28 days for VA in-house care or drive more 
than 30 minutes for VA in-house primary care or 60 minutes for VA in-
house specialty care, than he or she can choose to go outside the VA to 
a VCCP provider instead.
    The access standards have caused unprecedented number of VCCP 
referrals. But the double standard on wait times for VA vs. VCCP care 
has resulted in many veterans waiting longer and driving further for 
non-VA care than they would have if they continued receiving VA in-
house care. A Government Accountability Office analysis of VHA data 
from the third quarter of Fiscal Year 2022 found that VA medical 
scheduled timely referrals for VHA facility appointments more 
frequently than community care.
    The current double standard must be eliminated; a revised access 
standard must be applied equally to the VA and VCCP providers. 
Currently, the access standards do not consider the wait times and 
driving times that veterans will face to access care outside the VA.
    In addition, the driving time component of the access standard is 
not restrictive enough and results in the overuse of contract care even 
when a veteran would be better served by in-house care. VCCP providers 
should be supplementing, not supplanting the VA. Multiple studies have 
shown VA's own care to be of higher quality with better health 
outcomes, and less costly than private sector care.
    The access standards also apply a double standard to care provided 
by telehealth and tele-mental health (``telehealth''). The VA has long 
been recognized as a leading telehealth model by other health care 
systems. Yet, the access standards do not count VA in-house telehealth 
services in determining if the VA has met the standard. As a result, 
veterans who would have not had any wait for VA-provided telehealth 
care are sent to VCCP providers who treat them through telehealth 
programs of unknown quality and at greater cost to taxpayers.
    Last Congress, Secretary McDonough testified before the Senate 
Veterans' Affairs Committee that he was considering revising the access 
standards in order to address the skyrocketing costs of VCCP care. He 
also committed in his testimony to propose changing the way that VA 
telehealth availability is factored in determining eligibility for 
community care. The department has not yet proposed these changes.
    Oversight is needed to ensure that the VA Secretary revises the 
current access standards to increase the drive time limit and count VA 
in-house telehealth when determining whether the VA has met the 
standards. Additionally staffing levels at facilities must be adjusted 
so that veterans' needs for in-house care are not compromised by 
workloads associated with VCCP referrals.

Privatization

    The VA MISSION Act of 2018 established a nine-member Asset and 
Infrastructure Review (AIR) Commission to make recommendations 
regarding ``closure, modernization and realignment'' of VHA facilities. 
AFGE took a cautious approach at first to the Commission, hoping that 
the process might result in more attention to the VA significant need 
for infrastructure investment and modernization. However, in March 
2022, the VA announced its recommendations to the AIR Commission, 
calling for a vast privatization of VA services through the closure or 
downsizing of nearly 60 VA medical centers, around a third of the total 
across the country. The VA's plan called for transferring these 
functions to new, mostly smaller facilities that had yet to be funded 
or built, or to the private sector, with almost no analysis of the 
quality, cost, or availability of those private services. The VA used 
outdated, pre-pandemic analyses to support its recommendations, an 
approach that was lambasted by its own OIG, the Government 
Accountability Office, and a panel of private experts the VA convened 
through MITRE Corporation. Despite the obvious frailty of the VA's 
process, the MISSION Act established a fast-track process for approving 
the recommendations, with little opportunity for Congress or other 
stakeholders to exert any influence.
    AFGE and the NVAC mobilized across the country in opposition to the 
AIR Commission, holding rallies, contacting Members of Congress, 
publishing articles, and partnering with affected veteran 
organizations. As the result of these efforts, in June 2022 a 
bipartisan group of senators including many from the Senate VA 
Committee announced their opposition to confirming any AIR Commission 
members. In July 2022, a bipartisan House majority voted to strip 
funding from the AIR Commission and to deauthorize the commission in 
the annual NDAA. In December, Congress approved the 2023 omnibus 
spending bill which defunded the AIR Commission and imposed new 
restrictions on the VA ability to close or downsize rural healthcare 
facilities.
    Nonetheless, the threat of privatization persists. A separate 
section of the MISSION Act, unaffected by Congress's recent actions, 
directs the department to conduct strategic infrastructure reviews 
every four years, with the first review expected in 2023. In the late 
summer of 2022, following the collapse of the AIR process, several 
VISN's contacted AFGE locals with plans to continue pursuing the 
hospital closures recommended to the defunct AIR Commission, with no 
apparent attempt to update the discredited market assessments behind 
those recommendations.

