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






                           



 
                  U.S. DEPARTMENT OF VETERANS AFFAIRS


             BUDGET REQUEST FOR FISCAL YEARS 2024 AND 2025

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

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        THURSDAY, MARCH 23, 2023

                               __________

                            Serial No. 118-5

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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             U.S. GOVERNMENT PUBLISHING OFFICE 
 51-919                WASHINGTON : 2023
                    
                    
                    
                     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 
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                         C  O  N  T  E  N  T  S

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                        THURSDAY, MARCH 23, 2023

                                                                   Page

                           OPENING STATEMENTS

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

                                WITNESS

The Honorable Denis R. McDonough, Secretary, U.S. Department of 
  Veterans Affairs...............................................     4

                                APPENDIX
                     Prepared Statement Of Witness

The Honorable Denis R. McDonough Prepared Statement..............    45


                  U.S. DEPARTMENT OF VETERANS AFFAIRS



             BUDGET REQUEST FOR FISCAL YEARS 2024 AND 2025

                              ----------                              


                        THURSDAY, MARCH 23, 2023

                     Committee on Veterans' Affairs
                              U.S. House of Representatives
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 10:07 a.m., in 
room 390, Cannon House Office Building, Hon. Mike Bost 
(chairman of the committee) presiding.
    Present: Representatives Bost, Radewagen, Bergman, Mace, 
Rosendale, Miller-Meeks, Murphy, Franklin, Van Orden, Luttrell, 
Ciscomani, Crane, Self, Kiggans, Takano, Brownley, Levin, 
Pappas, Mrvan, Cherfilus-McCormick, Deluzio, McGarvey, Ramirez, 
Landsman, and Budzinski.

            OPENING STATEMENT OF MIKE BOST, CHAIRMAN

    The Chairman. Now, we can go to the committee, full 
committee. The committee will come to order. I would like to 
welcome Secretary McDonough where we received VA's budget 
request 2 weeks ago. The request will again look to an increase 
in the Department's budget. The request attempts to tackle 
hospital maintenance, backlogs, investment in mental health, 
community care, and works to end veterans homelessness. 
Congress has always prioritized the VA budget, despite all of 
the accusations about cutting care and benefits for veterans, 
which is not true. Mr. Secretary, I will always support giving 
you the resources you need to carry out the mission. As a 
veteran and the chairman of this committee, this is my number 
one priority. I also expect and demand that we be good stewards 
of the taxpayers' investment.
    When a budget grows as fast as VA has, there is always, I 
am sure, waste. The committee has already started highlighting 
it. VA is spending billions of dollars on management consulting 
contracts. The Department also owns or leases a huge number of 
empty or nearly empty buildings all over the country. VA is 
wasting hundreds of millions of dollars a year on failed IT 
projects. I hope you will work with me, as you always have, to 
eliminate the waste and find better uses for that money.
    That said, I have some concerns about how the budget 
request is structured. It has far too many gimmicks in it, and 
today's gimmicks are tomorrow's headaches. The Toxic Exposure 
Fund (TEF) is just the beginning. Let us not overcomplicate 
this. We have been building hospitals with discretionary money 
for 30 years. Why do we need one construction fund that uses 
discretionary and another fund that uses mandatory money now? 
We have always paid the claims processors' salaries out of the 
same account. Why do we now need to pay them from a different 
account now depending on the type of claim that they are 
working on?
    There has been a process for a long time called the second 
bite, where VA revises its medical care request during the 
year. It exists for a reason, and it works. Why should we get 
rid of it? I do not believe anyone intended to use the Toxic 
Exposure Fund to replace that. The more complex a budget is, 
the harder it is to manage and have transparency, as these 
complexities make VA less accountable to the veterans they 
serve. We are already dealing with some unintended consequences 
from changes in the budget. The last thing we need to do is 
create more. I look forward to digging into this issue today. 
Ranking Member Takano, I now recognize you for your opening 
statement.

        OPENING STATEMENT OF MARK TAKANO, RANKING MEMBER

    Mr. Takano. Well, thank you, Chairman Bost. Mr. Secretary, 
welcome, and thank you for appearing before us today. I believe 
that budgets reflect our priorities and values, and I am glad 
that President Biden's priorities for veterans align with mine. 
I am thrilled to see that the budget request includes 
investments that will strengthen veterans' healthcare, bolster 
mental health services, and suicide prevention programs, 
support women veterans, prevent and end veteran homelessness, 
begin improving VA's aging physical infrastructure, and 
modernize VA information technology for future generations of 
veterans. I am also glad that the administration is requesting 
significant funding for implementation of my Honoring Our PACT 
Act, the largest expansion of VA benefits and care in 
generations. I look forward to learning how resources dedicated 
to Promise to Address Comprehensive Toxics (PACT) Act 
implementation will be allocated across different programs.
    However, while I am glad to see the overall increases to 
the budget for VA in Fiscal Year 2024, I want to highlight a 
concern of mine regarding VA not requesting a second bite. I 
share the ranking member's concern about the second bite. Any 
of our freshman members are going what the heck is the second 
bite? We are going to delve into that question today.
    It has been the custom in previous budgets that we have a 
second bite. VA healthcare is funded through an advanced 
appropriations process, and the so-called second bite allows VA 
to adjust its previous asks of Congress to address unexpected 
changes to healthcare costs, such as new prescription drugs 
coming to market, or increased costs for labor and materials.
    Instead, this year's budget relies on a request of over $21 
billion to the Toxic Exposure Fund, which was only appropriated 
$5 billion for Fiscal Year 2023. That is a significant 
difference. Relying on the Toxic Exposure Fund as a means to 
address increasing budget demands is a risky proposition when 
VA has other tools, such as the second bite. Now, I want to 
understand the intent behind this proposal, especially in light 
of the volatile budget climate we find ourselves in.
    As I am sure you are aware, House Republicans have 
advocated for a return to Fiscal Year 2022 baselines, which 
would decrease funding for VA and put implementation of 
important laws like the PACT Act at risk. Now, I know my 
colleagues on the other side of the aisle will take umbrage at 
this statement, but let us be clear, this is not fear 
mongering. It is fact. This has been widely reported as part of 
the deal struck to appease Make America Great Again (MAGA) 
Republicans in exchange for votes for Speaker McCarthy. I would 
love for them to correct the record and prove me wrong, but 
maybe they will do that today.
    If we return to Fiscal Year 2022 baseline spending, the 
math does not work in veterans' favor. I understand the 
chairman of the Budget Committee said this week that even if we 
cut spending for the entire Federal Government in half, he 
would not be satisfied. That is the chair of the Republican--
that is the Republican chair of the Budget Committee. That 
statement is deeply troubling. Which half wins? Which half 
loses? The Department of Defense, and corporations, the top 1 
percent, or veterans, children, and seniors? Members throw 
these words around, but do not consider the math or the 
consequences of what they say. I have deep concerns that 
subjecting VA to large and arbitrary budget cuts would 
undermine VA's ability to deliver on the promise we have made 
to our veterans. Most significantly, the promise implied in the 
word pact, in PACT Act. Pact is a promise.
    I am also concerned with the level of funding for 
infrastructure in this budget. Year after year, we discuss the 
age and disrepair of VA facilities, yet we continue to see 
funding levels that are not realistic for solving the problems. 
As we have already seen in certain facilities, the lack of 
funding for improvement is jeopardizing the access to care for 
veterans, and we continue to ask veterans to support a 
healthcare system that is not well maintained and modernized 
for their needs. I hope this year that appropriators will step 
up to the plate and provide funding for VA to finally address 
these issues and not make veterans wait any longer for 
improvements to their facilities.
    Now, I also want to address another infrastructure issue, 
which is the amount of money that VA invests in modernizing its 
IT systems. VA is modernizing almost every major IT system in 
the Department, which I support, and which I believe is long 
overdue. What I do not support is VA continuing to fail at 
these endeavors. Thus, I have introduced two bills this week to 
address these issues. First, is a short-term solution requiring 
independent verification and validation of these major 
modernization efforts. The other is the Manage VA Act to create 
an undersecretary for management at the VA. Numerous other 
Federal agencies have such a position. VA is the second largest 
government agency with an important mission and a large budget, 
but it is not run this way. We need to provide programmatic 
budget acquisition management support and standardization 
across the Department to ensure that as budgets continue to 
grow at VA, we are spending that money appropriately and 
providing the best healthcare and access to benefits for 
veterans. We need to give VA the tools it needs to succeed.
    With this budget request, it is clear to me that President 
Biden, you, Mr. Secretary, and I share many of the same 
priorities. I firmly believe we can make responsible budgeting 
decisions without reneging on our sacred promise to our 
Nation's veterans. I look forward to continuing our 
conversation today as we discern what this budget request 
forecasts for the future of VA. Thank you, Mr. Chairman, and I 
yield back.
    The Chairman. Thank you, ranking member. In response, if I 
may. Well, first off, we agree on a lot from your opening 
statement. I also need to say that I do believe you are trying 
to--many of your colleagues and yourself are trying to drive 
fear into our veterans for something that is not and is not 
being talked about. I would request to put into the record a 
quote of a press release yesterday at 5:53, yesterday at 05:50 
p.m. from the Appropriations Chairwoman Kay Granger. In it and 
I quote, ``Republicans are working on policies that will grow 
and strengthen our economy. We will also find ways to reduce 
spending without impacting our Nation's defense, our commitment 
to our veterans, or the services that Americans depend upon.'' 
So, I just want to put that into the record. I do thank you for 
your comments and look forward to working together.
    Now, Mr. Secretary, I know that you are here today, and we 
are glad to have you here. Thank you for being here. I am going 
to recognize you for 10 minutes for your opening statement.

                  STATEMENT OF DENIS MCDONOUGH

    Secretary McDonough. Mr. Chairman, Ranking Member Takano, 
distinguished members of the committee, thank you very much for 
the opportunity to be here. My thanks in advance as well to the 
new members, including many among you veterans yourselves. 
Thank you for continuing your service to this country. VA will 
be strengthened by this committee's work, so I attach great 
importance to our relationship. I pledge to each of you my 
candor and transparency as we work together on these important 
matters.
    Let me start by telling you a story about army veteran Vika 
Mars. In 2019, Vika developed a cough that would not go away. 
So, she went to a urgent care where she was diagnosed with a 
lung mass and then Stage 4 lung cancer. Despite 11 years of 
honorable service, she thought she did not qualify for VA care 
and benefits because she had deployed as a reservist in a non-
combat role, albeit in the Central Command. That was not until 
she received an email from VA this past fall telling her about 
the PACT Act. Vika said, for the first time in my life, for the 
first time in my life, I was not worried. I submitted my 
paperwork. It was such an easy process. Today, thankfully, 
Vika's cancer is in remission. Her claim is service-connected, 
and she is getting the care she needs with VA.
    There are many veterans with similar stories. We are 
delivering now more care and more benefits to more veterans 
than at any time in our Nation's history. Vets had over 115 
million clinical encounters in the past year, nearly 40 million 
in-person VA appointments, 31 million telehealth appointments, 
38 million community care appointments. On benefits, we set a 
record of over 1.7 million claims processed, and we are on pace 
to break that record this year.
    Since the PACT Act was signed last August, veterans and 
survivors have filed more than 1.25 million claims, 25 percent 
more than the same period last year. I think we all agree that 
veterans, including those like Vika, deserve our very best, and 
with this budget, we can continue serving them with that.
    This year's budget request is $325.1 billion, the largest 
investment in U.S. history for veterans, their families, 
caregivers, and survivors. This year alone, this will mean 
411,000 vets attending their first VA healthcare appointment, 
joining approximately 9 million other enrolled vets, 308,000 
veterans and 56,000 families receiving their first earned 
benefits, in addition to the nearly 7 million we currently 
serve. Over 140,000 veterans and family members being interred 
a dignified lasting resting place.
    This budget is about more than numbers. It is about 
preventing veteran suicide, our top clinical priority, which 
gets $16.6 billion in this budget. It is about ending veteran 
homelessness, which gets $3.1 billion in this budget. It is 
about supporting healthcare for women veterans, which gets over 
1.2 billion in this budget. It is about restoring VA's severely 
aging infrastructure at nearly $10 billion. This budget 
recognizes that the traditional approach to infrastructure has 
fallen short of providing veterans with the modern environments 
of care they deserve.
    No investment in this critical budget is more critical to 
our success than the investments in people we hire and retain 
here at VA. We are incentivizing hiring, quickly onboarding 
staff, and incentivizing retention. We hired more staff at 
Veterans Health Administration (VHA) in the first quarter of 
this year than in any previous year in the history of VA. I am 
proud to report that we hired 2,465 registered nurses, 465 
licensed practical nurses, and 788 nursing assistants. We have 
hired more people in these three critical occupations than at 
any other time in the last 20 years. Overall, we have onboarded 
23,000 new hires this year, on our way to meet our goal of 
52,000 new onboarded VHA employees. At Veterans Benefits 
Administration (VBA), we used regional hiring fairs to 
interview thousands of applicants and extend same day job 
offers to nearly 1,100 applicants, putting us on track to fill 
all 1,871 of the authorized PACT Act hires.
    These new members of the VA join the best workforce in the 
Federal Government. Brittany Walker was hired at the Central 
Alabama VA Healthcare System this last November. Brittany's 
siblings, both grandfathers, many other family members, have 
served in uniform. Now, Brittany's serving their brothers and 
sisters in arms in a mission that is deeply personal to her. 
That is the kind of deep devotion that characterizes VA's 
workforce.
    This Monday, we mark the 20-year anniversary of the 
invasion of Iraq, a war in which many of you and many of your 
friends served and sacrificed. The work of caring for the brave 
men and women who fought that war and their families, 
survivors, caregivers is in full swing and will only grow. 
America made them a promise. It is our job at VA to keep that 
promise. We are looking forward to collaborating even more with 
you to build on what is working and to fix what is not. I look 
forward to your questions. Thanks again for the opportunity to 
be here.

    [The Prepared Statement Of Denis McDonough Appears In The 
Appendix]

