 Good afternoon. I want to welcome everyone to DAV Service and Legislative Seminar today. I'm Jim Marslack, DAV's National Service Director and I'm joined by Joey Elam, DAV's National Legislative Director as co-host for today's seminar. Today's Service and Legislative Seminar will be a little different than in recent years. We're going to have two parts. The first part will be a conversation with two important VA leaders, similar to the Town Hall format we have had in recent years. The second part will be a little different because we're going to have an open forum for you to ask questions about any service and legislative issues that are important to you. So as you're listening to us interview our VA guest, think about any questions you'd like to ask us in the second part of the seminar. Before we begin, I want to introduce each of our special guests starting with Dr. Clancy. Joey? Thanks, Jim. We're very pleased to have with us today an old friend, Dr. Carolyn Clancy, who's currently VA's Assistant Undersecretary for Health for Discovery, Education and Affiliate Networks. Dr. Clancy has served in a number of senior leadership positions in VA, including most recently as the Acting Deputy Secretary of Veterans Affairs. She has also previously served as Interim Undersecretary for Health and as VHA's Executive in Charge. Prior to joining VA, Dr. Clancy spent 10 years as the Director of the Agency for Healthcare Research and Quality, which is the lead federal agency charged with improving the safety and quality of America's healthcare systems. A general internist and health services researcher, Dr. Clancy is a graduate of Boston College and the University of Massachusetts Medical School and holds an academic appointment at George Washington University School of Medicine. Dr. Clancy has contributed to eight academic textbooks and authored, co-authored and provided invited commentary in more than 225 scholarly journal articles. In 2015, DAV selected Dr. Clancy as the Outstanding Federal Executive of the Year in recognition of her tireless efforts to strengthen and improve access to the VA healthcare system. Please join me in extending a warm welcome to Dr. Caroline Clancy. Dr. Clancy, would you like to make any opening remarks before we get started? Yes, just very briefly, Joy. First, it is really an honor to be here and I'm completely thrilled to be joining you. Listening to the Secretary's really phenomenal examples, what I know all too well is that is a very, very tiny tip of the iceberg of the phenomenal work that goes on all the time. So I wanted to echo his appreciation and thanks to all of you. I know some of you very, very well, like my old friend Ella Bell sitting down front here and I know that it is a never-ending mission, but one that is so incredibly important and never so much before during the pandemic. You have really done an awesome job and I want you to know that on our end, we're doing our utmost and I'll be telling you about that in more detail to match those efforts so that together, everywhere, we can be that other person on the end of the phone saying we haven't given up on you. So thank you. I have one last question. Who's here from New England? Just checking. All right. Just a shout out, home team. Thank you. Thanks, Joy. Jim. Thanks, Joy. We are also pleased to have with us today Mr. Michael James Frew, the Principal Deputy Undersecretary for Benefits who has two decades of experience working at VBA. Mr. Frew was appointed the Principal Deputy Undersecretary for Benefits on February 14th, 2021. He is responsible for administering benefit programs for veterans including education, home loan guarantee, insurance, disability compensation, pension, fiduciary, veteran readiness and employment and transition assistance, and in the 25,000 employee, $130 billion organization. Prior to his appointment, he served as a Deputy Assistant Secretary in the Office of Enterprise Integration where he was responsible for the Department of Veterans Affairs, strategic planning, enterprise risk management, performance management and enterprise governance. Mr. Frew joined VA in 2002 from a private sector career in finance and has led the Loan Guarantee Service Benefits Assistance Service and served as the VBA Chief of Staff. He received the Presidential Rank Award as a Distinguished Executive in 2017. Please join me in extending a warm welcome for VBA's Principal Deputy Undersecretary Michael Frew. Mr. Frew, would you like to make any opening remarks? Yes, thank you. And thank you for the introduction. And I always hate to follow Dr. Clancy because as you can hear from her resume and see what she's done for VA and for American Health Care, she's been very committed for a very long time. And in being here this morning and listening to the speakers, Dennis, starting it this morning and watching some of the videos, it really reinforces the honor that I feel when I made a decision almost 20 years ago to join VA and to do something to help veterans obtain the benefits that they've earned. As Jim said, I started out in the mortgage finance world. And in me, when I first 10 years of my career, mortgage finance was it and was everything. And 9-11 happened, it kind of changed my focus. And I said, well, I can actually use what I know and do something to help the people that serve this country. And as I thought for the first 10 years at VBA, the world of VBA through the lens of a mortgage finance guy is all loan guarantee. And as I moved along and became Chief of Staff and and worked over at VACO and got to know people like your former National Commander, Rob Reynolds, who has spent his lifetime supporting veterans as well. I realized that we have so many different impact points with veterans and areas that we can help. And we quite honestly cannot do it ourselves. We bring a lot of things to the equation. We bring a budget, a federal budget, which is important. And we bring a workforce of 25,000 people on my side and anywhere from 350 to 450,000 on Dr. Clancy's side, depending on how you count it. But we're still not everywhere we need to be and to get to that last mile and to get to that last veteran and to help everyone the way we need. We need all of you. And I really liked what Secretary McDonough said, you want to be the person on the end of the phone call that someone remembers as that person didn't give up on me. And I appreciate that you don't and I want you to know we certainly don't and we've been working together a whole lot the last six months when Dr. Clancy was acting Deputy Secretary, there is a ton of commitment on our side to help. So thank you and I'm happy to be here. Well, thank you. And I'll tell you that Joy and I are so pleased with the collaboration that we've had with both of you and working with both of you has been great. So thank you for being here today. We'll get right into some questions here this morning. This question in particular is for both of you. So as both, you know, one of the most important issues currently before Congress is comprehensive legislation to help veterans exposed to burn pits and other toxic substances. And we want to make sure they receive the health care and the benefits they deserve. Both the House and Senate Veterans Affairs committees have approved comprehensive legislation that would make it easier for exposed veterans to receive benefits, provide them with health care, establish presumptions of service connection for conditions associated with burn pits and create a framework for existing future presumptions. Can you please share VA's views on toxic exposure legislation moving through Congress, as well as talk about other activities and plans of both VBA and VHA to help veterans exposed to burn pits and toxic substances. And we heard this morning the Secretary talk about adding rhinitis, sinusitis and asthma as presumptive conditions for those who served and were exposed to burn pits. So we're very excited to hear that this morning and very hopeful that that passes very quickly. All right, well, I think we'll tag team on this. Yes. And I'll start with a little bit about the nature of presumptives in general. And the Secretary this morning talked about three of the NDAA presumptives that were added earlier this year for Agent Orange Exposure. And and we all think that that is far too long to have to wait to get presumptives added so that we can adjudicate a claim. It's, you know, 50 years