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

...veteran homelessness. In the Dole Act, we included bills from my Democratic colleagues that gave VA crucial authorities that communities need to address and end veteran homelessness. We actually increased the grant per diem rate and authorized the VA to purchase basic necessities for homeless veterans. Having been the executive director of a homeless service agency myself, I understand that oftentimes these organizations have to do more with less, and I know that every resource and every dollar matters when you're trying to provide the best service possible with very limited means. VA worked with committee staff for over a year to refine the homeless sections of the Dole Act before it was signed into law. The VA assured us that providing these increased resources to community providers and to homeless veterans would be simple as a quote, turning on a light switch, once the bill would pass. Under the Biden administration, VA was prepared, yet under Collins's disappointing dysfunctional and delinquent leadership, it has taken over a year to implement the most critical parts of the Dole Act. Homeless service providers are left receiving a paltry $85 a day to provide transitional housing services to veterans instead of the $128 a day we had actually authorized in the law. Community providers have left the GPD program in droves while they waited for the relief promised by Congress. And those exits create service gaps that are impacting our veterans every single day. Communities view VA Under Secretary Collins as an unreliable partner in the fight to end veteran homelessness and frankly, I agree with them. Because due to his delays, homeless veterans are also left without access to their basic needs, another critical resource Congress authorized in the Dole Act. We gave VA the authority to use funds to be able to pay for food, for shelter, for clothing, for transportation, for homeless veterans to get to and from job interviews or for medical appointments. And every single day that passes and Doug Collins fails to implement approved provisions of the Dole Act, he's defied congressional authority. Every day that passes that a veteran experiences homelessness on the streets of our country, they are left without the resources that they need to become stably housed and that to me is shameful. It's irresponsible and it's harmful failure of this secretary. But let me talk to you about another shameful note. I want to discuss the staffing provisions of the Dole Act that have yet to be implemented. You see section 146 required VA to develop and implement staffing models to ensure VA has the workforce it needs to provide care and benefits to the veterans. And staffing models are essential for aligning personal resources so they can be used efficiently so that workers with the right skills are in the right place at the right time. Folks listening may recall that the VHA is currently undergoing a massive reorganization which we discussed at a full committee hearing just last month. One would think that a reorganization of this magnitude of the largest integrated health system in the country would incorporate staffing models. But by VA's own admission, they have not complied with the Dole Act and lack staffing models for the vast majority of the medical facility service lines. Which begs the question. What is the evidence that the VHA reorganization is in fact needed? How can we be sure that the VA is making the correct changes if its leadership doesn't even know how many staff it needs and where they need them? Even worse, let me ask you this question. Why is VA cutting vacant positions if they do not have staffing models developed? VA provided data to my staff a couple weeks ago on over 26,000 positions that were cut from the books. The details of those cuts are alarming. For months VA has told us that these are quote, old COVID era vacancies for positions that are no longer needed at the agency, but let me tell you that the data, it paints an entirely different picture about the same nature of these cuts. You see over 18,000, not hundred, 18,000 of the positions VA cut had a person in that job in 2025 or even 2026. This included positions for nearly 3,000 nurses, 800 social workers, 300 psychologists, and over 1,000 physicians who were on the job in 2025. These VA positions were discarded at the hands of the secretary's reckless leadership and they're not going to be backfilled. Chair Kiggans, the medical center that serves your constituents had the most cuts of any VA facility in the country. 733 of the positions VA cut were at the Hampton VA Medical Center. At the facilities that serve my constituents in Chicago, Jesse Brown and Hines, 717 positions were cut. In addition to those 26,000 positions that were wiped from VA's books since Secretary Collins was sworn in at the VA, he has shed a net 30,000 employees representing centuries worth of experiences. Those losses included over 1,100 doctors, 2,300 registered nurses, 700 more social workers, and nearly 300 psychologists. All of these cuts and losses were made with no staffing models in place as required by the law. Cut after cut after cut with no analysis of how veteran care and benefits would be affected. It is the definition of negligence. The secretary and his political appointees intentionally misled and lied to Congress about the nature of these cuts. Secretary Collins is failing at the most fundamental part of his job, ensuring that veterans have access to world class care at the VA. It's why this hearing is so important. It's why we have to hold them accountable and I look forward to the conversation that we have in this hearing today and with that, chair, I yield back.

Thank you Ranking Member Ramirez. I will now recognize our witnesses on our first panel. Testifying before us today we have Dr. Thomas O'Toole, Acting Assistant Under Secretary for Health for Clinical Services at the Veterans Health Administration. Dr. Mark Koeniger, Acting Assistant Under Secretary for Health and Patient Services at the Veteran Health Administration. Mr. Kenneth Smith, Executive Director, Education Service at the Veterans Benefit Administration. And we also have Sharon Silas, Ms. Sharon Silas, Director of Health for the Government Accountability Office. Will the witnesses please stand and raise their right hand. Do you solemnly swear the testimony you are about to provide is the truth, the whole truth, and nothing but the truth? Thank you and you may be seated. Let the record reflect that the witnesses answered in the affirmative. Dr. O'Toole, you are now recognized for five minutes to provide the VA's testimony.

