Delivering for Veterans and Caregivers: Year One of the Dole Act

1[House Hearing, 119 Congress]2[From the U.S. Government Publishing Office]34                      DELIVERING FOR VETERANS AND5                  CAREGIVERS: YEAR ONE OF THE DOLE ACT6=======================================================================78                                HEARING910                               BEFORE THE1112                       SUBCOMMITTEE ON OVERSIGHT AND13                              INVESTIGATIONS1415                                 OF THE1617                     COMMITTEE ON VETERANS' AFFAIRS1819                     U.S. HOUSE OF REPRESENTATIVES2021                    ONE HUNDRED NINETEENTH CONGRESS2223                             SECOND SESSION2425                               __________2627                        WEDNESDAY, MARCH 4, 20262829                               __________3031                           Serial No. 119-493233                               __________3435       Printed for the use of the Committee on Veterans' Affairs3637[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]3839                    Available via http://govinfo.gov4041                              __________4243                    U.S. GOVERNMENT PUBLISHING OFFICE4463-836                     WASHINGTON : 202645=======================================================================4647                     COMMITTEE ON VETERANS' AFFAIRS4849                     MIKE BOST, Illinois, Chairman5051AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking52    American Samoa, Vice-Chairwoman      Member53JACK BERGMAN, Michigan               JULIA BROWNLEY, California54NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire55MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,56GREGORY F. MURPHY, North Carolina        Florida57DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky58MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois59JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois60KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York61JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon62ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey63KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota64    Mariana Islands65TOM BARRETT, Michigan6667                       Jon Clark, Staff Director68                  Matt Reel, Democratic Staff Director6970              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS7172                   JEN KIGGANS, Virginia, Chairwoman7374AUMUA AMATA COLEMAN RADEWAGEN,       DELIA RAMIREZ, Illinois, Ranking75    American Samoa                       Member76JUAN CISCOMANI, Arizona              TIMOTHY M. KENNEDY, New York77KEITH SELF, Texas                    HERB CONAWAY, New Jersey7879Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public80hearing records of the Committee on Veterans' Affairs are also81published in electronic form. The printed hearing record remains the82official version. Because electronic submissions are used to prepare83both printed and electronic versions of the hearing record, the process84of converting between various electronic formats may introduce85unintentional errors or omissions. Such occurrences are inherent in the86current publication process and should diminish as the process is87further refined.88                         C  O  N  T  E  N  T  S8990                              ----------9192                        WEDNESDAY, MARCH 4, 20269394                                                                   Page9596                           OPENING STATEMENTS9798The Honorable Jen Kiggans, Chairwoman............................     199The Honorable Delia Ramirez, Ranking Member......................     3100101                               WITNESSES102                                Panel I103104Dr. Thomas O'Toole, Acting Assistant Under Secretary for Health105  for Clinical Services, Veterans Health Administration, U.S.106  Department of Veterans Affairs.................................     5107108        Accompanied by:109110    Dr. Mark Koeniger, Acting Assistant Under Secretary for111        Health for Patient Care Services, Veterans Health112        Administration, U.S. Department of Veterans Affairs113114    Mr. Kenneth Smith, Executive Director of Education Service,115        Veterans Benefits Administration, U.S. Department of116        Veterans Affairs117118Ms. Sharon Silas, Director, Health Care, U.S. Government119  Accountability Office..........................................     7120121                                APPENDIX122                    Prepared Statements Of Witnesses123124Dr. Thomas O'Toole Prepared Statement............................    25125Ms. Sharon Silas Prepared Statement..............................    28126127                       Statements For The Record128129Elizabeth Dole Foundation Prepared Statement.....................    49130131                      DELIVERING FOR VETERANS AND132                  CAREGIVERS: YEAR ONE OF THE DOLE ACT133134                              ----------135136                        WEDNESDAY, MARCH 4, 2026137138             Subcommittee on Oversight and139                            Investigations,140                    Committee on Veterans' Affairs,141                             U.S. House of Representatives,142                                                    Washington, DC.143    The subcommittee met, pursuant to notice, at 2:45 p.m., in144room 360, Cannon House Office Building, Hon. Jen Kiggans145[chairwoman of the subcommittee] presiding.146    Present: Representatives Kiggans, Radewagen, Ciscomani,147Self, Ramirez, and Kennedy.148149          OPENING STATEMENT OF JEN KIGGANS, CHAIRWOMAN150151    Ms. Kiggans. Good afternoon, everyone. This subcommittee152will come to order.153    I would like to welcome everyone to this subcommittee154hearing to discuss the implementation of the Senator Elizabeth155Dole 21st Century Veterans Healthcare and Benefits Improvement156Act. This landmark bill, led by House Republicans and my friend157Representative Ciscomani from Arizona, made a slew of changes158at the U.S. Department of Veterans Affairs (VA) to modernize159healthcare delivery, especially for aging veterans.160    First, I would like to take a pause and ask that everyone161joining us that we keep the servicemembers deployed to the162Middle East and in harm's way in our thoughts and in our163prayers, as well as the families of the six servicemembers who164recently gave their lives.165    Today's hearing is about oversight, accountability,166ensuring that the promises Congress made to veterans,167caregivers, and their families are fully realized. While168veterans and their caregivers are beginning to feel the169benefits of this legislation, VA and Congress' work is not170done. Last year Congress passed with bipartisan support the171Dole Act with the goal of improving veterans' access to172education, healthcare, and programs designed to prevent and173reduce veteran homelessness. This was a sweeping, bipartisan,174bicameral package negotiated and supported by members in both175the House and the Senate, Democrats and Republicans alike,176united by a shared commitment to those who served.177    The Dole Act represented one of the most comprehensive178veterans reform package in recent years and I was proud to179support it. This legislation moves the needle to modernize VA180healthcare delivery, strengthen support for caregivers, expand181access to education and job training, improve long-term care,182address rural health disparities, and reduce veteran183homelessness. It was designed to make systemic improvements,184not incremental tweaks across the continuum of care for185veterans and their families.186    The Dole Act included my Caregiver Outreach and Program187Enhancement Act, or COPE Act, which intended to establish a188grant program to provide mental healthcare to family caregivers189supporting their veteran family members. The COPE Act was meant190to recognize that when we care for veterans, we must also191support those who care for them. Family caregivers are the192backbone of our long-term care system, often sacrificing193careers, financial stability, and their own health to support194their loved ones.195    As a veteran, the daughter of a veteran, the wife of a196veteran, and the mom to a future veteran and a healthcare197provider, I understand the importance of investing in our198veteran communities to improve health outcomes. I understand199firsthand the sacrifices military families make and the strain200that caregiving can place on spouses and loved ones. That201perspective makes oversight of this law not just a policy202responsibility for me, but a personal one.203    To my dismay, it appears the VA has not followed the204congressional intent of the COPE Act yet and, to my knowledge,205has not followed many other provisions within the Dole Act. Now206I am asking the VA to follow congressional intent and fulfill207all statutory promises in the Dole Act, and today we will208hopefully get a follow-up and hear about the progress that is209being made.210    Failure to carry out the will of Congress is unacceptable211and I hope my colleagues will be united in demanding212accountability from the VA. Passing a bill and having it signed213into law is only one part of our job, sometimes the easiest214part. The most important part of our responsibility is ensuring215that the law is faithfully and efficiently implemented in full216alignment with congressional intent on behalf of the veterans217and families it seeks to benefit. Oversight is not optional. It218Is a constitutional obligation. Today's hearing is about making219sure this landmark law does not fall short in execution.220    Over a year after enactment, 55 out of 72 sections are221currently in progress. The VA says it is on track to implement222most sections within the timeframes required, but two on track223sections are set to expire in less than a year. Section 106,224which would increase access to dental care, is set to end225January 2027, and it is my understanding that only one phase of226the pilot program has been rolled out. Section 143, which227covers ambulance costs for veterans in rural areas, is set to228sunset in September of this year. The VA has not fully229implemented this provision.230    These are not minor provisions. These are real benefits231affecting real veterans: access to dental care, emergency232transportation in rural communities, and essential services233that directly impact health outcomes. When implementation lags234and sunset dates approach, veterans are the ones who pay the235price.236    Another eight sections have been marked as at risk or237behind schedule. For example, the Veteran Employment Through238Technology Education Courses (VET TEC) Pilot Program to improve239short-term training and employment opportunities in specialized240high-tech fields is behind schedule, putting implementation at241risk.242    Congress and this committee are delivering on the promises243we have made to the veteran community. The VA needs to mobilize244and fully implement the Dole Act. This bipartisan, bicameral245package was meant to drive sweeping improvements, not sit in246prolonged implementation. Veterans, caregivers, and their247families upheld their end of the bargain through service and248sacrifice. Congress upheld its end by passing comprehensive249reform. Now the VA must uphold its end by executing the law250with urgency, transparency, and accountability.251    Today, we are not here to relitigate the merits of the Dole252Act. We are here to ensure that it succeeds because the true253measure of this legislation will not be the vote tally that254passed it, but whether veterans on the ground feel the255difference in their daily lives. I look forward to hearing from256our witnesses about concrete timelines, measurable benchmarks,257and the specific steps the VA is taking to ensure that every258section of this law is implemented as Congress intended.259    I now recognize Ranking Member Ramirez for her opening260comments.261262       OPENING STATEMENT OF DELIA RAMIREZ, RANKING MEMBER263264    Ms. Ramirez. Thank you, Chair Kiggans.265    It has been 225 days since our last Oversight and266Investigations Subcommittee hearing, so it is critical that we267are back finally at dais. A lot has happened since our last268subcommittee hearing. Secretary Collins has continued to269attack, erode, and disrespect the VA workforce. He has tried to270strip away veterans' earned benefits through a cruel Interim271Final Rule (IFR), only