in some cases that we're adding. And the NDAA was past January-ish. And we were looking at how can we implement this law. And and I know Congress passes a law, waves their magic wand. We have a requirement to do something. There's a lot of things that have to happen for us to actually implement it and to make it happen. And some of the things that we did in the first few months were decided exactly how can we implement this quickly? What's the fastest way? If we want to implement it with regulations that could take 16 months, 20 months a year. It depends on our two years. It depends on the complexity. So we worked hard to find a way to implement it without regulations. And then we took the added step of going to OGC and ask our general counsel and asking, can we apply the Namer provisions now rather than waiting for several years and finding out that we're going to have to apply the Namer provisions retroactively anyway? One, it's the right thing to do when it will help deliver benefits more quickly. Two, it's easier for us because we're not doing the same work twice and it's it is a lot of work. So we did get approval to do that. So when we announced that we were going to start adjudicating those claims as early as I think June 21st is when we started, we provided the Namer provisions at the same time that we began adjudicating it. And we would consider that in my mind, in my 19 years at VA, lightning quick adjudication, certainly not fast enough, but lightning quick. At the same time, the secretary announced that we were going to start providing Namer provisions to those NDAA presumptives. He announced the framework that he wants to apply to presumptives overall going forward, more specifically to the toxic exposures in Southwest Asia. And in that announcement, he talked about three, and he mentioned them again today, the rhinitis, sinusitis, asthma. And we began the process of a different way of working across the administration's VHA, VBA. And one of the biggest things that we're starting to add to the equation of doing the research that Dr. Clancy's group has done for years on presumptives, specifically Agent Orange, is looking at evidence in different areas. Evidence that we have in VBA from years and decades of claims experience. We always tell people if you don't have a presumptive, please file the claim anyway, because we're going to decide the claim on its own merits. Every single one of those adjudicated claims ends up being a bit of evidence for evidence for us to say this gives us proof that this is more likely than not to be caused by that veteran's exposure. So that is also part of this new framework that we quite honestly didn't look at before. Yeah, so what I'd like to highlight on is something that Mike just said, you know, that the Secretary has really set a new tone and as the Secretary himself said this morning, that really comes from the top, namely the President. And from a scientific perspective, what that means is a sense of urgency about the science. For many years, as I think many of you know, we relied on the Institute of Medicine for regular reports on updating the science, particularly about Agent Orange. And we still rely and turn to what we now call the National Academy of Medicine for the best science. But what we've now come to realize is that's a bit of a reactive mode. You know, we give them a contract and then we just kind of wait for the results to be delivered and so forth. And what we're trying to do now is to take a far more proactive stance. So underneath the three presumptions that the Secretary promised, news you'll hear about any moment, very, very soon that Mike just mentioned, is actually a very forward-leaning look, taking recommendations from the National Academies and actually adding to that a step in leaning forward and towards the veterans. And frankly, we're also looking at our own portfolio and trying to partner with others from the NIH and other federal funders, Department of Defense and so forth, trying to figure out how can we learn more about some of the veterans who've been severely impacted by burn pits. It turns out I did not know this till recently that Nashville, Tennessee, has got a cohort of veterans that they have been following with Constrictive Bronchiolitis, which I know many of you, if you haven't had it, probably are connected to someone who has. And we're going to be looking to see how we can add to that science. But it is not we're waiting for the reports. We're actually leaning forward to try to figure out how can we get faster, better science. Both great answers. And Mike, I like the part we were talking about how, you know, we're looking at what previous claims were filed, what evidence is already in the record to determine whether somebody is eligible for something. And I think that was a big part of the appeals modernization that if a requirement is meant for service connection, that requirement's in effect. And you can go back to that very easily. So that's perfect. And Dr. Clancy, you mentioned the National Academies of Medicine and I have a question about that right now, because also included in a toxic exposure legislation moving through Congress is a provision to finally add hypertension as a presumption condition associated with age and orange exposure. And as you know, the National Academy Medicine and his most recent age and orange report found that there was significant evidence of association between age and orange exposure and hypertension, the highest scientific classification. While Congress is trying to pass legislation, the VA secretary ultimately has the authority to add his own add hypertension as a presumptive. Can you please talk about VA's plans and timeline for making a decision on adding hypertension as a presumptive condition to age and orange exposure? And what are the major considerations impacting that decision? Yes, thank you. And it's a very great and important question. I think the biggest challenge there, which many of you would understand, and I'm not going to ask for a show of hands here, but as we get older, the proportion of people in this country, certainly in many other countries as well, who have high blood pressure increases dramatically. So the question is, can you make a fine distinction that being exposed to age and orange in some way accelerated that or enhance the probability that you would have been joining all of your friends discussing, you know, medications that we take to keep our blood pressure under control and so forth. And that's very tricky business. But we are taking a very, very hard look at it. And all I can say at this moment in time is watch this space. Clearly, in this moment, there is no interest in denying people benefits that they've earned and deserve. But this one is kind of tricky, right, but just because of the background. So we're looking very hard at existing studies following people who served in Vietnam, people who served were not deployed, comparing it to the civilian population who never served, and going over that with a fine tooth comb and seeing how strongly evidence is that that's going to be the crux of all this. Thank you very much, Mr. Fruity, of anything you want to talk about? No, I would say that when it comes to a timeline, the secretary was talking at our local regional office on Friday, which I guess was just yesterday, that seems like a lifetime ago. But he said he doesn't have a timeline. He said as soon as we can is when he wants to start putting disease and consequences of war through this new process that he's created. And this process is comprehensive to VA of examining the evidence that supports a decision for adding a presumptive. Congress always has the ability to do that. And several of the new toxic exposures legislation have hypertension in there for the Vietnam War, so Congress could do that right away. We would like to own the process in VA and in saying he doesn't have a timeline, he says we're putting everything on the table to look at as to see what shows evidence of consequence of war. Okay, thank you. Next, we have a couple of questions on VA health care. Joy. Thanks, Jim. One of the most important elements of modern health care delivery is the ability to maintain seamless electronic health records. Several years ago, VA decided to move from its longtime Vista system to a new system from Cerner and the same electronic health record system that the Department