Good afternoon, Chairwoman Kiggans, Ranking Member Ramirez, and distinguished members of the committee. Joining me today are Dr. Mark Koeniger, Acting Assistant Under Secretary for Health and Patient Care Services, and Mr. Ken Smith, Executive Director of Education Services at VBA. It is an honor to be here to discuss progress implementing the Senator Elizabeth Dole 21st Century Healthcare and Benefits Improvement Act. First, thank you for this legislation and what it will accomplish. Within VA alone, the Dole Act mandates implementing more than 40 enhancements, new guidelines or new programs. Executing six new pilot programs, conducting outreach and releasing new online tools for veterans, patients, and corner medical examiners, and completing 50 new congressional mandated reports. Given the scope and breath of the legislation, VA moved oversight of Dole Act implementation to the Office of the Secretary, ensuring senior most oversight. As of December 2025, the new Office of Strategic Initiatives is the responsible office. The lack of funding has been a hurdle, requiring us to change priorities and in some instances use funding from multiple areas to deliver on some of the sections. That said, we have made significant progress implementing this important legislation. Of the 72 sections, VA is fully implemented 25. And we are diligently working on the remaining sections with significant progress being made. I would like to briefly highlight key accomplishments within VHA, VBA, and NCA, which are leading to transformative changes for veterans and their families. Section 101 of the Dole Act eliminated an unnecessary layer of approval, allowing veterans to access community care when in their best medical interest. Section 120 increased coverage for non-institutional care alternatives from 65 percent to 100 percent of nursing home costs and the authority to exceed that cap for veterans with ALS, spinal cord injuries and similar conditions. This enables more veterans to receive care at home, preserving independence and dignity. Section 402 expanded per diem payments for homeless veterans to 133 percent of the state home domiciliary rate and up to 200 percent for sites identifying meeting identified criteria. To date, 150 sites have availed of the 133 percent increase and 40 sites have applied for the 200 percent rate. Section 149 requires an independent assessment of the National Veteran Suicide Prevention Annual Report and development of a public toolkit for coroners and medical examiners to improve reporting accuracy. The independent assessment was completed in January 2026. VA has experienced some challenges with the implementation of 143 and to a much lesser extent 129, and we welcome the opportunity to work with the subcommittee to ensure that VA can provide the benefits and services intended. The Dole Act expanded the VA's Native American Direct Loan program, giving Native American veterans more opportunities to purchase, build, improve or refinance homes on trust land. VA is also hiring additional coordinators to support these veterans and their families. Section 212 reestablished the Veterans Technology Education Courses program. VA has scheduled implementation of the managed service claims processing capability for the end of third quarter 2026 and published the student application in the Federal Register in December 2025. VA has also made progress implementing section 215, linking the GI Bill comparison tool to the Department of Education's College Navigator and is working to incorporate additional data. Of note, VA's conversion from the benefits delivery network to the digital GI Bill has impacted full implementation of sections 208, 210 and 212, as well as recent court decisions. We will continue to provide updates to Congress in our calls and briefings. Section 301 expands burial allowances for veterans who die at home while receiving VA hospice care, ensuring families receive timely support. Section 302 improves outreach to states and tribal governments to ensure veterans and their families are aware of burial and memorial benefits they have earned. Chairwoman Kiggans and Ranking Member Ramirez, this concludes my statement. We appreciate the opportunity to speak before you today and welcome any questions you or other members of the subcommittee may have. Thank you for your continued support of veterans, their families, caregivers and survivors and the many VA programs that serve them.

Thank you Dr. O'Toole. Ms. Silas, you are now recognized for five minutes to provide your testimony.