to be swiftly met with so much272opposition from veterans in Congress that he was forced to273retreat. We witnessed U.S. Department of Homeland Security274(DHS) and U.S. Immigration and Customs Enforcement (ICE)275terrorize our communities, including our veterans, and execute276one of our neighbors, including Alex Pretti, a VA nurse.277    Now the President has started an illegal war with Iran to278consolidate power, enrich himself and his donors. He is sending279servicemembers into harm's way. I am concerned that because of280Secretary Collins' leadership, what is left of VA will not be281adequate to meet servicemember needs when they return.282    Why am I concerned? Let me tell you why, because Secretary283Collins' legacy thus far has been dismantling VA and eroding284veteran benefits instead of improving the lives of the veterans285we are supposed to be serving. That much is clear from the fact286that the VA has not made much progress in implementing the287bipartisan Dole Act since it was signed into law over 14 months288ago. In defiance of Congress' authority, the vast majority of289the law has not been, in fact, implemented, leaving the most290vulnerable veterans without the resources that Congress291approved for them.292    Let us start, for example, veteran homelessness. In the293Dole Act, we included bills from my Democratic colleagues that294gave VA crucial authorities that communities need to address295and end veteran homelessness. We actually increased the Grant296Per Diem (GPD) rate and authorized the VA to purchase basic297necessities for homeless veterans. Having been the executive298director of a homeless service agency myself, I understand that299oftentimes organizations have to do more with less. I know that300every resource and every dollar matters when you are trying to301provide the best service possible with very limited means.302    VA worked with committee staff for over a year to refine303the homeless sections of the Dole Act before it was signed into304law. The VA assured us that providing these increased resources305to community providers and to homeless veterans would be simple306as a, quote, ``turning on a light switch'' once the bill would307pass. Under the Biden administration, VA was prepared. Yet308under Collins' disappointing, dysfunctional, and delinquent309leadership, it has taken over a year to implement the most310critical parts of the Dole Act.311    Homeless service providers are left receiving a paltry $85312a day to provide transitional housing services to veterans313instead of the $128 a day we had actually authorized in the314law. Community providers are left with the GPD program--315community providers have left the GPD Program in droves while316they waited for the relief promised by Congress. Those exits317create service gaps that are impacting our veterans every318single day.319    Communities view VA Undersecretary Collins as an unreliable320partner in the fight to end veteran homelessness and, frankly,321I agree with them. Due to his delays, homeless veterans are322also left without access to their basic needs, another critical323resource Congress authorized in the Dole Act. We gave VA the324authority to use funds to be able to pay for food, for shelter,325for clothing, for transportation for homeless veterans to get326to and from job interviews or for medical appointments. Every327single day that passes, and Doug Collins fails to implement328approved provisions of the Dole Act, he is defying329congressional authority. Every day that passes that a veteran330experiences homelessness on the streets of our country, they331are left without the resources that they need to become stably332housed. That, to me, is shameful, it is irresponsible, and it333is a harmful failure of the Secretary.334    Let me talk to you about another shameful note. I want to335discuss the staffing provisions of the Dole Act that have yet336to be implemented. You see, section 146 required VA to develop337and implement staffing models to ensure VA has the workforce it338needs to provide care and benefits to the veterans. Staffing339models are essential for aligning personal resources so they340can be used efficiently, so that the workers with the right341skills are in the right place at the right time.342    Folks listening may recall that the Veterans Health343Administration (VHA) is currently undergoing a massive344reorganization, which we discussed at a full committee hearing345just last month. One would think that a reorganization of this346magnitude of the largest integrated health system in the347country would incorporate staffing models. By VA's own348admission, they have not complied with the Dole Act and lack349staffing models for the vast majority of the medical facilities350service lines.351    Which begs the question, what is the evidence that the VHA352reorganization is, in fact, needed? How can we be sure that the353VA is making the correct changes if its leadership does not354even know how many staff it needs and where they need them?355Even worse, let me ask you this question. Why is VA cutting356vacant positions if they do not have staffing models developed?357    VA provided data to my staff a couple weeks ago and over35826,000 positions that were cut from the books. The details of359those cuts are alarming. For months, VA has told us that these360are quote, ``old COVID era vacancies for positions that are no361longer needed at the agency.'' Let me tell you that the data,362it paints an entirely different picture about the same nature363of these cuts. You see over 18,000, not hundred, 18,000 of the364positions VA cut had a person in that job in 2025 or even 2026.365This included positions for nearly 3,000 nurses, 800 social366workers, 300 psychologists, and over a thousand physicians who367were on the job in 2025. These VA positions were discarded at368the hands of the Secretary's reckless leadership and they are369not going to be backfilled.370    Chair Kiggans, the medical center that serves your371constituents had the most cuts of any VA facility in the372country; 733 of the positions VA cut were at the Hampton VA373Medical Center. At the facilities that serve my constituents in374Chicago, Jesse Brown and Hines, 717 positions were cut. In375addition to those 26,000 positions that were wiped from VA's376books since Secretary Collins was sworn in the VA, he has377showed a net 30,000 employees representing centuries' worth of378experiences. Those losses included over 1,100 doctors, 2,300379registered nurses, 700 more social workers, and nearly 300380psychologists.381    All of these cuts and losses were made with no staffing382models in place as required by the law. Cut after cut after383cut, with no analysis of how veteran care and benefits would be384affected. It is the definition of negligence.385    The Secretary and his political appointees intentionally386misled and lied to Congress about the nature of these cuts.387Secretary Collins is failing at the most fundamental part of388his job, ensuring that veterans have access to world class care389at the VA. It is why this hearing is so important. It is why we390have to hold them accountable. I look forward to the391conversation that we have in this hearing today.392    With that, Chair, I yield back.393    Ms. Kiggans. Thank you, Ranking Member Ramirez.394    I will now recognize our witnesses on our first panel.395Testifying before us today, we have Dr. Thomas O'Toole, acting396assistant undersecretary for Health for Clinical Services at397the Veterans Health Administration. Dr. Mark Koeniger, acting398assistant under secretary for Health and Patient Services of399the Veterans Health Administration. Mr. Kenneth Smith,400executive director, Education Services at the Veterans Benefit401Administration. We also have Ms. Sharon Silas, director of402health for the U.S. Government Accountability Office (GAO).403    Will the witnesses please stand and raise their right hand?404    [Witnesses sworn.]405    Ms. Kiggans. Thank you and you may be seated. Let the406record reflect that the witnesses answered in the affirmative.407    Dr. O'Toole, you are now recognized for 5 minutes to408provide the VA's testimony.409410                  STATEMENT OF THOMAS O'TOOLE411412    Dr. O'Toole. Good afternoon, Chairwoman Kiggans, Ranking413Member Ramirez, and distinguished members of the committee.414Joining me today are Dr. Mark Koeniger, acting assistant under415secretary for Health and Patient Care Services, and Mr. Ken416Smith, executive director of Education Services at Veterans417Benefits Administration (VBA). It is an honor to be here to418discuss progress implementing the Senator Elizabeth Dole 21st419Century Healthcare and Benefits Improvement Act.420    First, thank you for this legislation and what it will421accomplish. Within VA alone, the Dole Act mandates implementing422more than 40 enhancements, new guidelines, or new programs;423executing six new pilot programs; conducting outreach and424releasing new online tools for veterans, patients, and coroner/425medical examiners; and completing 50 new congressional mandated426reports. Given the scope and breadth of the legislation, VA427moved oversight of Dole Act implementation to the Office of the428Secretary, ensuring senior most oversight. As of December 2025,429the new Office of Strategic Initiatives is the responsible430office.431    The lack of funding has been a hurdle, requiring us to432change priorities and in some instances use funding from433multiple areas to deliver on some of the sections. That said,434we have made significant progress implementing this important435legislation. Of the 72 sections, VA has fully implemented 25436and we are diligently working on the remaining sections with437significant progress being made. I would like to briefly438highlight key accomplishments within VHA, VBA, and National439Cemetery Administration (NCA), which are leading to440transformative changes for veterans and their families.441    Section 101 of the Dole Act eliminated an unnecessary layer442of approval, allowing veterans to access community care when in443their best medical interest.444    Section 120 increased coverage for noninstitutional care445alternatives from 65 percent to 100 percent of nursing home446costs and the authority to exceed that cap for veterans with447Amyotrophic Lateral Sclerosis (ALS), spinal cord injuries, and448similar conditions. This enables more veterans to receive care449at home, preserving independence and dignity.450    Section 402 expanded per diem payments for homeless451veterans to 133 percent of the State home domiciliary rate and452up to 200 percent for sites identifying--meeting identified453criteria. To date, 150 sites have availed of the 133 percent454increase and 40 sites have applied for the 200 percent rate.455    Section 149 requires an independent assessment of the456National Veterans Suicide Prevention Annual Report and457development of a public toolkit for coroners and medical458examiners to improve reporting accuracy. The independent459assessment was completed in January 2026.460    VA has experienced some challenges with the implementation461of 143 and to a much lesser extent 129, and we welcome the462opportunity to work with the subcommittee to ensure that VA can463provide the benefits and services intended.464    The Dole Act expanded the VA's Native American Direct Loan465Program, giving Native American veterans more opportunities to466purchase, build, improve, or refinance homes on trust land. VA467is also hiring additional coordinators to support these468veterans and their families.469    Section 212 reestablished the Veterans Technology Education470Courses program. VA has scheduled implementation of the managed471service claims processing capability for the end of third472quarter 2026 and published the student application in the473Federal Register in December 2025.474    VA has also made progress implementing section 215, linking475the GI Bill comparison tool to the Department of Education's476College Navigator and is working to incorporate additional477data.478    Of note, VA's conversion from the benefits delivery network479to the Digital GI Bill has impacted full implementation of480sections 208, 210, and 212, as well as recent court decisions.481We will continue to provide updates to Congress in our calls482and briefings.483    Section 301 expands burial allowances for veterans who die484at home while receiving VA hospice care, ensuring families485receive timely support.486    Section 302 improves outreach to States and Tribal487governments to ensure veterans and their