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“Accountable or Absent?: Examining VA Leadership Under the Biden-Harris Administration"

House Veterans Affairs Committee Hearing & Business Meeting

September 10, 2024 (recording here)

HEARING INFORMATION

Witnesses:

• The Honorable Shereef Elnahal: Under Secretary for Health, U.S. Department of Veterans Affairs

• The Honorable Joshua Jacobs: Under Secretary for Benefits, U.S. Department of Veterans Affairs

• Mr. Edward J. Murray: Acting Assistant Secretary for Management and Chief Financial Officer, U.S. Department of Veterans Affairs

• The Honorable Michael J. Missal: Inspector General, U.S. Department of Veterans Affairs

Keywords mentioned:

• Accountability, bonuses, budget shortfall, community care, improper payments, infrastructure, staffing issues, transparency\

IN THEIR WORDS

BUSINESS MEETING SUMMARY

• Chairman Bost opened the business meeting by addressing a resolution to appoint Rep. Kennedy to the Subcommittees on Oversight and Investigations and Technology Modernization. Ranking Member Takano welcomed Rep. Kennedy and said he would make a valuable member of the Committee.

• The second item on the agenda involved issuing a subpoena to the Department of Veterans Affairs regarding documents related to Executive Order 14019. The Chairman expressed concern that the Biden administration had directed the VA to get involved in voter registration activities, which he argued might divert resources from its primary mission of providing care for veterans. He stated that the VA had ignored multiple requests for documents, and he considered the subpoena necessary to obtain the required information.

• Ranking Member Takano opposed the subpoena, arguing that it was politically motivated and unnecessary. He claimed that the VA had already produced many documents and was cooperating with the Committee. The Ranking Member suggested that the majority's demands were unreasonable and that the real motive behind the subpoena was to stoke conspiracy theories about voter registration.

• Rep. Bergman supported the subpoena, expressing concerns about transparency and the focus of the VA's voter registration efforts in Michigan. He questioned why the program was concentrated only in key swing areas like Detroit and Saginaw, and not in other regions, such as northern Michigan. He argued that the subpoena was necessary to get clear answers from the VA and to ensure that public resources were not being used for partisan gain.

• Rep. Landsman opposed the subpoena and urged the Committee to focus on expanding voter registration efforts for veterans rather than investigating the VA's current activities. He argued that registering veterans to vote should be a nonpartisan issue and encouraged a broader, collaborative effort to help veterans across all states register.

• Rep. Van Orden strongly supported the subpoena and called for greater transparency regarding the VA's voter registration activities. He expressed frustration over what he saw as a lack of clarity and focus on certain political areas, specifically Michigan. He offered to have the VA set up voter registration booths in his own district to ensure that the effort was balanced and not politically biased.

• Rep. Self voiced concerns about the organizations partnering with the VA for voter registration, questioning their political affiliations. He shared an anecdote about a questionable voter registration attempt in Texas and expressed skepticism about the nonpartisan nature of the voter registration efforts in Michigan.

• Rep. Ramirez opposed the subpoena, framing it as a voter suppression tactic. She argued that the focus should be on ensuring that veterans have full access to the voting process. Rep. Ramirez suggested that the Committee should work to expand voter registration efforts in all states rather than limit the discussion to one state or one political party.

• Rep. Kennedy also opposed the subpoena, stating that the focus should be on expanding voter access for all veterans, regardless of their political affiliation. He echoed previous statements advocating for expanding the VA's voter registration program to all states and argued that the Committee's time would be better spent working on ways to make voter registration more accessible to veterans.

• The subpoena resolution was agreed to by a 12-7 vote.

OPENING STATEMENTS FROM THE COMMITTEE

• Chairman Bost discussed ongoing investigations into VA leadership mismanagement, misconduct, and ineffectiveness at various medical centers across the country, citing examples of sexual harassment and leadership failure. He criticized the lack of accountability within the VA, stating that senior leaders are rarely held responsible for their actions. Chairman Bost called for stronger oversight to prevent budget mismanagement and improve care for veterans. The Chairman also mentioned legislation he introduced this Congress aimed at restoring accountability within the VA.