Chairwoman Kiggans, Ranking Member Ramirez, and members of the subcommittee. Thank you for the opportunity to be here today to discuss VA's progress implementing requirements in the Elizabeth Dole Act. The Dole Act authorized significant expansions to healthcare programs and support for veterans. Today I would like to highlight GAO's work in two areas that are addressed in the law. The Veterans Community Care program and the Caregiver Support program. First, the Dole Act contains a number of provisions for VA that are intended to improve the agency's healthcare operations, including community care. Relatedly, GAO has a long history of reviewing the community care program, including some of the more recent changes to how referrals are processed and appointments are scheduled. In a little more than 10 years, the community care program has tripled in size and represents nearly 42 percent of all VA healthcare appointments. With that expansion, the administrative processes at VA facilities have become more complex and continue to be labor intensive. Through this growth, the Veterans Health Administration has made numerous changes to how the program is administered in order to gain efficiencies and ensure that veterans understand their healthcare options. In 2020, we issued a report on VA's implementation of the Veterans Community Care program. In that review, we described the timeliness of processing referrals and scheduling appointments. We made three recommendations to VA in that report, two that remain open, including that VHA assess the staffing and resource needed to process community care referrals and schedule appointments. We also recommended the agency set standards for monitoring the appointment scheduling process, including the receipt of care with a community care provider. We also issued two reports in 2025 addressing two key VHA efforts: the establishment of the VHA's Integrated Veteran Care Office, or IVC, and the implementation of the Referral Coordination Initiative. The creation of the IVC was an organizational form to address VHA's progressively complex processes to manage healthcare delivery at facilities and through the community care program. It consolidated the management of VA healthcare delivered in the facilities and through community care with intent of improving coordination and ensuring veterans receive seamless access to care. The Referral Coordination Initiative was created to ensure veterans understood their care options and to also create efficiencies for facilities in processing referrals and scheduling appointments. In both reports, we highlight deficiencies in the implementation of these efforts that ultimately can impact veterans' access to care. Recommendations from both of those reviews remain open. As VHA prepares to go through additional changes, including restructuring and in the next generation of community care contracts, it is critical that the agency ensure it has the effective management structures in place to ensure veterans' timely access to care. Addressing GAO's outstanding recommendations and addressing the mandates in the Dole Act will help VA to ensure veterans receive consistent high-quality healthcare. The second program that I would like to highlight is VA's Caregiver Support Program. The Caregiver Support Program plays a critical role in supporting caregivers who assist veterans who have suffered serious injuries with essential tasks of everyday living. There are currently about 98,000 caregivers participating in the program. Given the toll that daily caregiving can take on caregivers' mental health, ensuring VHA effectively spreads awareness about the mental health support it offers to caregivers is essential to ensuring that interested caregivers participate in the program and they receive the help that they need. The Dole Act includes a number of provisions to bolster the supports for caregivers caring for veterans, including a mandate for GAO to review mental health support for caregivers. Our work is ongoing, however, I will preview some preliminary findings. In our report, we describe a variety of services to support caregivers' mental health and well-being, such as individual therapy, support groups, respite care, among others. We also identified some challenges caregivers experience in accessing these services, including the limited ability to travel to receive support in person. In our report, we describe some steps VHA is taking to address these challenges, such as creating a virtual psychotherapy program for caregivers. However, our preliminary findings also show that VHA has not fully implemented performance management practices for ensuring veterans and their caregivers are aware of the program. Effective implementation of performance management practices is not just a bureaucratic exercise. Following the practice of setting program goals with targets and timeframes, collecting data to measure progress towards those goals, and then using that information to assess results and inform decisions on any adjustments to those efforts can help to ensure the program is meeting its intended results, getting caregivers the support they need. The requirements for VA in the Elizabeth Dole Act align with many of the findings and recommendations from GAO's reviews. VA's adoption of those recommendations would aid the department's progress toward implementing the Dole Act's provisions. And that concludes my prepared statement. Thank you.

Thank you, Ms. Silas. We will now move to questions and I yield myself five minutes. I want to ask a quick question of Mr. Smith. Can you talk, I know you guys all kind of overviewed some of the work that the VA has done to implement the Dole Act and can you just briefly describe what the education outreach has been that's been done to educate veterans, their families, and community care partners too just about about these new resources that are available to veterans? Are we putting pamphlets in in waiting areas or are we just are we sending emails? What does that outreach look like? I know as a primary care provider, we we often had a large group of veteran patients. It was challenging to understand the resources that the VA has out there and we've put so many good things in place and and a lot of good changes in motion. So I just want to know how we're communicating with veterans and their families that these things are now available.

Thank you for the question. For our education programs, our outreach is predominantly through our website. We've published a number of information on our website as well as provide marketing to our our students directly through email campaigns. And lastly, our VSO community. They are a great partner in disseminating information.

The VSOs are are a good source and and I get the VA emails as a veteran married to a veteran and and I don't think I ever visited the VA website before my current job. So I don't do a lot of visit, I don't know how many veterans out there actively, maybe if they're Google searching. I just that outreach piece, there's a lot of primary caregivers out there so and there's probably a lot of patients sitting in waiting rooms. So posters, I'm thinking of even technology, the technology integration we see in waiting rooms, you know, just letting people know. I think that's one of our hardest parts. We have great benefits, but what are those benefits and communicating that? So and and keep in mind our primary care, our civilian counterparts as well. We all take care of veterans. I have a large veteran community in Hampton Roads. So it was just always a challenge knowing and I had a great office manager who would do that research and and try to connect with the VA, but even as a veteran provider, I I didn't even know all the resources that were out there. So I think that's half our battle. But just throwing that out there. And then going to Dr. O'Toole, the Dole Act has reoriented VA healthcare to put the best medical interest first in each veteran. I applaud the VA for enacting this provision. It saves lives. However, the VA was was marked section 122 complete and that's the operative section of my bill, the COPE Act. It's come to my attention that VA decided not to issue any grants specifically under this program. So just wondering, Dr. O'Toole, why that law has not been fully acted about the grants? There was 10 million, specifically there was $10 million appropriated for the program in fiscal year 25 and another 10 million appropriated in fiscal year 26. So just wondering where that money went.

Thank you, Congresswoman. I appreciate that. That's the awards contract for mental healthcare for family caregiver support. My colleague, Dr. Koeniger, I believe is better situated to comment on that.

The caregiver support, particularly in the mental health realm, we have implemented the virtual caregiver support program. And with that program, we have seen, let me see, actually almost 29,000 encounters. And that's a virtual, most of those encounters are the virtual program, but caregivers can also be seen face-to-face as well. And again, those almost 29,000 encounters, there are over 4,300 unique caregivers tied to those encounters.

That's that's good news. Thank you for that. And let's see, back to Dr. O'Toole. Section 142, it waived the pay cap for highly skilled medical staff. So Dr. O'Toole, can you tell us how many waivers the secretary has made for that? I know that was a complaint we heard frequently, especially with our surgeons, anesthesiologists, we had trouble recruiting, retaining physicians, specialty care physicians who could make so much more on the outside. We need those people at the VAs. So just wondering if an update for that.