of Defense is using. We, VA began what was planned as a 10 year, $16 billion electronic health record modernization initiative beginning first in the Pacific Northwest and next in central Ohio. The first rollouts occurred largely during the COVID pandemic making it more complicated to train staff and both GAO and the VA Inspector General have reported on problems with the rollout including training and estimating the cost of IT infrastructure. In addition, VA recently completed its 120 day strategic review of the modernization efforts and decided to slow down future rollouts and make some changes. So given the recent GAO and OIG reports and the findings from the Secretary's strategic review, how will VA ensure that the electronic health record modernization effort succeeds in creating a more accurate, timely and seamless transfer of veterans health information between VA and non-VA health providers? Thank you so much for the question, Joy. I cannot overemphasize how important the seamless flow of information is. It is important when we refer veterans to the community. Joy and I were having an informal conversation at lunch about how if that information moved back and forth electronically it would be really speed things up a whole lot. We're not there yet but we will be. And most in particular, and we've heard about this from the Congress for a long time, if we could get seamless flow of information from the Department of Defense, we would actually have a continuous record for veterans, which by the way would probably be very helpful to the science of military exposures and so forth. And in case I forgot that when I was testifying at a recent hearing, a recently retired Executive Director of another major veteran service organization was emailing me to remind me of this point. But it's a really, really important one. If you were to write a script for an initial deployment to not go well, that's what we had in Spokane. Some part of training, for example, depended on what they call at the elbow support. You can't do that as we're starting another surge and we're supposed to be social distancing, right? Some of the trainers were infected during the training period. So we have listened very, very intently to our colleagues at Spokane. And frankly spoken with a lot of external people who've implemented Cerner, who've implemented other records, and have learned a number of key lessons. Number one, initial deployment is always, always painful. So we owe our colleagues in Spokane really an amazing debt of gratitude for having been the first. Second, we believe quite strongly that we need to have a unified enterprise approach to this. I visited with a team, leadership team and others at the Orlando VA yesterday. And I said, you know, under the old model, we were going to be rolling out over 10 years. And you'd sort of look at where you were in the calendar. And they said, yeah, we were 2026. So we were never thinking about this at all. I mean, we're sort of watching, you know, sending notes to people in Spokane like good luck. But other than that, that had nothing to do with us. We won't get the most out of this record and provide the highest quality, highest value care to veterans, unless we are standardizing and making our workflows consistent across the system. That's not how we do it now. For all of you who've heard, if you've seen one VA dot, dot, dot, you've seen one VA, we can't work like that anymore. We had an initial start at that. But what we've now learned as a result of the Spokane experience is that we need to change up training quite a bit. Health care is a team sport. Health care teams need to train together and in some cases with veterans in a simulated environment before we turn on the switch and go live. So that's what we're going to be focusing on. The other reason for my going to Orlando yesterday was to check in with the Simler Center because that's part of my group now to make sure that they are going to be part of this now and into the future. All of us are going to have a lot to learn with each deployment, right? But it's going to be a process of continuous learning. And we have this incredible resource in the National Simulation Center. So that simulated testing environment I think is going to be hugely, hugely important. So it sounds like we are not doing much because the secretary looks forward to making a decision about the next deployments at the end of this calendar year. But in fact, we're going to be making technological deployments just not turning on the switch to go live. And we're going to be conducting readiness assessments. And we will be deploying an order of which facilities are most ready, which I think is exactly the way to go about it rather than tracking after the Department of Defense in terms of their geographic location. And frankly, we're learning a lot from the Department of Defense. They had a very rough start and things are going much, much more smoothly now. So that makes us optimistic. And last, I'll just say what makes me optimistic is that during the pandemic we had to break out of the if you've seen one VA. We had to be an enterprise to respond to veterans. It wasn't easy, but we actually to a very large extent we're able to accomplish that because we needed to. I'm quite confident we will do the same with the electronic health record. Well, we appreciate that. We know how important it is to VA, to Congress. They're holding your feet to the fire, but most importantly to our veterans. And it's of the veterans' health care system. And I know everybody really wants to see that succeed. And we want to see it move forward, but do it right. So I also have a question about VA's physical infrastructure, another really important topic of the day. As you know, VA has more than 1,100 outpatient clinics, over 170 medical centers with an average age of over 50 years old, yet for more than a decade the funding requested and approved has been far less than what's really been necessary to properly maintain VA facilities. For these reasons, DAV and other VSOs have worked with Congress to develop legislation that would lead to a more comprehensive plan to modernize and expand and perhaps realign some of VA's health care infrastructure, which was approved as part of the Mission Act. Can you give us an update on the Asset and Infrastructure Review or AIR initiative that is underway, including the status of the commission and market capacity assessments? And what should we expect from the AIR process over the next couple of years? Great, great questions. First, for any of you who provided feedback or input along the way, really, really appreciate it. And if you haven't had your opportunity yet, I can almost guarantee that you will, because the secretary is really committed to doing this in a very transparent way. This commission is all about VHA physical infrastructure, but it's not just about that. It also, by definition, is about how health care is changing. So the kinds of situations where when I was training, we would admit people to the hospital. We don't do that anymore. I mean, every day I'm learning about new procedures or old procedures that are being done on an outpatient basis, which just kind of blows my mind, right? When I was training, if you were having your gallbladder out, let me tell you, you were in the hospital for a week. This probably wasn't very good for you. And you were out of work a good six weeks now with new technology, right? This literally is a day procedure. That doesn't mean you're instantly better, but it is way, way different. And there's so much more now that can be done outpatient. And frankly, during the pandemic, right, we're providing so much care virtually, not that the Congress could have known this in 2018, but it does make you learn or think, reflect on what does physical infrastructure mean in a context when we can do a lot of work virtually. And frankly, what that means to me is that we can organize our care and services around veteran schedules and their needs rather than how we like to do business. Now, that's looking a little bit further out. In order to fulfill this legislation, we've been conducting a series of market assessments, trying to figure out what's going on in the private sector. Where might we partner? Where are veterans moving to, right? A lot of veterans moving to warmer climates. It's fair to say that our track record in terms of constructing