    The Chairman. Thank you, Mr. Secretary. We are going to go 
to questions, and I would like to recognize myself for 5 
minutes.
    Mr. Secretary, you know, the new mandatory construction 
account bothers me a little bit. We are going to struggle to 
authorize these projects. There could also be favoritism in 
which projects get put into which account. I need to know why 
did you request this? Does not it risk going back to the bad 
old days of politics determining where hospitals get built?
    Secretary McDonough. Yes, thanks so much. As with every 
dime in this budget, we will actively work, collaboratively 
work with you on oversight and on careful investment of each 
dime. We have a three-pronged strategy on infrastructure. One, 
non-recurring maintenance. That is keeping those facilities 
that we have running. Two, minor construction and leases. This 
is to maintain and grow access, including in so many of your 
districts, where there is such broad growth of veterans. Then, 
third, major construction, which allows us to replace entire VA 
medical centers.
    The reason we asked for the number we asked for is because 
in the last 10 years, VA has replaced four hospitals, four. 
Even though the average age of a hospital in VA is 62 years 
old, the average age of a hospital in the private sector is 13. 
I think that is an indictment of how we have invested in 
construction in the last decades. It is because, look, a lot of 
the blame rests with us. We did not effectively manage the 
Aurora construction. Since Aurora, we have had three very well-
managed replacement facilities, including in Orlando, where it 
came in under budget and ahead of schedule. Even Orlando is now 
bursting at the seams because of veteran demand.
    The thing that will drive every investment in 
infrastructure is where the veterans are. We know that data. We 
share that data with you. Every decision we will make will be 
pursuant to our established processes that we brief you on, at 
least quarterly. That Strategic Capital Investment Project and 
program is an effort by us to let the data and the veterans' 
requirements drive those investments.
    The Chairman. Mr. Secretary, you know, you are asking for 
20 billion in Toxic Exposure Fund next year, but you are not 
even planning on spending at least 3.5 billion of that. Why are 
you requesting money that you can not or will not spend?
    Secretary McDonough. Thank you very much, Mr. Chairman. I 
heard the comments from both you and the ranking member on the 
TEF, and I know our teams have been meeting regularly on this. 
I talked earlier this week with the Inspector General. I have 
just sent him a letter. I have asked, and obviously he is going 
to do this in all cases, that he give particular focus to the 
TEF and the investments we make in the TEF, to include the 
methodologies by which we count what we spend in the account, 
and the process by which we report that to you.
    The PACT Act is a new way of doing business. Importantly, 
you gave us authority in there that said, any dollars for toxic 
exposure related care and benefits above the Fiscal Year 2021 
baseline can be moved into the TEF. We have done exactly that 
and no more in this budget, exactly what you allowed us to do. 
My commitment to you on this is the same as my commitment on 
everything else, we will not spend one dime that we have not 
talked to you about, that we have not briefed you about, and 
that you are not comfortable, that you are not aware of, and 
understanding of the methodology for which we are making those 
decisions.
    The Chairman. Okay. That kind of leads to my follow-up 
question. You are already asking for 21 billion more of toxic 
exposure funds for 2025. Is not it too early to estimate that 
especially when we have not spent money from 2023 and 2024?
    Secretary McDonough. Yes, thanks very much. We are letting 
the data drive this for us and I know we have been talking to 
your teams about it. I will give you an example. Yesterday, for 
the first time, as near as I can tell, and I think I have been 
around Washington now longer than I would have ever anticipated 
and surely than I care to admit, but I have never seen VA go 
set up a claims clinic at the Pentagon. That is what we did 
yesterday. We had encounters with 1,200 Department of Defense 
(DoD) personnel who have deployed to United States Central 
Command (CENTCOM), like so many of you in the last three 
decades.
    The data is telling us what we need in the fund. We have 
our methodology. We are talking to your staff about it. We will 
be more than happy to continue to talk to you about it. As I 
said, I have taken the extraordinary measure of asking the 
Inspector General (IG) to make sure that he is spending 
whatever time he can on this question. Look, I am very excited 
about the PACT Act, but let us be clear, it is a new way of 
doing business. It is a big piece of business at that. That 
requires the kind of investment that you gave us the authority 
to use in that act and this budget uses it.
    The Chairman. Thank you. My time has expired. Ranking 
member, I recognize you for 5 minutes.
    Mr. Takano. Mr. Secretary, I want to continue on this line 
about the PACT, the TEF. You know, the TEF was, I think, 
envisioned as a way to avoid pitting toxic exposed veterans 
against other veteran programs and to protect, well, to prevent 
those same veterans from competing against other discretionary 
priorities, right? This choice to not ask for a second bite, a 
one-off given the new budgeting--is this choice to not ask for 
a second bite a one-off, given the new budgeting dynamic? Or is 
it something we should expect to see in the future and future 
budget requests?
    Secretary McDonough. Yes, look, I mean, we asked for what 
we need in the budget, not a dime more. We use the authorities 
you gave us to ask for the TEF. We assessed based on that, that 
we do not need the second bite. As we have briefed this out, 
including with other members on the Hill, both sides, I think 
there is some appreciation because frankly, as you know, the 
second bite in the last couple of years has been in a lot of 
different places. I know it is the tradition and I know that it 
is a tradition that we may avail ourselves again of in the 
future, but it is not like everybody loved the second bite in 
the first instance.
    Mr. Takano. Well, but here is the thing, though. The way 
that we are doing the congressional, the Congressional Budget 
Office (CBO), and the scoring of bills, the whole way we have 
set up the TEF is frankly, it has interfered with other 
priorities, such as my friend Julia Brownley's bill, the 
Elizabeth Dole bill. I mean, it was all ready to go, but then 
this whole new situation. We need experience and, you know, 
spending experience. If it is not clear, this idea of using TEF 
money instead of asking for a second bite, it just sort of 
muddies the water in terms of how we are going to be able to 
score these bills going forward.
    I do not understand why we can not make a clear delineation 
with sort of the nontoxic exposed expenditures that you have 
and not having a second bite sort of muddies this. Do you 
understand what I am trying to ask you here in terms of? It 
appears to me that what has happened is that you have simply 
increased the TEF request to make up the difference between 
what would have been the first bite and the second bite.
    Secretary McDonough. Yes, no, what the authority in the 
Act, this historic act that all of you, especially you, Mr. 
Takano, played such a critical role in, the authority says 
dollars above Fiscal Year 2021 baseline for care or benefits 
associated with toxic exposure can be placed in the TEF. That 
is the decision we have made here. That is the authority you 
have given us. That is the decision we have made.
    I have great respect for CBO, but I can not speak for them. 
Let me just say one other thing, which is you also said this 
question about making sure that the discretionary fund does not 
get crowded out. As you know, I have, in fact, last year had a 
very good exchange with Mr. Bost on this. It is one of the 
places where he and I do not see the same, you know, eye to 
eye, but we asked for the third budget category for medical 
care last year. We repeat that ask this year. That is where we 
are trying to protect the discretionary account across the 
board, not in the TEF. The TEF, all we do is what the statute 
says we can do. Again, we will talk to you about how we came to 
the conclusions. We have talked to your team about the 
methodology for those conclusions. We got nothing to hide here. 
We are just doing what you give us authority to do.
    Mr. Takano. I am not saying you are hiding anything, Mr. 
Secretary, I am just befuddled. So, I think I am aligned with 
you on trying to get our arms around the medical account----
    Secretary McDonough. Yes.
    Mr. Takano [continuing]. especially the care in the 
community, and what is driving that. I would urge you to come 
up with a plan to make it clear, how are you going to get----
    Secretary McDonough. I have been trying.
    Mr. Takano [continuing]. your arms. I get it, it is hard. 
If we need to--what do you need from Congress on that? Maybe 
stay focused on this TEF issue. You know, if the appropriators 
decline to provide VA its whole TEF request of 20.3 billion, 
which is entirely possible because they did not give you the 
full amount you requested previously for the TEF last year, has 
VA placed itself in an untenable position by not asking for the 
second bite? What happens if you do not get the 20 billion, is 
what I am trying to ask you?
    Secretary McDonough. Yes, I am not conceding that we are 
going to fail on that. You know, I think that the appropriators 
understand. We have been talking to them too. What we have done 
here is use the authority that is in the Act that gets a 
recognition that the Act is a new way of doing business.
    You are absolutely right. We do not want to get to the end 
of--the whole idea in the TEF, we do not want to get to the end 
of the year and have so many new say, for example, post-9/11 
vets coming in for care and somehow wrestling over a limited 
medical care account so somehow we have to choose between, you 
know, vets of other eras and vets of the post-9/11 era. The TEF 
allows us to have confidence that, as you said in your remarks 
a minute ago, we are not going to have to pit different kinds 
of care against one another.
    That is what we have done in this request and I think it 
holds up to scrutiny. Believe me, it has been closely 
scrutinized across the street at the Office of Management and 
Budget (OMB) and already, I think, being closely scrutinized by 
your staff who are very sharp eyed, I have noticed.
    Mr. Takano. Well, Mr. Chairman, before I yield back, I just 
want to say I hope that some other member of the committee will 
pursue this issue about the discretionary spending. Why is that 
needed? There has been only, you know, exactly one briefing for 
committee staff on the day that the President released the 
budget, and then VA took more than a week to provide its 
complete budget books to the committee. I just want to get you 
to commit that we will have more staff briefings in the near 
future all of this.
    Secretary McDonough. You have got my commitment on that. An 
easy one, yes.
    Mr. Takano. All right, I yield back, Mr. Chairman.
    The Chairman. Thank you, ranking member. Representative 
Radewagen, you are recognized for 5 minutes.
    Mrs. Radewagen. Talofa. Thank you, Chairman Bost and 
Ranking Member Takano for holding this hearing today. Thank 
you, Secretary McDonough, for your testimony. A special thank 
you to Representative Brownley for your help in organizing the 
Women Veterans Task Force this year. I look forward to working 
with you as co-chairs to address the needs of our female 
veterans and bring some actionable items before this committee 
over the next 6 months.
    I want to applaud VA's budget proposal for prioritizing 
hiring more women health professionals and recognizing that 
women veterans are the fastest growing veteran population. 
Secretary McDonough, while the number of women veterans served 
by VA has steadily increased over the last 5 years, the fact 
remains that over half of all women vets are still not using VA 
benefits or services. Other than hiring women's health 
personnel to fill in the gaps in female focused care, what are 
VA's plans to encourage women veterans to use the benefits and 
services they have rightly earned? What is VA doing to get the 
word out and ensure that women veterans feel safe and welcome 
at VA?
    Secretary McDonough. Talofa. Thank you very much for that 
question. We now serve about 600,000 women veterans. About 
300,000 of those women veterans are of childbearing age. In 
Fiscal Year 2021, we had about 6,000 deliveries. We anticipate 
about 10,000 deliveries this year. The trendline is up, but it 
is not near up as high as we would like it.
    Among the things, so, just to follow your questioning, you 
are obviously intimately familiar with our investments in what 
we call gender specific care, which allows us to hire specific 
specialists and to buy specific technology critical to women's 
healthcare. In addition to that, we are using the PACT Act to 
message women veterans, in particular. We have had more 
outreach events, including events specifically focused at women 
veterans across the country than in any time in VA history 
since the President signed that act into law. We have been 
using our local vet collaborative efforts, including most 
recently in the specific, where we had more Pacific based 
veterans participate in our outreach event than ever before. 38 
percent of the participants were women veterans.
    What I have given you here is a series of inputs. We will 
see what the output metrics suggest over the course of this 
year in terms of women veterans filing claims, getting service 
connection, and getting care. We will maintain an open line 
with you on that. There is no higher priority for us as it 
relates to outreach than ensuring that more eligible women 
veterans get their care.
    Last point, last week, we changed our mission statement to 
more completely incorporate the passion and the commitment from 
President Lincoln in our mission to make sure that every 
veteran in the country, including women veterans, see 
themselves in VA facilities. That is going to take more than 
changing the mission statement. It is going to require us to do 
the things you are talking about to include ensuring women feel 
welcome and safe at VA facilities and that they can get the 
full suite and access to care that they need.
    Mrs. Radewagen. Thank you. I also had a question. I am out 
of time now pretty much, about telehealth and broadband, but I 
will submit that for the record.
    Secretary McDonough. Thank you.
    Mrs. Radewagen. Thank you. Mr. Chairman, I yield back.
    The Chairman. Thank you. Representative Brownley, you are 
recognized for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chairman. Thank you, Mr. 
Secretary, for being here. Thank you for your announcement in 
the change of the motto. I think it is terribly important. We 
have had these discussions for a long time, and I think women 
veterans across our country will applaud it, very much so.
    Secretary McDonough. Well, nobody's more demanding of it 
than you. I did not want to have to face you one more time 
without having that for you.
    Ms. Brownley. I do not want to spend my whole 5 minutes on 
TEF again. I do want to just point out, you know, the problem 
is the way CBO is now scoring, and I know you said that CBO, 
you can not account for them, that is their department. The 
problem is, is the way they are scoring it is the appropriators 
are saying, for example, the Elizabeth Dole bill, they are 
scoring it at an astronomical price. The appropriators are just 
saying with regards to TEF, well, we just kind of have to see 
how this goes, you know, before we can really begin to account 
for any of this.
    As a consequence, it sounds to me based on the 
appropriator's response, is that we are going to have to wait 
years before we initiate any new programs. I would argue that 
Elizabeth Dole, for example, would actually save VA resources 
that can be reinvested into other programs. That is, you know, 
it is kind of that is the dilemma, you know, that we are just--
the PACT Act is really important, and the execution of it is 
really, really important, but it could stifle everything else 
in terms of good things moving forward for veterans. If you 
have a comment, great. I just wanted to get that point across.
    Secretary McDonough. Well, I can guarantee you I would not 
be the first administration official to disagree with a CBO 
ruling or a CBO score, but I think I probably should stay out 
of that. You know that we feel really strongly about the 
caregiver program. If there is something that we can--you and I 
have had this conversation, if there is something more we can 
do of our own authority to move out in the way that you guys 
want us to move out, smartly on that, I would be happy to do 
it. That is on the merits and on the substance. On the scoring, 
again, I just do not feel like I am in a position to help on 
that.
    Ms. Brownley. All right, well just, you know, based on 
long-term care, the Elizabeth Dole bill, it does seem like in 
the budgeting request for Fiscal Year 2024, you are still 
allocating 65 percent of the resources to institutionalized 
care. That is how it appears to me. To me, that is a problem, 
you know, because we want to get away from that. That is the 
way I read the budget is that the VA's Fiscal Year 2024 request 
of $12.9 billion really represents a similar spending dynamic 
from previous cycles in terms of institutionalized care.
    Secretary McDonough. Well, I am happy to look at that, but 
the fact is that the budget anticipates growth of at least 
another 1,000 participants in the caregiver program for the 
year ahead. We have seen remarkable growth in that program. We 
are working with you aggressively on that to make sure that we 
are acting consistent with your intent on it. The fact also 
remains that there is a high degree of demand for long-term 
care facilities in the country. I think that there is a 
cultural and individual based shift, I think, that we are in 
the middle of. We are making certain assumptions about how 
quickly that shift will be carried out. I think we are pretty 
realistic about this in the budget. Again, I would be happy to 
continue that conversation.
    Ms. Brownley. Thank you. I just have a few seconds left, 
but I just wanted to bring up funding for care for women 
veterans. Deborah Sampson mandated that a 5-year plan be 
submitted to Congress for retrofitting VAs across the country 
to address women and their healthcare. That report says that 
there is, you know, 75 projects nationwide accounting for $609 
million in total estimated costs. I think we know that maybe 
five or six of those projects have been done. Then you have a 
capital, or construction and long-term capital planning section 
within the VA that allocates a whole lot of money, but there is 
no delineation of does that cover more----
    Secretary McDonough. Yes.
    Ms. Brownley [continuing]. resources for retrofitting for 
women? Can we carve something out so that we can track that?
    Secretary McDonough. Yes, sure. I think we can get you more 
of this specific data. Here is how the process works for us. As 
I talked about it a minute ago in reaction to the chairman's 
questions, we have the three-pronged strategy. All that then is 
run up against our strategic capital improvement plan. The way 
that we work that is across the enterprise, our systems can 
appeal to be included in the SCIP, the Strategic Capital 
Improvement Plan. Our team rates those individual projects. 
Those projects that are designed expressly for access to gender 
specific care are given a quantum or a premium in the scoring 
on the SCIP process. In effect, there is a way in our existing 
processes to prioritize the fastest growing cohort of our 
veterans, women, and ensuring that our facilities are 
reflecting the needs that they have.
    I hope that is helpful. I think there is a way for us to 
cut that data for you so you can show it and not take my word 
for it. That is the way we try to make that work within the 
context of our existing program.
    Ms. Brownley. Very good. I hope the VA is demanding that 
retrofitting for women's health is happening in these 
facilities, but I hear you. Mr. Chairman, I yield back and 
thank you for the time.
    The Chairman. Thank you, General Bergman, you are 
recognized for 5 minutes.
    Mr. Bergman. Thank you, Mr. Chairman. Secretary McDonough, 
you, I think, lead the only bureaucracy in Washington, D.C. 
that has the potential to have a heart because that is not core 
of bureaucracies. Just like corporations, the heart. The heart 
of your bureaucracy is based upon the sacrifice of the men and 
women who, through their service and through their willingness, 
enabled us to still be the United States of America.
    You and I have had a chance to dialog, to talk, look at 
each other eye to eye on many occasions. I can only thank you 
for never giving up on what it really means, which is to take 
care of the veterans, to take care of their families, to enable 
them to take next steps, whatever that might be. You have got a 
big challenge because of the fact that the decisions that you 
are forced to make are largely viewed by those who are not 
deeply into it, as monetary. Again, the heart drives that.
    As we sit up here on the dais, it does not make any 
difference what side, we are faced with the challenges of how 
do we allocate, if you will, or how do we decide on what we do 
as a committee to enable you to do your job. Right now, I think 
if you looked at the two pots of money in the general, the 
federal spending, you know, we are 70-plus percent mandatory 
spending, which we do not spend a whole lot of time on, which 
concerns many of us who are trying to do better and make 
improvements. Sometimes improvements are you are required to 
reduce things in the area. In one area to give to another. When 
you put it into mandatory, that kind of limits our ability to 
do that. In this particular case, why does your budget take 
money out of regular discretionary medical care accounts to 
increase the Toxic Exposure Fund?
    Secretary McDonough. Yes, thanks, Mr. Bergman. I really 
appreciate the comments. As I was saying to the chairman and to 
Mr. Takano, as I understand the motivation for the TEF in the 
first instance back last summer, was to try to ensure that 
there was a way to not end up with, through our standard 
budgetary process, of pitting different characterizations of 
veterans against one another. By giving us the authority in the 
TEF to take any incidental dollar invested in benefits or care 
above Fiscal Year 2021 baseline for toxic exposure, we would 
avoid that.
    That is what we are trying to do, not trying to limit any 
additional oversight. In fact, I am inviting additional 
oversight, including from our IG, and I have just committed 
again to additional briefings, as many as we need, to Mr. 
Takano. What we are trying to do is be consistent with the 
statute. I think there is some wisdom in the statute in trying 
to make sure that we have the investments we need. I think we 
have worked really hard since the bill was enacted to come up 
with a way to do that and to come up with a way to do that that 
stands to oversight, that stands to scrutiny. We will hold 
ourselves to that standard going forward.
    Mr. Bergman. Thank you for using the keyword oversight.
    Secretary McDonough. Yes.
    Mr. Bergman. I know you will do that. I know I do not have 
much time left. As we move forward with still dealing with 
suicide prevention and I would ask, maybe to take for the 
record here, is VA considering looking at partnering with any 
other entities when it comes to really evaluating potential 
breakthrough therapies in suicide prevention to include, you 
know, the continued expansion of care in the community? Last, 
when you think about what are we really trying to do for 
veterans, and that is to give them the outcomes and give them 
the outcomes in an expeditious manner because they are at risk. 
Having said that, we will not see a reduction in the risk if 
we, as the bureaucracies, do not change and enable the free 
market to provide those veterans with everything from 
independent care to appeals process to get better claims. I 
just wanted to thank you for all you have done. Thank you, sir.
    Secretary McDonough. Thank you, Mr. Bergman.
    Mr. Bergman. I yield back.
    The Chairman. Representative Levin.
    Mr. Levin. Thank you, Mr. Chairman, and great to see you, 
Mr. Secretary. Thank you for your good work. Thank your entire 
team for their good work on behalf of our veterans. I wanted to 
hit a few different items. I wanted to start with the Veterans 
Transitional Assistance Grant Program, which was established as 
part of the Isakson and Roe Act. The program is designed to 
support local organizations that provide coordinated transition 
assistance services, such as resume assistance, interview 
training, and job recruitment training to veterans and their 
spouses. Can you provide an update on implementation of that?
    Secretary McDonough. In all candor, I can not because I did 
not study that provision this week.
    Mr. Levin. No problem.
    Secretary McDonough. Let me make sure I get you an answer 
on that.
    Mr. Levin. You got a lot on your plate, I know that. Back 
in 2021, VA estimated full program implementation would cost 
$26.3 million per year, but the budget request says only $1.3 
million for this program, and the Fiscal Year 2024 request 
includes 5 million. Our hope is that you can clarify when full 
funding will be used to fund that program, which is only 
authorized for 5 years. Hopefully you can----
    Secretary McDonough. Got it.
    Mr. Levin [continuing]. additionally provide the 
information, can commit to moving expeditiously to provide an 
update and fully fund that.
    Secretary McDonough. Yes, count on that.
    Mr. Levin. Great. Let us shift to infrastructure funding. 
There is a $10 billion request for construction, which does 
appear to be a pretty significant increase from previous years, 
but the devil's in the details. Your own budget request noted 
full implementation of the SCIP list would cost about 130 
billion. There is 5.7 billion for non-recurring maintenance, 
which I think continues the trend of using inefficient short-
term solutions to sort of piecemeal facilities together. There 
is 2.3 billion in discretionary funding set aside for major and 
minor construction, which really is a drop in the bucket of 
what you need.
    Two years ago, by comparison, Kaiser Permanente, and 
granted, Kaiser and VA are very different. VA is a very 
different entity. Kaiser told the Senate they invest 3 percent 
of their overall operating revenue on facilities and 
infrastructure. Then the independent budget Veteran Service 
Organizations (VSOs), they have noted their concerns with the 
fiscal 2024 request. My question for you, Mr. Secretary, is 
when will VA begin appropriately prioritizing its capital asset 
needs in the budget? Perhaps I should be directing this at OMB 
as well, but I would love your insights on this.
    Secretary McDonough. Yes, thanks so much. Just one second 
on NRM, the Non-Recurring Maintenance, that is a big number for 
non-recurring maintenance. You know, we have a very good track 
record on using those dollars expeditiously, transparently, and 
to good effect, including, you know, keeping facilities, 
updating facilities consistent with care requirements. We think 
that is a good investment. We think we can execute it well.
    I guess I would say that I welcome us investing even more 
in infrastructure. Our argument, which has been made in a lot 
of different ways and this was a big topic last year because it 
was before we were about to announce our recommendations, our 
comprehensive recommendations consistent with the PACT Act, but 
at nearly $10 billion here, we are talking about more money 
than we have ever asked for in the past. We are more than happy 
to talk you through our whole SCIP list and how we work that 
where that is the basis on which we make these decisions. The 
more money we have, the farther we can get down the SCIP list. 
But we are also mindful of the economy we are working in right 
now, where there is a lot of construction in the country, there 
are a lot of demands for inputs to construction. We also want 
to be clear eyed about this.
    If you get the sense that we are not sharing with you the 
full picture, it is true that our annual budget is not the full 
picture of our SCIP list. We will be more than happy to come 
briefly on that.
    Mr. Levin. Appreciate that and would just remind all my 
colleagues and for our freshmen that are here that polling on 
the popularity of investing in veterans infrastructure is off 
the charts. Republicans, Democrats, Independents, it is at 80-
plus percent. People want to see better investments in VA 