Yes, thank you, Congresswoman. And first, this is really important legislation for us as you know. And the wage gap between what these highly trained specialists would make in the private sector versus the VA is only growing. The challenge in issue for us quite honestly is that many, many more specialty groups and specialists among the 25,000 physicians, for instance, that we have in the VA far exceed the 300 people. We run the risk of second and third order consequences if we don't do this right. And particularly if we're picking out certain groups where one provider is afforded the expansion or the cap extension and others aren't, what that may do to the practice. The other dynamic that we are looking at is how can this be considered from an enterprise perspective so that if a telecare service such as teleradiology can be used in a rural community, it's probably going to be a lot more efficient and effective than trying to extend that cap to a radiologist in a rural community. So we are actively moving forward on this. I meet with the undersecretary and others to review the parameters for data. We anticipate having a criteria put forward within the next one to two months, I'm hopeful for, to be able to start awarding that cap. But I do want to pay notice to the fact that this is critical because it's going to have to extend beyond these 300 individuals that are ultimately selected in this first pass.

Keep us posted. I know that's an important part of the program. But thank you. My time is expired. I'll save some for maybe a second round and I now recognize the ranking member for five minutes questioning.

Thank you, Chairwoman. Dr. O'Toole, I just want to go ahead and and follow up on that. First, thank you for being here. As you know, a few weeks ago, the secretary testified before the full committee and in a back and forth with our ranking member, he asked Ranking Member Takano if he would commit to introducing a bill to raise the cap on physician pay so that he can compete in the market to hire more doctors. So I want to double down a little bit more on on this conversation because I know you just started a moment ago. In that committee hearing, the secretary claimed that he cannot recruit physicians because he doesn't have the authority to pay physicians more. But and I'm hearing you talk a little bit about the 300, but but here's the thing. Section 142 of the Dole Act does also authorize the VA to use waivers to increase pay for 300 physicians. So the VA does have the authority to pay its physicians more already, which actually contradicts the secretary's testimony when he said he didn't have the resources or the authority to be able to raise those wages. And it sounds like Secretary Collins apparently does not think it's important to learn the laws that govern his agency, much less enact those laws to improve the VA and veteran care. So that gets to my next point. I think you've answered this, but I just want to make sure that I put this on the record. How many pay waivers has the VHA requested for physicians under the Dole Act? And it sounds like it's zero. The answer is zero, correct? So look, in a request for information provided to my staff on February 12, the VHA indicated that it had not requested or approved any pay waivers for physicians. So I just really need to reiterate what I said to the secretary at our hearing last month. He can't come to our committee and state that he cannot hire doctors because he can't compete in the market when he won't even use the authorities he already has that we, Congress, have given him to make more competitive offers to attract physicians. Secretary Collins waited until January 9th of 2026, a year after the Dole Act was signed into law, to publish the implementation plan for the authority to make it easier to hire doctors. It didn't seem like there was any real urgency there. You have to understand why I'm concerned here. The secretary comes before the committee and he claims that he cannot hire doctors, but he won't even use the tools that we have already given him, authorized them to make some competitive offers for a number of these physicians. Instead, he lost 1,000 doctors and then he wiped 1,500 more physician positions from the VA books. And it makes no sense if our goal is to strengthen the services veterans receive. It makes no sense to continue to claim as the Collins does that veteran care and benefits are not affected when we're hearing from our constituents on a regular basis, veterans, that they cannot get appointments at the VA. However, his actions make perfect sense if Secretary Collins does not want to hire, let me say this again, does not want to hire the doctors because his goal is to ensure that the VA fails so that he can further dismantle and maybe even privatize it. So I want to follow up on another piece and this is more specifically to Ms. Silas. Ms. Silas, GAO has recommended that VA assess its community care staffing and resource needs to ensure timely, to ensure timely appointment scheduling for veterans seeking care in community. So my question to you, Ms. Silas, is why is such a staffing assessment important and how does this recommendation align with the requirement in the Dole Act for VA to implement a staffing model in the IVC, VISNs, and the local medical facilities?

Thank you for that question. So an agency's workforce is really central to an agency transitioning into a high-performance organization. And in GAO's high-risk work, we have worked with the Veterans Health Administration to try to get them to be better in terms of clarifying their resource needs. The staffing model and performance metrics that are provisioned in the Dole Act are incredibly important because it helps to align your resources and staff needs with your program needs. It also is important for being able to plan ahead and to manage any risks. As you all know, each VA facility is unique in terms of the veteran population that they serve and then also in the communities that they reside in. But I know that one thing that we have heard consistently for as long as I've been doing this work is that when we meet with staff in these facilities, they say there's not enough staff to process referrals in a timely manner and to do timely appointment scheduling. And we always hear about challenges with workload. So in our 2020 report where we recommended that VA assess their staffing resources, they had told us that they have the staffing tool and that they were in the process of updating that and they've been continually updating that staffing tool as the processes have evolved over the last five years. So that recommendation, as you know, remains open. But for the staffing model and performance metrics that have been required in the Dole Act, the staffing tool at the least can provide information or input into the staffing models they're delivering now. It's kind of unclear how these both fit in together. But regardless, GAO does have a mandate in the Dole Act to do a review of the VA's development of the staffing model and performance metrics and once they complete the effort and issue some reports, we will be doing our own review.

Thank you, Ms. Silas. My time is up. If we have a second round, I'll do a follow-up. Thank you, Chair.