new facilities would not actually get us called up to Sweden, I'll put it that way, to win big prizes and so forth, often delayed and so forth. And then the other question is, like we saw in Manchester, New Hampshire, are there opportunities to share space, right? Where VA might be using dedicated space in a private sector building, but where there would be a front door that effectively says this is for veterans only. Where they would have VA providers providing the care that otherwise would be provided in one of our facilities. This will be interesting business, but even before he was confirmed, the secretary made it really clear that he wants this to be as transparent as possible. The law specifies commissioners who need to be approved by the White House, but then nominated and confirmed by the Senate. So that's gonna take some time. Spent a lot of debate happily, a number of individuals who are enthusiastic about serving. I couldn't begin to tell you where they are in the process right now, but that's what the requirement is going to be all headed towards their getting down to work in January of 22. Not that far away. At one point in time it felt like an eternity when the law was first passed. But I think the big, big features here are that healthcare is changing itself, right? Where veterans are moving in the demographics of the populations we're serving are changing. And what post pandemic new normal looks like in healthcare, I think requires a crystal ball that is not all that clear to anyone right now. So what that says to me is that the input of veteran service organizations is going to be absolutely vital as we move throughout this process. Thank you for that response. I know you'll share with the secretary that DAV has been absolutely, supportive of dealing with the situ. It's been a long, long issue that hasn't been really fully addressed. And we just wanna make sure that that veterans healthcare system and all that that offers and means with the research and the really focus on service disabled veterans and the unique care and services that they need that that's gonna be remaining. And for well into the future generations for all of us that come next. So we appreciate that. Jim, I know you have more benefits questions. I'll try to answer. Thank you, Joy. Mr. Frew, in recent years, both the VBA and the board have seen their pending backlog slowly rising, a trend that was significantly accelerated by the COVID pandemic. Since last February, the number of disability compensation claims has more than doubled to around 188,000 while the number of board of veterans appeals hearings rose to over 90,000. What are VBA and the board doing to reduce the growing backlog of claims and appeals, including hearings, in order to provide veterans with timely and accurate decisions on their claims for VA benefits? Well, thank you for that. And in thinking about that, I want you guys to know that backlog is probably the one number that I hear to describe everything that VBA does the most and to have everything you do reduce to one number is kind of, it's tough to look at, especially as a mortgage guy that said, hey, we're running this loan program and it's great and we're delivering hundreds of billions of dollars of loans. And everyone says, but you have 600,000 claims and backlog. And I say that to set the stage that in 2010, when the original Agent Orange presumptives came out, we went from no definition of backlog, so unknown to about 611,000 claims and backlog. And we worked nonstop. There's people whose entire career at VBA were spent at the political level, building systems to deal with the compensation claims and how can we process these claims faster? If we're gonna do 15 things on a claim, we wanna do 15 things faster than we've ever done it before. And we started ingesting information around the country, ingesting claims folders that sit physically in office space around the country. And it was very nice to go to Ms. Boer's RO in St. Petersburg yesterday because one of the rooms that held all of their claims files before the last time I was here is now beautiful offices that people use to work in because we no longer have those claims files. But digitizing the claims files and going to federal record centers and ingesting federal records was essential for us to get faster at processing claims. And all of that work over the years, 10 years ago, brought the backlog down to about 70,000. And it was 70,000 at the beginning of the coronavirus pandemic. And that's what we would call steady state. The number of claims we get in, the number of claims we get out, 70,000 is pretty much a working zero inventory for us. So the pandemic hit and what we saw was we were ordering exams to the tune of about 100,000 disability exams every single month. When the claim, when the pandemic hit, we stopped seeing patients in person at VHA medical centers. We also ordered our private contract doctors, the due disability exams to follow suit with VHA. We had two months of no disability exams. And before we started that up in a sort of a slow progression as the CDC and evidence showed that we can open it up. So at 100,000 a month, that immediately shot our backlog of evidence to decide a claim by 200,000. At the same time, NARA, which holds most of the federal records that we get from the National Personnel Records Center and other federal records centers, they also closed and they were slowly allowing access to records over time. So the two primary sources we have to get evidence to decide a veteran's claim were either stopped or seriously slowed. And that caused a bubble of two months that we're still seeing today. So when you say we're at 188,000 claims in backlog, that's totally true, probably about 186,000 when I looked at it yesterday. And at 186,000, that's actually down from 220 or 210, which is what it was when I first returned to VBA about six months ago. And the reason it's coming down is we're starting to order a whole lot more disability exams. I've been working with Dr. Stone, who was acting under Secretary of Health, and Dr. Lieberman to see what capacity we can pick up in the VHA medical care system around the country as they stop providing so much COVID support and actual healthcare and support of the nation's response to COVID. As we start to get more into the delta variant and we're seeing the challenges on some of the healthcare systems and I can't describe them, that's more of their world. But we know that's an issue that we're probably gonna have some areas where we're not gonna get more support in VHA for medical disability exams. We're reaching out to our vendors and we're impressing upon them the need to expand their network. Please find more providers that you can use to see veterans and to help us deliver our mission to veterans. So we're trying to amp up our ability to generate disability exams. And we've gone from, well, from zero about a year ago to now on a very, very good week, we'll see 50,000 exams completed within a week. Average probably just under 40. So we need that to go up and we're gonna continue to drive that up because as we propose three new presumptives for Gulf War toxic exposures, we know we're gonna need more exams. The other thing, there's two other things that we're doing. One, on federal record space, we are trying to help NARA help us. They had a challenge where they closed their federal record centers and they're slowly opening them up for their personnel to come in. Part of it was they couldn't bring in enough personnel to work close to each other because of distancing guidelines for social distancing. So we worked with VHA to help vaccinate the personnel at the National Personnel Records Center so they could come to work. We provided our staff to work shift work at the National Personnel Records Center to actually locate files, pull files from the shelves so that they can send them out for scanning so we can use them to adjudicate our claims. That's a twofer for us, for the federal government, because every file we scan from NARA, we use it ourselves and we give it to NARA for use for future inquiries. So if any of you go online to the National Personnel Records Center, say I'd like to get my DD 214, or like I did, I want my grandfather's DD 214, or my father's, now if we've already pulled the record, they'll have that digitized and they can send it out right away. We're putting that up on our mail