[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
WOMEN, RURAL, AND SPECIAL NEEDS VETERANS
=======================================================================
FIELD HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
APRIL 21, 2008
FIELD HEARING HELD IN SANFORD, ME
__________
Serial No. 110-84
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois GINNY BROWN-WAITE, Florida
MICHAEL F. DOYLE, Pennsylvania MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada BRIAN P. BILBRAY, California
JOHN T. SALAZAR, Colorado DOUG LAMBORN, Colorado
CIRO D. RODRIGUEZ, Texas GUS M. BILIRAKIS, Florida
JOE DONNELLY, Indiana VERN BUCHANAN, Florida
JERRY McNERNEY, California VACANT
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
PHIL HARE, Illinois JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania HENRY E. BROWN, Jr., South
SHELLEY BERKLEY, Nevada Carolina
JOHN T. SALAZAR, Colorado VACANT
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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April 21, 2008
Page
Women, Rural, and Special Needs Veterans......................... 1
OPENING STATEMENTS
Chairman Michael H. Michaud...................................... 1
Prepared statement of Chairman Michaud....................... 42
Hon. Jeff Miller, Ranking Republican Member...................... 2
Hon. Thomas H. Allen............................................. 3
WITNESSES
U.S. Department of Veterans Affairs, Brian G. Stiller, Center
Director, Togus Veterans Affairs Medical Center, Veterans
Health Administration.......................................... 35
Prepared statement of Mr. Stiller............................ 62
______
American Legion, Department of Maine, Donald A. Simoneau, Past
Commander, and Member National Legislative Council............. 22
Prepared statement of Mr. Simoneau........................... 53
Disabled American Veterans, Department of Maine, Joseph E.
Wafford, Supervisory National Service Officer.................. 28
Prepared statement of Mr. Wafford............................ 59
Doliber, Dana, Sanford, ME....................................... 5
Prepared statement of Mr. Doliber............................ 42
Hartley, David, Ph.D., MHA, Director, Maine Rural Health Research
Center, and Professor, Muskie School of Public Service,
University of Southern Maine, Portland, ME..................... 16
Prepared statement of Dr. Hartley............................ 52
Maine, State of, Bureau of Veterans' Services, Augusta, ME, Peter
W. Ogden, Director, and Secretary, National Association of
State Directors of Veterans Affairs............................ 10
Prepared statement of Mr. Ogden.............................. 44
Maine Veterans Coordinating Committee, Waldoboro, ME, Gary I.
Laweryson, USMC (Ret.), Chairman, Commander, Military Order of
the Purple Heart, State of Maine, Judge Advocate, Marine Corps
League, State of Maine, and Aide-de-camp to Governor John
Baldacci....................................................... 12
Prepared statement of Mr. Laweryson.......................... 47
Maine Veterans' Homes, Augusta, ME, Kelley J. Kash, Chief
Executive Officer.............................................. 14
Prepared statement of Mr. Kash............................... 48
Veterans of Foreign Wars of the United States, Department of
Maine, James Bachelder, Commander.............................. 23
Vietnam Veterans of America, Maine State Council, John Wallace,
President...................................................... 26
Prepared statement of Mr. Wallace............................ 56
WOMEN, RURAL, AND SPECIAL NEEDS VETERANS
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MONDAY, APRIL 21, 2008
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:03 a.m.,
Sanford Town Hall, 919 Main Street, Sanford, Maine, Hon.
Michael Michaud [Chairman of the Subcommittee] presiding.
Present: Representatives Michaud and Miller.
Also present: Representative Allen.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. I would like to call the Subcommittee to
order. I would also like to ask unanimous consent for Mr. Allen
to sit at the dais and to be able to ask witnesses questions.
If there are no objections, it is so ordered.
I also would like to thank Sanford, the folks at Sanford
Town Hall, for allowing us to use their facility today. I
really appreciate it. Veterans' issues are extremely important,
and this definitely will give us a venue so we can hear from
our witnesses today.
I also would like to recognize in the audience Mike Aube
who works for Senator Olympia Snowe's office, as well as Bill
Vail who works for Senator Susan Collins' office, Kara
Hawthorne, who is the new Director of the Office of Rural
Health that Congress established a couple years ago, and Dr.
Patty Hayes who is a Chief Consultant for Women Veterans'
Health. They are both from Washington, DC. I want to thank both
of you for coming here today to hear what veterans have to say
about rural healthcare issues.
I also would like to recognize Adam Cote who is an Iraq War
veteran. I don't know if there are any other Iraqi War veterans
or Afghanistan War veterans here, but I want to thank you and
all the veterans here in this room for your service to our
great Nation. I am very pleased to see you here as well. I want
to thank everyone else who I have not mentioned for coming here
today to talk about veterans' issues.
Today, we will examine the U.S. Department of Veterans
Affairs (VA) programs regarding rural veterans, women veterans
and other special needs population. I am very happy that it is
held here in Sanford, Maine, this morning. Sanford is home of a
long-time veteran advocate, someone who I was honored to call a
friend, Roger Landry. Roger worked and served in the Maine
legislature. He worked very diligently in the veterans service
organization (VSO) community here in Maine, and he was very
well-liked and respected by all. Roger served his country and
his community with great pride and honor. Roger died,
unfortunately, last year. He is sorely missed. I would like to
dedicate this hearing to Roger Landry in honor of all of his
hard work with and for our veterans here in Maine and all
around the country.
It is appropriate that we are having this hearing in my
home State of Maine. Maine is a very rural State. Because of
this, we face many unique challenges in providing healthcare to
our veterans. Many have to travel long distance for care,
creating a significant burden for veterans and their families.
The VA has instituted some innovative programs to provide much
needed services to our rural veterans, and I look forward to
hearing from our panels today about their ideas to improve
access and decrease the travel burden for our veterans living
in rural communities all across Maine and also all across the
country.
At this hearing, we will also hear about women veterans.
Women make up about 14 percent of the active-duty military; and
consequently, they are making up more and more of our veteran
population. Women have some unique healthcare needs. I look
forward to hearing today about the unique needs of women
veterans and hearing ideas about how the VA can improve their
service targeted to women veterans.
When the United States made a commitment to care for
veterans, we made the commitment to care for all veterans:
Male, female, urban, and rural. Today, I hope that we will
learn how the VA is meeting the needs of these populations,
what challenges are on the horizon, and what can we do to
provide services for these veterans in the most cost-effective
manner.
I also want to thank Congressman Miller, who is the Ranking
Member of the Subcommittee on Health of the Committee on
Veterans' Affairs. Congressman Miller is from Florida. He has
been a strong advocate for veterans' issues. We deal with the
healthcare-related veterans' issues in Congress. And I know
that this is actually a holiday here in Maine and
Massachusetts, and I know that Mr. Miller has a lot of work in
his home State that he has to do. We really appreciate him
taking the time to come here, along with Committee staff, to
hear what veterans have to say. Indeed, he is a true advocate
for veterans' issues.
So, I would turn it over to Mr. Miller for an opening
statement.
[The prepared statement of Chairman Michaud appears on
p. 42.]
OPENING STATEMENT OF HON. JEFF MILLER
Mr. Miller. Thank you very much, Mr. Chairman. I am, in
fact, very pleased to be here in your great State of Maine to
examine how VA is addressing the healthcare needs of women,
rural needs and special needs veterans. It is appropriate that
we are here today on Patriots Day because I truly do believe
that there is no greater patriot than the veteran, a person who
has worn the uniform in defense of this Nation for all the
things we stand for. It is great to be here with my friend and
colleague, Tom Allen. We have had numerous opportunities to do
things legislatively in Washington. We have traveled together
as well. It is a great pleasure to be with you here today.
I know that rural America does have a strong military
tradition. A lot of people don't think of Florida as being a
rural State, but actually Maine and Florida are ranked in the
top 18 in the States in this country that, in fact, have access
issues. The veterans in my district, which is Pensacola to
Destin, northwest Florida, my veterans have to travel 3, 3\1/2\
hours to get to a hospital. Most people don't think about that
when they are thinking about the State of Florida because the
veteran population--I have--I actually have the largest veteran
population of any Congressional district in the country, and I
am proud to represent those individuals in Washington, DC.
Certainly being here today to have a chance to hear from the
folks from Maine and surrounding areas about how you are being
dealt with or not being dealt with I think is very important. I
do have a statement that I would like to have entered into the
record.
I would also like to add that the Chairman has continued to
promise me a taste of Moxie, and I have yet to get it. I
continue to wait with great anticipation. So, it is a pleasure.
Mr. Michaud. You definitely will have an opportunity to
have Moxie. As a matter of fact, I see it coming down the aisle
right now. And I want you to know that, actually, Moxie is the
official soft drink here in the State of Maine. So, enjoy.
[Whereupon Congressman Miller was handed a can of Moxie.]
Mr. Miller. I like it.
Mr. Michaud. Well, I am glad you like it. There are plenty
more.
It is now my distinct pleasure to introduce my colleague
from the State of Maine who actually is in this district. I
appreciate your willingness also, Congressman Allen, to take
the time out today to hear what people have to say about rural
veterans' issues, and also thank you for putting forward the
name for our first witness.
So, I will turn it over to Mr. Allen.
OPENING STATEMENT OF HON. THOMAS H. ALLEN
Mr. Allen. Thank you, Mr. Chairman. It is nice to say those
words in Mike Michaud's case. Thank you, Mr. Chairman, for
holding, organizing this hearing, and also for allowing me to
participate, even though I am not a Member of the Veterans'
Affairs Committee.
I do want to welcome Congressman Jeff Miller. It is a real
pleasure to have him here. He and I were on a trip together to
Afghanistan and Iraq and Pakistan last August. And you get to
know people pretty well when you are on a trip like that. And I
think we both came away with an enormous respect for what the
young men and women in the armed services are doing over there
under extraordinarily difficult and challenging circumstances.
And I just want you all to know, many of you veterans from
other conflicts, and I see Adam Cote here who is an Iraq
veteran, many of you from other conflicts that appreciate and
understand how challenging and difficult the work there really
is.
I also want to welcome today's witnesses to the hearing. I
look forward to their testimony about how we can improve care
for veterans in Maine and across the country.
Finally, I want to welcome and express my thanks to all of
the veterans who are here today. I want to thank you for your
brave and honorable service to this country. I thank you for
your service and thank you for being here.
Maine is home to over 150,000 veterans who have sacrificed
for our country. I have been honored for the last 12 years to
represent the veterans in the 1st District of Maine. And I
pledge to you I will continue my work in Congress to keep the
promises we have made to those who have defended us past and
present.