• Ranking Member Takano addressed the VA’s budget shortfall, stating that it was a result of the department’s success in implementing the PACT Act. He explained that the increase in veterans using VA services, particularly for disability claims and healthcare enrollment, contributed to the budget issues. The Ranking Member underlined the need to invest in VA infrastructure and staff while balancing community care and private care options. He criticized efforts by Republicans to privatize VA care, arguing that such actions undermine the agency and reduce veterans' access to quality healthcare.

SUMMARY OF KEY POINTS

• Mr. Missal underscored the importance of accountability within the VA, stating that leadership failures and governance issues have resulted in substandard care at some medical centers. He provided examples of leadership breakdowns at facilities in Hampton, Virginia, and Aurora, Colorado, where veterans' care was negatively impacted. Mr. Missal stressed the importance of VA leaders acting with urgency and transparency when mistakes occur and noted his office’s continued efforts to hold the VA accountable for mismanagement and misconduct.

• Under Secretary Elnahal discussed the success of the PACT Act in enrolling more veterans into healthcare services. He noted that since its passage, the VA has enrolled over 740,000 veterans and provided more than 130 million appointments this year. He acknowledged that while the VA has made historic gains, there have been challenges, and the department continues to take action when leadership fails. Dr. Elnahal reiterated the VA’s commitment to transparency and improving healthcare for veterans.

• Under Secretary Jacobs outlined VBA’s achievements in delivering benefits to veterans, highlighting that the department had processed over 1.2 million PACT Act-related claims with a 75% approval rate. He acknowledged the challenges faced in scaling up operations but claimed that VBA’s performance has been strong, processing a record number of claims and benefits. Mr. Jacobs also recognized the importance of accountability, stating that when issues arise, VBA takes corrective actions and informs external partners to maintain trust with veterans.

• Chairman Bost asked Mr. Jacobs how much money the VA needs to ensure veterans' benefits are paid on time and what happens if additional funding is not provided by September 20. Mr. Jacobs explained that if they are even $1 short, they would be unable to pay any veterans due to how the payment system is structured. He stated that they need approximately $3 billion to ensure payments are made on time, and every day past the 20th increases the risk of delays.

• The Chairman inquired why the VA waited until after the Appropriations Committees had completed their work to notify Congress about the budget shortfall. Dr. Elnahal explained that the VA's aggressive outreach and accelerated eligibility for veterans under the PACT Act led to higher demand for services. Once the budget risk became apparent in mid-year reviews, the VA allegedly notified Congress. He also cited increased care needs and unanticipated medical inflation as major contributors to the shortfall.

• The Chairman then asked about the lack of clarity on the use of the Toxic Exposure Fund (TEF) and questioned whether the $12 billion request was fully justified. Dr. Elnahal assured the Chairman that the VA can account for the use of the funds, especially for veterans exposed to toxic substances. He apologized for any previous lack of transparency and confirmed the VA's confidence in using the funds appropriately.

• Rep. Ramirez asked if the VA had the tools to investigate and discipline employee misconduct, particularly concerning the Trump-era VA Accountability Act. Dr. Elnahal confirmed that the VA has sufficient tools for handling misconduct, including respecting employees' rights while holding them accountable. He added that the majority of VA staff are dedicated to providing high-quality care, but leadership must take corrective actions when necessary.

• Rep. Ramirez inquired about the VA’s oversight over community care providers and whether they have adequate authority to ensure quality care. Dr. Elnahal acknowledged the challenges in overseeing community care but noted ongoing efforts to improve information sharing and accountability with private sector providers. He mentioned a new initiative, the "Veteran Interoperability Pledge," aimed at ensuring better data exchange between VA and private care providers.