portal, which is where we scan all of our daily mail. We've scanned all of their 500,000 or so pieces of inquiry that come in to say, please give us this record. They have that in a work queue. They also have access to the scanned files that we have. So we're sort of doing two for one as we go locate files and we scan them. Not only do we have personnel at the NPRC, when we pull a file up until last week, we would take the file, put it in giant pallets, shrink wrap it, send it out somewhere to scan it, and then bring the file back for storage. Now we've put high capacity scanners in the NPRC, so we can actually scan the same day that we pull the file and they get the file back in a record center. Someone's got to keep the files. We have system of records for the federal government. I hope it's like the end of that movie, was it Raiders of the Lost Ark, where they put that box on a shelf somewhere and no one ever sees it again because we don't ever need it. And I guess the third aspect about gathering more evidence or deciding claims to get our backlog down is we need to find ways to not order exams and to not need evidence. So part of our desire to scan records from the NPRC and federal record center, when what we've learned from when we get a request and we need to get a file is if we have the information, it's faster. So now we're actually starting to scan records we don't get requests for. We're, yeah, my image is park a giant scanner over the NPRC and scan the whole building. And if we get enough funding by next year, we will have every federal record in the NPRC available for any veteran, any dependent of a veteran that's filing a claim to have access to as soon as they file. We're looking at the types of claims that people file and say one of the advantages of an EHRM is that seamless data flow from DOD to VHA also comes to us. And if we can find evidence in that seamless data flow that says, here's what shows the condition that they're claiming, why do we need to order an exam? So we're trying to find ways to leverage the telehealth that VHA really, really was able to capitalize on this last year. I think the secretary said 45,000 encounters now a day. Yeah. That same technology we now use on the disability exam to do virtual disability exams when we can. We've leveraged it in other ways in VBA, but that's one primary way that we've done it. And we have the other thing where we look at available clinical evidence. That's where we don't need an exam at all. Let's look at what we have and try to make the decision. All of those combined will help us, but we still have 188,000 now. We would like to have zero. I'm not happy that it takes longer than we want for a claim to be adjudicated. My dream state would be veteran files a claim. We know instantly what we need to get. We either have it or we don't. We can find it and get it. And then we're ready to make a decision within a few weeks rather than within four months. Well, I do want to credit you and your team. I think bringing back disability benefit questionnaires to the public and allowing them to use them. And when they file a claim with those completed, typically we're able to get a decision very quickly where an exam isn't necessary. So kudos to VBA for bringing them back. How do you think VBA will handle the expected surge of claims based upon the new three age and orange presumptions? That's a very, very good question to follow the last one. One, we're scared. I don't think there's any better way to describe it other than that and coronavirus pandemic response and what we're gonna do. We thought as we're working out of it, probably the two things we've thought about the most since I've returned to VBA. Our new deputy secretary who unfortunately replaced Dr. Clancy in that role, I briefed him before his confirmation hearing and said, here's VBA 101, here's what we do. And of course I talked a lot about loans but I got to the end and said, if you remember anything about today, remember toxic exposure, because that is gonna be the drum beat that we're gonna go to going forward. So for the three presumptives that we've announced several months ago and the secretary mentioned today, for those three looking at our data, we know that we expect about 350,000 exams in the first year and another 200,000 exams in the second year. And of course that's an estimate and people often prove us wrong. It's just a guess, our guess based on data. But if we get 550,000 additional exams in the next year and a half, that's gonna look at our 188,000 backlog that's gonna go up. I like to say that VA and all of my time at VBA, we get better every year. And of course if you're not moving ahead, you're gonna fall behind as the world goes past you, we should improve every year. And for maybe a dozen years in a row we've decided a million claims a year. And it goes up, so 1 million, 1.1, 1.2, fantastic. We can pat ourselves on the back and are very proud of the technology and the work and the people that go into all of that. The problem is that veterans are getting faster too. And when we decide a million claims we get 1.1 million claims. Last year I think we decided a record 1.3 million, 1.35. We got over 1.4. That's not a ratio that's gonna help us stay ahead of the curve. And looking at another 550,000 claims that can come in is going to add to that. If we look at the toxic exposure legislation that the Senate has introduced or the House has introduced, that's a lot more claims in the order of millions more claims that are gonna come in that we have to adjudicate. So we have to find ways to do what I was talking about earlier. How can we adjudicate a claim without ordering exams? If we're gonna order an exam, veteran files a claim, it eventually routes to a person that develops it and says we need to order one exam or six exams. The exam order goes out. Then you have to schedule between a doctor and a veteran. That could be another three, four, five weeks before people have time to get together and their schedules connect. Then that happens, we get that evidence and we find out, oh, we need more federal records. So we'll order that. All of that goes into the backlog. 125 days is actually infinitely small, it seems like, when you're trying to take a month of it to schedule an exam and a month to order federal records, it really makes it seem like there's not enough time. So we've gotta take advantage of not taking that time at all because we don't need it. And we're really exploring options of beefing up an area of VBA that will only explore ways to accumulate that evidence and have that evidence ready at the time of claim. So we don't need it to go to someone to pull evidence or to decide what do we need. We want the claim to go from veteran hit submit or VSO hit submit. Raider gets everything they need to make a decision. And if they think they don't have everything, then we can go gather some more. But we know that there's giant groups of claims that we can put into this type of process and have very accurate, very deliberate results that will provide an avenue for us to not have to look at 500,000 claims in backlog at some time in the future. Yeah, I mean, you mentioned that over the years it keeps getting better and better and VBA's deciding more and more claims. And a backlog claim for the audience knowledge is any claim pending more than 125 days. And when I first started with DAV 20 years ago, it took a year to have a claim decided. So it certainly has gotten a lot better and there continues to be improvement. And something that I wanna talk about a little is working together the collaboration, VBA and VSOs were able to agree upon a new way to ensure VSOs can quickly get clear claims errors corrected, which we call the claims accuracy request which is a pilot right now. Just wanna see if you wanna talk about that a little bit and I know we've worked together on that so. I am so glad you brought that up because to me that epitomizes why we need each other and how we can work to deliver a better consequence and outcome for the veteran. Secretary talked about a couple of things. The VA's four principles of operation now are excellence, access, outcomes, and advocacy. I look at VBA as access. A decided claim adjudicated in favor of the veterans provides healthcare for the veteran for that service-connected disability. Anything that we can do to expedite that process provides that care more quickly, which