Other VHA Workforce Matters

    Veterans in need of screening and treatment for toxic exposure need 
and deserve the thorough, specialized, comprehensive care that only the 
VA provides. We received a concerning report from VISN 23 that veterans 
may be shortchanged by a new ``bookable hours'' policy that cuts the 
time that a provider can spend to assess a new patient from sixty to 
thirty minutes. Doctors unable to meet this standard must choose 
between working extra hours off the books to compensate for time they 
spend assessing new patients or depriving veterans of the care they 
deserve.
    Our members report that the online training on new screening tools 
that has been provided is a good first start but that more 
comprehensive training is needed to ensure that all clinicians and 
support personnel have a full understanding of the specialized 
screening processes and treatment needs of veterans with toxic 
exposure.

VA Police

    AFGE is proud to represent the VA Police Officers in facilities 
across the country. As is evidenced by a VA Office of the Inspector 
General (OIG) Report issued February 22, 2023, titled ``Security and 
Incident Preparedness at VA Medical Facilities,'' there are significant 
challenges facing the VA Police Department. As the summary of the 
report states that ``[t]he OIG identified multiple security 
vulnerabilities and deficiencies, most notably staffing shortages that 
contributed to the lack of a visible and active police presence. To 
meet VA's established security requirements, facilities will need to 
fill police officer vacancies, as employing sufficient security 
personnel and correcting security weaknesses are inextricably linked.''
    AFGE agrees with the need to recruit and retain more police 
officers to keep veterans and employees safe at VA facilities. 
Approximately 90 percent of VA police officers are veterans. Its 
officers are highly trained in crisis intervention to de-escalate 
situations at VA facilities, and these officers have unique knowledge 
of the facilities within their jurisdiction and how to interact with 
veterans. However, regardless of the number of officers recruited, if 
the VA cannot retain them, it does not help the agency. As AFGE 
advocated for years, the single biggest change that VA leadership can 
do to help with the recruitment and retention to the VA Police Force is 
to grant the VA Police Officers Law Enforcement Officer (LEO) 
Retirement either through administrative action or by supporting this 
bipartisan legislation.
    AFGE has raised this issue before, including in submitting a 
Statement for the Record on a hearing before the House Veterans Affairs 
Committee Subcommittee on Oversight and Investigations titled 
``Modernizing the VA Police Force: Ensuring Accountability'' in the 
117th Congress on July 13, 2021. As was stated previously, under 5 
U.S.C 8336(c), any LEO who either serves 25 years or is age 50 or older 
and serves 20 years is entitled to immediate retirement with a full 
pension and has mandatory retirement at age 57 (with few exceptions). 
These are commonly referred to as ``6(c) special retirement benefits'' 
(6(c) benefits). However, the definition of LEO relied upon in the code 
(5 U.S.C. 8401(17)) to grant 6(c) benefits does not include VA Police 
Officers, and in turn they do not receive special retirement benefits 
on par with federal law enforcement officers at other federal agencies. 
AFGE has endorsed the ``Law Enforcement Officers (LEO) Equity Act,'' 
introduced by Representatives Bill Pascrell, Jr. (D-NJ), Andrew 
Garbarino (R-NY), Gerry Connolly (D-VA), and Brian Fitzpatrick (R-PA) 
(this bill was H.R. 962 in the 117th congress, and is pending re-
introduction in the 118th Congress). If enacted, this bill would grant 
6(c) benefits to VA Police Officers as well as law enforcement officers 
of other federal agencies who do not have 6(c) benefits, including the 
Department of Defense (DoD), Federal Emergency Management Agency 
(FEMA), and the Federal Protective Service (FPS). In the 117th 
Congress, this legislation earned 105 bipartisan co-sponsors, including 
Chairman Mike Bost (R-IL), Ranking Member Mark Takano (D-CA), and seven 
members of the House Veterans Affairs Committee in the 118th Congress.
    Granting 6(c) benefits to VA Police Officers would significantly 
help the VA Police Force with recruitment and retention. Currently, the 
VA hires many new recruits, sends them to the Law Enforcement Training 
Center (LETC) for training, and sees these officers depart the force 
for other opportunities within the federal government that have 6(c) 
benefits, or to other State and local police departments. If VA Police 
Officers were granted 6(c) benefits it is expected many more would stay 
with the department and feel less financial incentive to leave.
    The continuous turnover of VA Police Officers represents a 
significant cost for the VA. Not only does the VA have to pay for new 
officers to attend LETC to backfill positions, at a cost of thousands 
of dollars per officer, but the VA is spending resources on specialized 
training for its officers who leave the VA. A key example of this is 
the suicide prevention training that was enacted as part of the Johnny 
Isakson and David P. Roe, M.D. Veterans Health Care and Benefits 
Improvement Act of 2020. Because of this law, VA Police Officers who 
serve at VA Medical Centers, Community Based Outpatient Clinics (CBOC), 
or VA Regional Offices are now trained to prevent a veteran in a crisis 
situation from harming himself or herself or others. This is incredibly 
critical and specialized training that the VA invests in to save lives. 
The high attrition rates of VA Police Officers who undergo this 
training puts an added strain on VA resources. Granting 6(c) benefits 
to VA Police Officers will diminish this turnover, and help the VA 
maintain a stronger and better trained police department with higher 
morale. While the ``Law Enforcement Officer (LEO) Equity Act,'' is not 
in the jurisdiction of the House Veterans' Affairs Committee, AFGE 
urges that members of this subcommittee, and consequently the full 
committee, to join their colleagues to become co-sponsors of H.R. 962 
and urge its passage in the House. Additionally, while not a permanent 
solution, AFGE urges Secretary of Veterans Affairs Denis McDonough to 
use his administrative powers to grant 6(c) benefits to the VA Police 
Officers until these benefits can be codified.