families are aware of488burial and memorial benefits they have earned.489    Chairwoman Kiggans and Ranking Member Ramirez, this490concludes my statement. We appreciate the opportunity to speak491before you today and welcome any questions you or other members492of the subcommittee may have. Thank you for your continued493support of veterans, their families, caregivers, and survivors,494and the many VA programs that serve them.495496    [The Prepared Statement Of Thomas O'Toole Appears In The497Appendix]498499    Ms. Kiggans. Thank you, Dr. O'Toole.500    Ms. Silas, you are now recognized for 5 minutes to provide501your testimony.502503                   STATEMENT OF SHARON SILAS504505    Ms. Silas. Chairwoman Kiggans, Ranking Member Ramirez, and506members of the subcommittee, thank you for the opportunity to507be here today to discuss VA's progress implementing508requirements in the Elizabeth Dole Act.509    The Dole Act authorized significant expansions to510healthcare programs and support for veterans. Today I would511like to highlight GAO's work in two areas that are addressed in512the law: the Veterans Community Care Program and the Caregiver513Support Program.514    First, the Dole Act contains a number of provisions for VA515that are intended to improve the agency's healthcare516operations, including community care. Relatedly, GAO has a long517history of review reviewing the Community Care Program,518including some of the more recent changes to how referrals are519processed and appointments are scheduled. In a little more than52010 years, the Community Care Program has tripled in size and521represents nearly 42 percent of all VA healthcare appointments.522With that expansion, the administrative processes at VA523facilities have become more complex and continue to be labor524intensive.525    Through this growth, the Veterans Health Administration has526made new, numerous changes to how the program is administered527in order to gain efficiencies and ensure that veterans528understand their healthcare options. In 2020, we issued a529report on VA's implementation of the Veterans Community Care530Program. In that review, we described the timeliness of531processing referrals and scheduling appointments. We made three532recommendations to VA in that report, two that remain open,533including that VHA assess the staffing and resource needed to534process community care referrals and schedule appointments. We535also recommended the agency set standards for monitoring the536appointment scheduling process, including the receipt of care537with a community care provider.538    We also issued two reports in 2025 addressing two key VHA539efforts: the establishment of the VHA's Integrated Veteran Care540Office, or IVC; and the Implementation of the Referral541Coordination Initiative.542    The creation of the IVC was an organizational reform to543address VHA's progressively complex processes to manage544healthcare delivery at facilities and through the Community545Care Program. It consolidated the management of VA healthcare546delivered in the facilities and through community care with the547intent of improving coordination and ensuring veterans receive548seamless access to care.549    The Referral Coordination Initiative was created to ensure550veterans understood their care options and to also create551efficiencies for facilities in processing referrals and552scheduling appointments. In both reports, we highlight553deficiencies in the implementation of these efforts that554ultimately can impact veterans access to care. Recommendations555from both of those reviews remain open.556    As VHA prepares to go through additional changes, including557restructuring and the next generation of community care558contracts, it is critical that the agency ensure it has the559effective management structures in place to ensure veterans'560timely access to care. Addressing GAO's outstanding561recommendations and addressing the mandates in the Dole Act562will help VA to ensure veterans receive consistent, high-563quality healthcare.564    The second program that I would like to highlight is VA's565Caregiver Support Program. The Caregiver Support Program plays566a critical role in supporting caregivers who assist veterans567who have suffered serious injuries with essential tasks of568everyday living. There are currently about 98,000 caregivers569participating in the program. Given the toll that daily570caregiving can take on caregivers' mental health, ensuring VHA571effectively spreads awareness about the mental health support572it offers to caregivers is essential to ensuring that573interested caregivers participate in the program and they574receive the help that they need. The Dole Act includes a number575of provisions to bolster the supports for caregivers caring for576veterans, including a mandate for GAO to review mental health577support for caregivers.578    Our work is ongoing, however, I will preview some579preliminary findings. In our report, we describe a variety of580services to support caregivers' mental health and well being,581such as individual therapy, support groups, respite care, among582others. We also identified some challenges caregivers583experience in accessing the services, including the limited584ability to travel to receive support in person. In our report,585we describe some steps VHA has taken to address these586challenges, such as creating a virtual psychotherapy program587for caregivers.588    However, our preliminary findings also show that VHA has589not fully implemented performance management practices for590ensuring veterans and their caregivers are aware of the591program. Effective implementation of performance management592practices is not just a bureaucratic exercise. Following the593practice of setting program goals with targets and timeframes,594collecting data to measure progress toward those goals, and595then using that information to assess results and informed596decisions on any adjustments to those efforts can help to597ensure the program is meeting its intended results: getting598caregivers the support they need.599    The requirements for VA in the Elizabeth Dole Act align600with many of the findings and recommendations from GAO's601reviews. VA's adoptions of those recommendations would aid the602Department's progress toward implementing the Dole Act's603provisions.604    That concludes my prepared statement. Thank you.605606    [The Prepared Statement Of Sharon Silas Appears In The607Appendix]608609    Ms. Kiggans. Thank you, Ms. Silas.610    We will now move to questions and I yield myself 5 minutes.611    I want to ask a quick question to Mr. Smith. Can you talk,612I know you guys all kind of overviewed some of the work that613the VA has done to implement the Dole Act, and can you just614briefly describe what the education outreach has been, that has615been done to educate veterans, their families, and community616care partners, too, just about these new resources that are617available to veterans? Are we putting pamphlets in waiting618areas or are we sending email? What does that outreach look619like?620    I know as a primary care provider we often had a large621group of veteran patients. It was challenging to understand the622resources the VA has out there and we have put so many good623things in place and a lot of good changes in motion. I just624want to know how we are communicating with veterans and their625families that these things are now available.626    Mr. Smith. Thank you for the question. For our education627programs, our outreach is predominantly through our website. We628have published a number of--information on our website, as well629as provide marketing to our students directly through email630campaigns. Last, our Veterans Service Organization (VSO)631community, they are a great partner in disseminating632information.633    Ms. Kiggans. The VSOs are a good source, and I get the VA634emails as a veteran, married to a veteran. I do not think I635ever visited the VA website before my current job, so I do not636do a lot of visit--I do not know how many veterans out there637actively--maybe if they are Google searching. I just--that638outreach piece, there is a lot of primary caregivers out there,639and there is probably a lot of patients sitting in waiting640rooms. A poster, I am thinking of even the technology641integration we see in waiting rooms, you know, just letting642people know. I think that is one of our hardest parts. We have643great benefits, but what are those benefits, and communicating644that, so.645    Keep in mind our primary care, our civilian counterparts as646well, we all take care of veterans. I have a large veteran647community in Hampton Roads, so it was just always a challenge,648you know. I had a great office manager who would do that649research and try to connect with the VA. Even as a veteran650provider, I did not even know all the resources that were out651there, so I think that is half our battle. I am just throwing652that out there.653    Then going to Dr. O'Toole, the Dole Act has reoriented VA654healthcare to put the best medical interests first in each655veteran. I applaud the VA for enacting this provision. It saves656lives. However, the VA was marked section 122 complete, and657that is the operative section of my bill, the COPE Act. It has658come to my attention that VA decided not to issue any grants659specifically under this program.660    Just wondering, Dr. O'Toole, why that law has not been661fully acted about the grants? There was 10 million--662specifically, there was $10 million appropriated for the663program in Fiscal Year 2025 and another 10 million appropriated664in Fiscal Year 2026. Just wondering where that money went.665    Dr. O'Toole. Thank you, Congresswoman. I appreciate that.666That is the awards contract for mental healthcare for family667caregiver support. My colleague, Dr. Koeniger, I believe, is668better situated to comment on that.669    Dr. Koeniger. The caregiver support, particularly in the670mental health realm, we have implemented the Virtual Caregiver671Support Program. With that program, we have seen, let me see,672actually almost 29,000 encounters. That is a virtual--most of673those encounters are the virtual program, but caregivers can674also be seen face to face as well. Again, those almost 29,000675encounters, there are over 4,300 unique caregivers tied to676those encounters.677    Ms. Kiggans. That is good news. Thank you for that.678    Let us see, back to Dr. O'Toole. Section 142, it waived the679pay cap for highly skilled medical staff. Dr. O'Toole, can you680tell us how many waivers the Secretary has made for that? I681know that was a complaint we heard frequently, especially with682our surgeons, anesthesiologists, we have trouble recruiting,683retaining physicians, specialty care physicians who could make684so much more on the outside. We need those people at the VA. I685am just wondering if you update for that.686    Dr. O'Toole. Yes, thank you, Congresswoman. First, this is687really important legislation for us, as you know, and the wage688gap between what these highly trained specialists would make in689the private sector versus the VA is only growing.690    The challenge and issue for us, quite honestly, is that691many, many more specialty groups and specialists among the69225,000 physicians, for instance, that we have in the VA far693exceed the 300 people. We run the risk of second and third694order consequences if we do not do this right. In particular,695if we are picking out certain groups where, you know, one696provider is afforded the expansion or the cap extension and697others are not, what that may do to the practice.698    The other dynamic that we are looking at is how can this be699considered from an enterprise perspective? That if a telecare700service, such as teleradiology, can be used in a rural701community, it is probably going to be a lot more efficient and702effective than trying to extend that cap to a radiologist in a703rural community.704    We are actively moving forward on this. I meet with the705under secretary and others to review the parameters for data.706We anticipate having a criteria put forward within the next 1707to 2 months, I am hopeful for, to be able to start awarding708that cap. I do want to pay notice to the fact that, you know,709this is critical because it is going to have to extend beyond710these 300 individuals that are ultimately selected in this711first pass.712    Mr. Kiggans. Keep us posted. I know that is an important713part of the program, but thank you.714    My time has expired. I will save some for maybe a