is good, provides financial income more quickly, which provides income security and food security and house security, many, many things that are good for that, but sometimes we make mistakes. And when we first started our electronic systems to adjudicate claims, which for those that don't know we call VBMS and every system we have starts with a V so you can just get used to that. But when we started it, I would go out to different state ROs, and every time I visit an RO I would visit the VSOs that are almost always co-located in our offices. And when we rolled out the ability to deliver work electronically to our workers, we also eliminated the geographical dependence of a veteran in North Dakota is only gonna get their claim looked at by a VBA worker in North Dakota and every other state. And that has positives and negatives with it. From a DC perspective, it's all positives. I can move work around where there's people. It's easier to move work than to move bodies. I can hire up over time in an area, but I can't instantly hire up if a lot of veterans file claims in a state and instantly hire down in another place. So moving the work helped us, but all of the VSOs said, Mike, we want to be able to go take this claim where we see there's definitely an error and go talk to the person that decided it. How can you get that toothpaste back in the tube and let us do that? And we said, well, there's really no easy way to do it. We don't want to not do national work. We want work to be able to go where it's needed. And we've had a lot of discussions over the years. How can we get back to where you, as a representative for a veteran, can help us get to the right answer? And we hadn't really solved it or found a method to do it until earlier this year where a lot of VSOs got together to say, here's the problem. We got together and said, we're open for ideas for a solution. And we came up together with an idea for when we can, how VA can present a claim that's already decided to your representatives so you can provide input if you see an error. We used to call it the 48 hour rule. And the 48 hour rule basically means we make a decision and we put it in the chiller for two days. And in those two days, the VSO rep can look at it and say, good, not good. What we found is almost 100%, a very, very tiny fraction of those claims were actually not looked at, but decided there's something wrong. So we were stopping every claim for a few claims that were incorrect. So as we started to figure out a process together, we said, well, we don't want to stop every claim. And if it happens to be the end of the month and you hold it for two days, every one of those claimants won't get paid till the end of the next month. We certainly don't want to do that. So we found a way to say, how can we communicate faster? How can we do this together? And the nice part, and Tom Murphy, our acting undersecretary, said to everyone in the room, this is the first time I've seen this. We're building this process together. It's not VA telling you, here's a new system that starts with a V, put in your cat cart and figure out how to use it and we'll train you a bit and all of that. They said, let's figure this out. How can we give you the ability to stop a bad decision? So we're in the middle of a pilot of something we call CAR, the Claims Accuracy Review, in it of all of the claims that the VSOs, and we're even using the attorney reps as well. They're in the part of this process as well of all of the claims that they've identified that have a clear and unmistakable error, 87% of those identified were correct, correctly identified as wrong and we fixed them right away. And instead of stopping 100% of claims from going out, we've actually gone out with 100% of claims and fixed the ones that the VSO reps found were wrong. And to me, that's as good a testament of how this works as I can find. You're using the process to clearly identify things that are clearly wrong. We're able to fix it. And by the way, we can fix it in less than 10 days. Yeah, we're using the new AMA process to adjudicate, to take that input and say, okay, here's new evidence, we are gonna change it right now for you. So we're three months into it, four months into the pilot, the pilot is ending, we're absolutely going to implement this. But there's ancillary part or corollary to this in that not being in the office with the veteran who filed the claim and the service center managers adjudicating the claim, we have a lot of communication issues. We're coming out of a year and a half of nobody going into the office. Yeah, I was very proud as of about three weeks ago, all of our offices are open, VSOs can go in, you can meet with veterans, we have public contact, the board is having hearings. So that's good, but it is not normal operations in terms of people coming to work every single day. We've got mail for the last 16 months for VSOs that has piled up in our ROs and we're trying to find a way to one, stop the mail from coming in to get the information to the VSOs. As a corollary to the CAR project, we actually now have veteran notification directly to the VSOs. So you get the information that you need, we don't have to print it and mail it and have it sit somewhere that's not working. I just checked on Friday, that was supposed to go live Friday. So I haven't had a chance to check. I don't know if anyone in the front row has heard whether it's out, I think we'll find out next week. But to me, that's a win between you and us working together to get something good for the benefit of our veterans. The collaboration there where we got everybody together and talked about what it is that we actually need and that electronic notification piece is significant for all of the VSOs that we're able to access that information and be able to determine what's happening with any claims that we provide representation for. I think the other big part of the CAR process is 10 days. We're able to get a decision to overturn within 10 days if there's a clear error on it. So we certainly appreciate that collaboration and are glad to hear that we're looking forward to implementing that fully. Joy? Dr. Clancy, this one's for you. As you know, DAV has been a leader on women veterans issues. How will VA ensure that women and minority veterans have equitable access to VA benefits and healthcare services, as well as robust gender-specific care and other services targeted to address healthcare disparities affecting underrepresented health populations? What a great, great question. Joy, I know that you are pretty familiar with our Office of Women's Health at VHA and our leader there, Dr. Patty Hayes, is utterly relentless. I've said this before, I'll say it forever. Frankly, watching her leadership had a lot to do with my joining VHA almost eight years ago because I was just truly inspired. No hills were too tall to climb and so forth. The linchpin, and there's a lot of legislation that affects this, are making sure that women get high quality care in a timely way and that they feel welcomed and not harassed when they come into our facilities. Are we done? No, but we have been working very, very hard on the harassment issues. For example, the Office of Women's Health issued a podcast called, She Wears the Boots. All trying to change the cultural expectation so that when people say things that the receiver feels harassed even though they may have been intended to be more benign than that, that you judge it by the platinum rule, right? It isn't treat others as you would like to be treated, it's treat others as they would like to be treated. That is really the cultural change that we're undergoing. For the healthcare piece, the foundation is having access to dedicated women's healthcare providers. Right now, all of our medical centers have at least two, which is great, and half of the community-based outpatient clinics have one. We are not gonna stop till at least 90% of those clinics have one so that women don't go into these clinics and then be told, well, you have to go to the main medical center to get what you need and so forth. We're also making sure that women have the choice of a dedicated PAC team, which includes not only the dedicated women's healthcare providers, but access to gynecological care on site. The Orlando VA, where I was yesterday, turns out to have a very high volume of women veterans relative to other facilities. And I'm