Today's hearing will focus on the particular needs of women
veterans, veterans in rural areas and other special
populations, including veterans with mental health needs. The
percentage of women serving in the armed forces, their scope of
responsibility, and their exposure to danger have all grown
dramatically in recent years. Therefore, we must work even
harder to ensure that the VA is ready to serve women veterans.
Women who have served in the military must receive the same
benefits as their male counterparts, but they also must have
access to healthcare targeted to their specific needs,
including gynecological care and mammography, an issue that
given my wife's illness, I am more aware of than ever before.
Another important component of care for women veterans is
the availability of military sexual trauma counseling at Togus'
Women's Clinic and the VA Vet Centers throughout Maine. Vet
Centers and community-based outpatient clinics (CBOCs) have
been extremely important for our rural State. Because of the
progress of these centers and clinics, most veterans no longer
have to travel for hours to get the healthcare benefits that
they have earned, though they still in many cases have to
travel some distance.
I am glad that Congress recently increased the mileage rate
from a meager 11 cents per mile that it was to 28.5 cents per
mile. The rate is still, as you know, far less than actual
costs and I am sure we can do better.
We are extremely proud of the dedicated VA employees here
in Maine working under the direction of Director Brian Stiller.
The VA is doing whatever it can to address the healthcare
requirements of veterans with special needs. The post traumatic
stress disorder (PTSD) program at Togus has been extremely
helpful.
I recently introduced legislation to help veterans applying
for disability compensation for post traumatic stress disorder.
The Full Faith in Veterans Act would change the VA standard of
proof for veterans who suffer from PTSD. The bill creates a
common sense approach that is long overdue.
And as you may know, as many of you know, when veterans
seek treatment and disability benefits for PTSD, they bear the
burden of proof to establish, first, that they have a diagnosis
of PTSD; and second, that the PTSD causing event happened
during their service. To prove the second factor, they must
produce existing military documentation about the event that
proves the event happened and that they were present, or they
have to come up with 2 buddy statements that attest to these
facts.
Often, however, particularly in the case of Vietnam vets,
no records were created at the time that document the event. In
many cases, moreover, finding a veteran's buddy who was at the
scene is difficult, and the military services have not been
especially helpful. This has led to situations where it is
clear to medical professionals that a veteran's PTSD was caused
by an event during the individual's service, but the veteran is
not eligible to receive disability compensation because the
veteran's military records are inadequate.
As I have learned from our veterans here in Maine, too many
of our Nation's heroes are denied benefits because of gaps in
military documentation that are not their fault. Forcing
veterans to jump through these hoops to receive compensation
they had earned while serving their country is simply
unacceptable. Under my bill, a certified mental health
professional could make a logical connection between the
diagnosis of PTSD and the veteran's military service, and a
service connection must be granted. The bill also directs the
VA to improve their procedures for evaluating and treating
PTSD.
I want, again, to thank Chairman Michaud for cosponsoring
this legislature with me and working to ensure that this
legislation gets considered by the full House of
Representatives for a vote. I want to thank you all for being
here again today. And, Mr. Chairman, I yield back.
Almost forgot, but not quite. Dana Doliber----
Mr. Doliber. Yes, sir.
Mr. Allen [continuing]. Is one of my constituents. He lives
here in Sanford. He is a Vietnam veteran. He doesn't need much
by way of introduction because he is going to tell his story.
In many ways, I was saying to Dana earlier, he is the poster-
child for the legislation that I have recently introduced about
PTSD. And in a few minutes, you will understand why.
Dana, thank you very much for being here.
Mr. Doliber. Thank you, sir.
Mr. Allen. You have to turn on the microphone.
STATEMENT OF DANA DOLIBER, SANFORD, ME (VETERAN)
Mr. Doliber. First, let me say what an honor and a
privilege it is to be here to provide this testimony for you.
In 1971, I filed my first claim with the VA. As PTSD was
not a known accepted condition at that time, I was denied. In
1985, at my wife's urging, I began seeing Robert Paige, LCSW,
for what in a short time was diagnosed by Mr. Paige and Dr.
John Scammon as PTSD. A claim was again filed with the VA for
service connected PTSD for service in Vietnam for service from
1967 to 1968.
From 1985 to 1992, despite documentation, the VA routinely
ruled against my claim. The VA did not provide the veteran with
assistance acquiring records when requested or ruled in the
veteran's favor providing the benefit of the doubt in favor of
the veteran or ruled in favor of the veteran without a
preponderance of the evidence to disprove what the veteran
provided as evidence. Those 3 of the VA's own regulations were
not followed in every denial of the veteran's claim.
The VA's own record was inaccurate in its portrayal of the
veteran's branch of service, birth date, and personal record
prior to service. Doctors at the VA routinely diagnosed other
conditions than PTSD due to their not being given the paperwork
submitted providing stressors, which would have permitted the
diagnosis of PTSD, as that is what eventually happened. It
reached a point that I felt I needed the serial number of the
round being fired at me to prove my case, a standard that the
VA seems to not have a problem requiring from many veterans.
With the submission of documentation of the combat action
ribbon awarded in 1992, I was granted a percentage rating with
service connection. From 1992 to the year 2000, the issue of
clear CUE, or clear and unmistakable error, and retroactivity
of date of service connection, along with percentage of
disability was the issue which dealt with the past issues from
1985 to 1992. In 2000, I was awarded 100 percent PNT, that's
permanent and total, retroactive to 1985. I agreed to drop the
CUE case and retroactivity to 1971 as I felt this would drag
the case out another 10 years. Claims for skin rashes and sores
and hearing loss were also denied by the VA in much the same
manner.
The VA has a choice to either be part of the problem or
part of the solution. As part of the solution, the VA should
improve claim processing being mindful to be proactive for the
veteran, abiding by the laws as passed by Congress as the will
of the people for the veteran as in the Haas Case, and to be
proactive regarding veteran medical care. If doctors ask for
equipment in the rehab of a veteran, provide it. If surgeries
require rehab for the healing process, provide it.
The other part of the solution comes from both houses of
the legislature, not with fancy pro-veteran sounding bills that
are anti-veteran, such as the Noble Warrior Act or the
America's Wounded Warrior Act, but proactive veteran
legislation is what is required. Servicemen and women
understand and expect that if they need help when they come
home, that help will be there. America's veterans provided
the--providing the freedoms that we have deserve no less than
the full support of the VA and the Congress. The American
people expect no less than your full support of our veterans.
We should not disappoint them by a lack of action. Thank you.
[The prepared statement of Mr. Doliber appears on p. 42.]
Mr. Michaud. Thank you, Mr. Doliber. I really appreciate
your willingness to come here today to give your testimony.
I guess my question is are you currently accessing the VA
care for your PTSD?
Mr. Doliber. Yes.
Mr. Michaud. Do you have trouble getting appointments
within the VA system to see your provider?
Mr. Doliber. For other medical problems that are ongoing,
there seems to be extending waiting periods. If, for instance,
2 or 3 years ago I fell on the ice and I had a multiple
compound fracture of my left arm. After getting treated at
Henrietta D. Goodall Hospital, I was--and having notified the
VA of the accident and everything like that, I called up the VA
to request help with their rehab services and the follow-up
appointment to have somebody from orthopedic to attend to my
multiple compound fracture of my left arm.
I was told that I would probably have to wait a month or 2
for that. The physicians here in town felt that the medical
help that was needed to be done within a week, not a month or
2.
Mr. Michaud. And the services that you have received from
the VA, do you think that they have been helpful to you?
Mr. Doliber. What I term the VA medical care is benign
neglect. They do not--they do not intentionally with malice, I
believe, do these things. It is just that that's the way their
system is set up. That's the way that the veteran, when he is
seeking help, can find himself in a long waiting line.
It is not beneficial for the veteran who is seeking the aid
and assistance from the VA for medical conditions or even for
conditions for PTSD to be put off. Usually, for instance, like
the PTSD, that's post traumatic stress disorder. That means
that it has already gone past the point of where it needs to be
dealt with. The veteran finally has to deal with it. And when
they seek help from the VA, a lot of times you have to be put
in a line or there is a waiting situation that has to happen
because they have to get the doctor there. Sometimes you will
see a physician assistant. There needs to be more proactive
work from the VA toward the veteran.
Mr. Michaud. My last question is whether you have talked to
other veterans who have the same problem, being put on a
waiting list?
Mr. Doliber. Yes, yes. I talked with an Iraqi veteran when
I was up at the VA about a month and a half ago. And he was
there for traumatic head injury, and he was in the pay office
and I was talking with him. And in the middle of the
conversation with him, he stopped in mid-sentence and it was as
if the lights were on, but there is nobody home. And he was
there trying to seek help from the VA. And his wife is beside
him, she's in tears. They are going financially broke. He is
not being--he is only 40-percent disabled. That is the rating
that the VA gave him. That is on the VA. He deserves far more
attention.
Mr. Michaud. Thank you. Mr. Miller.
Mr. Miller. Thank you very much. I appreciate your
willingness to come forward and testify.
What did the VA tell you when they said it would take time
for you to get into rehab? Just that there were no slots?
Mr. Doliber. They said the earliest that they could--the
earliest that the appointment could be made for would at least
be a month, possibly 2. The orthopedic doctor that had set my
arm and had operated on it said I needed to see a doctor a week
after that. Okay? I couldn't wait a month. As a result of that,
I incurred the expense from the orthopedic doctor and all of
the rehab services after that on my own.
Mr. Miller. Do you think a solution is a fee-for-service
type issue, where when you cannot get an appointment within an
acceptable amount of time you have the ability to continue to
use the physician that set your arm until you can get into the
VA system?
Mr. Doliber. Yes, sir. Yes, I do. Fee-for-service has
worked very well for a lot of veterans. It has been cut back
because of lack of funding, because of budget cuts. And if I
could, I would like to address the budget cuts part of it.
I had a conversation at one time up at the VA regarding
budget cuts with the then director, Mr. Sims. And he said that
the budget cuts are the responsibility of the Congress. And at
that time, the VA budget and the U.S. Department of Housing and
Urban Development (HUD) budget were both tied-in at the same
time when they were being considered. Well, since then, that
has changed. The HUD budget and the VA budget, from what I
understand, are 2 different things.
The problem was that I found out that the VA budget that
gets submitted to the Congress, the requests, come from the
directors of the Veterans Administration regional offices. In
other words, if they are not asking for the increase in
funding, the Congress has no way of knowing that an individual
regional office needs that increase in funding. And to my
knowledge, that is the way it is still being run.
Mr. Miller. The budget process works where the President or
the Administration submits a budget to Congress, but we are in
fact--one of the main things we do is pass appropriation bills.
So, Congress does have a very large impact. As you said, if the
information doesn't get to us----
Mr. Doliber. Right.
Mr. Miller [continuing]. That is why these field hearings
are so critical. Sometimes the request is not made and we don't
know, but we do, in fact, have control of the purse strings----
Mr. Doliber. Yes, sir.