Thank you, Ranking Member. The Chair now recognizes Ms. Radewagen for five minutes.

Thank you, Chairwoman Kiggans. Talofa lava. I want to thank the panel for being here today. [Coughing.] It's an important hearing today. So thank you to the witnesses as well. Mr. Smith, what has been the greatest barrier for implementation of Section 302 of the legislation?

Thank you for the question, ma'am. Right now, VA is working to publish a rule for that grant program so that we can perform or issue grants to perform the veteran outreach as required by 302.

And how has Section 302 helped VA better partner with state and tribal entities?

I believe that once implemented, we will be able to provide or at least provide grants to those organizations so that they can perform outreach on VA's behalf and ensure that they're communicating with their members in a culturally responsive way.

Ms. Silas, in GAO's review of Dole, the Dole Act implementation, what has been your greatest concern?

The GAO has a number of mandates to review implementation of various provisions within the Dole Act. Much of our work that we need to do is either waiting on VA to complete their enactment of their provisions so we can oversee that or we're waiting for some reports to be released in order for us to do the review. We haven't looked directly at the implementation of any of the specific provisions that VA is responsible for. We do have ongoing work for our own mandates around the dental services. We're looking at VA's oral health program. We are also looking at the Veterans Community Care Dentistry Program. And so we are making progress on those reviews. Otherwise, we're waiting for VA to complete their efforts before we look at them.

So do you believe that VA will be able to implement the Act in its entirety in the allotted timeframe?

I don't think I could state for sure. It would be up to VA to tell you what their progress is. Again, I can only speak to the programs that we have oversight of in terms of the mandate and provisions to review those programs and most of that work is ongoing right now.

Thank you, Chairwoman. I yield back the balance of my time.

Thank you, Ms. Radewagen. The Chair now recognizes Mr. Kennedy for five minutes.

Thank you. I want to look back at what we were told about the VA staffing cuts versus what has actually happened. In February 2025, Secretary Collins eliminated 2,400 VA jobs after publicly promising that 300,000 mission-critical positions would be protected to ensure uninterrupted services for our nation's bravest. One month later, a leaked memo showed plans to cut more than 80,000 employees, a number the Secretary confirmed, then denied, then revised to 30,000. On May 15, Secretary Collins assured our veterans that mission-essential jobs like doctors, nurses, and claims processors would be protected and that reforms would strengthen, not strain, veterans' access to care. That promise was broken. In December, a leaked memo revealed plans to eliminate up to 35,000 healthcare positions in a single month, the doctors, nurses, and support staff that veterans count on for timely, quality care. When a psychologist is cut, the veteran in crisis has fewer options and longer waits. When a community care scheduler is eliminated, the veteran waiting for a cancer consult or neurosurgery referral waits longer, sometimes dangerously longer. When nurses and physicians are cut, the people who catch conditions early and respond to emergencies aren't there when they're needed most. These aren't just workforce reductions, they're direct cuts to the care our veterans depend on, sometimes for their lives. That's why I requested detailed staffing data for the Western New York VA system to understand exactly how many positions were cut and how it's affecting veterans in my district. The VA refused and then days before this hearing, we received incomplete numbers. What we recently uncovered in my own district in Buffalo, New York, is demonstrative of what we're seeing in VA medical centers across the nation. On December 14, roughly 100 healthcare positions were eliminated at the Buffalo VA, 23 active critical roles including two psychologists, two social workers, one recreation assistant, one respiratory therapist, three physicians, two nurses, and 11 EKG technicians, all cut. These are the people who treat PTSD, diagnose heart conditions, coordinate the care that keeps veterans out of emergency rooms, and so much more. We already know what happens when staffing falls short because we've seen it happen at the Buffalo VA. In 2024, an OIG investigation found that dangerous delays in scheduling community care consults put veterans at serious risk. This investigation identified staffing shortages as a key cause of this degradation of care. Community care schedulers, in a follow-up conversation in response to the investigation, told us directly that staff shortages led to countless untreated patients and devastated health outcomes, including at least one death. And the Trump administration's response? Eliminate the staff who schedule the consults, the technicians who conduct exams, the personnel who ensure psychiatric care, and the professionals who ensure no veteran is left behind. We know what happens when those positions go unfilled. Veterans' care suffers and some veterans will die. This isn't just mismanagement, it's life and death for the veterans who rely on the VA for timely care. Secretary Collins stood before this committee and promised that the doctors and nurses who care for our veterans would not or would be protected. He promised that care for our veterans would not be cut. He was not telling the truth and our veterans are the ones paying the price. So I have a very simple question for those here representing Secretary Collins' VA. When veterans in my district get sick because of a lack of resources, which of you will take responsibility and what are we to tell them?