Conclusion

    AFGE thanks the House Veterans' Affairs Committee for the 
opportunity to submit a Statement for the Record for today's hearing. 
AFGE stands ready to work with the committee and the VA to address the 
workforce issues currently facing the department and find solutions 
that will enable VA employees to better serve our Nation's veterans.
                               __________

           Prepared Statement of Student Veterans of America

    Chairman Bost, Ranking Member Takano, and Members of the Committee: 
Thank you for inviting Student Veterans of America (SVA) to submit a 
statement on the topic of Building an Accountable Department of 
Veterans Affairs (VA).
    Through a dedicated network of campus-based chapters worldwide, SVA 
aims to inspire yesterday's warriors by connecting today's military-
connected students, student veterans, family members, and survivors 
with a community of dedicated SVA chapter leaders. Every day these 
passionate leaders advocate for the necessary resources anywhere. This 
population is pursuing their education while working to provide support 
through networking and fostering a sense of comradery post-military 
service to ensure student veterans can effectively connect, expand 
their skills, and ultimately achieve their greatest potential.

                    Transparency and Accountability

    SVA firmly believes that transparency and accountability go hand in 
hand. We encourage the Committee to focus on the following topics when 
considering how to build a more transparent and accountable VA so it 
can better serve student veterans and other military connected 
students.