• Rep. Bergman asked if there was a failure in the budget process that led to the shortfall not being discovered earlier. Mr. Jacobs responded that VBA had conducted an aggressive outreach campaign, resulting in a 40% increase in claims, which contributed to the higher demand for resources. He also noted that the workforce had grown significantly, and the budget shortfall was discovered during the mid-year review when new claims projections were made.

• Rep. Kennedy asked for a timeline on the investigation into leadership issues at the Buffalo VA Hospital, where leadership had been removed due to allegations of poor care. Mr. Missal explained that the investigation was complete, and the VA was reviewing the recommendations. The final report will be published soon.

• Rep. Kennedy voiced his concern over the aging infrastructure at the Buffalo VA Hospital and asked about the process for securing funding for a new facility. Dr. Elnahal acknowledged the need for substantial investment in VA infrastructure and committed to working with Rep. Kennedy to prioritize the Buffalo VA for improvements. He confirmed that the $12 billion supplemental request would help address staffing and infrastructure needs.

• Rep. Murphy questioned the VA's reliance on community care and the challenges veterans face in receiving timely referrals. He also criticized the use of the Cerner electronic health record (EHR) system, calling it a failure and urging the VA to abandon it. Dr. Elnahal admitted that the Cerner system's deployment had not gone as planned and pledged to keep Congress updated on efforts to improve the system.

• Rep. Rosendale pressed further into the EHR issue, stating that Cerner, now owned by Oracle, was not suitable for the VA’s needs. He called for the system to be replaced, citing its inefficiency in handling patient care data.

• Rep. Budzinski asked what steps the VA is taking to improve communication and information sharing with community care providers to ensure timely and high-quality care for veterans. Dr. Elnahal explained that the VA is focusing on reducing the time it takes to schedule care in the community and improving coordination between VA clinical teams and community care offices. He added that the VA is also working on selecting providers who effectively share records and using innovative methods like the interoperability pledge and external provider scheduling to speed up the process and improve information flow.

• Rep. Budzinski also inquired about how the VA ensures women veterans receive access to gender-specific care, including MST treatment and reproductive care. Dr. Elnahal responded that women veterans are the fastest-growing demographic and that the VA is training primary care providers to address gender-specific needs. He also mentioned expanded reproductive health services, including abortion counseling and services, where the veteran’s life or health is at risk.

• Rep. Rosendale asked Mr. Missal to estimate how much money the VA had not collected in insurance payments while the Program Integrity Tool (PIT) was offline. Mr. Missal estimated that the VA had missed $665 million over 12 months and $277.5 million in the five months following.

• Rep. Rosendale then asked Dr. Elnahal about the impact of the PIT issues on the budget. Dr. Elnahal acknowledged that the PIT problems had a significant impact, amounting to hundreds of millions of dollars. He mentioned efforts to get the PIT back online to prevent further losses and recoup missed collections.

• Rep. Landsman asked about how the national staffing contract could help facilities like Hampton and others facing staffing shortages. Dr. Elnahal explained that the integrated clinical staffing program allows facilities to quickly bring on temporary staff while recruiting permanent employees. He emphasized the need to minimize the time spent using temporary staff due to the higher costs involved.

• Rep. Landsman followed up about the role of interim leadership in facilities like Hampton and Aurora, which have faced leadership and cultural issues. Mr. Missal responded that interim leaders can be problematic if they act as caretakers rather than forward-looking managers. He stressed the need for engaged leadership focused on patient safety and quality assurance, while also criticizing the lack of oversight by regional VISNs (Veterans Integrated Service Networks) in identifying and addressing leadership issues.

• Rep. Luttrell asked how to improve communication between the VA and community care providers, especially in cases where veterans are sent to community care for surgery but return to the VA for rehabilitation. Dr. Elnahal acknowledged the issue and emphasized the VA’s responsibility to provide clear communication and coordination for veterans transitioning between care systems.