Mr. Miller [continuing]. In D.C. What other things, what
other types of outreach do you think that the VA can use,
especially in rural areas, to get the word out to those special
needs veterans or to other groups of veterans?
Mr. Doliber. Well, the Vet Centers--I have never been to a
Vet Center. Initially, when I began my PTSD therapy, it was
being funded by the Vet Center in Portland. I had never gone to
the Vet Center in Portland, but the Vet Center here in Sanford
requested the funding from them. That soon was cut because
their budgets were cut. So, the therapist I was seeing at the
time began seeing me pro bono, and he saw me for years pro bono
because the VA would not approve the funding for my therapy.
Outreach centers need to be there. They do provide a
helpful service to the veteran, especially in rural
communities. The funding, again, the 900 pound gorilla in the
room is money, and that is what it comes down to. Now, the
American people know that the funding--they want the funding
for their veterans. They know the veterans need the funding.
The VA needs to provide the request to the Congress for the
funding. And to be penny-wise and pound foolish doesn't seem to
make a whole lot of sense. And the first thing that can be done
in rural areas is to have the Vet Centers because they do
provide a needed service.
Mr. Michaud. Congressman Allen.
Mr. Allen. Dana, thank you for being here. I just have a
comment about the funding issues. I sit on the Budget
Committee, and I did want to make one clarification. Often the
regional directors will be asking for more money than they
actually get in the present budget, because the Office
Management and Budget----
Mr. Doliber. Right.
Mr. Allen [continuing]. The presidential operation will
trim down those requests. And then the regional VA director's
kind of stuck with the number that they have been given. Maybe
not the number they asked for privately, but the number that
they have been given by the Administration.
But as Representative Miller said, ultimately the decision
is going to be made in the Congress. And I agree with him that
the information that we get from our constituents is
fundamentally important to understanding how we can drive that
budget, as we did last year, in a much more positive direction.
I have a question; you indicated that you provided
documentation to the VA to support your claim of service
connection for your PTSD over all those years when you were
trying to get----
Mr. Doliber. Yes, sir.
Mr. Allen [continuing]. Trying to get benefits, but there
were certain gaps in the documentation that led to your claim
being denied.
Can you talk a little bit more about what those gaps were,
what it was you were being told you had to provide but could
not?
Mr. Doliber. Well, the main requirement was to provide what
the VA would term a stressor. Now, a stressor could be handling
wounded, a stressor could be being shot at or being around
explosions going off.
I provided pictures of my ship high-lining wounded from my
ship to the hospital ships, Repose and Sanctuary. I provided
documentation from my ship, albeit sketchy, and from the USS
St. Paul cruiser that we operated with, the USS Newport News,
another heavy cruiser that we operated with, and the USS
Collette, another destroyer, where they spell-out in their
record and their ship's log our receiving counter-battery from
coastal defense units from North Vietnam and South Vietnam. We
operated almost up to the Hai Phong Harbor in North Vietnam.
A lot of the American people believe that our participation
in Vietnam stopped at the demilitarized zone (DMZ). We were
routinely--and it wasn't any real big deal for us to be north
of the DMZ. We received fire from islands off of the DMZ, from
North Vietnamese, coastal batteries. I am at a loss as to how
those records could be misrepresented on the ship that I was
on, and yet to be so complete in the other vessels that we
operated with.
Mr. Allen. Did you think at some level was there any chance
the VA was thinking, well, you were on a ship, you weren't on
the ground on the shore? Was that a piece of it?
Mr. Doliber. Well----
Mr. Allen. Or how would you try to explain it?
Mr. Doliber. Let me explain it this way. I had a
conversation with a veteran's service officer at the VA. And he
was an on-the-ground marine in Vietnam, and more power to him.
When he heard that I had been onboard ship, he at that time
would not take my case because in his words, we were on a
cruise. It was if we were on the Queen Mary.
This was no Queen Mary. We were--we provided gunfire
support for the 3rd Marine Division at the Battle of Hue. We
were anchored in the Perfume--at the mouth of the Perfume
River. I was in the rangefinder. I was looking through. I was
watching it. I was providing--I was pressing the button on the
rangefinder that fired the guns. This is no Queen Mary. They
don't call them destroyers for nothing, and we did a damn good
job.
Mr. Allen. Thank you very much.
Mr. Doliber. Thank you.
Mr. Allen. Thank you for your testimony.
Mr. Michaud. Thank you very much, Dana. Without objection,
I would ask anything that has been said and for all the written
testimony to be submitted in full for the record. Hearing none,
it is so ordered.
I want to ask the second panel to come on up. While they
are coming up, I just want to let you know, Dana, that in your
written testimony you had asked that this Subcommittee be
assured that there be no retribution against you for your
testimony today. I assure you that there will not be any
retribution. I want to thank you once again for coming here
today.
Mr. Doliber. Thank you, sir.
Mr. Michaud. So, if the second panel could come forward.
While they are coming forward, the second panel is Peter Ogden,
who is the Director of Bureau of Veterans' Services for the
State of Maine. We have Gary Laweryson, who is the Chairman of
the Maine Veterans Coordinating Committee. Kelley Kash, who is
the Chief Executive Officer of the Maine Veterans' Homes (MVH).
And David Hartley, who is the Director of the Maine Rural
Health Research Center. I want to thank all 4 of you for coming
here today to give your testimony. We look forward to hearing
your testimony here today.
We will begin with Mr. Ogden. Please proceed.
STATEMENTS OF PETER W. OGDEN, DIRECTOR, BUREAU OF VETERANS'
SERVICES, STATE OF MAINE, AUGUSTA, ME, AND SECRETARY, NATIONAL
ASSOCIATION OF STATE DIRECTORS OF VETERANS AFFAIRS; GARY I.
LAWERYSON, USMC (RET.), CHAIRMAN, MAINE VETERANS COORDINATING
COMMITTEE, WALDOBORO, ME, COMMANDER, MILITARY ORDER OF THE
PURPLE HEART, STATE OF MAINE, JUDGE ADVOCATE, MARINE CORPS
LEAGUE, STATE OF MAINE, AND AIDE-DE-CAMP TO GOVERNOR JOHN
BALDACCI; KELLEY J. KASH, CHIEF EXECUTIVE OFFICER, MAINE
VETERANS' HOMES, AUGUSTA, ME; AND DAVID HARTLEY, PH.D., MHA,
DIRECTOR, MAINE RURAL HEALTH RESEARCH CENTER, AND PROFESSOR,
MUSKIE SCHOOL OF PUBLIC SERVICE, UNIVERSITY OF SOUTHERN MAINE,
PORTLAND, ME
STATEMENT OF PETER W. OGDEN
Mr. Ogden. Chairman Michaud, Congressman Miller,
Congressman Allen, thank you for this opportunity to speak
today on 3 extremely important issues for Maine's veterans:
Access to rural healthcare, women's issues----
Mr. Michaud. Excuse me, sir. Is your microphone on?
Mr. Ogden. The light's on. Okay. Should we start over?
Okay.
Chairman Michaud, Congressman Miller and Congressman Allen,
thank you for the opportunity to speak today on 3 extremely
important issues for Maine veterans: Access to rural
healthcare, women veterans, and outreach to veterans for
benefits. My testimony today comes from 3 perspectives: The
Director of the Bureau of Maine Veterans' Services, the
Secretary of the National Association of State Directors of
Veterans' Affairs, and as a disabled combat veteran who uses
the VA healthcare system in Maine.
I will begin with some facts that are key to understanding
Maine and its veterans. First, in 2000, Maine had the largest
per capita veteran population in the Nation and is still at
number 2.
Second, Togus Medical Center is the oldest VA hospital in
the Nation.
Third, Maine's aging veteran population is geographically
dispersed across a large land area. Veterans living in northern
Maine can drive 5 to 6 hours and up to 260 miles to reach the
one VA Medical Center at Togus.
Fourth, 65 percent of our veterans are age 55 or older.
This percentage should reach about 70 percent between 2020 and
2025, and these are the veterans that are most likely to need
and use the VA healthcare system.
Fifth, 73 percent of our veteran population served during a
wartime, which means they have more benefits available to them.
Last, we have over 52,000 or 36 percent of our veterans
enrolled in the VA healthcare system, and about 38,500 who
actively use the VA healthcare in Maine.
A lot of my speech will talk about the Capital Asset
Realignment for Enhanced Services (CARES) program. The CARES
market plan, the Far North Market--and Maine is unique because
Maine as a State has its own market identified by the CARES
plan--developed by Veterans Integrated Services Network (VISN)
1 recognized Maine's unique geographic characteristics, limited
transportation infrastructure, and rural nature.
The CARES Commission Report made several points about
access to VA healthcare in Maine, the Far North Market, that
are relevant to this hearing. Less than 60 percent of our
enrolled veterans are currently within the VA's access
standards for hospital care. Inpatient medicine workload is
projected to increase 209 percent by 2012. Only 59 percent of
the veterans residing in this largely rural area are within the
CARES plan guidelines are set for access to primary care. VISN
1 proposed only 5 new CBOCs, Community-Based Outpatient
Clinics, all of them in Maine. In short, to improve rural
access for veterans to VA healthcare in Maine and the Nation,
implement CARES in Maine and in other rural States, and
implement it as soon as possible.
Any conversation about aging veterans and access to
healthcare should include the importance of State Veterans'
Home Programs and the service they provide to our veterans.
Maine is fortunate to have Maine Veterans' Homes with their 6
facilities spread across the State providing excellent care at
the most reasonable cost. It is important that Congress
continue to fund the State Veterans' Home Construction Program
until each State has the capacity to provide long-term care to
its veterans.
Maine has over 10,000 women veterans with less than 1,800
using the VA healthcare system. Quality or availability of
types of care for women veterans does not seem to be as much of
an issue as the access and outreach to those women veterans to
know about their benefits. Approximately 40 percent of the
women veterans using the VA healthcare system receive it at the
CBOCs. So, access at the local area is important. The addition
of the new CBOC in the Lewiston/Auburn area and the access
points in Houlton, Dover-Foxcroft and in Farmington will allow
more women veterans to receive care closer to home and this
will increase the usage numbers for all of our veterans.
While growth has occurred in VA healthcare due to improved
access to CBOCs, many areas of Maine and the country are still
shortchanged due to the geographic and due to the veterans'
lack of information and awareness of their benefits. VA and
State Departments of Veterans Affairs must reduce this inequity
by reaching out to the veterans regarding their rights and
entitlements. Maine and the National Association of State
Directors of Veterans Affairs support the implementation of a
grant program that would allow the VA to partner with the State
Department of Veterans Affairs to perform outreach at the local
level.