just gonna tell you they're rocking it. I mean, they keep making improvements, they have a whole health person in there, mental health providers as well. So it makes coordinating all that care far, far more effective. I'll also just mention the Deborah Sampson Act, not the least of which is Deborah Sampson was from Massachusetts, which I'm embarrassed to say, I just learned recently. But that also calls on us to make sure that we address these cultural issues. And we are also going, making a big push on looking at disparities in access and quality associated with race, ethnicity, gender, and so forth. I think we've made big steps there. If I looked at numbers, I would tell you that in many ways we are doing better than the private sector. I don't care, we need to do more because we need to make this part of the fabric of what we do every day, that it's not an extra credit kind of thing, but it's actually part of the main show. Finally, I will just note that the Deborah Sampson Act has the Office of Women's Health reporting directly to the Undersecretary for Health, which I think is a fine move. So I think that we've made a lot of progress in the past several years, knowing Dr. Hayes and frankly, the growing number of senior leaders in VAJ who are themselves women, I'm very optimistic. But I know how much DAV has done on behalf of women veterans, so I fully expect you to be in our face if we're not doing as well as we aspire to. So thank you for all of your hard work. Thank you for that response. You touched on it regarding the work that's being done both by the secretaries of VA and DOD on this dealing with sexual harassment and assault within the two departments. And could you give us an update on the plan that's being developed by VA to ensure that the department has a system-wide culture of zero tolerance for sexual harassment and assault. We know that's so important. So many women veterans going to a medical center or minority veterans tell us that they feel they've been harassed in some way and that that's deterred them from getting the care they need. So we know how committed the secretary is to that. And I know that he's working to form an internal work group somewhat like DOD did for their independent review. So we're very curious what the progress is on that and what you've heard, how this secretary may be going about this. First I have to say within the first week of being sworn in, the secretary and I and so a few other key VA leaders were invited to participate virtually in Secretary Austin's listening session with survivors of MST and people who'd experienced sexual harassment. And I will say this was a tough conversation, lasted a couple of hours. Out of that grew an idea for sort of a two-pronged approach. One is that VA needed its own task force which has been working diligently. And the really good thing about this is it's not like it was a tough sell. The tough sell was that there were many people across the organization who were knowledgeable, dedicated, quite passionate about the topic but they didn't know that others were working on it as well. So this task force has really pulled a lot of people together and you will be hearing announcements from us very soon about that. The second part was that we had Kayla Williams who's now a veteran herself and participating in the DOD task force which recently issued its report. What I've always worried about since talking to some women veterans who experienced military sexual trauma themselves was that they felt that in some ways in trying to come to VHA for care that they were re-traumatized and re-experiencing that to me is a nightmare and without discussing this with the secretary he expressed a lot of concern about the very same issue so clearly he had been listening to VSOs especially DAV and others on this topic. Again this is not going to change overnight but we are making a big push. I've had a number of people asking me for these white ribbons and I'm looking into how much of a supply we have back at the ranch and I've got your cards and on the MST front VBA has made a lot of changes which are really, really important and I wouldn't speak for Mike but having referring those claims to people who've got specialized expertise as you heard this morning and ultimately the end game here would be to prevent that trauma to begin with but as an initial first step we certainly have to make sure that women veterans when they come in to us for assistance are not re-experiencing that trauma. Thank you. As you said that's such an important issue for so many of our members and we look forward to the continued progress but it was clear that the secretary is very committed and it was so good to see that he is collaborating with the DOD secretary as well. Jim I know you have a few questions on the budget so hopefully we have time for that. Thanks Joy, we have time for one more question as for the both of you so as you know DAV, Paralyzed Veterans of America and VFW produce an independent budget each year which contains recommendations for VA funding levels necessary to provide veterans with all the healthcare and benefits they've earned. In June the administration released its full VA budget request and after reviewing it the DAV and IRB partners said it had fully enacted, if fully enacted it would fully fund veterans programs, benefits and services for the time for the first time in a generation. Can you please share some highlights of the president's budget proposal for VBA and VHA and what do you see as VA's most critical resource needs over the next few years? We'll start with VBA. The 22 budget includes a mandatory advance request for FY23 for VBA for $155 billion. In fact the secretary last night said Mike you're getting $150 billion to deliver to benefits and think for those of you that don't know almost all of that goes out in compensation benefits to veterans. I think we were about $130 billion this year in compensation benefits by the end of the year. We'll break that by the end of FY21 but most of this is going out so the bulk of it will go out in compensation checks. The next largest number, $12 billion or so this past year was for education benefits. So post-9-11 GI bill, that is 95% of how we spend our money. The rest we have a little bit around the edges with discretion as how many people do we hire. We have empty offices they could work in if they came to work. We've got systems that start with the V that we build that help us get our work done. All of that's very, very important. So we've got some focuses in the future and the top focus is toxic exposures and how we're gonna deal with that and we're setting money aside that will help us with that for scanning number one. Like I said if we could park a scanner over the NPRC and do like the old fashioned copy machine and copy it that will cost us a few hundred million dollars. So we're putting some money into the scanning aspect of it which will allow us to adjudicate claims quickly. Another part will be in suicide prevention and activities we can do to connect in a caring way with veterans early. We own transition for the Department of Veterans Affairs. So we build the tap course for veterans at transition and we're pushing more information in different ways for veterans that are going through transition. We talked about women's health. We actually have a new women's health transition training that is in some parts optional and in addition to tap but available during tap to start the process of educating female service members what they can look forward to when they become female veterans and need healthcare for the veterans. So in addition to the suicide prevention and scanning, another big thing we're pushing for are rapid training programs. Like there's a program called the VRAP, Rapid Retraining Assistance Program that came out of the latest COVID Act bill that gave us $386 million to create a program to help rapidly retrain veterans who lost their jobs due to COVID. And this is instead of a four year degree or a two year degree think certificate program that takes three months or six months. You wanna become a licensed technician in something. It could be in computer code. It could be in the technical field, a hands-on field. It's Department of Labor publishes all the high demand jobs that are there. We're supporting that. We're starting to gather some more evidence on good outcomes of the education program. And a