    1. Increase oversight of VA communications with institutions and 
training providers.

    SVA heard growing concerns from School Certifying Officials (SCOs), 
institutions, and training providers recently concerning a lack of 
timely and accurate communications on policy changes and guidance.
    Over the last 3 years, many important and necessary changes have 
been made to laws governing VA education benefits. For instance, the 
landmark Johnny Isakson and David P. Roe, M.D. Veterans Health Care and 
Benefits Improvement Act of 2020--appropriately dubbed by VA as 
``transformative''--required the Department to implement more than 30 
new provisions.\1\ SVA supported this bill and will be forever grateful 
for this Committee's work. However, based on our conversations with 
SCOs and other institutional representatives, VA has had challenges 
implementing certain aspects of the legislation. This has been 
particularly true when it comes to the Department disseminating clear, 
consistent, and timely guidance to institutions.
---------------------------------------------------------------------------
    \1\ Isakson and Roe Veterans Health Care and Benefits Improvement 
Act of 2020, U.S. DEP'T OF VETERANS AFFAIRS, https://benefits.va.gov/
gibill/isaksonroe.asp (last updated July 18, 2022).
---------------------------------------------------------------------------
    Communications issues at VA have also impacted certain aspects of 
its Digital G.I. Bill modernization project. This long-overdue project 
is making significant changes to GI Bill IT systems.\2\ Of course, 
these changes have implications for institutions as well. For instance, 
the Department is about to release its new Enrollment Manager--an 
updated system for SCOs to use when certifying enrollment for students 
using VA education benefits.\3\ SVA believes this is an important 
update and supports the overall effort. Yet, we have been perplexed by 
some of the decisions made by VA and the seeming lack of consideration 
the Department has shown for input from insitutions.
---------------------------------------------------------------------------
    \2\  Transforming the GI Bill Experience, U.S. DEP'T OF VETEARNS 
AFFAIRS, https://digital.va.gov/delightful-end-user-experience/
transforming-the-gi-bill-experience/ (last updated Feb. 22, 2023).
    \3\ Bulletin from Veterans Benefits Administration to School 
Certifying Officials (Dec. 13, 2022), available at https://
content.govdelivery.com/accounts/USVAVBA/bulletins/33ced9d.
---------------------------------------------------------------------------
    Last year, for instance, VA announced plans to transition from the 
current VA-ONCE system to the new Enrollment Manager during arguably 
the busiest enrollment period of the spring semester. This decision 
came despite feedback from SCOs that doing so would have potentially 
disastrous consequences for student veterans and military-connected 
students due to delayed certifications resulting in late benefit 
payments, among other issues. We commend VA for ultimately heeding 
these concerns and delaying the rollout, but we still have reservations 
as to why the original decision was made in the first place and why 
input from SCOs was seemingly not considered earlier in the process.\4\ 
At the time of this hearing, VA-ONCE sunset a few days ago, and VA's 
new Enrollment Manager will kick in March 6. SVA stands by to hear 
those using the new system.
---------------------------------------------------------------------------
    \4\ See generally Letter from American Council on Education et. al 
to the Hon. Denis R. McDonough, Secretary, U.S. Department of Veterans 
Affairs (Dec. 8, 2022), available at https://www.acenet.edu/Documents/
Letter-VA-Enrollment-Manager-120822.pdf (explaining institutional 
concerns); see Bulletin, supra note 3 (explaining VA chose to delay the 
rollout to ``optimize functionality.'').
---------------------------------------------------------------------------
    SVA often hears from SCOs that they are not receiving the guidance 
they need from their VA Education Liaison Representatives (ELRs). The 
problem has sometimes been attributed to a shortage of ELRs. Though 
based on comments we have heard from VA representatives, it appears the 
Department simply views their ELR structure as in transition. Whatever 
the true nature of the issue, SVA believes ELRs are critical for VA to 
disseminate timely and accurate guidance to institutions. Considering 
what we have heard from SCOs about the current state of VA 
communications and guidance, SVA urges the Committee to explore whether 
ELRs are truly fulfilling their essential duties. If necessary, we ask 
that the Committee intervene to correct deficiencies.
    As a general matter, SVA encourages the Committee to ramp up its 
oversight of VA's communications at all levels with institutions and 
training providers. We ask that the Committee more closely monitor VA's 
communications for timeliness and consult with institutions and 
training providers regularly regarding the clarity, consistency, and 
workability of VA communications, including on policy guidance.

    2. Address concerns with VR&E processes and personnel.

    SVA believes the Committee should focus a brighter oversight 
spotlight on the Veteran Readiness and Employment (VR&E) program.
    In 2021, VA announced a self-identified change in how it assesses 
eligibility for VR&E as it relates to other veterans' education 
benefits. In short, a veteran may use their VR&E eligibility up to a 
36-month cap and then, separately, use another education benefit, such 
as the Post-9/11 GI Bill, up to its own 36-month cap, with a total cap 
of 48 months. SVA would like to commend VA for identifying and changing 
its interpretation. This change provides a greater benefit to eligible 
veterans and complies with the underlying statute.
    To continue this positive trend, SVA encourages the Committee to 
place a focus on ongoing areas of concern with the program that we hear 
about from student veterans, such as the lack of counselors, difficulty 
in contacting VA to determine eligibility, long timelines in the 
assessment process, inconsistent counselor guidance and determinations, 
among many other issues.
    VR&E is one of the most flexible and important programs in VA's 
portfolio. Indeed, in certain scenarios, it provides a vastly greater 
benefit than even the generous Post-9/11 GI Bill. Particularly 
considering the recent change to entitlement charges by VA. It is more 
important than ever to thoroughly review this program for obstacles, 
barriers, and shortfalls that prevent it from fulfilling its true 
potential as a benefit. We look forward to working with the Committees 
on the best path forward for the program.