There is no excuse to veterans not receiving benefits to
which they are entitled simply because they are unaware of
those benefits. I would encourage the Committee to support S.
1314, the ``Veterans Outreach Act of 2007,'' to help us with
that.
State governments are the Nation's second largest provider
of services to veterans next to the VA, and this role will
continue to grow. We believe it is essential for Congress to
understand this role and ensure we have the resources to carry
out our responsibilities. The States partner very closely with
the Federal Department of Veterans Affairs in order to best
serve our veterans. And as partners, we need to continuously
strive to be more efficient in delivering those services.
As I finish my testimony rather rapidly, I would like to
once again thank you for the opportunity to speak to you today
and thank you on behalf of Maine's veterans and the Nation's
veterans for all you are doing to ensure they receive the
proper healthcare and the benefits they have earned through
their service to the Nation. Thank you.
[The prepared statement of Mr. Ogden appears on p. 44.]
Mr. Michaud. Thank you very much. Mr. Laweryson.
STATEMENT OF GARY I. LAWERYSON
Mr. Laweryson. Congressman Michaud, Congressman Miller,
Congressman Allen, the Maine Veterans Coordinating Committee
wants to thank you for allowing us to testify again. Our
organization is made up of 14 different groups that do their
best to work for all the veterans in the State of Maine.
As I testified on August 1st, 2005, on the CARES program,
and you will see a lot of this overlaps everybody else, it has
been 2\1/2\ years and we have opened 1 clinic, Houlton,
possibly in June. And in that interim time period, there's been
a CBOC opened down in Connecticut, which wasn't even on the
table at that time. The rural veterans are not getting the care
that they deserve or need.
At that time, we discussed the cost of fuel, the cost of
living up here in Maine. And since that time, I bet it has
tripled. The gas is out of sight, the fuel oil is out of sight.
These people are working on a fixed income. They are not able
to travel. And when they do go down to Togus, there is a cost
share on the travel pay, they lose half of it, and it is
already putting a tremendous burden on them as it is. I think
we need to look at that again.
With Operation Iraqi Freedom/Operation Enduring Freedom
(OIF/OEF) troops coming back, and they have been extended
through a 5-year term with the VA. And I think that boots out
after they redeploy again, which is another issue. The older
veterans aren't getting the word that they can get in there.
So, they don't come down because OIF/OEF has a first run on
this or their assumption is that they do.
We discussed communications last time with the VA getting
out the proper word to clear up the fog. That hasn't happened
yet. We need to get more of the VA out into local communities
putting out these town meetings to pull these rural veterans
in. While Maine is a rural State, there is a subsection of
rural up there, and you will speak with Mr. Rural later. That
is where a large majority of your veterans are, especially your
combat veterans. They like to be out and about away from the
hustle and the bustle. We need to find out what's taking so
long for VISN to get our other clinics open. And we need to get
that moving, especially in the rural areas first.
The VA and Togus, we support, as we did back then. The past
director, Jack Sims, was doing a great job with what he had.
The new director has got a challenge and we are going to hold
his feet to the fire, but he is doing a great job. We have a
meeting with the Coordinating Committee once a month. He is
there, he is an integral part of this. We get the word, we pass
the word. And if there's any issues, we take it up and deal
with them, not in a public meeting place but a private matter.
Very effective, and Mr. Stiller is very receptive to that. We
are lucky to have him.
We have done something in Maine that the other States
haven't done yet, and that is called ``Operation I Served.'' We
put that package together. It has been very effective. And we
are putting it out now in doctors' offices, waiting rooms of
hospitals because the veterans do get that. They are allowed to
call in. We have worked with the Bureau of Veterans Services in
Maine, publish this, update it every year or so. It is a
tremendous tool, and we just need to get more of that out in
the public. And that goes along with what my brother, Pete, was
talking about that that would be a tremendous, tremendous way
to get this information out and if we can get the VA onboard
and do more town meetings in the rural areas.
Women veterans. They are combat veterans. A veteran's a
veteran. They have special needs. There's special needs
veterans out there with amputations and traumatic brain
injuries. There is no difference. They are veterans, and they
should have first-care priority to any area, and that's the
rural areas. Now, if we can't get them in out there, we could
temporarily take care of them with fee services until we can
get them down to the master hospital at Togus. Getting short on
time here.
And the Coordinating Committee's opinion is still that VA
should be a full-service hospital. We should not have to run
down to Boston. It is counterproductive and it is not in the
best interest of the veterans or their families. It wasn't
before, and it especially isn't now with the cost of
transportation and fuel.
We appreciate what you are doing for our veterans. We
continue to look forward to working with you. And we will hold
your feet to the fire to keep up the good work. Thank you.
[The prepared statement of Mr. Laweryson appears on p. 47.]
Mr. Michaud. Thank you. Mr. Kash.
STATEMENT OF KELLEY J. KASH
Mr. Kash. Mr. Chairman and Members of the Committee, thank
you for the opportunity to testify this morning.
I am the Chief Executive Officer of the Maine Veterans'
Home. MVH operates 6 long-term care nursing facilities
providing 640 skilled nursing, long-term nursing, and
domiciliary beds. The facilities are relatively small, each in
size, 30 to 150 beds each. This allows them to be located
throughout the State of Maine, allowing greater ease of access
to our facilities by veterans living in the most rural parts of
Maine.
MVH is part of a vital national system of State Veterans'
Homes. The State Veterans' Homes system is the largest provider
of long-term care to our Nation's veterans and provides 52
percent of the VA's total long-term care workload at well below
the cost of care in a VA facility for civilian contract
providers. The State Veterans' Homes provide long-term medical
services at a cost to the VA of only $71.00 per day, compared
to approximately $225.00 per day to the VA for the placement of
a veteran at a contract nursing home, or over $560.00 per day
in its own VA facilities. As such, the State Veterans' Homes
play an irreplaceable role in assuring that eligible veterans
receive benefits, services, and quality long-term healthcare
that they have rightfully earned by their service and sacrifice
for our country.
Traditionally, State Veterans' Homes residents have been
primarily male. However, more and more women are being admitted
to State Veterans' Homes as veterans themselves reflecting the
large and increasing numbers of women who have served in the
military since the Korean war and before.
While our experiences in the Gulf War and present conflicts
have given tremendous attention to post traumatic stress
disorder, the reality and effects of PTSD have been present in
every conflict. State Veterans' Homes provide a common culture,
reassuring surrounding, greater appreciation, and understanding
of the veterans' experiences and issues; however, much more can
be learned in treating PTSD in general.
We feel strongly that the State Veterans' Homes should play
a major role in meeting the many rehabilitative care needs for
veterans and that we should be treated as a resource integrated
more fully with the VA long-term care program. Here is one
example of how the VA can partner with the State Veterans'
Homes.
The State of Maine enacted legislation earlier this month
to establish a veterans' campus at Bangor, Maine. The concept
is to create a one-stop shop for veterans to receive most of
their healthcare and social service needs. The proposed project
will locate a new, larger, and more capable VA community-based
outpatient clinic next to the MVH Bangor facility. Other
veteran service organizations will be co-located at the campus,
bringing a wide range of veteran services to a single campus,
making it more efficient and convenient for veterans, families,
and the various agencies that serve veterans' healthcare and
social service needs.
The Bangor Veterans' Campus is a pioneering effort and it
is the first of its kind in the Nation. It should receive
special interest in our Nation's Capitol. The VA should
streamline its awards process and its success should be
replicated throughout the Nation.
The VA chronically has been slow to implement enacted
legislation. Legislation directing the VA to pay the full cost
of care for veterans with service-connected disabilities rated
70 percent or greater and to provide veterans with service-
connected disabilities rated 50 percent or greater with
prescription medications while residing in State Homes has yet
to be implemented by the VA, even though Federal law required
these provisions to take effect by March 2007. The result has
been tremendous confusion and frustration for the many
thousands of veterans who are waiting for these services and
for the State Veterans' Homes which will be required eventually
to provide these services.
Regarding VA grant funding, the administration has proposed
cutting State Veterans' Home construction matching grant
funding by almost 50 percent from $165 million in fiscal year
2008 to $85 million in fiscal year 2009. The backlog of
construction projects to repair, rehabilitate, expand, and
build new State Veterans' Homes is now approaching $1 billion.
Over $200 million of this backlog are life-safety projects.
In conclusion, I will quickly reiterate the issues facing
the State Veterans' Homes. First, thank you for your continued
support in the VA per diem payment to the State Veterans'
Homes. The loss or reduction of the VA per diem would place
Homes in an untenable financial position and could lead to the
closure of many State Homes, ultimately impacting our aging
veterans.
Second, we believe Congress must increase funding for
construction grants to State Veterans' Homes to at least $200
million to address the growing backlog of projects.
Third, we believe Congress must require the VA to
promulgate long-overdue regulations to strengthen State
Veterans' Homes and the veterans they serve.
Finally, we believe that the State Veterans' Homes can play
a more substantial role in meeting the long-term care needs of
veterans. We support the national trends toward de-
institutionalization and the provision of long-term care in the
most independent and cost-effective setting. We would be
pleased to work with the Committee and the VA to explore
options to develop pilot programs, such as the proposed Bangor
Veterans' Campus, providing innovative care and for more
closely integrating the State Veterans' Homes program into the
VA's overall healthcare system for our veterans.
Thank you for the opportunity to address you today, and
thank you for your commitment to long-term care for veterans
and for your support of the State Veterans' Homes as a central
component of that care.
[The prepared statement of Mr. Kash appears on p. 48.]
Mr. Michaud. Thank you very much, Mr. Kash.
Dr. Hartley.
STATEMENT OF DAVID HARTLEY, PH.D., MHA
Mr. Hartley. Well, thank you. Mr. Chairman, Mr. Allen, Mr.
Miller, thank you for the opportunity to testify before this
Committee. My testimony is based on my 12 years as a manager of
substance abuse treatment programs in rural areas, and 15 years
as a rural health researcher with a focus on access to mental
health services in rural America. I would like to make 4 points
in my testimony.
First, as you know, many veterans are returning from OEF
and OIF with mental health issues including PTSD, depression,
and traumatic brain injuries (TBI). A recent report from the
RAND Center for Military Health Policy Research refers to these
as the invisible wounds of war and reports that 31 percent of
servicemen deployed since 2001 have reported symptoms of one or
more of these injuries. This report I have here with me, it is
very long. It just came out a few days ago, and I highly
recommend it. What is not mentioned in the RAND Report is the
significant portion of these combat vets who are from rural
areas, nearly half are recent recruits.
My second point. The Veterans' Healthcare System has unique
expertise and resources to devote to the healing of these
injuries. In recent--excuse me. The VA also has an integrated
health information network. I am sorry, my notes are out of
order. I am going to have to switch to my other notes. Excuse
me. (Pause.) In recent years, the VA has opened more community-
based outpatient clinics, or CBOCs, to make their expertise and
these resources available to veterans who live at significant
distances from VA medical centers. We now have 6 CBOCs in
Maine.