Well, thank you, Congressman, and I appreciate what you are bringing up and I fully acknowledge the challenges and the issues. If I can, I appreciate I'm hoping for a time extension to be able to respond to your question if that's okay, Chairwoman. The issue of having enough providers for care is a significant one. It is one, however, that we share with the entire American healthcare system. Right now, there is an estimated shortage of physicians, nurses, social workers, psychologists, psychiatrists, estimated to be at 90,000 over the next 10 years in the American healthcare system. So what we are challenged by in the VA is what all of American healthcare is challenged by. And I think that's an important consideration to make and it's why I also emphasize the importance of Section 142 in really trying to help us be to be more competitive in attracting people to come in. It is absolutely important. I do need to emphasize though and clarify, when the DRP process went through, those clinicians who were involved in direct care with providers with patients were not allowed to pursue the DRP and those requests for DRP were denied by those direct clinicians. That does not mean that people are not going to retire. That does not mean that people are not that positions are going to attrit or that people may leave the VA. We all have workforce challenges in healthcare and I do not want to minimize that issue or point nor the importance of Congress in helping us navigate those waters. But it is a shared challenge for all of us that extends beyond this. The positions that were eliminated were vacant positions that had not been filled for quite some time. That does not mean that people were losing their jobs and I do think that's a really important clarifying point to the issues that I think are very valid that you are bringing up.

Thank you, Dr. O'Toole. The chair now recognizes Mr. Self for five minutes.

Thank you, Madam Chair. Dr. O'Toole, I don't question the President's authority to use impoundment. I just want to clarify, none of what we're hearing is an impoundment under the Dole Act, is it?

I'm sorry, Congressman. I'm not sure I'm following your question. Can you please...

Congress authorizes a certain level, President decides to spend less than that level. Is that is impoundment involved here, just to clarify?

Not that I am aware of at all, sir.

Very good. So I want to go to your written versus your verbal testimony. I think I heard something that is not in your written testimony. It's in the paragraph, I believe, where you talked about VA using funding from multiple accounts to deliver on some of the sections. Now, in your verbal testimony, you said lack of funding. Can you clarify what you said in that paragraph?

Thank you, Congressman. I will, obviously, you know far better than I the dynamics of appropriations, and I'm not trying to speak to that. Some of the provisions in the Dole Act did not involve appropriated funds, and we have tried to implement within the capacities that we have to the best of our abilities, or if funds were available through other accounts, use those, and just trying to be fiscally prudent within that context. But I want to defer to my colleagues who might be able to speak better to that.

Thank you. So for the digital GI Bill program, we are required to make changes to that environment in order to implement...

No, I'm not asking for specifics. Thank you. I just wanted to clarify your lack of funding. You did say that, I believe, and I'm not sure you clarified it, but thank you. So I want to move to accountability in the three minutes I have left, because we talk a lot in this committee about inputs. We get VA employees coming in and telling us about all the inputs. Who's going to be accountable for this? This bill was to improve ability to receive care at home, correct? So if you believe that changes in the fee schedule for reimbursement rates related to home health aide and homemaker services were to result in a reduction of up to 43 percent in rural Texas, some of which I represent, do you believe that that improves a veteran's ability to receive home health care? How is that how is that balanced?

Sir, thank you for the question. I cannot speak directly to veterans in Texas in terms of receiving home health care. I can say, though, that the home and community-based services, the VA has done actually a great job at expanding those services. The...

So do you think the 43 percent reduction is going to improve their ability to receive home health care?

So the again, I cannot speak specifically to that, but I can say that, again, over compared to fiscal year 24, over a roughly 600,000 veterans are actually have actually benefited from the home and community-based services.

Very good. Thank you. So Dr. O'Toole, can you name the specific individuals who in VA who are going to be responsible for each of the at-risk sections?

Thank you, Congressman. So as I mentioned in my opening statement, we have a centralized office, Office of Strategic Initiatives, that is overseeing this process. All of our senior leadership are fully engaged in this and, as the committee staff would know, meet with frequently. So I am more than happy to forward to you the org chart that delineates specific...

No, I don't need the org chart. I'm asking you if you're going to hold someone accountable, because you're what, one-third of the way through implementation? Is that about right, one-third of the way through in terms of sections? Sure. So what I'm really asking is who is going to be held accountable? Because we always talk about inputs. I want accountability for when you implement this.

Our senior leadership throughout the agency are responsible, sir, including myself.

Okay. Very good. What's the critical milestone between now and full implement... Oh, my time is up, Madam Chair. I yield back. Thank you.

Thank you, Mr. Self. The chair now recognizes Mr. Ciscomani for five minutes.

Thank you, Chair Kiggans, for convening this important oversight hearing. And thank you to the witnesses from the Department of Veterans Affairs and Government Accountability Office for being here today with us. I was proud to help introduce the Senator Elizabeth Dole 21st Century Veterans Healthcare and Benefits Improvement Act last Congress, and even more proud to see it pass and get into law, be signed into law, because I believe strongly that our veterans and their caregivers deserve a system that truly reflects the sacrifices they've made for our nation. Far too often, veterans and their families face barriers when trying to access care, navigate benefits, and receive the support that they've earned from the VA. This flagship VA legislation was designed to modernize the VA and create a system that works, that works better for veterans and their families and who stand beside them every single day. One year after enactment, it is important that we take a close look at how the department is implementing these reforms. While progress has been made in several areas, some provisions remain behind schedule or at risk of not fully being implemented. For veterans and their families, these timelines matter. Delays can mean waiting longer for care, missing out on important support service, or facing unnecessary barriers to benefits they earned through their service. So this is why I want to ask a couple of the follow-up questions here. And I'll start with Dr. O'Toole. The Dole Act includes a wide range of reforms touching clinical care, caregiver support, and community-based services. How has the VHA prioritized implementation across these areas to ensure that the most immediate needs of veterans are addressed first?

Thank you, Congressman. I'm going to defer to my colleague on the community care question, if that's okay.