hospitals and infrastructure.
    The last question I have time for right now, Mr. Secretary, 
back in 2020, we authorized an increase in the grant and per 
diem rate during COVID-19 that is set to expire on May 11. It 
will bring the maximum rate to $58.55. In your view, is that 
adequate for high cost of living areas to recruit and retain 
staff and provide high quality services?
    Secretary McDonough. We are already having a problem, and 
you and I have talked about this in San Diego. I was just in 
Seattle last week. This is a major problem for our--and, you 
know, I talked to Mr. Banks yesterday about the importance of 
this program in Fort Wayne. This is a very important program 
for us to meet our shared goal of getting every veteran under a 
roof. I think experience is showing us right now that those 
rates are not enough to keep the kind of staff that we need to 
help ensure that we are doing the outreach and getting people 
into houses.
    I do not have a specific proposal for you today. We are 
working this question. We are very proud of the work we are 
doing on veterans' homelessness, but we will not be satisfied 
till we are done with it.
    Mr. Levin. Just in closing, I could not agree more. We so 
appreciate all the work you are doing to try to house homeless 
vets. My concern, as I know many others are concerned, is that 
this is going to set us back and could considerably set us 
back. I appreciate all your work there, and I will yield back 
to the chairman.
    Secretary McDonough. Thank you.
    The Chairman. Thank you, Mr. Levin. I just want to make a 
quick comment on the statement of the we do need to add to the 
buildings and do our building. Maybe we should talk to our good 
friends over in the Senate and have them actually appoint the 
Air Commission, and then we can actually move forward with that 
too. You know, that law was just an suggestion for him. With 
that, Representative Murphy.
    Mr. Murphy. Thank you, Mr. Chairman, and thank you, 
Secretary, for coming today. I am a proud representative of the 
sixth most veterans in any district in the country. In fact, 
one in seven of my constituents is a veteran. You add active-
duty military with Camp Lejeune, and the other Marine bases, it 
is a big deal in eastern North Carolina.
    I am going to bring up the issue that I spoke with you just 
a few minutes ago. I just want to let everybody know about this 
because in the Doctors Caucus this morning, we talked about 
drugs coming into this country from China. That 90 percent of 
our APIs, Active Pharmaceutical Ingredients, come from China 
today. Our Food and Drug Administration (FDA) is doing an 
absolute abysmal job in looking at these drugs, seeing their 
purity, seeing their impurities.
    What happened in 2016 was that the VA, and I do not 
understand this policy, and we talked about it. I am not going 
to reiterate something we have already talked about. The fact 
that the VA Schedule 65 I B allowed drugs to come from non-TAA, 
Trade Agreements Act, country, which includes China. The DoD 
does not allow this. We are now, so subsequently, allowing 
drugs to come to our veterans, as well as, you know, other 
drugs coming into this country that are not being analyzed, are 
not being reviewed, are not being inspected.
    This is an absolute troubling thing to me as a physician, 
but it is really more troubling to me that this is what is 
going into our veterans. We now, you know, like it or not, 
ballistic or not, are at war with our greatest adversary. We 
saw this with a balloon. We saw this with the absolute flood of 
fentanyl coming into this country from China. You know, I do 
not expect you, we talked about this earlier, you were not 
aware about this, and that is no big, that is nothing against 
you at all. I would like a commitment from you, and I know I 
can stand by this, that this issue will be researched, because 
it is absolutely--I am ineffable about this, I can not 
understand why this was done. I know everything is about saving 
money. If we are giving our veterans drugs that have not been 
inspected, that is absolutely dangerous upon this country.
    I would just like your commitment that I would like to get 
back. I would like some ruling on this. If there is any way to 
get out of this commitment in 2016, I think for the sake of our 
veterans, we need to explore that.
    Secretary McDonough. Yes, you have got my commitment, Mr. 
Murphy, absolutely.
    Mr. Murphy. It is a big deal. We are trying to--one thing 
that the pandemic, there are some silver linings that brought 
back into this country that we are absolutely reliant on our 
greatest adversary for drugs in this country and we are coming 
in absolutely blind, not knowing what we are taking every day. 
These are going into the bodies of our veterans. It is not 
satisfactory.
    Our department, I will shift on this a little bit, we are 
talking a lot about money and efficiency and you are asking for 
a lot of money. I did some calculations just on the old 
interweb, got these the other day, that the VA spends five 
times more per patient than the United Kingdom (UK) does in 
their British healthcare system. I am going to disagree a 
little bit with my colleagues on the other side of the dais, 
that more money is always a good thing because we are being 
absolutely, and I have worked in VAs, I have visited the VA 
clinics, we are being absolutely abysmal in our efficiency in 
spending.
    Do you have a department of efficiency, or are you relying 
on outside consults, or folks to come in and tell you about 
what is efficient, what is not efficient? We are not spending 
our money wisely and just throwing money at something is not 
the right way to bring the best care to our veterans.
    Secretary McDonough. Yes, thanks very much, Mr. Murphy. You 
know, I think we would put VA outcomes for our vets up against 
anybody, most particularly the UK system. You know, I think 
that that is the most important measurement for us.
    Mr. Murphy. Agreed.
    Secretary McDonough. What is the outcome and the VA 
outcomes are first rate, one. Two, we are constantly measuring 
efficiency of outcome. Right now, we are going through a 
process I think----
    Mr. Murphy. I am just going to interrupt you. I understand 
that, but it is a big deal that we spend our money wisely. Just 
in my limited time----
    Secretary McDonough. I could not agree more with you.
    Mr. Murphy [continuing]. it really is crucial. It is just 
like if you looked in the private world, you know where every 
paperclip goes.
    I just want to bring one thing out. I was visiting one of 
our new VA clinics in Morehead City the other day, a nice 
facility, but I asked them about mental health and I am going 
to follow up with General Bergman's question. I asked them, 
when can they get an appointment, given our absolute abysmal 
suicide rate in this country with our veterans. You know, they 
can get a first appointment for mental health, but then it is 
four to five months later to get their second appointment. If 
we are not moving the needle on veteran suicide, what can be 
done about that?
    Secretary McDonough. Yes, thanks very much. One, I just 
want to say, we now have data for two successive years, 2019 to 
2020, 2020 to 2021, where we did reduce. It is still too high. 
We did reduce veteran suicides, one. Two, that wait time is not 
an outlier in the system for second appointments. You are 
absolutely right. This is a reflection of the limit that we 
have across the healthcare system in the United States, and VA 
is no exception, of trained mental health professionals. Third, 
that means we have to increase access in every way we can. I 
would be happy to talk more about that, and we have to go to 
more nontraditional methods.
    One I just want to call your attention to is a program 
where we are training and deploying veterans as peer support 
specialists with fellow veterans, veterans in recovery helping 
other veterans, which is not dissimilar, by the way, and 
something I am quite familiar with, which is Alcoholics 
Anonymous, where an alcoholic in recovery mentors another 
alcoholic. We see that as a very effective tool. We now have 
1,200 such specialists across the country. Veterans helping 
veterans. Those are the kind of innovative new treatments as we 
increase the number of healthcare professionals that are going 
to be critical to continue the downward trend on suicide. We 
are better. We are nowhere near where we need to be, and we 
will not rest until we get to zero.
    Mr. Murphy. Thank you. Just one thing, I would urge you to 
reach out to academic institutions via telehealth. That is what 
I am trying to do with our institution.
    Secretary McDonough. Definitely.
    Mr. Murphy. That moves the needle. Then finally, I just 
would urge, given all the money that you have requested, I am a 
very staunch advocate of hyperbaric oxygen for some of these 
disorders, and I would ask that you consider using some of that 
for chambers. Thank you.
    Secretary McDonough. Thank you.
    Mr. Murphy. I will yield back.
    Secretary McDonough. Thank you.
    The Chairman. Thank you. Representative Pappas.
    Mr. Pappas. Thanks, Mr. Chairman, and thank you very much, 
Mr. Secretary, for your comments. It is great to see you again 
here. I appreciated your comments in particular on PACT Act 
implementation. I know that continues to be a big-to crack. We 
look forward to working with you on that. Obviously, we have 
seen a very high volume nationwide of individuals signing up 
and filing claims. I have heard good things from my VSOs in New 
Hampshire on this front who are generally pretty satisfied with 
how things are going.
    In delving into the numbers a little bit, my State kind of 
lags other similarly sized states in terms of the number of 
veterans that are enrolling in healthcare, filing disability 
claims through PACT Act. I am wondering if you could address 
outreach efforts as it pertains to PACT Act, any gaps that you 
are identifying and how your department intends to fill those 
gaps.
    Secretary McDonough. Yes, thanks very much. I think you can 
look at the numbers and see a big number, see a small number. 
We had some time last week we passed the 400,000th claim filed 
under the PACT Act. As I said, you can see that as a big 
number, see it as a small number. I prefer to see it as a small 
number, especially when one considers that there is as many as 
4 million veterans who deployed into CENTCOM from 1991 to 2021. 
The question then is why are veterans not registering, filing 
claims? It may be a trust issue. Veterans may have had a bad 
experience in the past. We are trying to accommodate for that 
in our outreach efforts.
    Two, there is still bad info to include information that 
many vets fear an existing service connection rating will be 
lowered if they apply for the PACT Act. In the overwhelming 
more than 90 percent of cases, your service connection rating 
is going to increase. It will not decrease. This rumor is 
sticky enough in the community that that may be reducing 
certain filing.
    Two other historic trends, women, as Ms. Radewagen 
suggested, are not applying and have not traditionally applied 
at the same rate. Vika Mars, the soldier I talked about in the 
beginning, is an example. They do not see themselves as 
veterans. That is our failing, not theirs. We have a nettlesome 
history of Black veterans not applying at the same rate as 
their White counterparts, but also not having the success in 
getting ratings as their White counterparts. We have to address 
each of these things.
    Last point, we are doing this in a very concerted way, in a 
joint way between VHA and VBA at the local level. Any of you 
who would like to work with us on a claims clinic in your 
district, we would love to do that. Those are the kinds of 
things we are doing in Community Based Outpatient Clinics 
(CBOCs), in hospitals, in Veterans of Foreign Wars (VFWs), in 
American Legions, where we are doing claims clinics. We are 
doing toxic exposure screenings onsite, and we are using that 
to drive this specific outreach. We would be more than happy to 
do more of that, although we have done a lot of it in New 
Hampshire.
    Mr. Pappas. Well, thanks. I know we have a claims clinic 
scheduled next week, actually.
    Secretary McDonough. Great.
    Mr. Pappas. We look forward to that opportunity and 
continuing the conversation. I know the VSOs are very 
interested----
    Secretary McDonough. Good.
    Mr. Pappas [continuing]. in being a force multiplier on 
those efforts. I wanted to raise one additional issue with you. 
As you know, we have suffered at the Manchester VA Medical 
Center in terms of our infrastructure failing. We have seen 
flies in the emergency room on several occasions that have 
canceled surgeries. We had a major pipe burst in recent weeks 
that has flooded a large portion of the hospital, and cold 
weather left the facility without heat or hot water, which 
impacted a number of different services, including mental 
health and urgent care. I can not say enough about the hospital 
staff that worked round the clock to make sure veterans got 
appointments. They did a terrific job. Unfortunately, this is a 
recurring theme at the Manchester VA. We have seen some 
important investments in women's healthcare and mental health 
and other areas where services have been added. I am wondering 
if you can address specifically the issues there against the 
backdrop of the larger picture of the need for more money for 
maintenance and hospital infrastructure.
    Secretary McDonough. Yes, well, this is why that NRM number 
that we talked about a minute ago is so important, the non-
recurring maintenance, you know, that what do they call it 
Arctic vortex or whatever, that led to that burst pipe in 
Manchester wreaked havoc also in Maine. Our ability to move 
quickly with that is dependent on having an agile and robust 
NRM.
    On the broader question about access in New Hampshire, this 
is why we are asking for the historically large, by an order of 
magnitude, investment in infrastructure in this bill, because 
it will allow us to get further down those SCIP list priorities 
to ensure that we get the care we need.
    The last point is, I think our team does a very good job of 
this in New Hampshire, which is the longer we do not modernize 
these facilities, the more reliant we are on the community. 
That is a good thing and that is a bad thing. It is good if the 
community has access. In many communities across the country, 
the pandemic has demonstrated that the private sector 
healthcare system is also full. It is a good thing that we are 
collaborating with, getting better at paying, getting better at 
sharing records with our private sector colleagues, but they 
are not immune to the access challenges that we are having. 
This is again, why we need the kind of robust investment that 
we are asking for in the infrastructure in this budget.
    Mr. Pappas. Thanks for those comments and for your specific 
attention to the issues at Manchester.
    Secretary McDonough. Thank you.
    Mr. Pappas. I yield back my time.
    Ms. Mace. Thank you. Congressman Van Orden, you are up.
    Mr. Van Orden. Mr. Secretary, thank you very much for 
coming. I appreciate it. I also appreciate you hosting my 
Ranking Member Mr. Levin in your office. It was fantastic.
    I do want to make some comments referencing some remarks 
that were made earlier. I will remind my colleagues on this 
committee that there are several of us who have deployed 
repeatedly to combat understanding that we could be killed and 
leave our wives widows and our children without fathers. That 
we have been to many funerals and three of us have pounded our 
naval special warfare devices into several people's coffins and 
then buried them and then got on our knees and looked at their 
fatherless children in the eye.
    For anyone to imply that we do not understand the 
consequences of what we are talking about in relationship to 
service members' children is either ill-informed or 
disingenuous. I echo the comments of the chairman of this 
committee that we will not tolerate that. We know what we are 
doing and we care deeply about what we are saying. I would 
appreciate it if everyone would remember that.
    Mr. Secretary, I am the chairman of the subcommittee that 
deals with the transition from being an active-duty service 
member to a veteran. Many people do not understand that that 
process takes a millisecond. On Monday, you are an active-duty 
service member, on a Tuesday, you are a veteran. During that 
period of time, you lose your uniform, you lose a sense of 
purpose, you lose a rank, a title. That is when our servicemen 
and women kill themselves.
    It is my number one legislative priority. My Ranking Member 
Mr. Levin, who I am incredibly proud to serve with, his 
legislative priority is veterans' homelessness. We are doing 
this together. What I have found is that the problem is not 
with your organization. The problem is with the Department of 
Defense, because when we try to work out our transition 
assistance programs, they feel like we are trying to get people 
to retire from the military early. I knew when it was time to 
retire. Morgan, you are medically retired, and Eli was only in 
the military for about 20 minutes, I guess. I have boots that 
have served longer than you, pal, make sure that is clear. We 
knew when it was time to retire. We are not making people 
retire from the military. We want to make sure that we 
transition from being a productive member of the military to a 
productive member of society.
    I want to ask you, what is your relationship with the 
Secretary of Defense? You guys sit at the same table.
    Secretary McDonough. Yes.
    Mr. Van Orden. I mean, do you talk to Lloyd? I am going to 
call him Lloyd. You know why? I am in Congress now.
    Secretary McDonough. Yes.
    Mr. Van Orden. Do you talk to Lloyd often?
    Secretary McDonough. Yes, I do. Thank you for the question. 
I am also glad to know that somebody up here will understand my 
accent when I hear yours.
    Mr. Van Orden. It is from Stillwater, Minnesota.
    Secretary McDonough. Yes, that is right.
    Mr. Van Orden. Yes.
    Secretary McDonough. You are a cheese eater.
    Mr. Van Orden. Yes.
    Secretary McDonough. Although born in Minnesota.
    Mr. Van Orden. Of course, to my shame.
    Secretary McDonough. I talk a lot with Lloyd about this 
question.
    Mr. Van Orden. Okay.
    Secretary McDonough. He and I have spent a lot of time 
together, including on things that, you know, over the last 15 
years and things that you guys are all involved in too, I 
think. Yesterday's event at the Pentagon where we actually had 
a claims clinic, where we had toxic exposure screenings. We had 
1,200 Pentagon personnel engage with us, a VA component, about 
the PACT Act, about toxic exposure screenings is evidence of 
that. That he not only supports us but welcomed us into the 
Pentagon to have these conversations.
    Mr. Van Orden. I am going to ask you this. I am going to 
ask for your help.
    Secretary McDonough. Yes.
    Mr. Van Orden. I am going to ask for your help with the 
Secretary of Defense so that me and my Ranking Member Levin, 
can get in there to talk to these folks and explain to them 
that we are not trying to diminish the military, we are trying 
to make our country better. I am going to ask you to help 
facilitate that.
    Secretary McDonough. Yes.
    Mr. Van Orden. If we can all sit down together to get this 
done----
    Secretary McDonough. Yes.
    Mr. Van Orden.--the country is going to be better.
    Secretary McDonough. Yes.
    Mr. Van Orden. Can you do that, sir?
    Secretary McDonough. I can. You know he was Army.
    Mr. Van Orden. I know.
    Secretary McDonough. You are okay with that?
    Mr. Van Orden. Yes. Yes, in a show of bipartisanship, I 
will work with someone from the Army.
    Secretary McDonough. Okay.
    Mr. Van Orden. All right?
    Secretary McDonough. Thank you.
    Mr. Van Orden. With that, I yield back.
    Ms. Mace. Thank you. Congressman Mrvan?
    Mr. Mrvan. Thank you, chairwoman. Mr. Secretary, thank you 
for joining us today. I want to thank you for your 
implementation of the PACT Act. The 1.5 million individuals who 
are receiving treatment now, wherever I go, people talk about 
the success of that. Within my district, they also talk about 
the transition of the Mission Act also, and how that is 
benefiting different members of my community.
    Today, I wanted to talk to you as chairman of the 
Subcommittee of Technology Modernization last Congress and my 
current role as the ranking member of Oversight and 
Investigations Subcommittee, I have personally witnessed the 
acquisition and management challenges that VA is currently 
facing and has faced for years. As budgets grow, these issues 
are only going to become more pronounced unless we provide VA 
with leadership on these issues. Ranking Member Takano has 
introduced and I have cosponsored a bill to create the position 
of an undersecretary for management to help alleviate some of 
these issues. With the departure of the Deputy Secretary, it 
makes the need for leadership and coordination of management 
and acquisition initiatives across the VA that much more 
necessary. In your opinion, Mr. Secretary, what are your 
thoughts on that piece of legislation and is it purposeful?
    Secretary McDonough. Yes, thanks very much, Mr. Mrvan. I 
have not. I took a lot of notes when Mr. Takano was speaking. I 
have not seen the actual legislative text. My first reaction is 
we need the undersecretaries we have to be confirmed. You know, 
we got our Undersecretary of Health confirmed last year. That 
is the first time in 5 years the Department's had a confirmed 
undersecretary. We are still sitting with our--we have our 
Undersecretary of Benefits, hopefully he will be confirmed. It 
has been at least 5 years, or 4 years since there has been a 
confirmed Undersecretary of Benefits.
    The first thing is I would like to have like a full 
component to carry out the mission we currently have, one. Two, 
I think we take very seriously the fact that our information 
technology investments enable everything else we are doing. I 
think we are among the leaders in the Federal Government. That 
is why I think that is, in large measure, because of not only 
the people we have on staff, but also our new confirmed, or our 
new Assistant Secretary for Information Technology, Kurt 
DelBene. He is not only a well-regarded technologist; he is a 
proven manager. I would hate to see him layered. Again, I would 
have to look at the bill itself.
    Mr. Mrvan. I concur and agree with you in the technology 
drives the vision.
    Secretary McDonough. Yes.
    Mr. Mrvan. Then for my remaining time, I just want to 
address two things that you had mentioned.
    Secretary McDonough. Yes.
    Mr. Mrvan. You said the trust gap.
    Secretary McDonough. Yes.
    Mr. Mrvan. You had mentioned that you want to close that. 
If I can ask how? Then second, you had mentioned the disparity 
in the African American Black participation veterans in the 
system. How are you addressing to close that gap?
    Secretary McDonough. Yes. The answer in both instances is 
execution. I can say all sorts of things, but until people see 
a different VA than the one they fear or the one they 
interacted with before, then we will not develop the trust that 
we need. Now, there are places where this is not an issue. In 
those places, we see veteran to veteran, them talking to one 
another about and affirming to one another why they should go 
ahead and file a claim, why they should get their care at VA. 
Overwhelmingly, that is the experience. There are still pockets 
where that is not the experience.
    I will tell the story of one very highly decorated veteran 
who returned from Vietnam and went to his VA. They said, well, 
we only serve real veterans here. He said, well, what is a real 
veteran? The person said World War I and World War II, and 
Korea, not Vietnam. This is a person who worked for VA. He said 
he could not help but think that as a Native American, this 
person was also commenting on his race. We simply, you know, 
that person chose to wait another 50 years, that veteran chose 
to wait another 50 years before he went back to VA. That is a 
failing, right? When he comes back, we have to make damn sure 
that that does not happen again. We build the trust by 
executing. When we do that, vets affirm to one another that 
this is worth their time. Until we do that everywhere, they 
will not.
    Mr. Mrvan. Thank you, Mr. Secretary. With that, I yield 
back.
    Ms. Mace. Thank you. Congressman Luttrell is now recognized 
for 5 minutes.
    Mr. Luttrell. Good afternoon, Mr. Secretary. One of the 
biggest issues that I am always presented with the veterans in 
my district is the electronic healthcare records. I know you 
inherited this issue. It was mentioned also that maybe creating 
an undersecretary for management might drive that issue to bed. 
Do you believe that is a fact?
    Secretary McDonough. I think that right now we have a 
structure that is enacted by statute that says the budget for 
the EHRM, the Electronic Health Record Modernization effort 
needs to be managed by the Deputy Secretary.
    Mr. Luttrell. It that is in place, why is it taking, we are 
almost at a decade, correct?
    Secretary McDonough. Well, longer than that.
    Mr. Luttrell. Okay.
    Secretary McDonough. This is a 20-year project.
    Mr. Luttrell. That seems to me a problem.
    Secretary McDonough. You are right about that. You are 
right about that.
    Mr. Luttrell. I would love to hear a timeline of when hey, 
this is we are finished.
    Secretary McDonough. Yes.
    Mr. Luttrell. If you can give me an idea on that, please.
    Secretary McDonough. Sure, right now, we are in 
negotiations with a contractor, Oracle Cerner, on the existing 
contract to finish this project in 10 years. We need a record 
that is up. We need a system that is up and functioning and 
that is responsive to our clinicians across the system all the 
time. The outcome of those negotiations on the contract, which 
is this is envisioned in the initial contract, which was, I 
think, awarded in 2018 or 2019, I think 2018. This is the 
review period. The outcome of those negotiations will determine 
our ability to do just that. I would be more than happy to. We 
have talked at length with Mr. Mrvan, Mr. Bost, Mr. Takano, 
many of the members of the committee on this over the last 
couple of years that I have been in here. I would be more than 
happy to stay on top of this with you.
    Mr. Luttrell. This one is way too much time and way too 
much money.
    Secretary McDonough. You are right about that.
    Mr. Luttrell. I am in a very rural area, and we utilize our 
private institutions.
    Secretary McDonough. Yes.
    Mr. Luttrell. I am by no means saying that VA hospitals and 
new VA hospitals are not absolute. Are we missing the boat on 
possibly shifting our focus to allow our veterans to go to 
private institutes instead of pumping billions and billions of 
dollars to recreate new hospitals?
    Secretary McDonough. Yes. One is I just want to make sure 
that we are focused on I do not think as an entire healthcare 
system, we have the right amount. I do not think anybody 
believes we have the right amount of infrastructure, meaning 
especially in rural communities like yours, rural states like 
mine, that I think that we are under-resourced for 
infrastructure. In fact, in many communities, the only 
healthcare facility is a VA facility, CBOC, or hospital, one.
    Two, we are aggressive about using the authorities we have 
under the Mission Act that Mr. Mrvan just mentioned. Our budget 
this year going forward anticipates basically a 75/25 percent 
split on medical care between care in the direct care system 
and care in the community. Right now, we are running and have 
been running in the context of the pandemic, about 70/30, if 
not 65/35. We have tried a lot of different things to--this is 
what I think Mr. Takano was talking about--make sure that those 
referrals into the community are the right thing. Who 
determines whether they are the right? In large measure, the 
veteran. We want that to be the veteran in coordination and 
consultation with their healthcare provider.
    Now, what we have to make sure is when our veterans are 
referred to the community, we actually get records back from 
that visit so that we are not--in a resource constrained health 
economy already, we are not having unnecessary procedures done 
twice and three times, and that VA can then coordinate that 
care in an effective way. That is the thing we do best, right? 
I think we do a good job of making referrals. I think there are 
people who think we refer too many. I think there are people 
who wish we would refer more. I would like over time to be 
closer to 25/75 than 35/65. What is going to drive this 
question is going to be what drives every question, which is 
veteran satisfaction and veteran outcomes.
    Right now, veteran outcomes in the direct care system are 
the best. Veteran satisfaction without patient care is largely 
the same. Where we sag is women veterans, veterans of color. 