The VA also has an integrated health information network in
the Nation, the best in the Nation, with evidence-based,
patient-centered performance measures and a monitoring system
to assure that all patients receive high quality care. That
system gets very good outcomes for those veterans who receive
care from VA clinics and from CBOCs and from contract
providers.
There are several reasons why a veteran in need of help
might not seek care at one of these facilities. While CBOCs
have improved access in many rural areas, there remain vast
remote areas in our most rural States, including Maine, where
VA facilities are out of reach. Also, some veterans prefer to
seek care from a non-VA system provider for a variety of
reasons. This RAND report found that only half of those with
these injuries actually seek help for them.
My third point. The Federal Government, through the Health
Services and Resource Administration, has created several
programs to attract providers to under-served areas to support
them. These include federally qualified health centers,
critical access hospitals, and rural health clinics. Some rural
areas are also served by community mental health centers. Most
of these programs exist in areas that are designated as under-
served. While many of these programs are focused on primary
care, it is common in rural areas to seek mental health
services from primary care sites.
We have the technology and the expertise to help these
rural sites provide care to rural veterans that is of the same
high quality that urban vets receive. This can be done through
telehealth, through the VistA information system which is now
available to non-VA providers, through direct and clinical
consultation between the expert clinicians in VA medical
centers and rural providers, and through the placement of VA
providers in these non-VA rural sites, creating veterans'
access points. Such cooperation between VA and non-VA providers
must be encouraged.
My final point. To facilitate collaboration between Health
Resources and Services Administration (HRSA) and the VA, this
Committee should encourage HRSA's Office of Rural Health Policy
and the VA's new Office of Rural Health to collaborate on
demonstrations and on interagency research bringing HRSA's
Rural Health Research Center and the VA's researchers together
to explore options for improving access to high quality care
for rural vets.
Thank you. I will be happy to answer your questions.
And I would like to add that I am accompanied today by my
colleague, Dr. David Lambert, who is also an expert in rural
mental health. Thank you.
[The prepared statement of Mr. Hartley appears on p. 52.]
Mr. Michaud. Thank you very much, Dr. Hartley.
Once again, I would like to thank the 4 panelists here.
Mr. Laweryson, you had mentioned the CARES process and
CBOCs, and we are very much familiar with that whole process.
We keep that book, I know I do, right on my desk in Washington
to keep updated on how much progress we are making.
Former Secretary of the VA, Tony Principi said in order to
move forward in the CARES process, that they would need about a
billion dollars a year. That has not happened, unfortunately.
However, I think that if you listened to all the comments made
here thus far today, as well as in Washington, relating to
rural healthcare issues and access to healthcare, I think the
CARES process would actually quite frankly solve a lot of
problems with access points in rural areas.
My question is it is an expensive process. Part of that
expense is establishing some major hospitals that could cost
$500 million to establish compared to a $50 million dollar CBOC
or access clinic.
What would you recommend? Should the Subcommittee focus on
some of the lower-cost access points and put off maybe for a
year or whatever some of the higher dollar figure major
hospitals?
Mr. Laweryson. I think that hits it right on the head, sir.
It is--it is like a triage in the battlefield. You get the
veterans in. If they dictate that they have to go to further
treatment, then we can move them down to a larger CBOC. For
instance, we have Bangor. That is on the outreach of 50, 60
miles north of Togus. I think the problem there is that if we
can get Togus up to speed, then these veterans don't have to
travel even further south 2 or 3 hours into Boston, and that is
from the lower section of the State.
But on the rural as an overall picture, if you have your
access sites out there, you are going to find more veterans
getting into them. And once they are diagnosed and triaged, for
lack of a better word, then you can get them into the system
and they will feel more comfortable with it. But to do that, we
have to communicate to them that this is open, it is a great
system, because for years they haven't been getting that word.
Mr. Michaud. I am relieved to hear that answer because
actually later this week, Wednesday, I believe, our Committee
will be marking up a construction bill, and we have language in
there that will actually direct the VA to focus on exactly what
we were just talking about.
My other question, you had also mentioned the gas
reimbursement. As you heard earlier and you all know, we
increased the mileage to 28.5 cents. However, the VA did put on
a waiver or increased the waiver. When the Secretary was before
us in the hearing to the full Committee of Veterans' Affairs,
he said that the deduction is being waived.
Are you finding that to be true for your members?
Mr. Laweryson. No. I was told that it hadn't been waived.
And it is--we really appreciate the 28 cents, you know, the
increase to that. But when the gas goes up 28 cents in a day,
that is--if they could take that waiver off, that would be
really beneficial to a lot of them.
Mr. Michaud. So that deduction has not been waived?
Mr. Laweryson. At the last meeting, it hadn't been. We
brought it up and was told it hadn't been.
Mr. Michaud. Okay, because the Secretary had told the
Committee that it was.
Mr. Hartley, you had mentioned I think in your testimony
that you suggested the VA should establish a Rural Behavioral
Health Research Institute. What specific research questions
would you like to see the institute address?
Mr. Hartley. I think the most pressing question right now
is this fact that 50 percent of the folks who have these
symptoms aren't seeking care for it. I think there is a whole
variety of reasons why that must be the case. It is not just
about geographic access. I think there are other reasons. I
don't think we know the answers to those questions. This RAND
report asks some of those questions and begins to point the
direction, but that would be my first question.
Mr. Michaud. You also mentioned that you are an expert in
rural behavioral health. How would you assess the VA's current
system ability to meet the behavioral health needs for rural
veterans? Do you think they are meeting all those needs?
Mr. Hartley. Well, clearly they can't meet all those needs
in the most rural areas. And as a matter of fact, this isn't a
problem that faces only the VA, it faces our entire healthcare
system. Mental health needs and substance abuse needs in rural
areas are frequently cited as the most acute need in the most
rural areas by people all across the spectrum. So, it is true,
they are not meeting those needs.
I think what we need to do is pool our resources that are
out there that have been created through these Federal programs
to do the best job we can to meet as many people's needs as we
can.
Mr. Michaud. What are some of the specific things you think
the VA can do to improve the access to rural veterans?
Mr. Hartley. Well, as I suggested here, I think they--and I
like this idea of triage, of figuring out how to make a first
point of contact, a first point of access where we can get
folks in the door. And this may address some of those reasons
for that 50 percent who aren't seeking care. So creating what
we call the ``no wrong door'' approach, which means wherever
you show up, there will be somebody there who will say, yes,
you have this problem and, yes, you are eligible for these
benefits, let me help you.
Mr. Michaud. My last question, Mr. Kash, is do you have any
programs specifically for women veterans?
Mr. Kash. No, sir, not specifically. Although, we are
seeing more and more women and we are becoming much more adept
at handling them. Normal nursing home, a civilian, is 75
percent women, where it is about 25 percent or less in our
homes because of the nature of the veterans. But we are getting
much more adept at how we handle women.
Mr. Michaud. Mr. Miller.
Mr. Miller. Thank you, Mr. Chairman. For the record, I do
believe the Secretary sent a letter out clarifying that he did,
in fact, misspeak during our hearing in regards to the waiver,
and he is, in fact, looking at expanding and doing research. I
think we all support the waiver that he did in fact speak of.
Mr. Kash, you talked about the veterans' campus in Bangor.
Could you elaborate a little bit on the benefits? I think it is
a great idea. How did it come about and what are the options
that we are looking for?
Mr. Kash. It came about a year and a half ago. A group,
including several players in the legislature in the veterans'
organizations. The CBOC at Bangor right now is about half the
size that it needs to be. The veteran population there is
growing and getting big, so they knew they had to replace the
CBOC and they knew their lease was coming up due. So, a new one
needed to be built. This was an idea, the Dorothea Dix
Psychiatric Center up there is a large campus, and we are right
next to it, we are part of it. And we thought here is a great
opportunity to locate it nearer to where it is now, bringing a
large area to build its clinic.
And then also other ventures that we are looking at doing
up there, along with Veterans' Housing Coalition of Maine, is
establishing housing, low-cost housing for homeless or needy
veterans. And what we would also like to do for MVH is look
into hospice, building a fixed hospice facility. So, here we
have a bunch of ventures we would like to do to improve our
services to the veterans, and we know that we can co-locate
them all on one campus. We think that it will obviously be much
more convenient for the families and the veterans themselves,
but also the many service organizations that work together to
provide those services. We saw it as a win-win opportunity.
So, the State of Maine took the initiative to go ahead and
research it, to put it into action, to have a rather robust
Committee look at it and make sure all the stakeholders are in
agreement with it, and then to go ahead and pass legislation
that will in fact deed land over to MVH to help facilitate the
building and construction of that.
Mr. Miller. Thank you. Mr. Laweryson, do you support the
fee-for-service concept if veterans have no other options
available, in particular rural veterans?
Mr. Laweryson. I think the fee-for-service is great if it
is an emergency and it is also great for those veterans that
suffer from head colds, rashes, coughs, headaches, or for
glasses. But your other, you know, major surgeries and stuff
that can be done that are not emergency, they need to get to
the VA hospital because the turnaround time on healing, because
it is in a veteran's community, it is cut in half. These
veterans, they love being around each other. And that is an
important part of the system, that is why we have the VA
hospital, especially the combat veterans.
But, yeah, on a case-by-case, if they don't need to be
running down from Caribou or Presque Isle or Clayton Lake to
get some cough syrup or something, that would be fantastic. You
know, or if it was an emergency surgery, compound fracture, get
it over here, get it taken care of right here locally. It is
done, and the family unit is there to help with the healing
process.
Mr. Miller. I only ask that question because we do get
pretty good push-back from the VSOs out there with regards to--
and I understand part of the argument and the desire not to
berate the healthcare that is being provided now by allowing
veterans to, quote, ``flee the system,'' if you will. But we
are all trying to find a way to get at access problems, even in
the short-term, and it may be that fee-for-services is the way
to go.
I don't know how we establish the severity of an issue,
obviously, because there are a lot of people that will go to a
doc in the box, if you will, for a minor issue rather than go
to the hospital. I just wanted to see what your reaction was.
I am going to go ahead and yield my time over to Mr. Allen
so he can continue to ask questions.
Mr. Michaud. Mr. Allen.
Mr. Allen. Thank you. Thank you all for your testimony. I
had a couple of questions for Peter Ogden.
In your testimony, you say there are more than 10,000 women
veterans in the State of Maine, but only 1,800--less than 1,800
receive their healthcare from the VA. You mentioned lack of
access, lack of outreach as likely reasons for that number
being as low as it is, or at least I think that is what you are
saying.