• Rep. Luttrell also asked about delays in the transfer of medical records from community care providers to the VA. Dr. Elnahal confirmed that this was a problem and mentioned that the requirement for community care providers to send records back to the VA was previously linked to payment but had been removed. He committed to reviewing whether the VA could reinstate the requirement through policy or regulation.

• Ranking Member Takano asked how Dr. Elnahal identifies and addresses the many challenges within the VA system, including leadership issues. Dr. Elnahal explained that setting clear expectations for leadership, improving internal transparency, and ensuring that problems are elevated through the chain of command were key strategies. He also noted that the majority of VA leaders are achieving positive outcomes in veteran trust and care quality, but more oversight is needed in underperforming facilities.

• Ranking Member Takano inquired about the impact of community care growth on the VA’s budget and what strategies the VA is using to manage this growth. Dr. Elnahal reported that community care referrals had grown by 16% year over year and that the VA was working to offer more in-house options alongside community care. He also mentioned efforts to refine cost projection models to better forecast future needs, especially with the impact of the MISSION Act and PACT Act.

• Rep. Crane raised concerns about the additional $12 billion requested by the VA after being fully funded. He pointed to an IG report about $10.8 million in bonuses for senior executives at the VA, asking the witnesses to explain the rationale behind the bonuses and how the situation has been rectified. 

• Dr. Elnahal acknowledged that mistakes were made across the VA in handling the bonuses. He emphasized that he, along with others in leadership, is committed to ensuring this does not happen again and is implementing the recommendations of the OIG’s report. Mr. Jacobs admitted to signing off on the bonuses, explaining that it was to retain critical leadership needed to implement the PACT Act. However, he acknowledged that they erred in the way the bonuses were implemented and that 93% of the money had been recouped.

• Rep. Kiggans referenced several reports from the OIG about substantial failures at the Hampton VA Medical Center, which put patient safety at risk. She asked for the root cause of these issues and why the VISN oversight had failed. Mr. Missal stated that leadership at the facility was ultimately responsible for the failures and outlined a passive approach from the VISN in addressing problems. Dr. Elnahal responded that it was a difficult decision to remove the medical center director but, given the accumulation of findings from various investigations, the VISN made the recommendation. He accepted the recommendation immediately and replaced the leadership with an experienced director.

• Rep. Kiggans inquired about the staffing shortages, particularly in anesthesiologists, at Hampton, as well as outdated software and EHR concerns that contributed to patient safety problems. She asked how these issues were being addressed. Dr. Elnahal explained the use of the Integrated Clinical Staffing Program to address the shortage of anesthesiologists. Regarding the EHR issue, he acknowledged the impact of outdated systems and outlined steps to modernize scheduling and streamline care coordination.

• Rep. Kiggans then raised concerns about the challenges veterans face in accessing community care, particularly chiropractic care. She asked what steps are being taken to ensure veterans receive the pain management care they need. Dr. Elnahal agreed that veterans should receive care based on what works best for them. He committed to ensuring a veteran-centered approach in improving the approval process for services like chiropractic care, while also improving the overall care experience for veterans.

• Rep. Obernolte brought up concerns from a recent climate review at the Loma Linda VA facility that revealed a hostile work environment. He asked if this was due to poor leadership and what was being done to fix it. Dr. Elnahal acknowledged the troubling findings in the climate review and emphasized that building trust requires leadership to engage with employees regularly. He mentioned the importance of open communication and follow-through in addressing the toxic work culture at Loma Linda.

• Rep. Obernolte asked about the frustration expressed by whistleblowers who felt that reporting wrongdoing did not lead to action and that problematic individuals were promoted rather than disciplined. Dr. Elnahal stated that ensuring follow-through on concerns raised by staff is crucial to building trust. He reiterated that his team is committed to addressing these concerns and ensuring that leaders are held accountable.

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