Why? We do not have enough gender specific care for women and 
we have a trust issue that we have to continue to address with 
our veterans of color. I hope that answers the question.
    Mr. Luttrell. For the most part, yes, sir.
    Secretary McDonough. Yes.
    Mr. Luttrell. Thank you. My time is up.
    The Chairman. Representative----
    Secretary McDonough. Thank you.
    The Chairman.--Deluzio, you are recognized.
    Mr. Deluzio. Thank you, Mr. Chairman. Secretary McDonough, 
good to see you.
    Secretary McDonough. Nice to see you.
    Mr. Deluzio. I want to echo something Ranking Member Takano 
dug in on earlier and share his concern around the budget and 
the idea of cuts and what their impact would be on the VA, on 
my fellow veterans. I have heard talk in this committee earlier 
in the month about cuts, cuts to the discretionary budget. 
Earlier this week, an article in Roll Call dug into Republicans 
Issues Conference and other coverage around cuts to 
discretionary spending. Those cuts, I think, would be 
devastating to the VA, come on the backs of my fellow veterans 
should they hit the VA.
    I read your letter, Mr. Secretary. The Appropriations 
Committee Ranking Member DeLauro, copy of it here, outlining 
the effect of a multibillion dollar cut for the VA. It is a 
disturbing letter, to be frank. Amongst other things, a 
rollback to Fiscal Year 2022 funding would mean 13 million 
fewer outpatient visits in the VA for my fellow veterans. Mr. 
Chairman, I ask unanimous consent to include the letter in the 
record.
    The Chairman. Without objection.
    Mr. Deluzio. Thank you, sir. Mr. Secretary, for my 
colleagues and others who have maybe not seen this, could you 
explain as plainly as you could, how would these proposed cuts 
cripple and hurt veterans care?
    Secretary McDonough. Well, we have seen important historic 
growth in our budget over the last several years. Access to 
benefits has increased 71 percent in the last decade. Access to 
care is increasing. I laid out some of the numbers earlier. We 
would worry about going back to the Fiscal Year 2022 number, as 
I wrote to the Appropriations Committee, because it would lead 
to as much as $26.7 billion in reduced investment to us. That 
would, as you have already suggested, reduce healthcare visits 
by 13 million. That is 9 percent. It would increase the time 
necessary to process claims at VBA. It would lead to a $345 
million reduction in our Office of Information Technology for 
some of the technology investments we have just talked about.
    Then, of course, the kind of infrastructure investments the 
President envisions in this budget would not be possible. We 
would be back to something even less than what we experienced 
in the last decade, which has allowed us to only build four 
hospitals in 10 years. That is in a very resource constrained 
healthcare economy already, including in so many of our rural 
settings. I would be very worried about our ability to meet the 
high standards that you all expect of the investments that you 
gave us at Fiscal Year 2022 levels.
    Mr. Deluzio. I want to shift gears a bit to, and you have 
talked in some of the questioning, Mr. Secretary, about 
outcomes. We see tons of studies talking about the quality of 
care, the cost effectiveness of care in the VA relative to 
private sector care. Certainly, I am proud to receive my 
healthcare at the VA. We have seen ballooning costs on the fee 
for service care outside of the VA system relative to growth 
within VA medical facilities between Fiscal Year 2022 and the 
revised request for 2024, a 26.8 percent increase for VA 
medical services versus a 69.7 percent increase for care 
outside. Walk me through why we are seeing that growth explode 
on the one side. What is constraining the VA's ability to do 
more within VA facilities?
    Secretary McDonough. Yes, thanks very much. I think there 
are a couple of things. The biggest challenge for us is the 
demands of the pandemic and the complications of care coming 
out of the pandemic, one. Two, in the healthcare economy, we 
have seen a significant shift in where providers are working, 
right? Thankfully, over the course of the last quarter and a 
half, as I briefed in my opening remarks, we have seen a 
significant shift in hiring at VA, an improvement in hiring at 
VA. Throughout the course of the pandemic between us and then 
even more so in the private sector, we have just seen shortages 
in key places, including in specialties. A lot of that cost 
increase in the community reflects the need for us to move 
specialty care into the community because we do not have it at 
sufficient rates in VA to meet the wait times required.
    Third, that timeframe corresponds to the enactment of the 
Mission Act. I think the Mission Act does intend for it to be a 
easier experience for veterans to get care in the community. 
That is not a value statement. I think that is just consistent 
with what the statute intended. I think the statute is having 
its intended effect.
    Those are three of the trendlines that we are seeing. My 
goal is to make sure that we are adequately staffed such that 
we can apples to apples, compete for veterans to come keep 
their care in the VA. When we are adequately staffed and when 
we keep vets in our care, we offer the best healthcare in the 
world. I want to make sure that we are actively fighting for 
that vet's care at every turn. The thing I can do to ensure 
that we do that is to make sure that we have all the people we 
need. The thing I am asking you all to do is to invest, to make 
the investments the President's asked for here, to ensure that 
we have the institutions, the buildings, the technology, and 
the people to be able to do it.
    Mr. Deluzio. Thank you, Mr. Secretary. Mr. Chairman, my 
time has passed. Thanks for indulging me. I yield back.
    The Chairman. Representative Rosendale, you are recognized 
for 5 minutes.
    Mr. Rosendale. Thank you very much Mr. Chair. Mr. 
Secretary, always good to see you.
    Secretary McDonough. And you.
    Mr. Rosendale. Initially, I was encouraged by the 
Department of Veterans Affairs press release on March 3, 2023, 
that announced the relaxation of the masking requirement at the 
VA facilities. However, I was dismayed to hear that the Montana 
VA is not relaxing the masking requirements and instead has 
interpreted the new guidance to enforce mask mandates across 
all clinics. My office received a policy statement from Montana 
VA stating that all Montana VA clinics will require patients to 
wear a mask until a majority of counties have low rates for a 
consistent amount of time. ``The metrics and reasoning are not 
well defined.'' Montana has not had a mask mandate for over 2 
years throughout the State. Do you think that the transmission 
rates in Boise, Idaho, should impact the masking decisions in 
Lewis and Clark County in Montana?
    Secretary McDonough. I would have to dig into this. I am 
not exactly sure what the transmission rate in either one is, 
but obviously the intent behind the new guidance is to----
    Mr. Rosendale. I understand intent, but do you believe just 
based on, I mean, everybody talks about hard science, real 
science, accurate science. Do you believe that the transmission 
rates in Boise, Idaho, should impact the masking decisions in 
Lewis and Clark County, Montana, which is where Fort Harrison 
is located?
    Secretary McDonough. Yes, I think that the new guidance 
gives the local leadership the authority to make those 
decisions based on the local conditions. In as much as Boise is 
not in Montana, it strikes me as not a local site that----
    Mr. Rosendale. Okay. Well, we have a situation where 
transmission rates in Lewis and Clark County in Montana are 
impacting the masking decisions in Carter County, Montana. 
These two counties are 8 hours away from each other, the same 
distance that it is from Boise, Idaho to Lewis and Clark 
County, Montana. This is what we are being forced to deal with. 
It is a huge State. You have been there. We have traveled 
together.
    Secretary McDonough. Yes.
    Mr. Rosendale. We cannot be utilizing the information from 
one county 8 hours away to enforce some kind of a decision in 
another one that, quite frankly, has been determined to be 
ineffective anyway. Despite the Department's attempt to spin 
their new policy, the mask guidance could still result in 
veterans being denied care. They are being denied care, and 
that is unacceptable. Do you support the VA denying veterans 
medical care over their unwillingness to wear a mask?
    Secretary McDonough. Look, I think you are familiar with 
the strength of my feeling in ensuring that all vets get the 
care that they need.
    Mr. Rosendale. Okay. Well, then we need to send that 
message down to the veterans hospital and facilities throughout 
Montana so that they understand that as well. This policy is a 
disservice to the veterans, and I am going to continue to harp 
on it and push back against it until the mandate is completely 
lifted.
    Secretary McDonough, the Oracle Cerner, our favorite 
subject, Electronic Health Record (EHR) has created a lot of 
safety risks, delays, and morale problems, severe morale 
problems at the five medical centers where it is currently 
implemented. You know how strongly I feel that it should not be 
introduced at any more facilities until all these problems are 
solved and as we have stated for the last 2 years, until the 
system is fully functional.
    The Institute for Defense Analysis estimated it costs 
between $33 and $38 billion for implementation over the last 13 
years, or over 13 years. This is more than double the VA's 
initial cost estimate, more than double. I continue to see 
change orders and additional charges from Oracle to cover their 
shortcomings and unforeseen obligations and obstacles. What are 
you doing to hold Cerner accountable?
    Secretary McDonough. Thank you, Mr. Rosendale. I think, as 
you know, we are in negotiations right now with Oracle Cerner 
to successfully deploy a fully functional system within 10 
years. We are engaged in those conversations right now, and the 
way forward is heavily dependent on the results of those 
negotiations. We require, as you and I have discussed both 
privately and in this setting, efficient and properly 
functioning system across the entire system.
    At the end of the day, the vets do not care what technology 
we use. They just care that we have access to this. That is 
what the purpose of the program is. That is what the goal of 
these ongoing negotiations is. I will make sure that we 
continue to keep you and your staff up to date on that and on 
any further decisions, not only on the contract, but once that 
is resolved, onward deployments.
    Mr. Rosendale. Okay. I am about out of time. I would just 
like to say that literally lives have been put at risk because 
of that system, and we need to make sure that it is functioning 
properly, fully functional before it is rolled out at any other 
site. Thank you, Mr. Chair, I yield back.
    Secretary McDonough. Thank you, Mr. Rosendale.
    The Chairman. Thank you. Mr. McGarvey, you are recognized 
for 5 minutes.
    Mr. McGarvey. Thank you, Mr. Chairman. Thank you, Mr. 
Secretary. Appreciate you being here today. As we have talked 
about and has been discussed, we have talked a lot about the 
PACT Act and the resources given by the last Congress through 
the PACT Act to the VA. I know in Louisville, Kentucky, my home 
district, we get calls from our vets all the time. I even was 
stopped in a coffee shop recently by a vet thanking for the 
increased resources and what we are doing. I appreciate the 
tremendous work you all have done in that regard of getting out 
there, working on outreach, talking, getting a communications 
plan there, so people know about these new benefits, so that 
not just they know about it, but as we have hinted to today, 
survivors, children, that they understand these benefits as 
well.
    Of course, we can always do more, and we always want to do 
the most we can to help those who have served our country. I 
just want to ask you first, how are you, Mr. Secretary, using 
the resources that Congress provided to specifically reach out 
to our underserved communities, in our traditionally 
underserved communities? How are you guys promoting VA benefits 
and services, including those PACT Act benefits? I think this 
is important, and I know I have asked you more than one 
question in this.
    Secretary McDonough. Yes.
    Mr. McGarvey. As part of this, how are you all measuring 
the reach and the impact of these resources that are being 
given to you in this communication?
    Secretary McDonough. Yes, thanks very much. We are going 
about this as aggressively as we can, consistent with 
additional both authorities and resources you gave us in the 
PACT Act to reach veterans where they are. That includes 
traditional media, earned media. You gave us a generous budget 
for paid media, aggressive use of social media, and each of 
those gives us metrics that we can measure, and we would be 
happy to share those with your teams.
    We are also using our VA presence in communities across the 
country to talk directly to veterans and to make sure that we 
are demonstrating through things like claims clinics and, you 
know, for deployed toxic exposure screenings so that veterans 
can see themselves what this means and can actually start the 
process to get them. That is ultimately going to be the metric 
for us, which is service connection is established, benefits 
provided, and care provided.
    At the end of the day, this is an outcomes-based effort. 
Everything else is inputs and that is obviously important, but 
at the end of the day, meaningless. I want to get to the point 
where we are succeeding in such a way that veterans are talking 
to each other about the success of their engagements with VA. 
That is the most important thing that, which happens to be true 
in every other walk of life too, when somebody you trust, 
somebody with a similar experience tells you that something has 
worked out for them, it is going to make you more likely to try 
it yourself. That is our goal at the end of the day.
    Mr. McGarvey. I appreciate that. I know you guys in getting 
this effort, and I agree with you that getting to that point 
where veterans are telling other veterans is going to be 
crucial in building that trust and getting people to get the 
benefits that they have earned, and they deserve. I know you 
guys also use a lot of contractors to do this work. Just 
looking at this, does the VA right now have the resources to 
provide the oversight of these contractors? Do you feel you 
have enough sufficient resources?
    Secretary McDonough. Yes, I mean, I am very mindful of what 
the chairman said in his opening remarks, which is that he kind 
of put a flag on this issue of the use of management 
consultants, I think he said. I am taking from this hearing 
that this issue keeps coming up. I believe we have sufficient 
checks on oversight of all the contractors we use, but it is a 
fair question, let me, in all candor, let me take that and work 
it.
    Can I go back to your earlier question one second? I want 
to say one thing to veterans who are watching, which is I think 
there is a belief sometimes among veterans that either they do 
not qualify, or they are not deserving, or that somebody is 
more deserving than they are of these benefits or of this care. 
I guess I want to say the following, which is this is not only 
care and benefits you have earned, but I want to directly 
address this issue about whether you would be taking something 
from another veteran or from a battle buddy. Because of the way 
we now use claims and our ability to automate the claims and 
all the data that comes from the claims, you filing a claim and 
telling us your story will help us understand the story of 
other veterans in your unit, other veterans in the unit you 
relieved, other veterans in the unit that relieved you. Not 
only are you not taking something from another veteran, but in 
fact, you are helping us get a better picture of what other, 
your battle buddies, have experienced, and that might actually 
open the door to additional care and additional benefits to 
your battle buddies whom you may feel deserve it more than you.
    The thing we want more than anything is for veterans to 
file those claims and to come in to see us. Those of you who 
did not have a great experience with us in the past, we get 
that. We want to be better. I think we can be better. Surely 
you are all going to hold us to account on whether we are 
better.
    Mr. McGarvey. Thank you, Mr. Secretary. I appreciate that 
point. Mr. Chairman, Ms. Chairman, Madam Chairman, I yield 
back. There we go.
    Ms. Mace. Thank you. Representative Ciscomani, you are up 
for 5 minutes.
    Mr. Ciscomani. Thank you, Madam Chair. Mr. Secretary, good 
to see you. Thank you for being here to give us your time and 
to testify on the Department's budget. I am proud to represent 
Arizona's 6th congressional District, as you know, and it is 
home to about 70,000 veterans in Arizona. As a member of this 
committee, I am going to continue to support our veteran 
community and look forward to working with my colleagues and 
you to advance a bipartisan solution and solutions for those 
who fought to protect our country.
    In light of that, in the last few years, the Veteran 
Employment Through Technology Education Courses (VET TEC) Pilot 
Program, which you mentioned in your testimony that you 
submitted to the committee, seems to have been a great success, 
with 12,644 veterans having completed the program at an 84 
percent graduation rate. The program boasts a 64 percent 
employment rate. Graduates of the program making an average 
salary of over $65,000 per year with some of the best 
technology companies in America.
    However, it is my understanding that the funding for this 
pilot program will run out as early as May of this year. I have 
introduced bipartisan legislation that will make this program a 
permanent educational benefit offered to veterans. Would you 
support a permanent authorization of this program, and can you 
speak to the experience of the Department of Veteran Affairs in 
administrating this VET TEC program?
    Secretary McDonough. Yes, thanks very much. We are very 
proud of the VET TEC program. We do think that we like working 
back from outcome. Outcome here is not just the possession of 
the skill or the certificate that you have the skill, but 
rather a job. When you think about what the American economy 
needs, especially in the 21st Century, we need agility, ability 
to learn new things, ability to lead people, ability to operate 
in a complex environment. Those are all skills that our 
veterans have woken up and judged themselves against, been 
judged against, for their entire career.
    Our then challenge, if they already have those skills, is 
how do we give them, or how do we help them get additional 
skills? VET TEC has proven itself. I would be happy to look at 
a permanent authorization. I am just not going to commit to it 
yet because I want to make sure I understand, consistent with 
the tone of the rest of the discussion, the cost, and how we 
would account for that. It is a high performing program. We 
feel quite good about it. Vets seem to find it useful. At the 
end of the day, the outcome measure that matters most, which 
is, is it leading to jobs and increased quality of life? The 
answer seems to be yes. It is very attractive. I will be happy 
to look at a permanent authorization with you.
    Mr. Ciscomani. Thank you, Mr. Secretary. Madam Chair, I 
yield back.
    Ms. Mace. All right, thank you. Representative Ramirez is 
recognized for 5 minutes.
    Mrs. Ramirez. Thank you, chairwoman. Well, I think it is 
still morning, so good morning and welcome, Secretary 
McDonough. Today, I want to speak about the address--I want to 
address the proposed $31 billion cut to the VA funding that 
will directly impact the veterans I serve in the Illinois 3rd 
congressional District. It is no secret that homeless veterans 
remain at significant risk with their numbers rising steadily 
in recent years, as we have talked about today. We also know 
that many factors contribute to this trend, such as 
unemployment, mental health issues, and substance abuse 
disorders, all of which can make finding stable housing 
extremely difficult. As such, I know that one of the priority 
initiatives for the VA is ensuring that people experiencing 
homelessness are able--veterans experiencing homelessness are 
able to find permanent housing.
    I was pleased to see that the VA's request came in for $3.1 
billion for its homeless programs, and it is a continuing 
investment of resources and funding to provide services to 
veterans at risk of experiencing homelessness. I also know that 
it is a lot cheaper to help someone prevent homelessness than 
someone who now has to become homeless and then get rapid 
rehousing. I know that for a fact it costs three times more 
when someone has lost their home to be able to move into 
permanent housing than the prevention work that we do.
    I am really grateful that we continue to do this work and 
that last year we permanently housed 38,000 veterans, a lot due 
to the additional funding and flexibilities provided in the 
COVID relief packages. Can you, Secretary, explain to me the 
potential effects funding cuts, and the pending expiration of 
the pandemic flexibilities will have on progress toward 
reducing both sheltered and unsheltered veteran homeless?
    Secretary McDonough. Yes, thanks very much. We are very 
proud of the work that we have done to reduce veteran 
homelessness. We set a goal to house 38,000 homeless vets last 
year, calendar 2022. We actually housed about 40,400 vets last 
year. We have set a similar goal this year. This year's goals 
also focus on, as we have going back to 2009, prevention of 
homelessness, as you suggested. We believe that, and we show 
that VA programming since about 2009 has prevented homelessness 
for about a million veterans and family members because of the 
agility and the flexibility of the funding that Congress has 
generously given us each of the last several years.
    I do have a particular concern about the grant and per diem 
rates going forward after the expiration of the public health 
emergency. We are working through that with our homeless 
program office, and we will talk to you guys about that. I 
would worry about reduction in that traditional bipartisan 
support for homelessness programming, and especially as we are 
getting good progress, good momentum on the numbers that we are 
facing, and especially understanding that for many of our 
homeless vets, getting them under a roof is the first step to 
addressing whatever issues may have led to homelessness in the 
first instance, joblessness, untreated mental health disorder, 
substance use disorder.
    I feel really good about our success. I feel good about our 
transparency on this. I feel good about our outcomes. That is 
why the President's asking for $3.1 billion this year.
    Mrs. Ramirez. Thank you, Secretary. I know my time is 
running out, so I want to really quickly pivot to GI benefits 
for student veterans. It is critical we protect veteran access 
to quality higher education, but currently, we do not have a 
pathway to address what happens to veterans' GI benefits if 
they have been defrauded by their college. Today, I am 
introducing a bill to change that, and in fact, restore GI 
benefits for those veterans who have been defrauded. 
Approximately how many student borrowers who have filed a 
borrower defense claim with Department of Education are 
veterans utilizing a GI benefit?
    Secretary McDonough. You know what, I do not have that 
number off the top of my head, but I would be more than happy 
to get you that specific number.
    Mrs. Ramirez. Thank you. I would appreciate that. Just to 
close in these 3 seconds----
    Ms. Mace. Time is running out. I apologize.
    Mrs. Ramirez [continuing]. I want to thank you for your 
work, and I will continue to work with you to make sure we do 
not cut vital services to our veterans. Thank you.
    Secretary McDonough. Thank you, ma'am.
    Ms. Mace. Representative Crane is now recognized for 5 
minutes.
    Mr. Crane. Thank you, Madam Chairwoman. Thank you, 
Secretary McDonough, for showing up today. I know you got a lot 
on your plate, must be a tremendous job. From talking to you 
briefly, I think one of the best things about my perception of 
you is that I do believe you have a heart to help and serve and 
support one of our most important communities.
    I do want to address real quick what is becoming a theme up 
here, and I do not think it is going to go away. Mr. Ranking 
Member Takano's remarks about the math not working with MAGA 
Republicans wanting to return to 2022 levels and cut spending. 
He said the math does not work. You guys want to know what math 
does not work? The fact that year after year after year after 
year up here, we continue to spend more money than we have. 
That is why we have over $31 trillion in debt.
    One of my other colleagues over here said if we cut money 
from our budget, it would be disastrous to our veteran 
community. You guys want to know what would be disastrous to 
our veteran community? If we went completely bankrupt and we 
plummeted this country into some Third World nation because 
again, nobody up here in any committee hearing that I ever go 
to talks about spending less money or being more responsible. 
Yes, they talk about being responsible with the money that we 
spend, but you never see them wanting to make any cuts 
whatsoever.
    I am telling you right now because I am looking at a bunch 
of folks out here in chairs, and I know you guys have kids and 
grandkids, and I know you love this country and our way of life 
here. I am telling you right now, if we do not knock this stuff 
off and quit making it partisan or political, the fact that we 
keep spending money we do not have, my kids, your kids and our 
grandkids are not going to have squat, period, point blank. 
That is just a fact. I really hope I am not alive to see that 
day and all the blank faces when that day comes and your kids 
can not afford, you know, to go to college or a car, or a 
house.
    On that note, Secretary McDonough, you said you are letting 
data drive the future spending that you are looking at in 2023, 
2024, 2025 in this record budget. Does the $31 trillion in 
national debt factor into the data you are using to create your 
historically large budget, sir?
    Secretary McDonough. Yes, the data I was referring to there 
is the data for the TEF, the Toxic Exposure Fund, which is 
obviously governed, as the statute suggests----
    Mr. Crane. Right.
    Secretary McDonough [continuing]. by any incidental dollar 
over the Fiscal Year 2021 baseline. That is the data I am 
talking about. How many vets, what kind of care, what kind of 
benefits, so that we can then certify to you that we are 
following the law.
    Mr. Crane. I know. I do not want to downplay your job, sir, 
because again, I know it is very difficult. I want you to think 
about that and I want you to consider because honestly, when I 
talk to other folks, other secretaries, nobody seems to be 
factoring that into their data. It seems like everybody has 
front sight focus on I am just going to get through the next 2 
years and I am going to do the best job I can for this little 
group that I look after. I totally understand that. The bottom 
line is we are bankrupting this country and nobody wants to do 
anything about it but pay it lip service.
    The next question I want to ask you, sir, what are you 
doing to make sure that vets are not hindered from utilizing 
the Mission Act where they can utilize private facilities, 
doctors out in town? I know you have this goal of, you know, 
having world class healthcare, and I think that is great, I 
really do. Here is another fact, it is very difficult for the 
U.S. Government or any government for that fact to compete with 
the private sector. One of the reasons is because the private 
sector does not have to deal with a lot of the bureaucratic red 
tape that anybody in government does. I want to make sure that 
we are, you know, championing the Mission Act and making sure 
that our veterans have access and they are supported in going 
out into town to use private facilities and private doctors as 
well, sir?
    Secretary McDonough. Thanks very much for the question. I 
had mentioned earlier that last year we had 38 million 
community care appointments. Now, the question is, is that too 
many? Is that too few? I choose to, as I said earlier, let the 
results tell us. The most important result for us is the 
veteran experience. Each time a veteran has this engagement, an 
engagement with us, we ask them a survey that is designed to 
get to three things. Was it easy to get access? Was the 
engagement with us effective? Then an emotional quotient. The 
three Es. The emotional quotient is, did you feel respected?
    Mr. Crane. Yes.
    Secretary McDonough. Were you treated with dignity? Our 
data suggests that is good. There is unevenness across the 