So that's a great question. In terms of community care or even caregiver support, I mean, we recognize that taking care of veterans, no matter what their problems are, is very important. And so in terms of the community-based services, we have four programs that we have rolled out. Those programs have actually seen an increase, as I mentioned earlier, in terms of supporting caregivers as well.

How do you prioritize? I'm sorry to interrupt because we're going to run out of time, but how do you prioritize? How do you how do you make sure that those that have the most immediate need of veterans get seen first? What's the process like?

So again, the veterans that have the highest needs in terms of medical issues, you know, those are the folks that we want to make sure that we take care of.

I agree. So how do you get there? How do you identify that?

So the specific process, I would have to get back to you on. Certainly...

I want to make sure that that's actually happening. It's just, you know, I think you get the sense from the committee here on both sides of the aisle, we're running a little impatient on the implementation of a lot of these programs. This was supposed to be a much more expedited process and seeing the benefits of this. We're not seeing that. And this is this is coming from from every angle and every state representative here. We're all seeing this in our districts. So we need to we need to really zero in on this and we need to start seeing some results. So I'm going to move on here. Dr. O'Toole, again, one of Congress's goals in the Dole Act was to improve timely access to care. From your perspective, what measurable changes should a veteran expect to see in appointment availability or service delivery as implementation continues? I keep hearing from our veterans the care they receive at the VA is excellent once they receive it. Receiving it and getting there is the main issue. So again, we're I'm starting to see a trend here of of what was passed not being enacted, and I want to start seeing some results, and so do our veterans. And what way are you measuring this?

So thank you, Congressman, and this is very important, and I think to follow up with your second question as well, or previous question as well. So this is a massive piece of legislation, as you know, 72 provisions that impact across the agency. And I can't I've been a primary care provider in the VA for 20 years. This is one of the most significant pieces of legislation I've seen having impact across the entire agency. So first, thank you for that. As your staff knows, in meeting with them and having sat in on several of the calls, this is something where we have to be able to chew gum and walk at the same time and implement multiple efforts concurrently. And we are. This has been a difficult year in both securing our senior our most senior leadership, our Senate-confirmed leadership, going through the government shutdown, which created some undue slowdowns in terms of getting things through. We are on the cusp with several of these provisions within the next weeks to month or two to having them posted in the Federal Register and being implemented. So very much I feel confident that we will be able to implement all of the provisions in the time allowed, and they are priorities for us because they're priorities for our veterans across many different contexts.

I'm out of time. So I do look forward to seeing results. I think we understand it. We know the significance and size of the legislation we worked on it, we passed it. It's big, and it's going to take time, we know that, but it's been over a year. We need to we need to see some results here. And you say weeks, months, I hope it's weeks, and I hope we can get a report exactly on numbers on what this matters. Madam Chair.

Madam Chair, I know we're over time. Congressman, you mentioned access to care, and I would just like to say it is a very complicated process, as you know. There are just so many things that have to be taken into account to improve access. I can tell you that as of May of last year, the Veterans Health Administration stood up the Access Choices and Excellence Group, of which I am the executive sponsor, and we have been working diligently on all aspects of access to care to, again, objectively measure all of those things and to work on improving access. As a 36-year veteran of the United States Air Force myself, that sits that's near and dear to me to make sure that veterans can get in when they need to get in.

Thank you. I think we have a few minutes for a second round of questions. I just have two questions for Dr. O'Toole. For Dr. O'Toole, as a former geriatric nurse practitioner, one of my greatest concerns was ensuring our aging veterans are getting the care that they deserve. And can you provide the committee just with an update on the rollout of the pilot program, Section 127, to fortify the assisted living services for veterans and what that looks like?

Thank you, Congresswoman. I think is that in your scope? Yes.

Yes. Thank you for the question. As you know, our population is aging. Again, we have 49 percent of all our veterans are 65 and older. So we are working in terms of the two pilots as Section 127 states. The VA is has been working on a purchasing authority and a fee schedule options are under development because we are we need to get those things in place so we can ramp up those pilots. So we are making progress and working the details of getting the pilots going.

Okay. Well, we'd love to see some movement in that too. I think that's important. There's not enough options, especially housing options for aging Americans, and perhaps the VA should hire more geriatricians, but that's just my my two cents. And then Dr. O'Toole, our stakeholders have highlighted that the best medical interest standard is coming into conflict with transportation benefits that usually accompany care for disabled veterans. Veterans should not have to sacrifice the best standard of care because the VA won't pay for transportation. So how does the VA intend to harmonize this conflict to deliver patient-oriented care?

Thank you. It's a huge issue. And obviously, providing care that somebody can't get to sort of misses the mark. We are working specifically and having some challenges specifically on the transportation provision. I think I mentioned that in my opening statement, and it's something that we would like to be able to work with the committee further to be able to go through those provisions to address some of the challenges we're having with that implementation.

That would be great. I think that should definitely be a priority for us moving forward. And the chair now recognizes Ranking Member for any remaining questions.

Thank you, Chair. Here you go. Dr. O'Toole, I just want to follow up on some of the conversations we had at the beginning of the hearing and specifically I want to talk about my own district. Before the VA cut the 130 nurses at the Jesse Brown and Hines VA Medical Centers, did the VA have staffing models in place as required by the Dole Act to determine that those 130 nurses were no longer needed at those facilities in Chicago?