So, I guess I am curious about what you think the limits
are of your current outreach efforts, and really are there
places that you think more could be done? I guess the first
question is do we have a problem here or not?
Mr. Ogden. Yes, we have a problem. Actually, outreach--I
think part of our problem is I know about my World War II
veterans, Korean war veterans that we are wrestling to bring
into the VA system now. It is like the women veterans. They are
there, we know they are there. We know--we can tell what
counties they are in, but we haven't been able to reach to them
and say, you have some benefits, please come use them.
And I think it has a lot to do with the female veterans
that come back, the younger ones get married, they have
families or those things. They kind of get drawn into other
things. And because the access is not convenient for them to
the women's clinic at Togus or any of the CBOCs that we have
available to go to them, I think they kind of do other things
in the process. I really believe that having the CBOCs, the
access points out there, will bring more women veterans into
the system.
And the other part is for us to reach out. And as a State,
we struggle with how do we reach out to veterans. That is part
of my job is outreach and working with the VA to be able to say
to every one of those women veterans that here's the benefits
available to you, here's what we need to do, please come see
us. I write letters to every DD-214 that comes into my office.
There's about 1,500, 1,800 this last year. I send letters to
every one of those people saying, here's your benefits, if you
have a question, come call to us.
Well, we still need to keep community outreach. A lot of
those are young women veterans, and we have a lot of other
veterans here. It is a problem with us. I think outreach would
bring the veterans in, not just the women, but the other
veterans. And to bring them in, we need the access points to
bring them into because I think one of the things that we need
to do is--because access points will give us primary
healthcare.
And if we get primary healthcare in a preventive medicine
kind of timeframe, we will reduce the cost and severity of
those things when the veteran shows up down at Togus later on.
If we can get them in sooner and take care of their healthcare
and be preventative about what we are doing with those things,
it will reduce the total healthcare costs because when they
show up--if we haven't done that, they are going to show up
with a more severe problem than needs to be, I think.
Mr. Allen. Is there a way to use other women's groups to
reach women veterans? Part of the question is, should you be
thinking about outreach to the women veterans any different
than you do with men?
Mr. Ogden. Well, the State of Maine has a Commission for
Women Veterans. They work under my kind of control as a
commission established by women veterans. There is no funding
for the women veterans. I try to help them. I do the
newsletters for them, we send them out and they work with us to
try to outreach. It is about having some money to travel,
having some money to have town hall meetings and those kind of
things. These women are all volunteers. They don't get paid for
anything they do, but they do travel around, they do work with
those things.
Maine just has now--we have a great chapter of the WAVES
National that are mostly World War II female veterans. We have
now the Vietnam--actually, the Women Veterans of America just
started a chapter in Maine. That is going to be helpful, I
think, to gather the women into the process. But it is about
outreach, and you need to have female veterans reaching out to
female veterans.
Mr. Allen. My other question is for Kelley Kash. In your
written testimony, you said that the VA recently estimated
nationally that nursing care beds in the State homes are 87
percent occupied, but that many of the State veterans' homes
nationally have occupancy rates near 100 percent and some have
long waiting lists. In Maine, I understand it is around 97
percent.
Mr. Kash. Yes, sir.
Mr. Allen. Is that right? What do you think is going to
happen? Has that number been stable? Is it likely to increase?
Are we at risk of having longer lines, or do you think that,
you know, you have been adding beds at a pace that will be able
to take care of the potential influx in the population?
Mr. Kash. There are 155,000 veterans in the State of Maine,
plus their families. And on average, about 5 percent of the
aging population will require nursing home care. So you can see
that that number is really askew. I think what is going to
happen is even though we are legally constrained to 640 beds,
we could easily grow and still not have enough room to provide
all the services. So, the VA is going to have to look at other
mechanisms to do that.
But the short answer to your question, I think we could use
a lot more beds.
Mr. Allen. Do you think you are likely to have waiting
lists in the future? Do you have waiting lists now?
Mr. Kash. Yes, we do. We have waiting lists right now, and
a lot of those are family members who would like to get in as
well. I think that we could address immediate needs in areas
like York County. But then there are about 40 percent of folks,
their primary reason for choosing a nursing home is convenience
of location. And there aren't too many locations that are
convenient in Maine. So, if we could deploy more homes, we
could certainly, I think, fill those beds.
Mr. Allen. Thank you. I yield back.
Mr. Michaud. Thank you. Once again, I would like to thank
the 4 panelists for your testimony this morning. I look forward
to working with you as we move forward in dealing with these
issues. Thank you very much.
Next, panel 3 includes Joe Wafford, who is the Supervisory
National Service Officer for the Department of Maine Disabled
American Veterans (DAV); Donald Simoneau, who is a past
Department of Maine Commander for the American Legion; John
Wallace, the Maine State Council President for the Vietnam
Veterans of America (VVA); and James Bachelder, who is the
Maine Department Commander for the Veterans of Foreign Wars
(VFW) of the United States. I want to thank all of you for
coming here today. I look forward to hearing your testimony.
We will start with Mr. Simoneau.
STATEMENTS OF DONALD A. SIMONEAU, PAST COMMANDER, DEPARTMENT OF
MAINE, AND MEMBER, NATIONAL LEGISLATIVE COUNCIL, AMERICAN
LEGION; JAMES BACHELDER, COMMANDER, DEPARTMENT OF MAINE,
VETERANS OF FOREIGN WARS OF THE UNITED STATES; JOHN WALLACE,
PRESIDENT, MAINE STATE COUNCIL, VIETNAM VETERANS OF AMERICA;
AND JOSEPH E. WAFFORD, SUPERVISORY NATIONAL SERVICE OFFICER,
DEPARTMENT OF MAINE, DISABLED AMERICAN VETERANS
STATEMENT OF DONALD A. SIMONEAU
Mr. Simoneau. Mr. Chairman, that has a nice ring to it,
Congressman Miller, Congressman Allen, I thank you for the
opportunity to present the American Legion's views on women,
special needs, and rural veterans. The American Legion commends
the Subcommittee for holding a hearing to discuss this vitally
important issue.
According to the VA research, women make up approximately
15 percent of the active force serving in all branches of the
military, and the State of Maine has approximately 9,396 women
veterans. Research has shown that women veterans encounter 3
large barriers when trying to access healthcare through the VA
system: The lack of knowledge of the VA health administration
services, unaware of the eligibility for healthcare benefits,
and the perception that the VA caters to male veterans.
The American Legion recommends that once women veterans'
needs are identified, the VA develop and implement policies to
address these deficiencies in a timely manner and conduct an
extensive outreach campaign to ensure that this special
population of those who served and those who served them are
aware of the enhancements in the healthcare services.
Special needs veterans. The American Legion is very
concerned about the needs of all veterans, but we must reassure
that special needs veterans do not slip through the cracks: The
chronically mentally ill, the major affective disorders, post
traumatic stress disorder, traumatic brain injuries, the frail,
the elderly, those veterans 65 years of age or older with
chronic health problems, and we must always be on-watch for the
homeless veteran.
Recently, in my own hometown, a young man who served 2
tours in Iraq, found that he could not handle what he dealt
with, and he took his own life. And it was a great loss to the
community, a great loss to the Nation. He is one of those that
slipped through the cracks. We cannot allow that.
The American Legion believes veterans, many of whom are
elderly and infirm, are isolated from regular preventative
medical attention they need and they deserve. The VA's ability
to provide treatment and rehabilitation to rural veterans who
suffer the ongoing wars in Iraq and Afghanistan will continue
to challenge the system. The American Legion believes CBOCs
that serve as a vital element of the VA's healthcare delivery
system in States such as Maine, veterans face extremely long
drives, shortage of healthcare providers, and bad weather.
The American Legion urges Congress to adequately fund
CBOCs, construction and maintenance. The VA must enhance
existing partnerships with communities and other Federal
agencies to help alleviate the barriers that exist such as the
high cost of contracted care in the rural setting. Lastly, the
American Legion urges Congress to provide adequate funding to
the VA to accommodate the modernization of all VA structures.
Mr. Chairman, I thank you for giving the American Legion
this opportunity to present its views on such important issues.
You can see a much more in-depth report in my printed report
which I have submitted. I thank you for my time.
[The prepared statement of Mr. Simoneau appears on p. 53.]
Mr. Michaud. Thank you very much, Mr. Simoneau.
Mr. Bachelder.
STATEMENT OF JAMES BACHELDER
Mr. Bachelder. Mr. Chairman, Congressman Miller, and
Congressman Allen, I want to thank you for being here today.
I would like to start by saying that we did have a
communication problem due to the fact that Rosemary Lane is
very sick. But I want to thank you for waiving the need to have
my testimony ahead of time. I am going to record it and I will
get it to Jim Pineau at Congressman Allen's office for the
Committee.
Mr. Michaud. Thank you.
Mr. Bachelder. As the Commander of the Veterans of Foreign
Wars in the State of Maine, a Board Member of the Veterans'
Housing Coalition, Co-Chairman of the Southern Maine Veterans'
Memorial Cemetery Association, the Chairman of the Sanford
Veterans' Memorial Committee, the host of the Sanford veterans'
cable access program which both Congressman Michaud and
Congressman Allen have been to in the past and we hope to have
you in the future, a driver of the Disabled American van in
Sanford for Togus for 5 years, and a disabled veteran due to
combat in Vietnam, I would like to put some light on some
issues that we found in the VA healthcare.
Transportation. If you are not service-connected, you have
to deal with the Disabled American Veterans' van system which
is made up of volunteers. And due to health restriction of
drivers, sometimes it is hard to have people drive the van. So
in this area, in Sanford, if you need to go for a Tuesday
appointment, you need to take a van ride on Monday. You need to
spend the night at Togus. The VA will give you food and
housing. You would have your appointment for 15 or 30 minutes
on Tuesday, and you have to stay at Togus hospital Tuesday
night and take the van back on Wednesday.
The VA healthcare has the best electronic records, and in
those records are flags where the Mental Health Department can
put in information about the patient, about the needs, about
the concerns. And with research, I have talked with the
computer department, I have talked with the schedulers, and
those flags should be used so that the people that need to use
the DAV van, when they make an appointment, they will know that
these people should be able to get a ride on Monday and have
the appointment before noontime and be able to return on the
same day. And it would reduce the cost of housing and feeding
these veterans, but we have not been able to get the Mental
Health to allow these flags to be used for transportation
reasons.
And when we have the van that needs to go to Boston, and
somebody has to get there from up in Caribou, they have to come
down the day before. They have to take the van to Boston. They
have to have their procedure done. They have to take the van
back to Togus. They have to spend the night in Togus and wait
until there is a van to take them back to Caribou. So, the
transportation issue is something that as veterans you know
about, but we need Congress to understand. That if we have the
communication in the records, then we can key-in to the
transportation system and these veterans can be serviced in 1-
day service.