second715round.716    I now recognize the ranking member for 5 minutes of717questioning.718    Ms. Ramirez. Thank you, Chairwoman.719    Dr. O'Toole, I just want to go ahead and follow up on that.720First, thank you for being here. As you know, a few weeks ago721the Secretary testified before the full committee and in a722back-and-forth with our ranking member, he asked Ranking Member723Takano if he would commit to introducing a bill to raise the724cap on physician pay so that he can compete in the market to725hire more doctors. I want to double down a little bit more on726this conversation, because I know you just started a moment727ago.728    In that committee hearing, the Secretary claimed that he729cannot recruit physicians because he does not have the730authority to pay physicians more. I am hearing you talk a731little bit about the 300, but here is the thing. Section 142 of732the Dole Act does authorize the VA to use waivers to increase733pay for 300 physicians. The VA does have the authority to pay734its physicians more already, which actually contradicts the735Secretary's testimony when he said he did not have the736resources or the authority to be able to raise those wages.737    It sounds like Secretary Collins apparently does not think738it is important to learn the laws that govern his agency, much739just enact those laws to improve the VA and veteran care. That740gets to my next point. I think you have answered this, but I741just want to make sure that I put this on the record. How many742pay waivers has the VHA requested for physicians under the Dole743Act? It sounds like it is zero. The answer is zero. Correct?744    Look, in a request for information provided to my staff on745February 12, the VHA indicated they had not requested or746approved any pay waivers for physicians. I just really need to747reiterate what I said to the Secretary at our hearing last748month. He cannot come to our committee and state that he cannot749hire doctors because he cannot compete in the market when he750will not even use the authorities he already has, that we,751Congress, have given him to make more competitive offers to752attract physicians.753    Secretary Collins waited until January 9th of 2026, a year754after the Dole Act was signed into law, to publish the755implementation plan for the authority to make it easier to hire756doctors. It did not seem like there was any real urgency there.757    You have to understand why I am concerned here. The758Secretary comes before the committee, and he claims that he759cannot hire doctors, but he will not even use the tools that we760have already given him, authorized them, to make some761competitive offers for a number of these physicians. Instead,762he lost 1,000 doctors and then he wiped 1,500 more physicians763positions from the VA books. It makes no sense, if our goal is764to strengthen the services veterans receive, it makes no sense765to continue to claim, as Doug Collins does, that veteran care766and benefits are not affected when we are hearing from our767constituents on a regular basis, veterans, that they cannot get768appointments at the VA. However, his actions make perfect sense769if Secretary Collins does not want to hire, let me say this770again, does not want to hire doctors because his goal is to771ensure that the VA fails so that he can further dismantle and772maybe even privatize it.773    I want to follow up on another piece, and this is more774specifically to Ms. Silas. Ms. Silas, GAO has recommended that775VA assess its community care staffing and resource needs to776ensure timely appointment scheduling for veterans seeking care777and community. My question to you, Ms. Silas, is why is such a778staffing assessment important? How does this recommendation779align with the requirement in the Dole Act for VA to implement780a staffing model in the IVC, Veterans Integrated Service781Networks (VISN), and the local medical facilities?782    Ms. Silas. Thank you for that question. An agency's783workforce is really central to an agency transitioning into a784high-performance organization. In GAO's high-risk work, we have785worked with the Veterans Health Administration to try to get786them to be better in terms of clarifying their resource needs.787The staffing model and performance metrics that are provisioned788in the Dole Act are incredibly important because it helps to789align your resources and staff needs with your program needs.790It also is important for being able to plan ahead and to manage791any risks.792    As you all know, each VA facility is unique in terms of the793veteran population that they serve and then also in the794communities that they reside in. I know that one thing that we795have heard consistently for as long as I have been doing this796work is that when we meet with staff in these facilities, they797say there is not enough staff to process referrals in a timely798manner and to do timely appointment scheduling. We always hear799about challenges with workload.800    In our 2020 report where we recommended that VA assess801their staffing resources, they had told us that they have the802staffing tool and that they were in the process of updating803that, and they have been continually updating that staffing804tool as the processes have evolved over the last 5 years. That805recommendation, as you know, remains open.806    For the staffing model and performance metrics that have807been required in the Dole Act, the staffing tool, at the least,808can provide information or input into the staffing models they809are delivering now.810    Ms. Ramirez. That makes sense.811    Ms. Silas. It is kind of unclear how these both fit in812together. Regardless, GAO does have a mandate in the Dole Act813to do a review of the VA's development of the staffing model814and performance metrics. Once they complete the effort and815issue some reports we will be doing our own review.816    Ms. Ramirez. Thank you, Ms. Silas. My time is up. If we817have a second round, I will do a follow-up. Thank you, Chair.818    Ms. Kiggans. Thank you, Ranking Member.819    The chair now recognizes Mrs. Radewagen for 5 minutes.820    Ms. Radewagen. Thank you, Chairwoman Kiggans. Talofa lava.821I thank the panel for being here today. It is an important822hearing today, so thank you to the witnesses as well.823    Mr. Smith, what has been the greatest barrier for824implementation of section 302 of the legislation?825    Mr. Smith. Thank you for the question, ma'am. Right now, VA826is working to publish a rule for that grant program so that we827can perform or issue grants to perform the veteran outreach as828required by 302.829    Ms. Radewagen. How has section 302 helped VA better partner830with State and Tribal entities?831    Mr. Smith. I believe that once implemented, we will be able832to provide, or at least provide grants, you know, to those833organizations so that they can perform outreach on VA's behalf834and ensure that they are communicating with their members in a835culturally responsive way.836    Ms. Radewagen. Ms. Silas, in GAO's review of the Dole Act837implementation, what has been your greatest concern?838    Ms. Silas. The GAO has a number of mandates to review839implementation of various provisions within the Dole Act. Much840of our work that we need to do is either waiting on VA to841complete their enactment of their provision so we can oversee842that or we are waiting for some reports to be released in order843for us to do the review. We have not looked directly at the844implementation of any of the specific provisions that VA is845responsible for.846    We do have ongoing work for our own mandates around the847dental services. We are looking at VA's oral health program. We848are also looking at the Veterans Community Care Dentistry849Program. We are making progress on those reviews. Otherwise, we850are waiting for VA to complete their efforts before we look at851them.852    Ms. Radewagen. Do you believe that VA will be able to853implement the act in its entirety in the allotted timeframe?854    Ms. Silas. I do not think I could state for sure. It would855be up to VA to tell you what their progress is. Again, I can856only speak to the programs that we have oversight of in terms857of the mandate and provisions to review those programs. Most of858that work is ongoing right now.859    Ms. Radewagen. Thank you, Chairwoman. I yield back the860balance of my time.861    Ms. Kiggans. Thank you, Ms. Radewagen.862    The chair now recognizes Mr. Kennedy for 5 minutes.863    Mr. Kennedy. Thank you. I want to look back at what we were864told about the VA staffing cuts versus what has actually865happened. In February 2025, Secretary Collins eliminated 2,400866VA jobs after publicly promising that 300,000 mission-critical867positions would be protected to ensure uninterrupted services868for our Nation's bravest. One month later, a leaked memo showed869plans to cut more than 80,000 employees, a number the Secretary870confirmed, then denied, then revised to 30,000.871    On May 15, Secretary Collins assured our veterans that872mission-essential jobs, like doctors, nurses, and claims873processors would be protected and that reforms would874strengthen, not strain, veterans access to care. That promise875was broken. In December, a leaked memo revealed plans to876eliminate up to 35,000 healthcare positions in a single month,877the doctors, nurses, and support staff that veterans count on878for timely quality care.879    When a psychologist is cut, the veteran in crisis has fewer880options and longer waits. When a community care scheduler is881eliminated, the veteran waiting for a cancer consult or882neurosurgery referral waits longer, sometimes dangerously883longer. When nurses and physicians are cut, the people who884catch conditions early and respond to emergencies are not there885when they are needed most. These are not just workforce886reductions. There are direct cuts to the care our veterans887depend on, sometimes for their lives.888    That is why I requested detailed staffing data for the889Western New York VA system to understand exactly how many890positions were cut and how it is affecting veterans in my891district. The VA refused and then days before this hearing, we892received incomplete numbers. What we recently uncovered in my893own district in Buffalo, New York, is demonstrative of what we894are seeing in VA medical centers across the Nation.895    On December 14, roughly 100 healthcare positions were896eliminated at the Buffalo VA, 23 active critical roles,897including 2 psychologists, 2 social workers, 1 recreation898assistant, 1 respiratory therapist, 3 physicians, 2 nurses, and89911 Electrocardiogram (EKG) technicians, all cut. These are the900people who treat Post-traumatic Stress Disorder (PTSD),901diagnose heart conditions, coordinate the care that keeps902veterans out of emergencies rooms, and so much more.903    We already know what happens when staffing falls short904because we have seen it happen at the Buffalo VA. In 2024, an905Office of Inspector General (OIG) investigation found that906dangerous delays in scheduling community care consults put907veterans at serious risk. This investigation identified908staffing shortages as a key cause of this degradation of care.909Community care schedulers in a follow-up conversation in910response to the investigation told us directly that staff911shortages led to countless untreated patients and devastating912health outcomes, including at least one death.913    The Trump administration's response? Eliminate the staff914who schedule the consults, the technicians who conduct exams,915the personnel who ensure psychiatric care, and the916professionals who ensure no veteran is left behind. We know917what happens when those positions go unfilled: veterans care918suffers and some veterans will die. This is not just919mismanagement. It is life and death for the veterans who rely920on the VA for timely care.921    Secretary Collins stood before this committee and promised922that the doctors and nurses should who care for our veterans923would not--would be protected. He promised that care for our924veterans would not be cut. He was not telling the truth and our925veterans are the ones paying the price.926    I have a very simple question for those here representing927Secretary Collins' VA. When veterans in my district get sick928because of a lack of resources, which of you will take929responsibility and what are we to tell them?930    Dr. O'Toole. Well, thank you, Congressman, and I appreciate931what you are bringing up and I fully acknowledge the challenges932and the issues. If