    3. Support and monitor ongoing improvements to the GI Bill 
Comparison and Feedback Tools.

    The GI Bill Comparison and Feedback Tools are important 
transparency mechanisms that give students critical information to make 
informed choices about where to use their VA education benefits. 
Students can get cost estimates, see if a school has key veteran 
support programs and services, and view complaints against 
institutions, among other things. Yet, the tools also remain a source 
of great untapped potential. We urge the Committee, as we have in the 
past, to consider the following options to improve the GI Bill 
Comparison and Feedback Tools.
    As it stands, the lack of coordination between the Department of 
Education (ED) and VA on College Navigator, College Scorecard, and GI 
Comparison Tool reduces the overall delivery of powerful data to 
veterans.\5\ The Comparison Tool has unique data, justifying itself as 
a separate tool from ED's options, but the underlying data is not being 
shared effectively between these tools, leaving prospective students an 
incomplete view of their options. We encourage members to explore ways 
to better share and integrate the data across ED and VA resources.
---------------------------------------------------------------------------
    \5\  See generally College Navigator, NATIONAL CENTER FOR EDUCATION 
STATISTICS, US DEPARTMENT OF EDUCATION, https://nces.ed.gov/
collegenavigator (last visited March 1, 2020); College Scorecard, US 
DEPARTMENT OF EDUCATION, https://collegescorecard.ed.gov (last visited 
March 1, 2020); GI Bill Comparison Tool, US DEPARTMENT OF VETERANS 
AFFAIRS, https://www.va.gov/gi-bill-comparison-tool/ (last visited Feb. 
24, 2021).
---------------------------------------------------------------------------
    SVA also believes student outcome measures should be displayed in 
the GI Bill Comparison Tool. Establishing the appropriate data feeds 
and displaying the information in the tool would require IT upgrades 
that fit neatly alongside those currently happening at VA. In one of 
our most common-sense recommendations, each institution should be 
required to disclose how effective it is at delivering on its promise 
to students. By informing military-connected students, student 
veterans, family members, and survivors about the effectiveness of GI 
Bill-eligible programs, we allow them to make informed decisions about 
how to spend their education benefits.
    Additionally, we ask that the Committee encourage VA to note 
whether an institution participates in the VA VITAL Program. VITAL can 
provide critical mental health support for student veterans, assistance 
with academic accommodations, and foster a more veteran-inclusive 
campus culture. The GI Bill Comparision Tool currently includes a 
section on ``Veteran Programs and Support'' where VA could easily note 
whether the institution participates in VITAL and link to more 
information about the program's benefits.
    The GI Bill Comparison Tool also suffers from a lack of detailed 
information about student complaints. For any given school, the tool 
simply shows a tally of complaints across broad categories. The tool 
also only publishes complaints from the prior 24 months. SVA provided 
specific recommendations to address these issues in a public comment on 
VA's continued collection of information through the GI Bill Feedback 
Tool:

        VA should publish and maintain a comprehensive data base of all 
        school-specific complaints submitted through the Feedback Tool. 
        Students should be given the option to disclose their narrative 
        comments publicly, and those comments should be included in the 
        data base. The feedback data base should be presented in a 
        familiar interface, preferably one that mirrors other popular 
        review websites. This means it should include helpful user 
        features like search, filters, and sorting. We further 
        recommend the Department include a link on each school's 
        profile page in the GI Bill Comparison Tool that directs 
        students to a full, detailed list of complaints submitted about 
        that institution. This will help students identify and better 
        understand the true nature of complaints submitted about each 
        school. It will also improve the ability of advocates and 
        researchers to monitor and analyze past and present 
        institutional compliance with the Principles of Excellence and 
        other laws.\6\
---------------------------------------------------------------------------
    \6\  SVA Comment on OMB Control No. 2900-0797 Agency Information 
Collection Activity: Principles of Excellence Complaint System Intake, 
STUDENT VETERANS OF AMERICA 3 (2020), available at https://
www.regulations.gov/comment/VA-2020-VACO-0001-0084.