Appointments. I just had a Ryan Lilly come down who is the
Associate Director of the Medical Center. And when he came
down, we talked about some letters that I received.
I had an appointment for May 30th. I received a letter that
it was canceled because the doctor wasn't going to be
available, so it was moved to the 7th of May. Then I received a
letter that the 7th was canceled, it was moved to the 8th. Then
I received a letter saying that the 8th was canceled, it was
moved to the 9th. The letter canceling the 7th and the 8th and
the 8th and the 9th were written on the same day.
When I talked with Mr. Lilly, he said when you have a
change in your appointment, the healthcare should be calling
you to find out if you are available for the day that they are
going to give you an appointment. That wasn't being done. And
when he did get it taken care of, the employees did not have a
very good attitude when they call up and try to arrange an
appointment with you. And I just don't see that the veteran who
is trying to get healthcare and isn't being cared for properly
should have a bad attitude from an employee when they are being
told to do their job properly. I did get to see a doctor, and
that's been taken care of.
I do have another issue, and I am using myself as an
example because of the fact that I can speak of what I know.
But I do work as a service officer in the VFW here in Sanford,
and I know that I am not the only person that has these issues.
But I do have another appointment I called on, and it takes 2
months to get the appointment. And it would be nice if we could
find a way to get these appointments quicker than 2 months.
Also, I was driving up to Togus 1 day, and I called up just
to make sure that they understood I was on my way. And when I
got to Brunswick they said, oh, don't bother coming, the
doctor's not available. I have gone up to Togus at other times,
the doctor wasn't available, and all of the people were coming
in for their appointments and they were never notified that
this doctor wasn't available and they continued to go to Togus.
And it is not a one-time deal. This happens often, that they
have too few of doctors, they have so many veterans, and an
emergency comes up and the doctor has to be taken away. But
nobody picks up the phone to try and call these veterans and
tell them not to come.
The question about post traumatic stress and traumatic
brain injury. Peter Ogden was just testifying from the Bureau
of Maine Veteran Services. And his chapter had a meeting with
all of the State commanders and with other people about making
sure that we are servicing our National Guard, our Reserve, and
any of the military that are coming back.
And in that meeting, it was stated that traumatic brain
injury and post traumatic stress have the same symptoms. It is
very difficult to try and find out what the cause is for the
veteran. But it has also been found out that the post traumatic
stress disorder therapy can be devastating to an individual
with traumatic brain injury. So if you try to resolve the wrong
issue not knowing, you could actually be putting the veteran's
life in danger.
With the assessment of post traumatic stress disorder in
relationship to this bill which Congressman Allen has created,
if you have an analysis from a social worker, it can be
overturned by a VA psychiatrist and you can lose your claim.
The Vet Centers that are created by the VA are all staffed by
social workers. If you go to a VA hospital for healthcare, you
see a social worker. So the assessment that you have can be
overturned by the psychiatrist that is now doing your
competence evaluation.
So, how can individuals get an assessment that will be
accepted by the regional office if the psychiatrist has the
power to negate the assessment that you have gone through over
months or years? And that's a question that has been brought
up, and I think that it needs to be looked at. And I understand
that part of your bill may even address that.
Mr. Michaud. Well, thank you very much, sir. I really
appreciate it. And if you want to submit your written remarks
for the record, we will definitely include them.
And please give Rosemary Lane our best, our prayers and
thoughts are with her as well.
Mr. Bachelder. Thank you very much.
Mr. Michaud. Mr. Wallace.
STATEMENT OF JOHN WALLACE
Mr. Wallace. Mr. Chairman, Ranking Member Miller, and
distinguished Members of the Subcommittee, my guests, my name
is John Wallace. I am a combat veteran who is presently Vietnam
Veterans of America State Council President. I serve on Maine's
BigMac and MiniMac since their inception, and that's for more
than 20 years. I am also on the Network Communications Council.
I also serve on the Veterans Coordinating Committee, the
Caribou Veterans Cemetery Committee, the Maine Veterans' Home
Liaison Committee in Caribou, and I participate in the
Commanders Call with the Governor and National Guard General.
Mr. Chairman, the Maine Department of Veterans' Affairs is
located in Togus, 6 miles east of Augusta. Opened in 1866,
Togus was the first national home for disabled volunteer
soldiers. This VA Medical Center provides medical, surgical,
psychiatry and nursing home care. The VA operates community-
based outpatient clinics in Bangor, Calais, Caribou, Rumford,
and Saco to provide better access for veterans living in rural
areas. In 2007, they opened a part-time clinic in Lincoln.
There is also a Mental Health Clinic located in Portland.
More than 1,400 active-duty servicemembers and veterans of
the Global War on Terror have sought VA healthcare in Maine.
Many veterans from the conflicts of Iraq and Afghanistan have
visited VA counseling centers in Bangor, Caribou, Lewiston,
Portland, and Springvale. These community-based Vet Centers are
an important resource for the veterans who, once home, often
seek out fellow veterans for help transitioning back to
civilian life. Over 6 million veterans live in rural areas
across America, and most fall below the poverty line. They
travel hours to get to the nearest VA medical facilities.
At a hearing of the Subcommittee on Health, Mr. Chairman,
you pointed out that although 20 percent of the Nation's
populace lives in rural areas, 40 percent of the veterans
returning from deployment in Afghanistan and Iraq live in rural
areas. This leads to a significant challenge maintaining core
healthcare services. The average distance for rural veterans to
access care is 63 miles according to the National Rural Health
Association.
The difficulty in accessing healthcare is a significant
problem for many Maine veterans. Although Togus is almost
centrally located in Augusta, the State's geographic expanse
makes it a problem for many veterans to use the hospital as a
primary care provider. In 2004, the Government Commission
expressed concern that only 59 percent of Maine's veterans were
living within the geographical guidelines for access to care
which ranged from 60 minutes for urban areas and 120 for very
rural areas.
Of Maine's 6 CBOCs, with 2 more planned under CARES, the
closet CBOC is around 80 miles from its hub, the furthest is
260. For primary care, this is okay. But for specialty care
services, veterans have to travel to Togus or Boston. The
distance a veteran may have to travel is more than 300 miles,
which is clearly outside the 75-mile radius established by the
VA. To make matters worse, most rural medical care providers,
weary of the paperwork and long delays involved in the Federal
benefits system, often do not accept TRICARE.
There is evidence that the VA has known for some time about
the need to focus more on rural care. In 2004, the study of
750,000 veterans found that those living in rural healthcare
areas tended to have seriously high--more seriously high health
costly problems than their urban counterparts. Perhaps the VA
could reach a lot of veterans who live in rural Maine by
expanding the use of fee-basis care, in which the VA contracts
its services out to a third-party provider. Certainly, issues
involved in providing rural healthcare must be addressed by the
VA's new Office of Rural Healthcare, which has been slow to get
started.
Mr. Chairman, we are in an emergency situation in Maine,
and VVA is seeking your help in Congress to expedite the
provision stated in lower P.L. 109-61. Otherwise, our disabled
veterans, both young and old, would be forced to continue the
long-distance travel for care and treatment to the nearest VA
Medical Center, clinic, or hospital.
We pioneered the first rural, or rural-rural VA clinic as I
like to call it, in Maine. We started out 1 day a week, and
quickly went to 7. Excuse me, not 7, 5 days with 3 providers,
staff, 2 mental health providers currently on, and telemental
health being given access to. This covers an area bigger than
the State of Rhode Island and Connecticut put together. We, the
veterans, had to fight every step of the way for this. In the
beginning, we were told this would never happen. We proved them
wrong.
If you travel into the farm towns of any State in this
union, you will see lots of veterans who need help and are
having difficulty finding it. Should we lose veterans who
protected this Nation so honorably because our government is
unwilling to look past politics? I think not.
Women veterans' healthcare issues have come a long way,
basically, in the last 15 years. There are 2 bills before
Congress, 1 in the Senate, 1 in the House. The Senate version
addresses the women veterans program manager issue, the House
doesn't. At present, under the VA guidelines, they have 20
hours a week to work on that besides doing what they were
actually hired for in the other position. This needs to be
changed to a full-time position so that they can take care of
our women veterans.
I will briefly discuss the rest of it. Mental healthcare
issues with the women veterans. There is a big problem there
because inpatient care for them, they are basically in with the
men and it is hard for women to talk about military sexual
trauma, spousal abuse, et cetera, and feel comfortable. The VA
needs to get a lot more gender-oriented when it comes to women,
especially with the mental healthcare problems. When you take
PTSD and military sexual trauma, they have very few, if any,
clinicians--can't pronounce it--any qualified medical people
that handle it that can handle both at the same time because it
is a concurrent treatment. So, they do have a special problem
there.
In the last 15 years, the VA, especially here in Maine, has
come a hell of a long way with the Women Veterans' Clinic and
their issues, regular veterans and their issues, but their
hands are tied and they have been tied because of funding.
They'd do a lot more with the buck they get, but they need the
funding to be able to take care of these rural issues. And if
they do not have sufficient funding there when the government
year begins, and not 3 to 6 months later when Congress finally
gets off its duffs and votes for a budget, you won't overcome
any of these problems.
In closing, I would like to thank you, and I am open to any
questions.
[The prepared statement of Mr. Wallace appears on p. 56.]
Mr. Michaud. Thank you very much, Mr. Wallace.
Mr. Wafford.
STATEMENT OF JOSEPH E. WAFFORD
Mr. Wafford. Good morning, Mr. Chairman, Congressman Miller
and Congressman Allen. The DAV would like to thank you for
inviting us to today's field hearing of the Subcommittee. DAV
is a national veterans service organization representing 1.3
million members and is dedicated to rebuilding the lives of
disabled veterans and their families.
The topics before the Subcommittee--women, rural and
special needs veterans--are of acute interest to DAV both in
Maine and nationwide. With the adult population of 970,0000,
Maine is home to 155,000 veterans who constitute 16 percent of
our adult population, among the highest proportions in the
State, in any State. In regard, we urge the Subcommittee to
swiftly consider and approve H.R. 4107, the ``Women Veterans
Health Care Improvement Act,'' offered by Representative
Herseth Sandlin and Brown-Waite, 2 Members of your Committee.
We are seeing a large number of rural veterans, both men
and women, coming home from these wars with severe injuries and
illnesses as we see today. Therefore, we are pleased that the
Subcommittee is turning its attention to these issues, and urge
you to maintain a strong focus.
As you know, VA operates a major regional medical center in
Togus. It opened in 1866, and Togus is the first national home
for disabled volunteer soldiers. Today, Maine's only VA Medical
Center plays a major role in the community and State, providing
medical, surgical, psychiatric and nursing home care. It is
also a civilian employer, significant in Augusta.