I can, I appreciate--I am hoping for a time933extension to be able to respond to your question, if that is934okay, Chairwoman.935    The issue of having enough providers for care is a936significant one. It is one, however, that we share with the937entire American healthcare system. Right now there is an938estimated shortage of physicians, nurses, social workers,939psychologists, psychiatrists, estimated to be at 90,000 over940the next 10 years in the American healthcare system. What we941are challenged by in the VA is what all of American healthcare942is challenged by. I think that is an important consideration to943make. It is why I also, you know, emphasize the importance of944section 142 in really trying to help us be to be more945competitive in attracting people to come in. It is absolutely946important.947    I do need to emphasize, though, and clarify. When the948Deferred Resignation Program (DRP) process went through, those949clinicians who were involved in direct care with providers--950with patients were not allowed to pursue the DRP. Those951requests for DRP were denied by those direct clinicians. That952does not mean that people are not going to retire. That does953not mean that people--that positions are going to attrit or954that people may leave the VA. We all have workforce challenges955in healthcare, and I do not want to minimize that issue or956point, nor the importance of Congress in helping us navigate957those waters. It is a shared challenge for all of us that958extends beyond this.959    The positions that were eliminated were vacant positions960that had not been filled for quite some time. That does not961mean that people were losing their jobs. I do think that is a962really important clarifying point to the issues that I think963are very valid that you are bringing up.964    Ms. Kiggans. Thank you, Dr. O'Toole.965    The chair now recognizes Mr. Self for 5 minutes.966    Mr. Self. Thank you. Thank you, Madam Chair.967    Dr. O'Toole, I do not question the President's authority to968use impoundment. I just want to clarify. None of what we are969hearing is an impoundment under the Dole Act, is it?970    Dr. O'Toole. I am sorry, Congressman, I am not sure I am971following your question. Can you please----972    Mr. Self. Congress authorizes a certain level. The973President decides to spend less than that level. Is that--is974impoundment involved here? Just to clarify.975    Dr. O'Toole. Not that I am aware of at all, sir.976    Mr. Self. Very good. I want to go to your written versus977your verbal testimony. I think I heard something that is not in978your, excuse me, your written testimony. It is in the979paragraph, I believe, where you talked about VA using funding980from multiple accounts to deliver on some of the sections. Now,981in your verbal testimony, you said lack of funding. Can you982clarify what you said in that paragraph?983    Dr. O'Toole. Thank you, Congressman. You know, obviously,984you know far better than I, you know, the dynamics of985appropriations, and I am not trying to speak to that. Some of986the provisions in the Dole Act did not involve appropriated987funds. We have tried to implement within the capacities that we988have to the best of our abilities or if funds were available989through other accounts, use those and just trying to be990fiscally prudent within that context. I want to defer to my991colleagues who might be able to speak better to that.992    Mr. Smith. Thank you. For the Digital GI Bill program, we993are required to make changes to that environment in order to994implement----995    Mr. Self. No, I am not asking for specifics. Thank you. I996just wanted to clarify your lack of funding. You did say that,997I believe, and I am not sure you clarified it, but thank you.998    I want to move to accountability in the 3 minutes I have999left because we talk a lot in this committee about inputs. We1000get VA employees coming and telling us about all the inputs.1001Who is going to be accountable for this?1002    This bill was to improve ability to receive care at home.1003Correct? If you believe that changes in the fee schedule for1004reimbursement rates related to home health aid and homemaker1005services were to result in a reduction of up to 43 percent in1006rural Texas, some of which I represent, do you believe that1007that improves a veteran's ability to receive home healthcare?1008How is that balanced?1009    Dr. Koeniger. Sir, thank you for the question. I cannot1010speak directly to veterans in Texas in terms of receiving home1011healthcare. I can say, though, that the home and community-1012based services, the VA has done actually a great job at1013expanding those services. The----1014    Mr. Self. Do you think the 43 percent reduction is going to1015improve their ability to receive home healthcare?1016    Dr. Koeniger. So the--again, I----1017    Mr. Self. Okay.1018    Dr. Koeniger [continuing]. cannot speak specifically to1019that, but I can say that, again, over--compared to Fiscal Year10202024, over roughly 600,000 veterans have actually benefited1021from the home----1022    Mr. Self. Okay.1023    Dr. Koeniger [continuing]. and community-based services.1024    Mr. Self. Very good, thank you.1025    Dr. O'Toole, can you name the specific individuals who, in1026VA, who are going to be responsible for each of the at-risk1027sections?1028    Dr. O'Toole. Thank you, Congressman. As I mentioned in my1029opening statement, we have a centralized office, Office of1030Strategic Initiatives, that is overseeing this process. All of1031our senior leadership are fully engaged in this and as the1032committee staff would know, meet with frequently. I am more1033than happy to forward to you the org chart that delineates1034specific----1035    Mr. Self. No, I do not need the org chart. I am asking you1036if you are going to hold someone accountable because you are1037about one-third of the way through implementation. Is that1038about right? One-third of the way through in terms of sections?1039    Dr. O'Toole. Sure.1040    Mr. Self. What I am really asking is who is going to be1041held accountable?1042    Dr. O'Toole. Our senior leaders----1043    Mr. Self. We always talk about inputs. I want1044accountability for when you implement this.1045    Dr. O'Toole. Our senior leadership throughout the agency1046are responsible, sir, including myself.1047    Mr. Self. Okay. Very good. What is the critical milestone1048between now and full--oh, my time is up, Madam Chair. I will1049yield back. Thank you.1050    Ms. Kiggans. Thank you, Mr. Self.1051    The chair now recognizes Mr. Ciscomani for 5 minutes.1052    Mr. Ciscomani. Thank you, Chair Kiggans, for convening this1053important oversight hearing. Thank you to the witnesses from1054the Department of Veteran Affairs and Government Accountability1055Office for being here today with us.1056    I was proud to help introduce the Senator Elizabeth Dole105721st Century Veterans Healthcare and Benefits Improvement Act1058last Congress and even more proud to see it passed and get into1059law, be signed into law, because I believe strongly that our1060veterans and their caregivers deserve a system that truly1061reflects the sacrifices they have made for our Nation.1062    Far too often, veterans and their families face barriers1063when trying to access care, navigate benefits, and receive the1064superior that they have earned from the VA. This flagship VA1065legislation was designed to modernize the VA and create a1066system that works, that works better for veterans and their1067families and who stand beside them every single day. One year1068after enactment, it is important that we take a close look at1069how the Department is implementing these reforms.1070    While progress has been made in several areas, some1071provisions remain behind schedule or at risk of not fully being1072implemented. For veterans and their families these timelines1073matter. Delays can mean waiting longer for care, missing out on1074an important support service, or facing unnecessary barriers to1075benefits they earned through their service. This is why I want1076to ask a couple of the follow-up questions here, and I will1077start with Dr. O'Toole.1078    The Dole Act includes a wide range of reforms touching1079clinical care, caregiver support, and community-based services.1080How has the VHA prioritized implementation across these areas1081to ensure that the most immediate needs of veterans are1082addressed first?1083    Dr. O'Toole. Thank you, Congressman. I want to defer to my1084colleague on the community care question, if that is okay.1085    Dr. Koeniger. That is a great question. In terms of1086community care or even caregiver support, I mean, we recognize1087that taking care of veterans, no matter what their problems1088are, is very important. In terms of the community-based1089services, we have four programs that we have rolled out. Those1090programs have actually seen an increase, as I mentioned1091earlier, in terms of supporting caregivers as well.1092    Mr. Ciscomani. How do you--I am sorry to interrupt because1093we are going to run out of time, but how do you prioritize? How1094do you make sure that those that have the most immediate need1095of veterans get seen first? What is the process like?1096    Dr. Koeniger. Again, the veterans that have the highest1097needs in terms of medical issues, you know, those are the folks1098that we want to make sure that we take care of.1099    Mr. Ciscomani. I agree. How do you get there? How do you1100identify that?1101    Dr. Koeniger. The specific process I would have to get back1102to you on. I mean, certainly----1103    Mr. Ciscomani. I want to make sure that that is actually1104happening. It is just that, you know, I think you get the sense1105from the committee here on both sides of the aisle, we are1106running a little impatient on the implementation of a lot of1107these programs. This was supposed to be a much more expedited1108process and seeing the benefits of this. We are not seeing1109that. This is coming from every angle and every State1110represented here, we are all seeing this in our district. We1111need to really zero in on this and we need to start seeing some1112results.1113    I am going to move on here. Dr. O'Toole, again, one of1114Congress' goals in the Dole Act was to improve timely access to1115care. From your perspective, what measurable changes should1116veterans expect to see in appointment availability or service1117delivery as implementation continues?1118    I keep hearing from our veterans the care they receive at1119the VA is excellent once they receive it. Receiving it and1120getting there is the main issue. Again, I am starting to see a1121trend here of what was passed not being enacted. I want to1122start seeing some results and so do our veterans. What way are1123you measuring this?1124    Dr. O'Toole. Thank you, Congressman. This is very important1125and I think to follow up with your second question as well--or1126previous question as well.1127    This is a massive piece of legislation, as you know, you1128know, 72 provisions that impact across the agency. I cannot--I1129have been a primary care provider in the VA for 20 years. This1130is one of the most significant pieces of legislation I have1131seen having impact across the vast entire agency. First, thank1132you for that.1133    As your staff knows and meeting with them and having sat in1134on several of the calls, this is something where we have to be1135able to chew gum and walk at the same time and implement1136multiple efforts concurrently. We are. This has been a1137difficult year in both securing our most senior leadership, our1138Senate-confirmed leadership, going through the government1139shutdown, which created some undue slowdowns in terms of1140getting things through. We are on the cusp with several of1141these provisions within the next weeks to a month or two to1142having them posted in the Federal Register and being1143implemented.1144    Very much I feel confident that we will be able to1145implement all of the provisions in the time allowed. They are1146priorities for us because they are priorities for our veterans1147across many different contexts.1148    Mr. Ciscomani. I am out of time. I do look forward to1149seeing results. You know, I think we understand it. We know the1150significance, the size of the legislation. We worked on it. We1151passed it. It is big and it is going to take time, we know1152that. It has been over a year. We need to see some results1153here. You say weeks, months. I hope it is weeks and I hope we1154can get a report