lot is pointing to these rapid retraining programs as one, short in duration and two, quick to lead to sustained employment. So we want to double down on that. I think that's the highlight for us for the next budget. Yeah, so I think as you heard, we all heard from the president this morning, this really, really starts at the top and the fiscal year 22 budget includes resources to support priorities for veterans health care that I think all Americans support. One is timely, high quality care for the 9.2 million enrolled veterans, preventing veteran suicide with additional resources for all of mental health, including just under $600 million for expanded suicide prevention outreach, right? That phone that's gonna be ringing could be ringing anywhere. And we need to use as many allies and partners as we possibly can. And now we've got resources to do that. Continued work to eliminate veteran homelessness, supporting caregivers, 1.4 billion, all funding sources for the caregiver support program. As we were discussing a few minutes ago, improving support for women veterans, a total of 8.4 billion, including a little over $700 million for gender specific care so that women don't have to be referred to the community for care that we can provide on site. And that to me is very, very exciting. Additional support for research on toxic exposures and traumatic brain injuries and so forth. In addition, these are not just like, let's make up a big number, right? We have to be mindful of the impact of the pandemic on veterans and their families, right? And one of the issues that we're very, very worried about is deferred care. Obviously very early when we were all in total lockdown, we were worried about our employees being exposed and we were worried about our veterans being exposed to other veterans and so forth. And we learned a lot. So as you heard the secretary say, we're not going back to the old normal. We're actually gonna be building on what we learned. The deferred care piece, I think is gonna be very, very interesting. We've used the best actuarial models we can possibly find out. There's a lot of, for example, cancer screening that did not happen across the country this past year, not just in VA and lots of other places because veterans were understandably a little shy about coming in and worried if they might be exposed and so forth. Plus, as you all know, we've had some stops and starts, right? First three months of March, April, May of 2020, va boom, right? And particularly in some very high hard hit areas. And then we started our reopening plan and then we got hit again. And hard to know where we're gonna be going with the Delta variant, but we are doing everything now to pre-position to be ready for that potential impact of deferred care. And this budget will allow us to do that. So we're very grateful for all the support to put it mildly and I wanna assure you that we will be making the most of those resources. Well, thank you. Thank you very much. So we are about out of time for part one, but I wanted to give each of you an opportunity for any final remarks if you have any final comments. Dr. Clancy? I wanna emphasize this point about not going back, right? We've seen some steady improvements since we had a pretty substantial access crisis 2014, 2015. We're gonna be redefining access and frankly greater reliance on telehealth and virtual strategies, which by the way isn't just primary care and mental health. Increasingly, it's about rehabilitation. Some of our colleagues in New Jersey I learned recently are trying to figure out if you can do acupuncture virtually, which feels amazing. Wait a minute, veterans don't have these little tools at home, but they're testing out using acupressure because they couldn't do anything else and some veterans report positive results. We'll see that's not quite the same thing as evidence, but many, many parts of rehab we're using virtual platforms for as well. So integrating that and making sure that access is about timely care, but also that we can coordinate and make all the pieces work together. If you need care from the community, fine. But we've gotta be very, very clear that that piece happens in a timely basis, that the information comes back and that we have a prime role, working with the veteran as a partner to make sure that that care is as seamless and coordinated as possible. So I think this is the vision I've always heard from disabled American veterans and working together, I'm very, very optimistic about the future. I mean, you heard the current secretary this morning, he's pretty relentless and also very, very transparent about where we're making progress, where we need more help and so forth. So I'm extremely excited about where things are right now. Excellent, thank you, Dr. Clancy. Mr. Frue? I think one thing or thought I'd like to leave you with is the word that I've used more the last two months than in my entire life and that's resilience. And one thing I've seen in coming back to VBA is the evidence of an extremely resilient organization. And it's an organization that's not just VBA, it's trends over to the health administration and NCA and all of our VSO important partners as well to say, how are we gonna keep doing this important mission of providing benefits and services to veterans when the world is very different than it was before? And I would say that a lot of the things that we talked about, things that we've done in VHA to increase access to electronic records and deliver that to us, whether it's Vista or the new EHRM, the work that we've done before to scan the world basically and give it to us and prepare our work to be sent to workers all around the country. If we hadn't done that before, we would have not been sitting here in July or August now of 2021 with anything like the track record we had. We would have had people coming to work to get giant files of folders to bring them home in a lock box and work on them one at a time and then fold them up and lock them and bring that back in if we could have even done that. We wouldn't access medical records across the country from people on one side of the country doing the work to a veteran that lives somewhere else. We are in such a good spot to help us be where we are, even though it's been a rough year, even though it's taken a lot of creative thinking and a lot of effort from people in ways that we didn't anticipate, we've all come together to do it. So when I look ahead, say I don't even care what's in front of us because whether it's a million claims for toxic exposures whether the Delta variant throws us another loop and we're gonna have to figure out what happens, I know that we're gonna figure it out. I know that we've got the tenacity and the work ethic and the brain power to get it done and I know we've got an ecosystem with people that will always step up to the table. They will always answer the phone. They will always show up with a car to drive someone to an appointment or send food to people that don't have food and find a way to meet that veteran on the bridge to Juarez. Like I said the other day, how do we make something happen and we do it by starting the process of trying and then figuring out where we have resources and if anything I've learned in this last year and a half is we figured that part out and if we could do it in this last year and a half I'm not concerned about the future. All right. Can I make one additional point? Absolutely. You heard the secretary about vaccines and how many deaths from here on out almost all are preventable if they get the vaccines. Just making a pitch to those of you who may have friends, colleagues, family members who are what I would call in a pre-contemplative state with respect to getting a vaccine many will hear from you very differently than they will from healthcare providers, from VA, from anyone else. So you never know when the right kind of encouragement will make a difference. So I would implore you to use the same energy that you use to help disabled veterans to help some of your colleagues and friends at a difficult moment in time for our history. Thank you. Thank you. On behalf of Joy, myself and all of the DAV I want to thank both of our guests for joining us here today. We look forward to continuing our work with you to strengthen the VA benefits and healthcare for veterans, their families and survivors. Let's give them a big round of applause.