system on this. Some veterans, and I know you and I have talked 
about this, there are veterans in different communities across 
the country who feel that they are being denied that right.
    Mr. Crane. Yes.
    Secretary McDonough. When you see those, I hope that you 
will raise those directly with me and we will get to the bottom 
of them. I also want us all to be mindful of right now as we 
come out of the pandemic, access times in the community are not 
great either.
    Mr. Crane. Right.
    Secretary McDonough. I want our veteran to be able to get 
the care they need when they need it with a good outcome. That 
is the basis on which we will make these decisions. I will tell 
you, though, as we have discussed, my guess is at the end of 
the day, I might be more defensive of the system and keeping 
more care in the system than----
    Ms. Mace. We are up on time.
    Secretary McDonough [continuing]. you might be, but I will 
never let that predisposition drive the outcome. The goal here 
is the outcome for the veteran.
    Mr. Crane. Thank you, Mr. Secretary. I appreciate it.
    Ms. Mace. All right, thank you. Representative Landsman, 
you are recognized for 5 minutes.
    Mr. Landsman. Thank you, Madam Chair, and thank you, 
Secretary. I appreciate it. I want to comment on a point that 
was made about spending and our budget. Obviously, this is a 
hearing about the important investments we make in veterans. I 
agree that we can no longer pay lip service to this issue. I 
think there is a debate as to how we resolve it. Many of us, 
including a lot of Republicans, believe that it is about paying 
a person's fair share in taxes. If you get to a place where our 
tax code is fixed and everyone is paying their fair share, we 
will have a balanced budget and we will not have to do anything 
to undermine the work that you are doing to help veterans.
    I went to our VA, we have a great VA facility in 
Cincinnati, this past week. I was, as I always am when I am 
there, really taken by the professionalism, the care, the 
compassion, but also just how packed our VA always is, and the 
fact that when folks come in, they get tremendous care. I mean, 
they get the best care, and the data says as much. I have just 
a few comments. I am more than happy to have you comment on 
them. They are not questions as much as they are, just things I 
would love to put on, you know, put in the record and share 
with you.
    One is when a veteran comes in, they get great care. On the 
mental health issue in Cincinnati, in particular, incredible 
care. Nearly half of those veterans who commit suicide, 
however, never receive mental health care. I think one of the 
questions is how do we look at what others are doing in terms 
of best practices, getting out into the community, doing that 
outreach. Social media is one thing, earned media, you know, 
how do we get to where folks are living and build those 
relationships? I think those are dollars well spent to get them 
in the door, and that is boots on the ground more than anything 
else.
    Number two, there is a big backlog in claims. Obviously, 
the PACT Act is a big part of that. I think something around 
200,000. As you are looking at the budget and investments, I 
think investing in the staffing required to alleviate those 
backlogs is going to be really important.
    Then three, I am really glad that you mentioned Mr. DelBene 
and his work because he was instrumental in making sure the 
Affordable Care Act (ACA), that system worked. Having his 
leadership to me will be transformative and not doing anything 
to undermine his ability to get this thing where we need it to 
be is really important. I am glad you said that.
    With that, I yield back my time unless the Secretary wants 
to comment on any of those.
    Secretary McDonough. Well, out of sensitivity to 
everybody's time, let me take and come see you about the 
specific things we are doing on outreach. I agree with you very 
much. Then, you know, what are we also doing to find veterans 
who are not tethered to us but may be tethered to something 
else? I have talked to some members of the committee about 
interesting other technologies, capabilities, processes, and, 
you know, there is one called I think it is called Towering 
Oaks that we are now looking into because one of the members 
has raised that with us. Let us find vets where they are.
    Mr. Landsman. Yes.
    Secretary McDonough. Let us support what works and let us 
take care of them.
    Ms. Mace. Thank you, Mr. Secretary. Thank you for being 
with us again today. We are very deeply appreciative of your 
work here. A few questions. Last year, we spoke about the 
prevalent issue in Charleston, South Carolina, at the Ralph H. 
Johnson VA center. The cost of living in Charleston is 
enormous. To rent an apartment nearby, a three-bedroom 
apartment for a family of four will cost you $3,000. You go 2 
miles down the road, it will cost you $5,000 a month, month to 
month. The price and cost of living post-COVID has just been 
enormous.
    Housing costs have been up almost 30 percent over the last 
year and a half. I get complaints all the time in our office 
from those that work at the VA and the inability to make ends 
meet with the jobs that they do. They have one of the most 
important jobs in the country, as you are aware of. Despite the 
high cost of living, locality pay combines both rural and city 
costs of living as you know and it sort of it disrupts the data 
in Charleston, right? That does not really impact us in the way 
that it should. We talked about this last year and I realize 
that General Services Administration (GSA) plays a primary role 
in establishing locality pay. Certainly, you have a voice and 
can advocate for these issues because we want to give our vets 
the best and the brightest that we can offer. That means they 
have got to be able to afford their bills and afford their rent 
in very expensive places.
    My first question is what has been done in the last year 
since we last spoke and what do we need to do now? How do we 
fix this? I do not want to have this conversation a year from 
now and just, you know, be talking about all the good things we 
are going to do and then we never get them done.
    Secretary McDonough. Yes, fair enough. I remember our 
discussion last year. I know that you and our staff in 
Charleston takes great pride in that sign on the facility which 
shows it is the highest ranked hospital for all of South 
Carolina.
    Ms. Mace. What have we done in the last year specifically?
    Secretary McDonough. Since we discussed this last year, I 
have raised this issue of locality pay, rest of the U.S. versus 
some locality pay bump for Charleston and several other of our 
localities.
    Ms. Mace. Is there a legislative fix? Like how do we get 
this for these localities.
    Secretary McDonough. Unfortunately, the way locality pay 
works is there is a, you know, Congress has set up a salary 
commission.
    Ms. Mace. Yes.
    Secretary McDonough. We work that with Office of Personnel 
Management (OPM). I am hoping we are in a position to address 
that the next time you and I talk. I can not say when that gets 
resolved by OPM.
    Ms. Mace. Yes.
    Secretary McDonough. Third, we are exercising what we call 
special salary rates for particular capabilities everywhere we 
can. I can get you the numbers of what that means----
    Ms. Mace. Are we doing it----
    Secretary McDonough [continuing]. for Charleston.
    Ms. Mace [continuing]. at the Ralph H. Johnson?
    Secretary McDonough. Yes.
    Ms. Mace. I would love that information after this hearing.
    Secretary McDonough. I will get you that information.
    Ms. Mace. It would be great.
    Secretary McDonough. Yes, the one that is going to come new 
next is one for technologists in particular. OPM has been very 
helpful with us on that especially with all the tumult in the 
private sector and technologists being laid off. We think we 
should be competitive there. Special salary rates will help us 
be competitive there. We will get you the Charleston specifics.
    Ms. Mace. Yes, that would be great. Then I have a few other 
questions. You know, a lot of us have talked about veteran 
suicide, 6,500 more or less vets----
    Secretary McDonough. Less.
    Ms. Mace [continuing]. commit suicide every year. Are you 
familiar with the seven privately funded MDMA assisted therapy 
clinical trials being conducted at different VA facilities 
around the country?
    Secretary McDonough. In as much as I know about them, yes. 
Am I intimately familiar with them, no. I am proud of the fact 
that we are testing a lot of different things across to try to 
make sure that we are doing the most effective thing. I did 
visit one last weekend in Orlando.
    Ms. Mace. In the studies that have been done at these VAs 
that are privately funded at seven facilities around the 
country, do you know the effectiveness of these trials with 
vets with Post Traumatic Stress Disorder (PTSD)? Do you know 
how effective these breakthrough therapies and plant-based 
therapies have been for the vets?
    Secretary McDonough. I can get you the answers there.
    Ms. Mace. I know the answer. The answer is 88 percent have 
seen a significant reduction overall in their PTSD. Even better 
than that, 67 percent of vets who have gone through 
breakthrough therapies, we are talking about MDMA specifically, 
when they do three therapeutic sessions, controlled environment 
over an extended period of time, the percentage of those that 
have zero indications of PTSD is 67 percent.
    If we are going to lose 50 to 60,000 vets to suicide over 
the next decade, what do we have to do to get this plant-based 
therapy, the breakthrough therapies to our vets so that almost 
90 percent of them have seen a huge improvement in their 
quality of life, their depression, an improvement in their 
PTSD, 88 percent. Then you have got 67 percent have zero 
indication of PTSD. This is huge. So far, it has been privately 
funded. What do we got to do to get? I guess there has been 
about 559 million set aside for suicide prevention. This is it. 
I mean, this is just huge in what it can do for our vets. How 
do we get this to all of our facilities across the country? 
What do we got to do to get there?
    Secretary Mcdonough. Yes, well, we have the National PTSD 
Center of Excellence we are very proud of. We consider 
ourselves a mission with years of----
    Ms. Mace. Sixty-seven percent of vets who have been through 
these trials at seven of your VA facilities see zero indication 
of PTSD after going through three sessions of MDMA. I would 
encourage you to get read up on it, get educated on it, 
understand the data, and the science, and the statistics behind 
it because this is literally life saving measures for our 
veterans.
    There are many of them here who were on this committee who 
sacrificed everything in their lives, were willing to take a 
bullet for our country. I hope like hell that we can do what is 
right for them so that they do not commit the number of 
suicides we are seeing on a daily basis. Thank you. The 
chairwoman will yield back. Thank you. Next up, we have 
Representative Budzinski for 5 minutes.
    Ms. Budzinski. Thank you, Madam Chairwoman, and Mr. Ranking 
Member. Mr. Secretary, it is nice to see you again. I 
appreciated the opportunity to visit with you a couple of weeks 
ago. I think when we visited, I had mentioned that as a new 
member of the committee, I was going to go back home during 
recess and establish a veterans council to hear directly from 
veterans throughout Central and Southern Illinois about their 
concerns and so I can bring them to this committee and really 
be the best advocate I can be. We did that last week in 
Decatur, which was great. We had a diverse set of veterans that 
were participating in that discussion.
    I also had the opportunity to visit our Decatur Veterans 
Clinic that we have. We have two clinics, as I know you are 
aware of. One of them is in Springfield. I have to say there is 
a lot of excitement in Springfield that we are going to be 
getting a new CBOC facility there. I do just want to mention I 
look forward to continuing to work with you and your team on 
the progress of that CBOC because there was a lot of great 
discussion around that.
    But one of the issues that came up during the council was 
around rural healthcare and access. That is really where my 
question is going to be focused on. The pandemic changed not 
only the way we care--the way care is provided, but also 
reshaped the actual care delivery structure across the country. 
As you know, more than 600 rural hospitals, which represent 
nearly 30 percent of our system, are at risk of immediate 
closure because of poor financial performance in 2022. Other 
small sites of care disappeared entirely during the pandemic. I 
can say that my district is certainly not unfamiliar with this 
reality.
    While in some parts of the country the prudent decision 
would be to buy care from the community, it simply may not 
exist in some communities. VA must ensure it has developed best 
practices for delivering care in rural and highly rural 
communities like those as I mentioned in my district. My 
question is really related to the budget. The budget request 
specifically notes, the Office of Rural Health, ``expects to 
see significant expansion of many of these programs in 2023 and 
2024 as new sites are added and new rural access innovations 
are created.'' My question, Mr. Secretary, is, given what I 
have just outlined, can you help me kind of to better 
understand why the funding for our Office of Rural Health 
remains stagnant at Fiscal Year 2023 levels for Fiscal Year 
2024 and Fiscal Year 2025?
    Secretary McDonough. Yes, thank you for the question. 
Obviously, the Office of Rural Health, we have expanded that 
over the course of the last couple of years, and we will 
continue to use that as an important platform. The medical care 
account will allow us and then the infrastructure account will 
allow us to using the analysis from the Office of Rural Health 
to make sure that we have the care in the communities where we 
need it, where our veterans are. Mindful, as you say, that the 
whole topography of healthcare delivery, especially in rural 
communities, has been deeply affected by the pandemic. I take 
great pride in the fact that among healthcare providers, VA is 
often the single most robust investor, increasing access or 
ensuring access for our rural vets. That is the first part of 
the answer.
    The second part of the answer is we are also going to 
continue to use the new platforms for the delivery of care, 
including through our Office of Connected Care, which again, 
would not be funded by the Office of Rural Health. The Office 
of Connected Care will make sure that we have forward deployed 
capabilities in our rural communities so veterans can connect 
through telehealth, even in areas where broadband is not 
sufficient, highly rural and rural settings.
    Think of it as the Office of Rural Health, as a key 
component, a key coordinator of all the other investments that 
we are making in rural communities. Veterans are more likely to 
be in rural settings. As a result, we take very seriously the 
need to ensure access across all of our communities in the 
country.
    Ms. Budzinski. Thank you very much. That is helpful. I will 
yield back my time.
    Mr. Self. Thank you. Mr. Secretary, I think you and I are 
called the survivors of this briefing.
    Secretary McDonough. Well, I am not, I have not survived 
yet. When it is done, I will call myself a survivor.
    Mr. Self. First of all, I want to address some of the 
comments that I heard. By the way, this is Cabinet Secretary 
Day on Capitol Hill. I apologize for having to step out, as 
everyone has, but we have multiple Cabinet Secretaries here 
today. I want to address some things I heard early, though, 
before I left. The cuts to VA, when you look at the VA today 
with this request, that would be a 45 percent increase just 
from 2020 from $220 billion to $325 billion. That does not 
sound like much of a cut to me over 4 years to increase by $100 
billion.
    Let us take a look at the percentage of veterans. It has 
continued to go down since 1970. Obviously, our World War II 
vets are aging. Our Korean vets are aging. Our Vietnam vets are 
aging. We tend to look at post-9/11. As a percentage of our 
population, veterans are decreasing as a whole. Then the last 
one I want to look at is the increase in employees in the VA. 
Let us go back to the 2020 date again. You have gone from 
389,000 to 453,000 over those same 4 years. $100 billion, a 45 
percent increase of those employees.
    I have got three topics that I would like to address with 
you. The rehire of the employees that were terminated under the 
last administration. I think even one of the papers called them 
bad apples, but I will leave that to you to describe them. 
Under what authority are you rehiring? You and I have had this 
conversation on the phone, so this is for the record. Under 
what authority are you rehiring them and what are the 
circumstances? The second topic I would like for you to cover 
is veteran suicide. Obviously, it is not in my district, but it 
is in the Metroplex, the Dallas Metroplex, the second largest 
VA center in the Nation, I believe, well over 200,000 veterans 
in that area. I will tell you that the veterans that I talk to, 
and frankly, I was at something called the veterans outpost 
just a couple of weeks ago, and the veterans really do not want 
to go to the VA when they have suicidal thoughts. They want to 
go to a local organization where they can talk to fellow 
veterans or people who understand them.
    I see your $52 million for I think it is 52 million for 
grants. I think we ought to reorient the suicide to get them 
into the local organizations, because there is even a mental 
hospital in the area that would be happy to help. I ask you to 
take a look at how we are preventing suicides amongst our 
veterans. It may not be they want to go to big VA. They may 
want to go to the smaller organizations, the local 
organizations, where they can talk to fellow veterans, people 
who can truly understand them.
    My last topic is, as you know, the Deputy Director of the 
Veterans Intergrated Services Network (VISN) there in Dallas, I 
do not believe, and I am getting an ear full on this. This is 
another local issue, but it is the second largest VA, which is 
why I am bringing it up. I do not think that he was given due 
consideration for the top job. He has done a fine job for 
years. Did you post the director position in the Dallas VISN?
    Secretary McDonough. Yes, Mr. Self, thanks so much. On the 
first question, there is a section of law called Section 714 of 
the VA Accountability Act and Whistleblower Protection Act. 
Some time in the 2017, 2018 period, that section of law was 
used to relieve thousands of VA employees. There has been a 
series of administrative actions at the Merit System Protection 
Board, at the National Labor Relations Board, and then also 
judicial activity in the Federal court system that has found 
that the exercise of that authority at that time was 
inconsistent with established practice and statute.
    I sent a detailed letter to Mr. Takano and to Chairman Bost 
about this topic earlier this year. As a result of all of those 
findings, we obviously have to work with the representatives, 
in large measure, the union representatives of those employees 
who have now have these series of administrative and judicial 
rulings such that they may have authority to try to come back. 
That is the subject of an ongoing set of negotiations. I want 
to be careful about what I say in public about this.
    My commitment to you and to the committee is to keep you 
fully informed about how this proceeds. This is why I sent the 
letter I sent to Mr. Takano and to Chairman Bost earlier this 
year to make sure that you had a good understanding of the 
statutory and legal jurisprudential basis for this ongoing set 
of conversations. You know, I believe in the context of those 
settlement negotiations, we can come to some reasonable outcome 
that ensures that if there are bad actors, that they will not 
have to come back to VA. That is the first issue.
    The second issue on veteran suicide, thank you very much 
for raising it. I think your point about local, making sure 
that a veteran goes where the veteran feels comfortable is 
extraordinarily important. What we apply to this is an all of 
the above approach. Yes, those veterans who want to come to big 
VA, let us get them into big VA. Those veterans who reach us 
through the veteran crisis line, if they are in crisis, we are 
going to get them into care today. Irrespective of where it is, 
we are going to get them into crisis today. Any veteran who is 
feeling crisis today, please contact us, dial 988, and then 
press 1. We will get you into care today.
    Those veterans who want to go to, you know, what used to be 
called VA without the hassles, the vet centers, we have 350 vet 
centers across the country, counselors available to you today 
in retail settings in Dallas, throughout Texas, in California. 
Those counselors, trained counselors, largely veterans, 
including combat veterans themselves. Those veterans who need 
to get care in the community, we are moving a lot of mental 
healthcare into the community. That is to say, through the 
community care program. We make those referrals. We then pay 
for it.
    Last, and most importantly, Mr. Takano led the enactment of 
a new statute that says to any veteran in crisis today, go to 
get care anywhere, in the community, at VA, go to anywhere to 
get that care. There will be no copay. There is not going to be 
no pay. We are going to take care of your emergency situation. 
That is an important set of new authorities that Mr. Takano has 
ensured that we have gotten. It is incumbent on us to use those 
effectively. We are about, Mr. Takano, 6 months into the 
exercise of those authorities, I believe. We were late in 
getting them started. We are still learning about how this can 
function and function well. That feedback to us is really 
important. Feedback from vets, from VSOs, from the veteran 
outpost, that will make us better at this new authority.
    Look, we are going to do all of the above, including, as 
somebody earlier talked about, the Sergeant Fox Community 
Grants, which is now we are into the second notice of funding 
opportunity. We have moved about $50 million. This envisions 
another $50 million into local organizations where those 
organizations know their veterans best. Let's invest in them so 
they can help our veterans most. I hope that is responsive to 
the questions, Mr. Self. Sorry, on Dallas.
    Mr. Self. The deputy.
    Secretary McDonough. On Dallas, yes. So, you are right. I 
looked into this yesterday. It was not listed. I can get you 
more information behind why that was the case. I did check in 
with the VISN director, and we should have a conversation about 
that, if you do not mind, in private. I will say this. I am 
told that our leadership in North Texas for the North Texas 
system prioritized the data stream that we think is most 
important for performance, which is the veteran experience data 
stream. Into the hiring for this position, because that data 
stream had not been as strong in the North Texas system as it 
has been in earlier periods, they prioritized somebody with a 
proven track record in addressing that is what I am told. 
Again, I think we can have a broader conversation. I want you 
to know, I did, after we had our conversation yesterday, follow 
up personally on this issue, and I am more than happy to stay 
in touch with you personally on it to make sure you receive it.
    Mr. Self. Please do so, Secretary, because we have the 
second largest, again, well over 200,000 veterans that serve, 
that are served by this medical center. I believe the man 
chosen came from a 17,000 veteran center. There is a vast 
difference between the two and the skill sets. With that, thank 
you. I turn to the ranking member for any closing comments.
    Mr. Takano. Thank you, Mr. Chairman. Mr. Secretary, thank 
you for your testimony today. I look forward to have my staff 
get together with your staff. Obviously, Chairman Bost and I, 
you know, have a lot of concerns about the second bite and the 
TEF. And I look forward to working that all out with you.
    Secretary McDonough. I picked that up.
    Mr. Takano. It is mainly in the service of wanting to get 
you more authorizations and more bills through, like Ms. 
Brownley's Elizabeth Dole Caregiver bill, which I know you care 
about. There may be some disconnect between Congress, OMB, and 
your department in terms of just what is going on with our TEF 
process here. Anyway, I hope we get that straightened out.
    With regard to the chair's comments about the increase in 
funding for VA, it is true funding has increased. I want to 
point out that even though the total number of veterans has 
decreased, you know, thanks to medical science, we have seen 
veterans come back from conflicts who would not have survived 
in previous conflicts and who have far more complicated 
comorbidities. Medical science in general has meant that 
notwithstanding a veteran's combat experience, people are 
living longer with more comorbidities, and it has become more 
expensive to take care of the number of veterans that we do 
have.
    The cost of healthcare is rising, is universally rising. We 
see it expanding in private sector healthcare, and it is not 
any different for VA healthcare. It is part of what we are 
seeing, what I see in the Department of Defense wanting to 
relieve themselves of an obligation to provide healthcare for 
active duty. We are seeing people on TRICARE for Life who 
located near military bases believing they could get access to 
the military hospitals being denied that access because the 
military wants to reduce its cost exposures. Where are they 
going? They are going into the community, which also has a 
shortage of folks. I believe that we need to solve this problem 
of not enough practitioners both in the private sector and for 
the VA, which I also believe is understaffed. How are we going 
to do that? How are we also going to take care of the 
military's needs? We need combat surgeons. We need combat 
teams.
    I share the chair's interest in making sure that a veteran 
in crisis can get to the emergency care that they need without 
having to worry about the cost. By the way, without worrying 
about their eligibility for VA care. The bill that was 
successfully signed by President Biden says that even if you 
are a veteran that is not enrolled in VA, if you are having an 
emotional mental healthcare emergency, you call that emergency 
number. Sorry, Mr. Secretary, can we repeat that number? I 
think it is important. What is that number? 988 and you press 
1, right? 988, press 1. You can be connected with someone at VA 
who can get you connected with care that you do not have to 
worry about the cost for, and that includes care in the 
community.
    Finally, to just say, yes, I believe that many, many 
veterans would prefer mental healthcare in a community setting. 
Let us also remember that that statistic, whether it is 18, 20, 
21, 22 veterans dying a day by suicide, that those that are 
connected to VA care are actually less likely to die by 
suicide. There is something about being connected to VA which 
is actually helping to reduce the risk of suicide. That 
connection to VA is important. I also want to acknowledge that 
there is a segment of the veteran population that, for whatever 
reason, would prefer to get their care elsewhere. We have to be 
respectful of that as well and make sure that we have the 
capacity to do that.
    With that, I look forward to working with my colleagues 
across the aisle and all over the Congress to make sure that 
the interests of our veterans is fully served and we will make 
sure that we fully implement the PACT Act as you are doing. It 
is a revolutionary bill. Thank you for the work that we have 
been able to do together, and I yield back.
    Mr. Self. There seems to be nothing new under the sun. In 
Vietnam, we had PTSD and Agent Orange. In Afghanistan, we 
continue to have PTS as we refer to it now and burn pits. There 
seems to be nothing new under the sun. I will comment on the 22 
number of suicides a day. Whether that is the exact number or 
not, I think it is still true that that does not include 
California and New York. Is that correct? They do not report?
    Secretary McDonough. I do not believe that is true.
    Mr. Self. Okay.
    Secretary McDonough. I believe it does include them.
    Mr. Self. It does include all of them. Okay. In any case, 
the number is too high.
    I ask unanimous consent that the written statement of the 
coauthors of the independent budget be inserted into the 
hearing record. Hearing no objection, so ordered.
    Mr. Self. I ask unanimous consent that all members shall 
have 5 legislative days in which to revise and extend their 
remarks and include any extraneous material.
    Hearing no objection, so ordered. This hearing is now 
adjourned. Thank you.
    [Whereupon, at 12:40 p.m., the committee was adjourned.]