exactly on numbers and what this matters.1155    Madam Chair.1156    Dr. Koeniger. Madam Chair, I know we are over time. Could1157I--Congressman, you mentioned access to care and I would just1158like to say it is a very complicated process. As you know,1159there are just so many things that have to be taken into1160account to improve access.1161    I can tell you that as of May of last year, the Veterans1162Health Administration stood up the Access Choices in Excellence1163Group of which I am the executive sponsor and we have been1164working diligently on all aspects of access to care to, again,1165objectively measure all of those things and to work on1166improving access.1167    As a 36-year veteran of the United States Air Force myself,1168that sits--that is near and dear to me to make sure that1169veterans can get in when they need to get in.1170    Mr. Ciscomani. Thank you.1171    Ms. Kiggans. Thank you. I think we have a few minutes for a1172second round of questions. I just have two questions for Dr.1173O'Toole.1174    As a former geriatric nurse practitioner one of my greatest1175concerns was ensuring our aging veterans are getting the care1176that they deserve. Can you provide the committee just with an1177update on the rollout of the pilot program, section 127, to1178fortify the assisted living services for veterans and what that1179looks like?1180    Dr. O'Toole. Thank you, Congresswoman. I think--is that in1181your scope?1182    Dr. Koeniger. Yes. Yes. Thank you for the question. As you1183know, our population is aging. Again, we have 49 percent of all1184our veterans are 65 and older. We are working in terms of the1185two pilots as section 127 states. The VA is--has been working1186on a purchasing authority and a fee schedule options are under1187development because we are--we need to get those things in1188place so we can ramp up those pilots. We are making progress1189and work in the details of getting the pilots going.1190    Ms. Kiggans. Okay. We would love to see some movement in1191that, too. I think that is important. There are not enough1192options, especially housing options, for aging Americans.1193Perhaps the VA should hire more geriatricians, but that is just1194my two cents.1195    Then, Dr. O'Toole, our stakeholders have highlighted that1196the best medical interest standard is coming into conflict with1197transportation benefits that usually accompany care for1198disabled veterans. Veterans should not have to sacrifice the1199best standard of care because the VA will not pay for1200transportation. How does the VA intend to harmonize this1201conflict to deliver patient-oriented care?1202    Dr. O'Toole. Thank you. It is a huge issue and obviously1203providing care that somebody cannot get to sort of misses the1204mark. We are working specifically and having some challenges1205specifically on the transportation provision. I think I1206mentioned that in my opening statement, and it is something1207that we would like to be able to work with the committee1208further to be able to go through those provisions to address1209some of the challenges we are having with that implementation.1210    Ms. Kiggans. That would be great. I think that should1211definitely be a priority for us moving forward.1212    The chair now recognizes Ranking Member for any remaining1213questions.1214    Ms. Ramirez. Thank you, Chair. Here you go.1215    Dr. O'Toole, I just want to follow up on some of the1216conversations we had at the beginning of the hearing.1217Specifically I want to talk about my own district. Before the1218VA cut the 130 nurses at the Jesse Brown and Hines VA Medical1219Centers, did the VA have staffing models in place as required1220by the Dole Act to determine that those 130 nurses were no1221longer needed at those facilities in Chicago?1222    Dr. O'Toole. Thank you, Congresswoman. It is important to1223keep in mind, particularly as I know a lot of questions about1224the staffing model come up in consideration of the Rise1225Initiative and the reorganization, there has been no change1226whatsoever in terms of direct care staffing modeling based upon1227the reorganization efforts under Rise.1228    Ms. Ramirez. Doctor----1229    Dr. O'Toole. The----1230    Ms. Ramirez. Dr. O'Toole.1231    Dr. O'Toole. The staffing models have--we continue to do.1232They are being refined in the context of the Dole Act.1233    Ms. Ramirez. Did we have staffing models in place there to1234determine that we did not need those 130 nurses? It is more of1235a yes or no. Just trying to get clarity.1236    Dr. O'Toole. Ma'am, those positions were not removed. Those1237were not active positions. Those were positions that had not1238been filled and not have been filled for quite some time.1239    Ms. Ramirez. I am just looking here at some of the reports1240we got from all of you here. For example, there are 41 nurses1241positions filled in 2025 or 2026 that were no longer filled1242after. These were positions that were--they had bodies in them1243prior to the cut of these. Of these nurses, yes or no? Did you1244have people working there? Were there nurses working there?1245    Dr. O'Toole. No.1246    Ms. Ramirez. Okay. Well, the data says a different--the1247thing is that I am looking at the data that you provided for me1248for these centers, and so it is inconsistent with what I am1249getting from you. Let me just wrap up here because I know we1250only have a few minutes and we want to close this hearing.1251    Dr. O'Toole. We can take that for the record for further1252clarification.1253    Ms. Ramirez. Yes, I would appreciate that.1254    I want to just come back to housing real quick. You heard1255me say I ran a homeless shelter for about 9 years, of which I1256had the honor and opportunity to serve many veterans who were1257experiencing homelessness. I just want to wrap up with sections1258402 and 403 of the Dole Act, which provided the crucial1259resources to the VA and community providers who serve homeless1260veterans. I want to make sure that it is clear that due to the1261delays in implementing these provisions, homeless veterans and1262community organizations are having to go without these1263resources.1264    During the Biden administration, the homeless program's1265office staff told me and my team repeatedly that it would be1266ready to swiftly implement the Dole Act, that it would be like1267turning on a light switch. It is hard for me to know that we1268are 14 months in, and it sounds like for Secretary Collins it1269is going to take over a year to flip a light switch. You know,1270to me, it is a testament to poor leadership that homeless1271veterans still do not have the resources they need.1272    Sadly, I know there is something nefarious going on that1273led to the delay in implementation of these homeless sections.1274Specifically, the administration, including Secretary Collins,1275has wielded attack after attack against veterans experiencing1276homelessness. They prioritize handcuffs and jail cells over1277getting these veterans help that they need in place of getting1278them a home. Look, I believe that the swift--and they are1279swifting away from interventions that we know have worked1280address homelessness, programs like Housing First models. This1281administration's focus on programs that have proven time and1282time again to actually make homelessness worse are leading the1283delay that we see here.1284    You see, I see that Collins is actively pushing a strip1285down, in effect a for-profit model of homeless service delivery1286driven by special interest instead of leaving intervention to1287the experts in homeless program offices. We know that the VA,1288especially the political leadership, meddled in implementation1289of the Dole Act is getting in the way of these programs that we1290actually know work.1291    Instead of relying on the expertise of an office that has1292housed over 50,000 homeless veterans last year, these political1293appointees substituted their poor profit-minded judgment for1294expertise. The consequence? Fourteen months of veterans not1295having access to the housing, transportation, clothing, and1296food that they need. I find that to be unacceptable. Frankly, I1297find it to be despicable.1298    These same political appointees are pushing a dangerous1299proposal to destroy Housing and Urban Development-Veterans1300Affairs Supportive Housing (HUD-VASH), the most successful1301permanent supportive housing program in the history of this1302country and replacing it with a poorly conceived program that1303we know will fail called Bridging Rental Assistance for Veteran1304Empowerment (BRAVE).1305    I want to make sure, on the record, in the last few seconds1306I have, that I am going to tell you I am going to continue to1307defend our homeless veterans. They should not be homeless to1308begin with. We cannot sit here idly watching this1309administration destroy these programs so that billionaire1310buddies can get enriched as a result of it1311    I look forward to getting an update in the immediate future1312that the VA has fully implemented the homeless sections of the1313Dole Act and has abandoned the BRAVE proposal because anything1314less is a disgrace and a disservice to our most vulnerable1315veterans.1316    With that Chairwoman, I yield back.1317    Ms. Kiggans. Thank you. I just wanted to take a minute to1318thank the witnesses for coming today. I appreciate the candor1319in your testimony and your willingness to participate.1320    Implementing the Dole Act remains a top priority of this1321committee. I look forward to continuing to ensure the VA1322remains committed to this goal. Thank you all for being here1323today.1324    I ask unanimous consent that all members shall have 51325legislative days in which to revise and extend their remarks.1326Did you have any concluding remarks, sorry, as well?1327    Ms. Ramirez. I do, Chairwoman, thank you.1328    As I reflect back on the hearing, our first one in over 2001329days, I am struck by some of the answers that were received1330here. First, Dr. O'Toole, you said that no doctors or nurses1331were allowed to take the Deferred Resignation Program. However,1332data the VA has provided themselves to Mr. Kennedy shows that1333two nurses from Buffalo were allowed to take the DRP last year.1334    You also reiterated that the Secretary's talking point that1335many of these positions eliminated were not filled in a long1336time. However, again, the data that has been provided by you1337all says the opposite. Seventy-one percent of these 26,0001338positions were filled at some point since January 2025. If1339these were really COVID era positions, then why were these1340positions still there? Specifically, I am thinking about the1341Jesse Brown/Hines positions.1342    Look, I am glad that we are here. I know that we are going1343to go ahead and follow up. I think that the work that we do in1344this committee is incredibly important because we have to1345implement every facet and every provision of the Dole Act.1346Twenty-five of the 72 is unacceptable. I look forward to1347following up with you to make sure that you take the urgency1348necessary to implement every single section so that our1349veterans have what they, in fact, need and they deserve.1350    With that, I yield back.1351    Ms. Kiggans. Thank you all again for being here today. I1352ask unanimous consent that all members shall have 5 legislative1353days in which to revise and extend their remarks and include1354any extraneous material. Hearing no objection, so ordered.1355    The hearing is now adjourned.1356    [Whereupon, at 3:55 p.m., the subcommittee was adjourned.]1357=======================================================================13581359                         A  P  P  E  N  D  I  X13601361=======================================================================13621363                    Prepared Statements of Witnesses13641365                              ----------13661367                  Prepared Statement of Thomas O'Toole13681369    Good afternoon, Chairwoman Kiggans, Ranking Member Ramirez, and1370distinguished members of the Committee. Joining me today are Dr. Mark1371Koeniger, Acting Assistant Under Secretary for Health for Patient Care1372Services, VHA, and Mr. Ken Smith, Executive Director, Education1373Service, Veterans Benefits Administration (VBA). It is an honor to be1374here on behalf of VA to discuss our progress on implementing the1375Senator Elizabeth Dole 21st Century Veterans Healthcare and Benefits1376Improvement Act (the Dole Act; P.L. 118-210).1377    Enacted on