Thank you, Congresswoman. It's important to keep in mind, particularly as I know a lot of questions about the staffing model come up in consideration of the RISE initiative and the reorganization. There has been no change whatsoever in terms of direct care staffing modeling based upon the reorganization efforts under RISE.

So Doctor...

The staffing models have we continue to do. They are being refined in the context of the Dole Act.

So did we have staffing models in place there to determine that we didn't need those 130 nurses? It's more of a yes or no. Just trying to get clarity.

Ma'am, those positions were not removed. Those were not active positions. Those were positions that had not been filled and not had been filled for quite some time.

Jesse Brown last year. So I'm just looking here at some of the reports we got from all of you here. For example, there's 41 nurses positions filled in 2025, six, 25 or 2026 that were no longer filled after. So these were positions that were they had bodies in them prior to the cut of these of these nurses. Yes or no? Did you have people working there? Were there nurses working there?

No.

Okay, well the data says a different... The thing is that I'm looking at the data you provided for me for these centers and so it's inconsistent with what I'm getting from you. So let me let me just wrap up here because I know we only have a few minutes and we want to close this hearing.

And we can take that for the record for further clarification, ma'am.

Yeah, I would appreciate that. So I want to just come back to housing real quick. As you heard me say, I ran a homeless shelter for about nine years of which I had the honor and opportunity to serve many veterans who were experiencing homelessness. And so I just want to wrap up with Section Sections 402 and 403 of the Dole Act, which provided the crucial resources to the VA and community providers who serve homeless veterans. I want to make sure that it's clear that due to the delays in implementing these provisions, homeless veterans and community organizations are having to go without these resources. During the Biden administration, the Homeless Programs Office staff told me and my team repeatedly that it would be ready to swiftly implement the Dole Act, that it would be like turning on a light switch. So it's hard for me to know that we're 14 months in and it sounds like for Secretary Collins, it's going to take over a year to flip a light switch. You know, to me it's a testament to poor leadership that homeless veterans still do not have the resource they need. And sadly, I know there is something nefarious going on that led to the delay in implementation of these homeless sections specifically. The administration, including Secretary Collins, has wielded attack after attack against veterans experiencing homelessness. They've prioritized handcuffs and jail cells over getting these veterans help that they need in place of getting them a home. And look, I believe that the swift and and they're swifting away from interventions that we know have worked to address homelessness, programs like Housing First models. And this administration's focus on programs that have proven time and time again to actually make homelessness worse are are leading the delay that we see here. You see, I see that Collins is actively pushing a stripped-down, ineffective for-profit model of homeless service delivery driven by special interest. Instead of leaving intervention to the experts in homeless program offices, we know that the VA and especially the political leadership meddled in implementation of the Dole Act is getting in the way of these programs that we actually know work. And so instead of relying on the expertise of an office that has housed over 50,000 homeless veterans last year, these political appointees substituted their poor, profit-minded judgment for expertise. The consequence, 14 months of veterans not having access to the housing, transportation, clothing, and food that they need. I find that to be unacceptable. Frankly, I find it to be despicable. These same political appointees are pushing a dangerous proposal to destroy HUD-VASH, the most successful permanent supportive housing program in the history of this country, and replacing it with a poorly conceived program that we know will fail, called BRAVE. And so I want to make sure on the record in the last few seconds I have that I'm going to tell you I'm going to continue to defend our homeless veterans. They shouldn't be homeless to begin with. And we cannot sit here idly watching this administration destroy these programs so that billionaire buddies can get enriched as a result of it. So I look forward to getting an update in the immediate future that the VA has fully implemented the homeless sections of Dole Act and has abandoned the BRAVE proposal because anything less is a disgrace and a disservice to our most vulnerable veterans. With that, Chairwoman, I yield back.

Thank you. And I just want to take a minute to thank the witnesses for coming today. I appreciate the candor in your testimony and your willingness to participate. Implementing the Dole Act remains a top priority of this committee and I look forward to continuing to ensure the VA remains committed to this goal. So thank you all for being here today. And I ask unanimous consent that all members shall have five legislative days in which to revise and extend their remarks. Did you have any concluding remarks, sorry, as well?

I do, Chairwoman, thank you. As I reflect back on the hearing, our first one in over 200 days, I'm struck by some of the answers that were received here. First, Dr. O'Toole, you said that no doctors or nurses were allowed to take the deferred resignation program. However, data the VA has provided themselves to Mr. Kennedy shows that two nurses from Buffalo were allowed to take the DRP last year. You also reiterated that the Secretary's talking point that many of these positions eliminated were not filled in a long time. However, again, the data that's been provided by you all says the opposite. 71 percent of these 26,000 positions were filled at some point since January 2025. So if these were really COVID-era positions, then why were these positions still there? Specifically, I'm thinking about the Jesse Brown Hines positions. Look, I'm glad that we're here. I know that we're going to go ahead and follow up. And I think that the work that we do in this committee is incredibly important because we have to implement every facet and every provision of the Dole Act. 25 of the 72 is unacceptable and I look forward to following up with you to make sure that you take the urgency necessary to implement every single section so that our veterans have what they in fact need and they deserve. With that I yield back.

Thank you all again for being here today. I ask unanimous consent that all members shall have five legislative days in which to revise and extend their remarks and include any extraneous material. Hearing no objection, so ordered. And the hearing is now adjourned.