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                         A  P  P  E  N  D  I  X

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                     Prepared Statement of Witness

                              ----------                              


                 Prepared Statement of Denis McDonough

    Chairman Bost, Ranking Member Takano and distinguished Members of 
the Committee, thank you for the opportunity to testify today in 
support of the President's Fiscal Year 2024 Budget and Fiscal Year 2025 
Advance Appropriations (AA) Request for VA and for your longstanding 
support of Veterans and their families.
    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 Veterans throughout their lives. Over the last 2 
years, we have delivered more care and more benefits to more Veterans 
than at any other time in our Nation's history. In Fiscal Year 2022 
alone, the Veterans Benefits Administration (VBA) completed more than 
1.7 million disability compensation and pension claims for Veterans, 
and set a new VA record, breaking the previous year's record by 12 
percent. VA is on track to set another year record in Fiscal Year 2023. 
During this same period, the Veterans Health Administration (VHA) 
provided more than 115 million clinical encounters, with VA serving 
over 6.3 million patients. This included roughly 40 million in-person 
appointments; over 31 million tele-health and telephone appointments; 
and approximately 38 million community care appointments. VA's 
relentless commitment to Veterans and a continued emphasis on 
fundamentals contributed to VA meeting these goals.
    I am incredibly proud to report that for the 7th consecutive year, 
the National Cemetery Administration (NCA) received the top rating 
among participating organizations in the American Customer Satisfaction 
Index, with a score of 97 (out of 100), the highest result ever 
achieved for any organization in either the public or private sector. 
Committed to excellence and dignified committals, NCA interred nearly 
150,000 Veterans and eligible family members in our national cemeteries 
in Fiscal Year 2022, the highest number of annual interments VA has 
ever recorded. NCA delivered more than 350,000 headstones, markers and 
columbarium niche covers around the world and provided nearly 12,000 
medallions in 2022 to mark the privately purchased headstones of 
Veterans.
    VA appreciates the tremendous work the Congress has done to enable 
VA to achieve these exceptional results and we will continue to partner 
with Congress to secure authorities needed to improve our agility, 
responsiveness and accessibility to more Veterans than ever before. 
Both the Veterans Access, Choice, and Accountability Act (Choice Act) 
of 2014 (P.L. 113-146) and the VA Maintaining Internal Systems and 
Strengthening Integrated Outside Networks (MISSION) Act of 2018 (P.L. 
115-182) made it easier for Veterans to receive care from non-VA 
community providers while continuing to benefit from VA's Veteran-
centric care coordination. The Veterans Comprehensive Preventions, 
Access to Care and Treatment Act of 2020 (COMPACT Act; P.L. 116-214) 
enabled VA to provide health care services to all eligible individuals 
in acute suicidal crisis at no cost both in VA and in the community.
    The enactment of the Johnny Isakson and David P. Roe, M.D., 
Veterans Health Care and Benefits Improvement Act of 2020 (P.L. 116-
315) ushered in significant improvements to various GI Bill programs, 
expanded the Veteran Employment through Technology Education Courses 
(VET TEC) program and enhanced education benefits for Veterans, 
Servicemembers, families and survivors. Both the Commander John Scott 
Hannon Veterans Mental Health Care Improvement Act of 19 (Hannon Act; 
P.L. 116-171) and the Support the Resiliency of Our Nation's Great 
Veterans Act of 2022 (STRONG Veterans Act; Division V of P.L. 117-328) 
have broadened mental health care and suicide prevention programs and 
have advanced VA's efforts in promoting well-being among Veterans. The 
Joseph Maxwell Cleland and Robert Joseph Dole Memorial Veterans 
Benefits and Health Care Improvement Act (Cleland Dole Act; Division U 
of P.L. 117-328) will enhance VA's ability to furnish health care and 
benefits to Veterans, including rural Veterans. These authorities 
buildupon VA's ability to meet the unique needs of the Nations' heroes 
and ultimately save lives.
    In 2022, Congress passed the Sergeant First Class Heath Robinson 
Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT 
Act; P.L. 117-168). The PACT Act represents the largest expansion of 
Veterans' benefits in a generation, and I am immensely proud that our 
broad efforts, spanning nearly every Administration and office within 
VA, have yielded positive results. We continue to see steady increases 
in the number of toxic exposure-related disability compensation claims 
filed and processed as Veterans' understanding of the PACT Act grows. 
Even with these early successes, there is more to do to ensure every 
possible eligible Veteran receives the benefits and health care they 
have earned. Our focus will remain on increasing Veteran outreach, 
processing claims timely, providing health care, modernizing our IT 
systems and having the right number of people in place to deliver on 
our promise to Veterans.
    VA greatly appreciates Congress' commitment to providing VA the 
necessary funding to support the PACT Act through its establishment of 
the Cost of War Toxic Exposures Fund (TEF). As we continue to learn 
what the full resource requirements are for this incredibly important 
support to Veterans, we remain committed to transparency and will work 
closely with our partners, as demonstrated through our recent publicly 
available dashboard. The 2024 President's Budget request, including our 
TEF request, will ensure VA fulfills our responsibilities to Veterans, 
Congress and American taxpayers.