    To address concerns about fake or inaccurate reports, we believe VA 
should verify that reports come from current or former students of the 
institution for which feedback is being provided and that schools be 
given the opportunity to issue public responses to complaints.
    VA should also place caution flags on schools in the GI Bill 
Comparison Tool that receives an inordinate number of student 
complaints. VA currently only places caution flags on schools with a 
program of education subject to ``increased regulatory or legal 
scrutiny'' by VA or other Federal agencies.\7\ SVA supports this use of 
caution flags, but student veterans also deserve to be alerted when a 
school has received a troubling number of student complaints.
---------------------------------------------------------------------------
    \7\  GI Bill Comparison Tool: About This Tool, U.S. DEPARTMENT OF 
VETERANS AFFAIRS (June 11, 2020), https://www.benefits.va.gov/gibill/
comparison--tool/about--this--tool.asp#sourcedata.
---------------------------------------------------------------------------
    SVA also asks that VA develop a mechanism to maintain closed 
schools within the GI Bill Comparison Tool versus having them simply 
disappear. This removal of schools from the tool means associated data 
also disappears, leaving significant gaps in the overall picture of how 
those schools served students. We look forward to working with Congress 
and VA to update this valuable resource so it can better serve student 
veterans, service members, and their families.
    SVA applauds Senators Schatz, Rounds, Portman, and Coon's 
leadership on this issue with their championing of the Student Veterans 
Transparency and Protection Act last Congress. The bill would make 
numerous improvements to the GI Bill Comparison and Feedback tools, 
while also providing entitlement restoration for beneficiaries that are 
the victims of misconduct perpetrated by bad-actor institutions. We 
look forward to that bill being reintroduced this Congress and 
encourage the Committees' members to support it as well as the other 
improvements we have outlined here.
    Finally, SVA acknowledges and applauds VA's ongoing efforts to 
improve the GI Bill Comparison Tool. The Department has made great 
strides in recent years, by adding new information like context about 
accreditation and details on institutional ownership as well as 
important new features like side-by-side comparison and map 
functionality. We look forward to collaborating closely with Congress 
and VA to further refine these important tools.

    4. Establish a Veteran Economic Opportunity and Transition 
Administration with Undersecretary representation for all economic 
opportunity and transition programs.

    For years, SVA and others have called for the creation of a fourth 
administration at VA--a Veteran Economic Opportunity and Transition 
Administration. This new administration would provide VA's economic 
opportunity programs with the dedicated, senior-level leadership they 
deserve. As DAV, PVA, and VFW pointed out in the 2016 Independent 
Budget, a ``new undersecretary for EO would refocus resources, provide 
a champion for these programs, and create a central point of contact 
for veterans service organizations and Congress.'' \8\ If we want to 
``build a more accountable VA''--especially with regards to economic 
opportunity programs--a fourth administration would do just that.
---------------------------------------------------------------------------
    \8\ Id. at 121.
---------------------------------------------------------------------------
    As SVA has noted, we believe the greater focus must be placed on 
economic opportunity for veterans, including through higher education. 
This would be best achieved by building on the early success of the new 
office at VA dedicated to transition and economic opportunity and 
elevating it, and Education Service, to its own administration at VA. 
Presently, economic opportunity programs such as the GI Bill, home loan 
guaranty, and many other empowering programs for veterans are buried 
within the bureaucracy of Veterans Benefits Administration and 
functionally in competition against disability compensation policy for 
internal resources.
    Over the past century, VA has focused on compensating veterans for 
loss, but the reality of the 21st century and beyond demands the 
additional goal of empowering veterans to excel post-service and 
improving a veteran's social determinant of health. Critically, this 
will further advance our nation's goals of enhancing economic 
competitiveness and increasing protective factors against suicide. A 
focus on veteran contributions to business and industry, to 
governments, to non-profit organizations, and to communities through 
the best education programs in our country will result in impressive 
returns on the taxpayers' investments and save lives.
    The continued success of veterans in higher education in the Post-
9/11 era is no mistake or coincidence. In our Nation's history, 
educated veterans have always been the best of a generation and the key 
to solving our most complex challenges. This is the legacy we know 
today's student veterans carry.
    We thank the Chairman, Ranking Member, and Members of the Committee 
for your time, attention, and devotion to the cause of veterans in 
higher education.

                                 [all]