January 2, 2025, the Dole Act is a comprehensive law1378with more than 70 sections that require action from VA, the Department1379of Labor, educational institutions that serve Veterans and their1380families, and the Government Accountability Office. The Dole Act1381includes requirements for VA to:13821383      implement more than 40 enhancements, new guidelines, or1384new programs;13851386      execute six new pilot programs;13871388      conduct outreach and release new online tools for1389Veterans, patients, and coroners/medical examiners; and13901391      complete 50 new congressionally Mandated Reports.13921393    This variety of new requirements required VA to realign its1394priorities and establish an enterprise-wide approach to support Dole1395Act implementation. This approach has been updated several times as new1396VA leadership was sworn in and VA uses funding from multiple accounts1397to deliver on some of the sections.1398    VA moved oversight of implementation of the Dole Act to the Office1399of the Secretary to ensure senior official oversight and involvement in1400these critical responsibilities. In December 2025, the new Office of1401Strategic Initiatives became the office responsible for VA-wide1402oversight, facilitation, and monitoring of implementation efforts, such1403as those required by the Dole Act.1404    We are pleased to report that VA has made significant progress1405toward implementing the Dole Act. Of the 72 sections that required VA1406implementation efforts, VA has fully implemented 25 sections as of1407February 9, 2026. We are diligently working on the remaining sections.1408    While implementation spans the Department, I will begin by1409highlighting key accomplishments within VHA, which has led to1410transformative changes in care delivery and support for Veterans and1411their families under the Dole Act.14121413VHA14141415    In alignment with section 101 of the Dole Act, effective May 19,14162025, VA eliminated an unnecessary layer of approval in the community1417care process, allowing Veterans to access care when it is in their best1418medical interest (BMI). Removing that unnecessary layer has made a real1419difference. Between June and December 2025, referrals to community care1420under the BMI criterion increased by over 66 percent compared to the1421same period in the previous year. Additionally, VA launched a1422nationwide outreach campaign, including updates to VA.gov and targeted1423communications through the Solid Start program, reaching over 83,0001424newly separated Veterans. These efforts help Veterans understand their1425options for care from day one, creating a more seamless and responsive1426health care experience.1427    The Dole Act also delivered expanded options for Veterans needing1428long-term and home-based care. Using the authority granted by section1429120 of the Dole Act, VA increased coverage for noninstitutional care1430alternatives from 65 percent to 100 percent of nursing home costs, with1431authority to exceed that cap for Veterans with amyotrophic lateral1432sclerosis, spinal cord injuries, and similar conditions. This expansion1433enables more Veterans to receive care at home, preserving independence1434and dignity. These changes, combined with new pilot programs for1435assisted living and enhanced Homemaker and Home Health Aide programs,1436reflect VA's commitment to meeting Veterans where they are--with care1437that honors their service and supports their families.1438    VA has also made critical strides in addressing homelessness and1439suicide prevention under the Dole Act. Section 402 of the Dole Act1440expanded per diem payments for homeless Veteran programs, increasing1441the maximum per diem rate from 115 percent to 133 percent of the State1442Home domiciliary rate and allows VA to waive the maximum rate for per1443diem payments to provide payments at a rate that does not exceed 2001444percent of the rates authorized for State Homes for domiciliary care1445under 38 U.S.C. Sec.  1741(a)(1)(A) for no more than 50 percent of all1446grant recipients and eligible entities for a Fiscal Year (FY), subject1447to the availability of funding.1448    Section 403(a) of the Dole Act authorizes VA to provide to covered1449Veterans, as VA determines necessary, food, shelter, clothing,1450blankets, and hygiene items required for the safety and survival of the1451Veteran; transportation required to support the stability and health of1452the Veteran for appointments with service providers, the conduct of1453housing and employment searches, and the obtainment of food and1454supplies; and tablets, smartphones, disposable phones, and other1455technology and related service plans required to support the stability1456and health of the Veteran through the maintenance of contact with1457service providers, prospective landlords, and family members. Section1458403(b) authorized VA to collaborate with one or more organizations to1459manage the use of VA land for homeless Veterans for living and1460sleeping.1461    Section 404 created a new 38 U.S.C. Sec.  2069, which requires VA,1462to the extent practicable, to ensure that Veterans participating in or1463receiving services from a program under chapter 20 have access to1464telehealth services to which the Veterans are eligible under the laws1465administered by VA.1466    These changes, from implementing sections 402, 403 and 404,1467strengthen the safety net for Veterans at risk of homelessness and1468improve access to care. VA published a Federal Register Notice on1469February 6, 2026, notifying the public of subregulatory guidance to1470implement section 402 of the Dole Act, and we expect to publish very1471soon a Federal Register Notice to inform the public about VA's1472implementation of section 403 of the Dole Act.1473    In addition, section 149 of the Dole Act strengthened1474accountability by requiring an independent assessment of the National1475Veteran Suicide Prevention Annual Report and development of a public1476toolkit for coroners and medical examiners to improve reporting1477accuracy. The independent assessment was completed in January 2026.1478VA's most recent Annual Suicide Prevention Report, published February14795, 2026, shows 6,398 Veteran suicides in 2023--down from 6,442 in14802022--with the average daily rate falling slightly to 17.5. However,1481suicide rates remain elevated among younger Veterans and those facing1482risk factors such as homelessness, health challenges, and chronic pain.1483To address these risks, VA has expanded outreach and care access. Since1484January 2026, VA has conducted a new outreach campaign that has led1485more than 33,000 unenrolled Veterans to sign up for VA care, and1486partnerships with civilian health systems have helped identify and1487contact 140,000 at-risk Veterans. VA has made good progress on the1488remaining requirements and anticipates meeting the statutory timelines.1489    VHA has experienced some challenges with implementation of certain1490sections of the Dole Act, particularly section 143 (regarding1491reimbursement for transporting certain Veterans by ambulance from rural1492locations for care) and, to a lesser degree, section 129 (regarding1493recognition of organizations and individuals to assist Veterans, family1494members, and caregivers in navigating VHA programs and services). VA1495would greatly welcome the opportunity to work with the Subcommittee to1496modify these provisions to ensure VA can provide the benefits and1497services intended by these sections.14981499VBA15001501    These efforts within VHA demonstrate our commitment to improving1502health care access and support for Veterans and caregivers. Equally1503important are the provisions under the Dole Act that strengthen1504Veterans' benefits and streamline claims processing.1505    Native Americans have historically served in the U.S. military at a1506higher per capita rate than any other group. However, they face unique1507challenges in obtaining home loans on Federal trust land. To help VA1508address this challenge, the Dole Act expanded VA's Native American1509Direct Loan (NADL) program, thereby strengthening VA's authority to1510make, evaluate, and secure loans on trust land and giving Native1511American Veterans more opportunities to purchase, build, improve, or1512refinance homes on trust land. VA is also hiring additional NADL1513coordinators and collaborating with other Federal agencies to develop1514effective policies that support Native American Veterans and their1515families and developing new policies to support a Native Community1516Development Financial Institution relending program.1517    VA continues to prioritize systems enhancements to support1518implementation of sections 208, 210, and 212 of the Dole Act. In 2025,1519after years of planning and coordination, VA had scheduled and1520committed to the decommissioning of the Benefits Delivery Network (BDN)1521system. The Fiscal Year 2025 decommissioning date could not be moved1522due to the ending of the BDN support contract in October 2025, and a1523requirement to close out Fiscal Year 2025 books in BDN.1524    The largest provision of the Dole Act to be implemented by VBA is1525section 212, which reestablished the Veterans Technology Education1526Courses (VET TEC) program, or VET TEC 2.0. VA will implement the VET1527TEC 2.0 claims processing capability in Fiscal Year 2026 and has made1528other significant progress toward implementation. For example, on1529December 16, 2025, VA published the Student Application in the Federal1530Register, starting the 60-day public comment period. VA also1531successfully completed updates to the payment management systems that1532will enable Education Service to implement a claims adjudication and1533process capability by the end of the third quarter of Fiscal Year 2026.1534Finally, VA completed several other tasks to ensure a smooth rollout of1535VET TEC 2.0 as soon as the information technology solution is1536available. For example, VA completed:15371538      the Training Provider application,15391540      a draft Communications plan to notify the Training1541Providers and begin soliciting and accepting new Training Provider1542applications,15431544      a Training Provider and Expert Credentials checklist, and15451546      a training plan for the Training Providers and Education1547Liaison Representatives.15481549    VA has made progress toward implementing section 215 of the Dole1550Act. For example, VA has linked the GI Bill Comparison Tool to the1551Department of Education's (ED) College Navigator and recently met with1552ED to identify the appropriate points of contact to incorporate1553additional data.1554    VA will also schedule and adopt additional updates following two1555recent court decisions - Rudisill v. McDonough and Perkins v. Collins.1556Specifically, by 2027, VA will aim to achieve 1-day completion of1557education claims and reinstitute VET TEC 2.0.1558    VA has not yet scheduled:15591560      DGIB updates necessary to support the integration of the1561new monthly housing allowance requirements under section 208; and15621563      integration of electronic certificates of eligibility and1564award letter requirements under section 210.15651566    VA anticipates it will schedule these updates in 2026. To mitigate1567challenges until they are scheduled, VA conducts quarterly reviews of1568DGIB enhancements and continues to prioritize enhancements. VA will1569continue to provide updates to Congress in our calls about DGIB1570progress about sections 208 and 210.1571    In addition to benefits focused on the Native American community1572and education services, the Dole Act strengthens memorial benefits1573administered by the National Cemetery Administration. For example,1574section 301 of the Dole Act expanded burial allowances for Veterans who1575die at home while receiving VA hospice care, ensuring families receive1576timely support during a difficult time.15771578National Cemetery Administration15791580    VA is working under section 302 of the Dole Act to improve outreach1581to States and tribal governments, helping ensure that Veterans and1582their families are aware of burial and memorial benefits they have1583earned. These provisions reflect VA's commitment to honoring Veterans1584not only throughout their lives but also at life's end, with dignity1585and respect.15861587Conclusion15881589    Chairwoman Kiggans and Ranking Member Ramirez, this concludes my1590statement. We appreciate the opportunity to speak before you today and1591welcome any questions you or other Members of the Subcommittee