                 FY 2024 Budget and FY 2025 AA Request

    The total 2024 request for VA is $325.1 billion (mandatory and 
discretionary, including collections and the Recurring Expenses 
Transformational Fund (RETF), a $16.6 billion or 5.4 percent increase 
above the 2023 enacted level. This includes a discretionary budget 
request of $142.2 billion (with $4.3 billion from medical care 
collections), a $3.4 billion or 2.4 percent increase above 2023. When 
combined with $600 million from RETF, the total discretionary funding 
level is $142.8 billion, including collections. The 2024 mandatory 
funding request is $182.3 billion, with $20.3 billion for the TEF, an 
increase of $13.6 billion or 8.1 percent above 2023.
    The 2024 Budget again proposes to separate out the VA medical care 
program as a third category within the discretionary budget based on a 
recognition that VA medical care has grown much more rapidly than other 
discretionary spending over time, largely due to systemwide growth in 
health care costs. In 2024, the Budget reflects $128.1 billion in 
enacted AA for VA medical care programs, together with a proposed 
cancellation of $7.1 billion in unobligated balances, for a 
discretionary total of $121 billion for VA medical care, which is in 
addition to a $17.1 billion TEF request for medical care.
    The 2025 Medical Care AA request includes a discretionary funding 
request of $112.6 billion, together with a mandatory advance 
appropriation request of $21.5 billion for the TEF. The 2025 mandatory 
AA request is $193.0 billion for Veterans benefits programs 
(Compensation and Pensions, Readjustment Benefits, Veterans Insurance 
and Indemnities), which, together with the TEF, results in a combined 
mandatory total of $214.7 billion.

                                PACT Act

    The PACT Act is a major factor in the expansion of care and 
benefits to Veterans. In Fiscal Year 2024, VA will continue to work to 
provide a ``One-VA'' experience to all Veterans, survivors, family 
members and caregivers as we proactively work to deliver timely 
benefits, services and high-quality health care.
    VA began nationwide PACT Act-related disability compensation claims 
processing on January 1, 2023. As of March 4, 2023, VA has received 
more than 362,000 PACT Act-related claims since August 10, 2022 and 
completed over 157,000 claims. Using the new PACT Act authorities, VA 
has granted service connection for over 1,800 terminally ill Veterans.
    VA began a comprehensive, targeted outreach effort to encourage 
Veterans and survivors to apply immediately for PACT Act-related care 
and benefits. For example, VA hosted 127 PACT Act ``Week of Action'' 
events in all 50 States, the District of Columbia and Puerto Rico. More 
than 50,000 attendees participated in person or online. During these 
events, VA completed 5,600 toxic exposure screenings and received 2,600 
claims for benefits and more than 800 health care enrollment 
applications. As of March 20, 2023, more than 2.5 million toxic 
exposure screenings have been performed.
    VA has been running a robust advertising campaign to educate 
Veterans and their families about the PACT Act. To date, VA has spent 
over $4 million with digital, social and traditional media advertising 
across the country. The campaign's focus is on maximizing awareness of 
the PACT Act, and the call to action to all eligible Veteran survivors 
to apply for these benefits that they have earned and deserve. In 
Fiscal Year 2024, VA will continue to drive paid advertising campaigns 
as an important way to reach Veterans not currently connected with VA 
or Veterans Service Organizations (VSOs). VA will continue to focus on 
marketing efforts on reaching Veterans of all generations, races and 
genders.
    One of the biggest challenges VA will continue to face in Fiscal 
Year 2024 is identifying and contacting survivors, even more so now 
that many more are eligible for benefits under the PACT Act. We have 
mailed nearly 300,000 letters to potentially eligible survivors. VA is 
also leveraging social media and posting YouTube videos to provide easy 
to read information on the PACT Act. VA's goal in Fiscal Year 2024 is 
to continue 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.
    To ensure all eligible Veterans obtain the benefits and care they 
earned through their service, the Budget for VA medical care provides 
$82 million for the Health Outcomes and Military Exposures (HOME) 
Office, an 85 percent growth over 2022. VHA will regularly screen 
enrolled Veterans for military-related toxic exposures and ensure 
clinicians understand how such exposures affect Veterans' health. VA is 
working to improve the Airborne Hazards and Open Burn Pit (AHOBP) 
registry and will track the VHA health care utilization of the PACT 
Act-eligible cohort. To ensure these Veterans receive the highest 
quality care available, the Budget also provides $68 million for 
Military Occupations and Environmental Exposures research, which will 
yield improvements in the identification and treatment of medical 
conditions potentially associated with toxic exposures.
    VA is also committed to recruiting, onboarding and integrating new 
employees across the enterprise to further implement the PACT Act for 
Veterans and survivors. In Fiscal Year 2023, VA held a series of 
successful hiring fairs. Throughout the next year, VA will continue to 
hold hiring fairs across the country, with an emphasis on hiring Claims 
Examiners, H.R. Specialists, IT Specialists, nurses and more. In 
addition, VA has actively engaged the workforce through a variety of 
avenues and solicited feedback. These investments in employee 
engagement will continue to be critical as we look to continue to hire 
more employees than ever before. Under the initial TEF spend plan 
approved on October 6, 2022, VA allocated 1,871 positions toward claims 
processors and support staff. As of March 1, 2023, VA has hired 1,299 
of the 1,871 positions (69.4 percent). In addition, VBA Human Capital 
Services (HCS) secured a PACT Act direct hire authority (DHA) from the 
Office of Personnel Management (OPM) that will expedite the hiring of 
mission-critical occupations through September 30, 2027, for Human 
Resources Management, Human Resources Assistant, General Legal and 
Kindred and Veterans Claims Examining series positions. The DHA is used 
with a system of open continuous announcements that results in a steady 
flow of eligible and available applicants for selection at 
predetermined timeframes that suit the needs of the organization. VBA 
has also created opportunities to increase hiring by hosting onsite 
hiring events designed to connect job seekers nationwide with current 
PACT Act positions for Veterans Service Representative (VSR), Rating 
Veterans Service Representative (RVSR) and Legal Administrative 
Specialist (LAS) positions. VA will continue to leverage 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.

                        Investing in Our People

    Providing world class health care is only possible with an 
enterprise-wide team of the best and brightest in their respective 
fields. We are hiring more staff across the Department to ensure that 
care and benefits are delivered in a timely manner while also focusing 
on improving the employee experience to deliver positive outcomes for 
Veterans, their families, caregivers and survivors. VA is investing in 
our people by dramatically increasing hiring, holding 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. For example, using 
the recently approved DHA 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 4 months of Fiscal Year 2023, compared to 
less than 1 percent growth in the workforce over the same time period 
in Fiscal Year 2022.
    A nationwide onboarding event held in November 2022 resulted in 
onboarding more new staff in VHA in the first quarter of Fiscal Year 
2023 (12,900 staff) than in the first quarter onboarding in any 
previous year. This was 86 percent higher than the historical average 
number onboarded in the first quarter. Onboarding for VHA continued to 
be high in January 2023 (5,603 new staff onboard, approximately 600 
more than last January). VHA's emphasis on hiring has resulted in an 
overall net increase of onboard staff of 2.1 percent as of January 31, 
2023. This is already two-thirds of VA's annual target of 3 percent 
growth just 4 months into the fiscal year.
    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. In addition, 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 reduce losses in for 
critical shortage occupations and help VA successfully compete for 
health care and entry level staff.

                     Focus on Wellbeing of Veterans

    VA's 2024 Budget will provide the resources to ensure we provide 
the benefits and services to support Veterans' health and economic 
well-being.

Veterans Benefits

    The 2024 Budget includes $3.9 billion in discretionary funding for 
the General Operating Expenses, VBA account, a $36 million increase 
over the 2023 Budget. This includes funds for the Veteran Transitional 
Assistance Grant Program (VTAGP) required under P.L. 116-315, Section 
4304, and increased overtime funding to support the timely processing 
of claims.
    The President's Budget provides disability compensation and 
survivor benefits to over 6 million Veterans and their families; 
education and job training benefits to 928,000 Veterans and qualified 
dependents; guarantees about 553,000 home loans and funds 5.6 million 
total lives insured for Veterans, Service members and qualified 
dependents.
    Last fiscal year, VBA set a record for the highest claims 
production with more than 1.7 million claims completed. As of March 4, 
2023, VBA already has completed 755,271 claims, which is 10 percent 
more claims than last year at this time. Since the PACT Act was signed, 
as of March 4, 2023, Veterans and their survivors have filed more than 
1,185,301 total claims, an increase of more than 25.4 percent over the 
same period last year. As mentioned above, VBA continues to hire to 
increase its claims processing capacity in anticipation of the influx 
of claims filed due to the PACT Act. VBA developed a robust claims 
projection model which shows what the claims inventory will look like 
with the inclusion of PACT Act claims. In addition to hiring, VBA is 
reviewing processes and developing technology to address the growing 
complexity of claims. Using Automated Decision Support technology, VBA 
is automating multiple administrative tasks within the claims process 
such as locating and compiling information from Veterans' electronic 
records, verifying military service eligibility for PACT Act claimants, 
ordering examinations when required, and expediting claims that can be 
decided based on the evidence of record. The PACT Act authorizes the 
use of appropriations to modernize and expand the capabilities and 
capacity of information technology (IT) systems and infrastructure at 
VBA.

Prevent Veteran Suicide

    VA has made suicide prevention a top clinical priority and is 
implementing a comprehensive public health approach to reach all 
Veterans. Funding for mental health, including suicide prevention, is 
$16.6 billion in Fiscal Year 2024, up from $15 billion in Fiscal Year 
2023. Our commitment to a proactive, Veteran-centered Whole Health 
approach is integral to our mental health care efforts and includes 
online and telehealth access strategies. Whole Health can help Veterans 
reconnect with their mission and purpose in life as part of our 
comprehensive approach to reducing risk.
    Suicide is a complex issue with no single cause. Maintaining the 
integrity of VA's mental health care system is vitally important, but 
it is not enough. We know some Veterans may not receive any health care 
services from VA. To support this nationwide effort, the budget 
specifies $559 million for suicide prevention outreach programs, in 
addition to $2.5 billion in suicide-specific medical treatment, which 
includes a new $10 million program to further bolster these efforts 
under the authority of section 303 of the STRONG Veterans Act.
    In 2022 and 2023, VA conducted a $20 million open innovation grand 
challenge, known as ``Mission Daybreak'', to accelerate the development 
of solutions across the Nation to reduce Veteran suicide. ``Mission 
Daybreak'' is part of VA's 10-year strategy to end Veteran suicide 
through a comprehensive, public health approach. VA launched the 
multiphase challenge in May 2022, receiving more than 1,300 concept 
submissions from Veterans, VSOs, community-based organizations, health 
tech companies, industry startups and universities. Mission Daybreak 
Phase I selection of 30 Grand Challenge finalists was completed in 
November 2022 and 10 Mission Daybreak innovation winners were announced 
on February 16, 2023.
    The Staff Sergeant Parker Gordon Fox Suicide Prevention Grant 
Program (SSG Fox SPGP) awarded $52.5 million to 80 community-based 
organizations in 43 States, the District of Columbia and American Samoa 
in Fiscal Year 2022. These organizations provide or coordinate the 
provision of suicide prevention services for eligible individuals, 
including Veterans and their families. VA has provided technical 
assistance to grantees, who began providing suicide prevention services 
in January 2023. Twenty-one grantees serve Tribal lands including the 
Navajo Nation, Cherokee Nation, Choctaw Nation, Alaskan Native Tribes 
and others. Funding decisions prioritized grants to rural communities, 
Tribal lands, Territories of the United States, areas with medically 
underserved groups, 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 alignment with VA's National 
Strategy for Preventing Veteran Suicide, SSG Fox SPGP assists in 
further implementing a public health approach that blends community-
based prevention with evidence-based clinical strategies through 
community efforts. The Fiscal Year 2024 Budget plans to award $52.5 
million in grants.
    The Veterans COMPACT Act created a new authority in 38 U.S.C. Sec.  
1720J for VA to provide health care services to all eligible 
individuals in acute suicidal crisis at no cost both in VA and in the 
community. This provision increases access to care and is in full 
alignment with VA's National Strategy for Preventing Veteran Suicide. 
VA published an interim final rule on January 17, 2023, and immediately 
began providing this new benefit to eligible individuals. As part of 
implementation VA developed a robust communications plan targeted 
toward eligible individuals, Veterans and community providers. VA 
continues to aggressively address critical cross-platform information 
technology enhancements to ensure that multiple administrative and 
clinical systems work seamlessly together to ensure timely and 
efficient care at no cost. We are committed to ongoing education and 
training efforts within VA and in the community as we deploy this new, 
life-affirming benefit in our ongoing suicide prevention efforts.
    Women Veterans carry an especially high burden of mental health 
conditions. These include gender-specific conditions associated with 
heightened suicide risk, such as premenstrual dysphoric disorder, 
postpartum depression and perimenopausal depression. Among eligible 
women receiving VHA care, nearly 60 percent are diagnosed with at least 
one mental health condition (as compared to 37.8 percent of eligible 
men), and many struggle with multiple mental health concerns, medical 
comorbidities and psychosocial challenges. VA has implemented numerous 
initiatives to ensure VHA mental health providers have the expertise to 
address women Veterans' unique and diverse treatment needs and assess 
and address their risk for suicide, and we are committed to expansion 
of these innovations. VA is also ramping up efforts to increase the 
visibility of all VA services for women Veterans, including developing 
a cadre of women Veteran--focused peer support resources and outreach 
campaigns. Today's women Veterans need to know what VA has to offer.
    Among the risk factors for suicide, substance use disorder (SUD) is 
strongly implicated. In addition, drug overdose fatalities inclusive of 
suicide have escalated. Therefore, the need for effective interventions 
to address substance use cannot be overstated. The President's Budget 
includes $254 million to improve VA's opioid safety initiative and to 
continue our joint work with DoD in the field of pain management, 
consistent with the requirements of the Comprehensive Addiction and 
Recovery Act of 2016 (P.L. 114-198, Title IX, Subtitle A, 
Sec. Sec. 911-912, the Jason Simcakoski Memorial and Promise Act). VA 
is also expanding evidence-based SUD treatment and harm reduction 
initiatives consistent with the Biden-Harris Statement of Drug Policy 
Priorities. The President's Budget includes $231 million supports VA 
staff initiatives to support Veterans specific needs, including 
employment, housing, case management, peer support, as well as in-
patient and out-patient care.
    Furthermore, VA's budget continues to support expansion of its 
Psychotropic Drug Safety Initiative to address the growing crisis of 
stimulant use overdose fatalities. This initiative ensures the safe and 
appropriate prescribing of stimulant medications as well as expanding 
Veterans' access to evidence-based treatments for stimulant use 
disorder. These include cognitive-behavioral therapy and contingency 
management, both of which are recommended by the 2021 VA-Department of 
Defense (DoD) Clinical Practice Guidelines for the Management of SUDs.
    President Biden's continued focus on the national mental health 
crisis recognizes that access to mental health care is challenging. VA 
continues to evaluate staffing needs and prioritizes mental health 
hiring and training. However, we recognize that hiring additional 
mental health staff in VA will not resolve the growing demand. To 
address President Biden's vision to increase system capacity, connect 
Veterans to care and create a full continuum of support for Veterans, 
VA is committed to being the Nation's leader in ongoing research 
enhancing current mental health treatment, identifying new mental 
health interventions and developing effective prevention and at-risk 
identification protocols. Ongoing congressional support for VA Mental 
Health Centers of Excellence, the Mental Illness Research, Education 
and Clinical Centers, and mental health research initiatives through 
the Health Services Research and Development Service will be essential 
as VA continues to address access, mental health care and suicide 
prevention.

                       Health Care Budget Request

    Providing Veterans access to the soonest and best care 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 the Nation's history. Veterans completed more than 
73 million outpatient appointments in VA and an additional 38 million 
community care outpatient appointments in calendar year (CY) 2022. 
While enrolled Veterans continue to receive most 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 one third of 
all Veterans enrolled in VA health care have been eligible for and 
chosen to receive at least one community care appointment at some point 
in the last 5 years.
    Veterans today have more options for care through VA than ever. 
This includes care delivered both in-house and by our network of 
community providers. More specifically, VA has more than 1,100 VA 
medical centers (VAMCs) and community-based outpatient clinics (CBOCs) 
in which Veterans may 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, Territories and possessions of the 
United States, The District of Columbia and the Commonwealth of Puerto 
Rico. Enrolled Veterans also have access to community urgent care, and 
all eligible individuals have access to emergent suicide care.

Whole Health

    Whole Health is an approach to health care that empowers and equips 
Veterans with the ability to take charge of their health and well-being 
and to live their life to the fullest. Transforming VA into a Whole 
Health system of care has successfully launched and is receiving full 
support at both the national and local levels, including strong 
endorsement in a recent National Academy of Medicine report. In Fiscal 
Year 2022, 16.3 percent of all Veterans receiving care through VA also 
received Whole Health services. This care was delivered to 1.1 million 
Veterans through 3,998,602 encounters which were both Whole Health-
specific and which integrated the Whole Health approach into routine 
clinical encounters. Tele-Whole Health encounters have grown to include 
98,000 unique Veterans participating in 513,000 encounters in Fiscal 
Year 2022, an increase of 39.0 percent unique patients and 32.9 percent 
of encounters over Fiscal Year 2021. Robust formal evaluations continue 
to focus on outcomes for Veterans and employees, which includes a 
review of specific cost avoidance that is traceable to implementation 
of Whole Health Services (e.g., opioid use reduction, decrease in 
spinal procedures). The 2024 President's Budget for Whole Health 
includes $108 million. VA is fully committed to making the Whole Health 
approach an integral part of how we deliver care to Veterans and our 
employees.

Women Veterans

    Women make up 17.2 percent of today's Active Duty military forces 
and 21.1 percent of National Guard and Reserves. VA continues to reach 
out to women Service members and Veterans, to encourage them to enroll 
and use the services they have earned. As a result, the number of women 
Veterans enrolling in VA health care is rapidly increasing. 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 five years. Investments support comprehensive specialty 
medical and surgical services for women Veterans at a VA facility or 
through referrals to the community. The number of women Veterans using 
VA services has more than tripled since 2001, growing from 159,810 to 
more than 625,000 today. VA is committed to providing high quality, 
equitable care to women Veterans at all sites of care.
    The Budget requests $257 million for women's health and childcare 
programs, a 66 percent increase over 2023. This increase supports $174 
million for the Women's Health Innovation and Staffing Enhancement 
Initiative. VA is strategically enhancing services and access for women 
Veterans by hiring women's health personnel nationally to fill any gaps 
in capacity across all Veterans Integrated Service Networks (VISNs). In 
Fiscal Year 2023 VA is providing funding for a total of over 1,000 
women's health personnel nationally: primary care providers, 
gynecologists, mental health providers and care coordinators. VA is 
also addressing clinical equipment needs such as those for mammography, 
exam tables designed for women with low mobility, and breastfeeding 
privacy pods. VA is also expanding childcare benefits beyond the 
current pilot sites.
    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. This 
program includes expanding follow up with Veterans for the particularly 
vulnerable first year postpartum, as well as providing lactation 
services, training, toolkits and support community of practice.
    VA is focusing on enhancing care coordination for preventive care, 
such as breast cancer screening. VA is implementing the Dr. Kate 
Hendricks Thomas Supported Expanded Review for Veterans in Combat 
Environments Act (SERVICE Act, P.L. 117-133); beginning in March 2023, 
VA is providing SERVICE Act breast cancer risk assessments to Veterans 
eligible under that Act (generally those who served in certain 
locations where burn pits were used during the Gulf War and the Post-9/
11 era) 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. VA policy requires each facility to have a process for 
tracking results and timely followup for breast and cervical cancer 
screening. VA policy also requires that facilities have personnel 
assigned to breast and cervical cancer care coordination. 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. VA is also 
implementing section 603 of the PACT Act by conducting toxic exposure 
screening for all enrolled Veterans, including women Veterans. The 
Breast and Gynecologic Cancer System of Excellence is providing state-
of-the-art breast and gynecologic cancer care and care coordination 
across the system through VA's tele-oncology program.

Homeless Programs

    VA's longstanding support for Veterans who are homeless or at risk 
of homelessness is enhanced through taking a Whole Health approach. VA 
will ensure Veterans who are housed in VA programs do not return to 
homelessness by implementing a case management model to mitigate risk 
factors. VA will also leverage its existing programs through targeted 
outreach to reduce the number of unsheltered Veterans.
    The 2024 Budget increases resources for Veterans' homelessness 
programs to $3.1 billion, with the goal of ensuring every Veteran has 
permanent, sustainable housing with access to high-quality health care 
and other supportive services to end and prevent future Veteran 
homelessness. This Budget includes funds to assist with the design and 
development of expanded services for aging and disabled Veterans, a 
growing need and area of focus for the Department of Housing and Urban 
Development (HUD) - VA Supportive Housing (VASH) program. In addition, 
funds will be used to provide a medical home model and population 
tailored approach to provide in-home primary care and wrap around 
services to Veterans actively enrolled in the HUD-VASH program, provide 
additional resources to increase outreach and community engagement 
efforts, as well as expansion of Veteran justice services, such as 
treatment courts and Veteran-focused criminal justice initiatives. 
Funding will also support the VA Grant and Per Diem (GPD) program to 
increase per diem rates to community partners actively supporting VA's 
effort to end Veteran homelessness.
    On a single night in January 2022, there were 33,129 Veteran 
experiencing homelessness in the U.S. However, significant progress is 
being made to prevent and end Veteran homelessness. Since 2010, efforts 
by VA and our Federal partners have led to a more than 55 percent 
reduction in Veteran homelessness. Since 2015, there have been 83 
communities and three States (Delaware, Connecticut and Virginia) that 
have met the criteria and benchmarks established by the U.S. 
Interagency Council on Homelessness, for effectively ending Veteran 
homelessness. Additionally, in CY 2022, VA permanently housed more than 
40,000 homeless Veterans, exceeding our permanent housing goal for CY 
2022 by more than 6 percent.

Research

    The 2024 Budget requests a total of $984 million for research 
through the Medical Prosthetics and Research account and TEF. These 
combined resources will improve Veterans' health and well-being via 
basic, translational, clinical, health services, rehabilitative, 
genomic and data science research; apply scientific knowledge to 
develop effective individualized care solutions for Veterans; attract, 
train and retain the highest-caliber investigators and nurture their 
development as leaders in their fields; and ensure a culture of 
professionalism, collaboration, accountability and the highest regard 
for research volunteers' safety and privacy.

Military Environmental Exposures

    In Fiscal Year 2024, the Office of Research and Development (ORD) 
will expand its investment in this important area and to coordinate 
with environmental exposure focused programs as part of the 
implementation of the PACT Act. Critical components of this effort in 
Fiscal Year 2024 are building capacity (including the number of 
researchers funded to conduct military exposures research) and building 
inter-governmental partnerships. One major step forward is convening an 
interagency workgroup on toxic exposure research, called for in Section 
501 of the PACT Act, to identify evidence gaps and craft a strategic 
plan to address gaps.

Traumatic Brain Injury (TBI)/Brain Health

    Increased investment in TBI remains critical as it is the signature 
injury of post-9/11 Veterans who served in the wars in Iraq and 
Afghanistan. While the acute care of TBI has improved, treatments for 
the longer-term consequences most relevant to Veterans have proven 
elusive. This injury can lead to lifelong disabilities that can vary by 
severity, the characteristics of the event or events that caused the 
injury (e.g., blast versus blunt force) and the number of incidents of 
injury.

Mental Health, including continued execution of projects under the 
    Hannon Act

    This request supports mental health and suicide prevention 
research, including the Hannon Act. This effort also includes clinical 
trials and epidemiological studies on risk and prevention factors, as 
well as biomarker-driven precision mental health projects done in 
collaboration with VHA's Office of Mental Health and Suicide 
Prevention.

Cancer and Precision Oncology

    VA is committed to promoting measurable progress toward President 
Biden's Cancer Moonshot initiative. To that end, VHA's research and 
clinical oncology programs both collaborate with the National Cancer 
Institute (NCI) and other external entities to maximize Veterans' 
benefit from cutting edge improvements in oncology care (for example, 
by increasing Veterans' access to clinical trials). The 2024 Budget 
includes $94 million to support 369 research projects to improve our 
ability to diagnose and treat cancers.
    Clinical trials are often part of standard clinical care for 
patients with cancer and are a second area of clinical-research 
integration in Precision Oncology. Together, these elements form a 
System of Excellence for the full spectrum of care for a particular 
cancer type. Systems of Excellence are established for Prostate/
Genitourinary Cancers and Lung. In 2024, VA will expand on the Rare 
Cancers System of Excellence, add additional molecular testing 
capabilities, enhance the pathology and laboratory infrastructure and 
partner with DoD and others to improve cancer care through the White 
House Cancer Moonshot.
    The Budget invests $33.3 million within VA's cancer research 
programs, together with $215.4 million within the VA medical care 
program, for precision oncology to provide access to the best possible 
cancer care for Veterans. The vision of VA's Precision Oncology 
Initiative is for Veterans to have access to care as close to their 
homes as possible that is comparable to the Nation's leading cancer 
centers. Funds support research and programs that address cancer care, 
rare cancers and cancers in women, as well as genetic counseling and 
consultation that advance tele-oncology and precision oncology care. 
The 2024 investment for precision oncology represents a 31 percent 
increase over 2023.

Caregivers

    VA expanded its Program of Comprehensive Assistance for Family 
Caregivers (PCAFC) to eligible family members and eligible Veterans of 
all service eras on October 1, 2022. From that date through February 8, 
2023, VA received over 44,300 applications. Originally, PCAFC was only 
available to eligible Veterans who incurred or aggravated a serious 
injury in the line of duty on or after September 11, 2001. On October 
1, 2020, VA expanded the program to eligible Veterans who incurred or 
aggravated a serious injury in the line of duty on or before May 7, 
1975, or on or after September 11, 2001. As of February 8, 2023, there 
are over 45,500 Veterans participating in the PCAFC across the country, 
including U.S. Territories and 98 percent of PCAFC applications are 
dispositioned in under 90 days.
    The Budget recognizes the important role of these family caregivers 
in supporting the health and wellness of Veterans. The $2.4 billion 
included in this Budget supports staffing, stipend payments, the 
Program of General Caregiver Support Services (PGCSS), training and 
education, as well as other services to empower family caregivers of 
eligible Veterans. In addition, this funding allows for further 
improvements and enhancements, such as extending telemental health care 
to caregivers, allowing VA to reach and support more caregivers than 
before.
    VA is currently undertaking a broad programmatic review of the 
PCAFC to ensure it meets the needs of Veterans and their family 
caregivers. While this review is underway, VA has suspended annual 
reassessments for participants of the PCAFC. VA will not discharge or 
decrease any support to PCAFC participants and their family caregivers, 
based on reassessment, to include monthly stipends paid to primary 
family caregivers, as the current eligibility criteria are examined.
    As we look to the year ahead, VA seeks to buildupon the CSP program 
with an emphasis on the ``Year of the Caregiver.'' The Year of the 
Caregiver is about ensuring caregivers know they belong to a community 
that cares. Through this theme, VA is not only adding to what it offers 
to caregivers but focusing on how it is offered and implementing and 
improving support and services for caregivers of Veterans.

          Transforming Systems, Processes, and Infrastructure

    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 are the ultimate judges of our success.

Digital Transformation

    VA continues its Digital Transformation journey with the Office of 
Information and Technology (OIT) providing the infrastructure, 
engineering, leadership and functions to deliver world-class IT 
products and services and to improve the end-user experience for 
Veterans, their families, caregivers and survivors.
    Modern Veteran IT services include telehealth services with VA care 
teams, seamless transition of health care information from DoD to VA 
systems, acceleration of benefit claims processing, and improved 
customer digital interactions. To become the Best IT Organization in 
Government, OIT's 2024 Budget includes $6.4 billion in discretionary 
funding for continued transformation efforts from modernization of 
aging infrastructure, efficient delivery of IT services to VA employees 
and enhancement of the Veteran experience.
    The Budget prioritizes Cybersecurity, the Infrastructure Readiness 
Program (IRP) to reduce technical debt, Financial Management Business 
Transformation (FMBT), Human Resource IT Solutions, Telehealth Services 
and Claims Automation that allows for timely access to benefits and 
care for Veterans. Notably, the cybersecurity budget includes $927 
million (combined Base Budget and TEF) to deliver enterprise-wide 
cybersecurity strategies, policy, governance and oversight to protect 
Veteran data and VA critical information systems. Also, the 2024 Budget 
invests in the implement of Zero Trust Architecture (ZTA) principles. 
Our goal is to secure Veterans' data - where it may live -while 
allowing legitimate access to Veteran and VA data.
    Further, the 24 Budget includes re-platforming for VA's oldest 
legacy systems onto modern low-code/no-code Platform as a Service 
(PaaS) and Software as a Service (SaaS) solutions. This will satisfy 
the increased demand for new IT capabilities, free space for clinical 
purposes and enhance IT infrastructure services.

Electronic Health Record Modernization (EHRM)

    We readily acknowledge there have been challenges with our efforts 
to modernize VA's electronic health record (EHR) system. As we work 
through the challenges, our commitment remains unwavering--to provide 
world-class patient care and prioritize patient safety for the Veterans 
we serve. Though there is still a lot of work to do, important progress 
has been made since our first go-live in Spokane. For example, VA 
requested corrective actions within the Oracle Cerner data base 
configuration that resulted in a 6-month period without a complete 
outage. We also continue to improve the system based on feedback from 
our health care personnel in collaboration with Cerner. On February 17, 
23, the three priority pharmacy enhancements were installed as part of 
the Block 8 upgrade to the EHR system. These enhancements are an 
important step in resuming EHR system deployment and will reduce burden 
on personnel at the five sites using the new EHR.
    We are focused on assessing and remediating any identified issues 
at live sites, with a continued focus on patient safety. When we move 
forward with deployments, we will, of course, incorporate lessons 
learned and implement continued improvements we have identified, so 
that we can achieve the benefits of a modern EHR system. We strive to 
have a system that will support improved access, outcomes and 
experiences for Veterans, through a single health record from entry 
into military service through their VA care.
    To support the EHR modernization effort, the EHRM Integration 
Office's (EHRM-IO) 2024 Budget request is $1.9 billion. This reflects 
the funding needed to sustain deployed sites and prepare for the next 
program requirements at sites scheduled to go-live in Fiscal Year 2024 
through early Fiscal Year 2026.

    The funding will support:

      EHR ($1.2 billion): Contracts for enterprise integration 
and site implementation activities.

      Infrastructure ($424 million): IT and other 
infrastructure investments, such as IT upgrades, modifications to 
existing systems and interfaces.

      Program management support ($253 million): Government 
staff (e.g., salaries and benefits), Government administrative expenses 
and contractor support.

    VA continues to align requirements and fiscal resources to the EHRM 
program in support of the long timelines associated with its deployment 
methodology. For example, planning for deployments requires a 2-year 
process for infrastructure readiness and 13-months of pre-go-live 
activities. Interruptions to VA's EHRM funding will create risk for 
planned activities and significantly impacts sustainment.
    In addition to the funding requested for the EHRM account, VHA's 
Medical Facilities request includes $750 million in Non-Recurring 
Maintenance (NRM) funding for facility EHR infrastructure projects, 
which are aligned to the EHRM deployment methodology.
    The EHR has been deployed to five VAMCs, including 22 CBOCs and 52 
remote sites with more than 10,000 medical personnel using the system, 
serving more than 200,000 Veterans. As improvements continue to be made 
over the next few months, VA will continually evaluate the readiness of 
each site as well as the EHR system to ensure success. To be clear, we 
will not go live at any site with unresolved safety critical findings, 
yet we remain firm in our resolve to continue modernizing the EHR. VA 
intends to deliver an updated deployment schedule to Congress by May 
2023.

FMBT

    The FMBT program is increasing the transparency, accuracy, 
timeliness and reliability of financial and acquisition activities 
across the Department. The 2024 Budget includes $394.7 million 
(including General Administration, Information and Technology, Supply 
Fund and Franchise Fund sources) for FMBT, a program that is improving 
fiscal accountability to taxpayers and enhancing mission outcomes for 
our employees who serve Veterans. So far, we have completed five 
successful deployments of the new Integrated Financial and Acquisition 
Management System (iFAMS) across NCA, VBA and staff offices, all of 
which have provided invaluable lessons learned and numerous 
opportunities to improve our approach. As part of FMBT's commitment to 
continuous improvement, we continue to work with stakeholders and end 
users to proactively adjust our deployment approach to better manage 
the complexities inherent in a financial and acquisition system 
transformation effort of this magnitude. Each implementation brings us 
one step closer to providing a modern, standardized and secure 
integrated solution that enables VA to meet its objectives and fully 
comply with financial management and acquisition mandates and 
directives. As of February 2023, there have been over 2.1 million 
transactions successfully processed in iFAMS, and over $6 billion in 
payments made through the Department of the Treasury.
    Deployment of iFAMS is taking place in phased implementations, 
called ``waves,'' across VA administrations and staff offices. In just 
a few months, we will go live with our largest system rollout yet. This 
includes some of VA's largest staff offices and will increase the 
current iFAMS user base by almost 50 percent. In December 2023, we will 
deliver an iFAMS upgrade, which will provide substantial enhancements 
to system performance, functionality and ease of use. iFAMS will also 
go live for VBA Loan Guaranty later in Fiscal Year 2024 and continue 
system rollouts across the remaining VA administrations and staff 
offices until enterprise-wide implementation is complete.

Infrastructure

    The President's 2024 Budget includes $4.1 billion for construction 
requirements -$3.5 billion in Major and Minor Construction 
appropriations in addition to $600 million in estimated unobligated 
balances from RETF planned for Major Construction requirements. Funding 
for two major medical facility projects, including the St. Louis 
Replacement Bed Tower, Clinical Building Expansion, Consolidated 
Administrative Building and Warehouse, Utility Plan and Parking Garages 
project supporting over 149,000 Veteran enrollees, and two national 
cemetery expansion projects are included in the request. The 24 Budget 
includes $112 million in major construction funds for a gravesite 
development project at Tahoma National Cemetery and a gravesite 
expansion project at Jefferson Barracks National Cemetery. The Budget 
also includes $182.6 million in Minor Construction funds for gravesite 
expansion and columbaria projects to keep existing national cemeteries 
open and for projects that address infrastructure deficiencies and 
other requirements necessary to support national cemetery operations. 
RETF will provide funding for eight additional medical facility Major 
Construction projects, bringing the total to 12 major construction 
projects funded in Fiscal Year 2024. In addition, VHA's Medical 
Facilities account includes $5.75 billion for NRM.
    VA's robust Fiscal Year 2024 capital request reflects 
infrastructure's importance in enabling the delivery of care and 
benefits and doing so in ways that are sustainable and resilient as 
guided by Executive Order 14057. For example, the PACT Act 
significantly expands benefits, and VA must plan for infrastructure 
required to support this increase in health care for Veterans.
    The VA infrastructure portfolio consists of approximately 184 
million owned and leased square feet which is one of the largest in the 
Federal Government, but is rapidly aging and deteriorating. While the 
median age of U.S. private sector hospitals is 13 years, the median age 
of VA's portfolio is 60 years. With aging infrastructure comes 
operational disruption, risk and cost. VA's 2024 Budget highlights the 
importance of modernizing our infrastructure to maintain and expand our 
portfolio and support the continuing mission growth.
    As part of our Budget request, the Department has included 
mandatory funding for one ongoing Major Construction project and the 
completion of various Minor Construction projects that improve VHA 
facilities. This mandatory funding helps ensure appropriate and 
required investment in the infrastructure to prevent service delivery 
disruptions in the future.
    Also included in VA's 2024 Budget request are 10 major medical 
facility leases totaling over 1.5 million square feet of space 
supporting cutting-edge research and a workload of over 1.7 million 
outpatient stops and bed days of care. These leases are key to 
modernizing VA's clinical points of care and increasing access for the 
increasing number of Veterans anticipated to access VA care because of 
benefit expansion offered by the PACT Act. These leases will also be 
the first to go through the new PACT Act committee resolution approval 
process.
    VA has previously presented the need to fully upgrade and modernize 
our facilities to meet the service delivery objectives expected of 
modern health care delivery infrastructure, bringing them up to the 
standards Veterans deserve. VA's aggressive 2024 Budget sets us on this 
path to modernize or replace outdated VAMCs with state-of-the-art 
facilities. Additionally, VA is aggressively working to pursue 
implementation of the goals of Executive Order 14057, which creates a 
broad set of challenging goals and requirements for Federal agencies to 
eliminate their carbon footprint and make their operations more 
sustainable and resilient.

                      Honoring Veterans' Legacies

    The President's 2024 Budget includes $480 million for NCA's 
operations and maintenance account, an increase of $50 million (11.6 
percent) over the 2023 Budget, to ensure Veterans and their families 
have access to exceptional burial and memorial benefits including 
expansion of existing cemeteries as well as new and replacement 
cemeteries. With this Budget, NCA will provide for an estimated 140,472 
interments, the perpetual care of almost 4.3 million gravesites and the 
operations and maintenance of 158 national cemeteries and 34 other 
cemeterial installations in a manner befitting national shrines. This 
request will fund 2,331 full-time equivalents needed to meet NCA's 
increasing workload, while maintaining our reputation as a world-class 
service provider.
    While every eligible Veteran may be interred at any one of VA's 
open national cemeteries and a significant majority of the 122 VA 
grant-funded Veterans cemeteries, VA realizes that proximity to a 
cemetery is an important consideration in whether Veterans and family 
members choose a VA-funded cemetery for their final resting place. For 
this reason, NCA is committed to providing 95 percent of the Veteran 
population with access to first interment burial options (for casketed 
or cremated remains, either in-ground or in columbaria) in a national 
or State Veterans cemetery within 75 miles of the Veteran's place of 
residence. VA has made continuous, significant progress toward meeting 
that target. In 2024, 93.9 percent of the Veteran population will be 
served with such access. The 2024 Budget also includes $60 million for 
the Veterans Cemetery Grants Program to continue important partnerships 
with States and Tribal organizations. This grants program plays a 
crucial role in achieving NCA's strategic target of providing 95 
percent of Veterans with reasonable access to a burial option.
    Additionally, the 2024 Budget continues NCA's implementation of the 
Veterans Legacy Memorial (VLM), the Nation's first digital platform 
dedicated to the memory of more than 4.5 million Veterans interred in 
VA's national cemeteries and VA-funded State, territorial and tribal 
Veterans cemeteries. VLM allows family, friends and others to preserve 
their Veteran's legacy by posting tributes. NCA will also use grant 
funding requested in the 2024 Budget to provide Veterans Legacy Grants 
to tell the stories of Veterans interred in our national and grant-
funded cemeteries, with an emphasis on those from underrepresented 
communities.

                               Conclusion

    Chairman Bost, Ranking Member Takano, thank you for the opportunity 
to appear before you today to discuss our progress at the Department 
and how the President's Fiscal Year 2024 and Fiscal Year 2025 Advance 
Appropriations Request will serve the Nation's Veterans.