may1592have. Thank you for your continued support of Veterans, their families,1593caregivers, and survivors as well as the many VA programs to support1594them.15951596                   Prepared Statement of Sharon Silas1597[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]15981599                       Statements for the Record16001601                              ----------16021603            Prepared Statement of Elizabeth Dole Foundation16041605    Chairwoman Kiggans, Ranking Member Ramirez, and members of the1606subcommittee, the Elizabeth Dole Foundation would like to thank you for1607the opportunity to submit our views on the status of implementation of1608the Senator Elizabeth Dole 21st Century Veterans Healthcare and1609Benefits Improvement Act.1610    The passage of this legislation during the 118th Congress marked1611one of the most significant Federal policy advancements secured on1612behalf of veterans, caregivers, and survivors in recent years, and1613Senator Dole remains both proud and humbled to have had it named in her1614honor.1615    The Foundation worked tirelessly with caregivers and our veteran1616service organization partners to secure its passage not only because of1617the impact on family caregivers, but also because of the broad array of1618issues covered in the bill that impact veterans and families. While as1619an organization we focus on issues of direct impact to caregivers, we1620also address issues of significant interest to that population.1621Clearly, the quality of the care and services available to veterans is1622at the top of that list.1623    Daily we hear from caregivers asking about the long-delayed1624finalization of the rule governing the Department of Veterans Affairs1625Program of Comprehensive Assistance for Family Caregivers (PCAFC). We1626are now entering year 4 of waiting for a new rule to expand eligibility1627and improve the program. Even more often, however, we hear from1628caregivers about their struggles navigating VA's programs and services1629including Veteran Directed Care, CHAMPVA, respite, home health, skilled1630care, benefits, home and vehicle modifications, etc.--all programs1631intended for the veteran but with real life impacts for the whole1632family.1633    While there is still work to be done, the Dole Act was intended to1634address many of these challenges for the benefit of the entire veteran1635community. We are especially pleased that Section 120, which1636drastically increased the expenditure cap for non-institutional care,1637was implemented in September 2025. The enactment of this provision1638helps our most vulnerable veterans and their caregivers by removing a1639long-standing barrier to keeping loved ones at home. We encourage VA1640and the Office of Geriatric and Extended Care (GEC) to continue1641training clinical providers and social workers both inside and outside1642GEC on this opportunity to ensure those in need are aware of available1643services.1644    However, the Elizabeth Dole Foundation has questions and concerns1645regarding multiple remaining provisions and their current status.16461647Section 101:16481649    Section 101, also known as the ``Medical Best Interest'' provision,1650allows veterans to access care in the community if it is determined by1651the clinician that it is in the veteran's medical best interest to do1652so. We supported this provision because we recognize both the need to1653ensure VA is able to offer robust, high-quality care as well as provide1654access to necessary care in a timely manner, sometimes found in the1655community. We are familiar with cases where this provision was1656especially helpful in getting a veteran to appropriate specialty care.1657However, VA's regulations that govern necessary travel often associated1658with care in the community have not yet caught up to the intent of1659section 101.1660    Under the current rules, VA can only authorize travel reimbursement1661to the closest medical facility that can provide the necessary care.1662Since the relevant provision does not comment on the facility's1663capability--only on the veteran's medical best interest--we are seeing1664travel authorizations denied even though the care itself is authorized.1665We encourage VA to reconcile this language to ensure that veterans and1666their family members are not unnecessarily and unintentionally caught1667in a bureaucratic trap that leads to either increased out-of-pocket1668expenses or an inability to access care.16691670Section 122:16711672    Based on the Chairwoman's COPE Act, this provision authorizes the1673VA Secretary to award grants to community-based organizations to1674provide mental health services to family caregivers participating in1675PCAFC. According to a 2024 RAND study commissioned by the Elizabeth1676Dole Foundation, caregiving often places significant strain on1677caregivers and increases their risk for developing physical and mental1678health conditions, including depression and suicidal ideation.1679Relatedly, caregivers' mental well-being directly affects the quality1680of care provided, impacting outcomes for both caregivers and those they1681support. By prioritizing the mental health of caregivers, the overall1682effectiveness of care can be enhanced.1683    Recognizing both the value and risks associated with caregiving, VA1684established a program through which PCAFC caregivers can receive mental1685health care from VA providers, with options available through both1686telehealth and in person. With approximately 29,000 encounters among16874,374 patients in Fiscal Year 2025, the program is certainly beneficial1688and a significant step in the right direction. However, caregivers1689enrolled in PCAFC are often hesitant to seek mental health services1690directly from VA for fear their participation will impact their1691eligibility for the caregiver support program. In addition, they are1692hesitant to use another VA program, as it is perceived as an additional1693care coordination burden.1694    While VA has not yet issued grants in accordance with section 122,1695as it was discretionary and not mandatory, the Elizabeth Dole1696Foundation strongly supports the establishment and issuance of these1697grants to increase opportunities for access to necessary mental health1698care for family caregivers. In addition, the Elizabeth Dole Foundation1699supports increasing the pool of eligible participants to those enrolled1700in the VA's Program of General Caregiver Support Services (PGCSS),1701rather than just PCAFC, to improve the health and well-being of a1702larger pool of caregivers as well as that of the veterans for whom they1703care.17041705Section 123:17061707    Derived from the original Elizabeth Dole Home Care Act introduced1708by Representatives Brownley and Bergman, Section 123 codifies the Home1709and Community Based Services (HCBS) programs to ensure their long-term1710viability. Under this provision, the Veteran Directed Care (VDC)1711program, provided in partnership with the Administration on Community1712Living (ACL), is required to be provided at each VA medical center. VDC1713provides a flexible, monthly budget, allowing veterans to hire their1714own caregivers---- including family or friends--and purchase services1715to manage their care. This system offers more control and ownership of1716that care to the veteran and caregiver and, where utilized, has proven1717very effective.1718    VA has stated that VDC is now technically available in all VA1719medical centers, but we have learned that access remains difficult due1720to a limited number of contracts in place, staffing VDC as a collateral1721duty, and a general lack of knowledge of program availability. In order1722to learn what steps may have been made to address some of these1723challenges, the Elizabeth Dole Foundation requests VA brief all1724interested veteran service organizations regarding the current status1725of VDC implementation including enrollment numbers and locations,1726current contract availability, and staffing models. This briefing will1727help VA identify ongoing challenges as they seek the full1728implementation of this valuable program.17291730Sections 123 and 124:17311732    The Elizabeth Dole Foundation was pleased to participate in a1733recent roundtable hosted by the Senate Veterans Affairs Committee to1734discuss many of the improvements to PCAFC required under sections 1231735and 124. These include the enhanced use of automation to facilitate1736information gathering and eligibility determination processes as well1737as improvements to decision letters to better inform applicants. The1738Elizabeth Dole Foundation was also pleased to learn that steps are1739being taken to improve the coordination of care between the PCAFC1740program and services available to individuals under GEC.1741    While we appreciate these positive steps, the Elizabeth Dole1742Foundation is gravely concerned that the final rule governing the PCAFC1743program has not been issued. As mentioned above, recognizing1744significant challenges and an excessive number of caregiver removals in1745March 2022, the VA suspended discharges from the program in an effort1746to pause, review, and discuss needed changes. Eventually, VA entered1747into a new rulemaking process and issued a proposed rule in December17482024. Garnering over 800 comments, this proposed rule appears to be1749stalled; we are now well over a year after its issuance, leaving this1750highly vulnerable population of family caregivers in limbo as they wait1751to learn their fate. Worse, the very rule that was recognized as1752insufficient in 2022 and that resulted in the pause, is still being1753used today to determine eligibility for new applicants, leaving many1754out of the program whom Congress intended to cover. The Elizabeth Dole1755Foundation strongly urges Congress to use its oversight authority to1756impress upon VA the urgency of finalizing a rule quickly that supports1757family caregivers and aligns with congressional intent.17581759Section 129:17601761    Commonly referred to the ``Pathway to Advocacy'' this provision1762requires the VA Secretary to establish a process by which organizations1763can become trained, certified and recognized to help a veteran,1764caregiver, or survivor to navigate the services of the Veterans Health1765Administration. Too often, this committee learns of situations where1766vulnerable individual veterans or their family members are unaware of1767or unable to access the programs intended to help them, even though VA1768has the services necessary to support them. Given the potential1769positive impacts of this initiative on connecting veterans, caregivers,1770and survivors with needed resources, the Elizabeth Dole Foundation1771again recommends that VA brief interested organizations on the status1772of this provision's enactment and solicit feedback to ensure any1773recommendations align with congressional intent.17741775Section 130:17761777    Given veteran preference for care in the home, GEC provides an1778invaluable set of tools to both accommodate the veteran's wishes and1779support the family caregivers who are often thrust into this role.1780Among other things, section 130 requires that VA undergo an extensive1781review of these services to ensure consistency in program management,1782appropriate staffing levels, proper care coordination, and eliminate1783service gaps. While this provision was enacted prior to the current1784reorganization efforts underway at the agency, the Elizabeth Dole1785Foundation encourages VA to enact the provisions in the spirit in which1786they were intended to ensure that these vital programs are staffed1787appropriately to better serve veterans and caregivers.17881789Conclusion:17901791    The passage of the Senator Elizabeth Dole 21st Century Veterans1792Healthcare and Benefits Improvement Act provided an opportunity for VA1793to implement bipartisan legislation that was carefully crafted with the1794support of many in the veteran community. As VA continues its work on1795the implementation of this law, we encourage the agency to update and1796solicit regular feedback of relevant veteran service and non-profit1797organizations to achieve our mutual goal of serving veterans,1798caregivers, and survivors.1799    The Elizabeth Dole Foundation would once again like to thank the1800subcommittee for the opportunity to present our views today. We look1801forward to continuing to work with you on the full and prompt1802implementation of this law and would be happy to answer any questions.18031804                                 [all]