The VA also operates community-based outpatient centers
which have been attested to many times today. Mr. Chairman, as
you know, the VA had planned to open a CBOC in Dover-Foxcroft,
but those plans were shelved due to an insufficient veteran
population base to support a full-time clinic.
The DAV believes that area still needs the VA's attention
as it is very rural. And we highly recommend that Togus provide
a satellite van or a portable physician office to serve
veterans in that area. And once the veterans in the Dover-
Foxcroft area become aware that the VA has established a
healthcare presence for them, even on a part-time basis, this
may help justify a full-time clinic at a later date in that
community. And then that will allow the portability of the van
to travel to other areas, other rural areas to provide service,
and leave Dover-Foxcroft as a storefront operation, per se. We
appreciate the Subcommittee making that recommendation to the
VA.
According to VA, in 2006, latest information available,
inpatient admissions to the VA healthcare facilities in Maine
totaled 1,696, while outpatient visits reached 325,000. Also,
17,474 veterans 65-years of age or older that received
healthcare from the VA in 2006.
Mr. Chairman, in Maine, more than 1,400 active-duty
servicemembers and veterans of the Global War on Terrorism have
sought healthcare here. Many veterans from the conflicts in
Iraq and Afghanistan have visited our Vet Centers throughout
the State.
The State of Maine operates 6 veterans homes, as you have
heard earlier. One difficulty, however, that concerns us in the
State homes, they do not provide a rehabilitation or
convalescence capability. Given to our elderly population that
needs these State homes, could offer veterans a greater new
service if they embrace a rehab/convalescence mission in
partnership with the Togus VA Medical Center. Many veterans
that are in inpatient care at Togus live in Bangor or Caribou
and other communities at a great distance.
In general, the current law limits the VA in contracting
private healthcare services, entrances providing necessary, the
VA facilities do not have the capability. And we feel that fee
services and contracting are a good way to go. But beyond these
limits, there is no general authority, though, in the law to
support a VA--a broad VA contracting for an oversight, which
needs to be addressed.
We believe the best course for most enrolled veterans in
healthcare is to provide continuity of care in facilities under
the direct jurisdiction of the Secretary of Veterans Affairs.
And aside from these concerns, we know the VA's contract
workloads have grown significantly.
The VA must ensure that the distance of travel be addressed
because it does provide hardships in the face of consideration
in the VA policy. VA must fully support the right of rural
veterans to healthcare and insist that funding for additional
rural care and outreach is appropriated for that purpose.
Mobile Vet Centers should be established, or at least on a
pilot basis, to provide outreach and counseling.
Recognizing that in areas of particularly sparse veteran
population, the absence of VA facilities, the Office of Rural
Health should sponsor and establish demonstrated projects with
available providers of mental health and other health provided
services to veterans, taking care to observe and protect the
VA's role as coordinator of care.
Again, Mr. Chairman, most of this is provided in my legal
or written testimony, and most of these recommendations are
clearly applicable to our State. On behalf of The Independent
Budget, we hope that the Subcommittee will address these
recommendations in oversight and further legislation, if
needed, to ensure that they are implemented. Rural veterans,
whether in the State of Maine or elsewhere, deserve access to
quality VA healthcare, despite obvious changes and challenges
we face in providing it.
Mr. Chairman, this concludes my testimony and I will be
pleased to consider your questions on these important topics.
[The prepared statement of Mr. Wafford appears on p. 59.]
Mr. Michaud. Thank you very much.
Once again, I would like to thank all 4 of our panelists,
not only for your testimony here today, but also for your
service to this great Nation of ours.
I have a couple of questions I know some of you mentioned
the CARES process. You wanted the Committee to move forward on
the Dover-Foxcroft facility. Actually, we did pass a piece of
legislation that required the VA to submit a business plan for
the Lewiston/Auburn CBOC, the Houlton facility, as well as the
Dover-Foxcroft facility within 180 days after the enactment of
the legislation. The whole facility, I am sure the Togus
director will probably talk about that, is moving forward. The
Lewiston/Auburn CBOC, actually that's down in the central
office in the VA, and they are looking at that as well as--I
haven't heard anything about the Dover-Foxcroft facility.
As you know, we have a lot of issues before our Committee.
The CARES process is part of it, dealing with women's
healthcare issues, dealing with the Montgomery GI Bill, dealing
with the traumatic brain injury, post traumatic stress
disorder, just so many issues that we have to deal with and
such a short time to deal with them.
I guess my question would be to each of you, if we had to
focus on the top priority that is a must for Congress to pass
this year, what would that top priority be for your different
organizations?
We will start over here.
Mr. Wafford. Under rural healthcare, probably the satellite
van should be a significant push because that will enable to
touch more veterans. Similar, the DAV has a mobile service
office to provide outreach to veterans that don't have the
access or capability of coming to us, we go to them. And I
think the VA should probably do the same, sir. Thank you.
Mr. Michaud. Mr. Wallace.
Mr. Wallace. The speciality care to the clinics that are
already in place, specifically orthopedics and dermatology. We,
the Vietnam veterans, are now the older generation, and those
seem to be the needs as we get older.
Mr. Bachelder. Medical staff, because if you don't have the
medical staff, then you can't have the appointments. And I
think that is one of the biggest problems we have here in
Maine, trying to find professionals to come in and take the
positions so that the appointments can be set.
Mr. Simoneau. I still believe that it comes down to the
CBOCs. We need to have the community-based outreach. We need
those veterans to be able to go locally and get the help they
need, whether it is in a time of crisis or whether it is in a
time of just a checkup. But they need to know that locally they
can turn someplace. And if we cannot fund these CBOCs, then we
need to find a way to fund it so that these veterans can get
the help they need urgently at that moment they need help, not
to be told, well come see me in 3 weeks or 6 months.
So whether it is a CBOC or whether we loosen up some way of
funding for local doctors to help these people, we have to do
this. We have to get the help to the veterans immediately, not
postpone it.
Mr. Michaud. As you well know, we have heard a lot about
rural areas and providing healthcare, and some of your
organizations support more contracting out. When you look at
the healthcare shortage we have here in Maine and all across
the country, there is a healthcare shortage. There are not
enough providers, whether they are Federal, State or private
facilities.
Are there any concerns that your organizations would have
as far as dealing with non-VA providers treating veterans, or
is it only under certain circumstances should they contract
out? I know some of you addressed that earlier, but if we can
actually have each one of you address that.
Mr. Wafford. Yes, sir. I do believe fee service is a needed
item and a plus for the VA. I do believe in cost control,
monitoring. VISN 1 had a problem at one time, they over-
contracted. So, it can be used and it should be used on a case-
by-case basis, depending upon the individual's needs and the
availability of the services.
As you know, Maine has no medical school. We have no
``ologies'' or ``ologists'' available to us on a rotating basis
in this State. We have to go out-of-State. And that creates a
very tough time for the director to get qualified individuals
to provide healthcare at Togus. So, I do believe the fee-basis
is a way to go to help alleviate the backlog.
Mr. Michaud. Mr. Wallace.
Mr. Wallace. I believe fee-based--whoops. I believe fee-
basis is a way to go, but there have to be some limit put on
it. There has to be a proven track record. You can't just fee-
basis out to every doctor out there. Most of our clinics are
near a local rural community hospital. Maybe fee-basis with
that hospital, at least those doctors will have a proven track
record.
But the VA, if we do go that way, would also have to open
up our medical records to those doctors so that unnecessary
medical tests don't have to be repeated again, and those
doctors will have a complete history of the veteran and not
have to take it again. And also, the biggest problem with fee
services in the civilian part of it is a lot of the civilian
doctors don't understand the type of sicknesses we have,
whether it be mental or physical. So, they have to be educated
in that, and that is part of the thing the VA would have to do.
Mr. Michaud. Mr. Bachelder?
Mr. Bachelder. A couple years back, we had a problem with
the urology because they had a piece of equipment that needed
to be calibrated. It was so old that the manufacturer said that
the equipment shouldn't be calibrated, it should be replaced.
The cost of sending the veterans out to have that service done
outside was 4 times as much as it would cost to replace the
equipment. With the help of Bill Vail, who is here today, his
name was mentioned earlier through Susan Collins' office, it
was brought to the attention, the equipment was purchased, and
we saved some money.
So fee-for-service is something that we need to help that
veteran out in the middle of the countryside to get taken care
of immediately, but we need to not disassemble the VA
healthcare. We need to not take the funding necessary to make
sure that the healthcare runs right because everybody is going
to the local doctor and not being seen through the VA
healthcare. It is a system that we have throughout the whole
country. We need to fix it, not disassemble it. But fee-for-
services does have the necessary time period where the veteran
needs to be cared for.
Mr. Simoneau. Once again, CBOCs, fee-for-services. I think
Mr. Bachelder made a very poignant point, and that is if we
take all the money we use and we spend it on fees for other
doctors, we are taking away from the VA system and the VA
hospital that is a vital part of that network. We can't do that
in order to do the fee-for-service, because we still have needs
at that hospital that are way beyond anything that local
doctors would have knowledge to or knowledge of.
So fees for service for the certain items, absolutely. For
emergency items, absolutely. But we have to be very careful on
how we use it, when we use it, and where it goes.
Mr. Michaud. Thank you. Mr. Miller?
Mr. Miller. Thank you, Mr. Chairman. I understand not
wanting to take money away from the VA system, but in a
particular area such as Maine, it is so expensive to build a
community-based outpatient clinic, and I am a big proponent of
those. VA at one time was very central in their thought, they
wanted everything to go to huge medical centers, and we are
doing what we can to try to change that process within the VA
program.
I think we just have to be very careful as we are looking
at how to provide these services that we spend what little
dollars are there as wisely as we possibly can. The dollars are
there in Washington to do the job. You know, we are spending
money on things that many of you in here, and both sides have
done it in the past, where we probably should be spending money
on them in our Federal role. We have needs right here in our
own country that need to be done.
Mr. Wallace, I am particularly interested to talk about the
rural--rural healthcare. The mental healthcare that is being
provided, the telemental health, how are veterans taking to
that? There are a lot of people out there who have kind of
shied away from that, and they don't want to do these things
via the telephone, they don't want to do it via the Internet,
they don't--you know, they feel like they have to be sitting
right across from somebody.
How is that being received by the veteran population?
Mr. Wallace. Well, I've got extensive knowledge on that. A
little over 4 years ago when they pioneered it up in Caribou,
the 2 social workers that were handling it retired suddenly.
So, I volunteered and I took it over for almost 2 years. In
that 2 years time, 3 veterans didn't like it, the rest did. And
when the VA upgraded the equipment they had there so you
actually sit in front of a wider TV screen that's crystal
clear, you get the impression you are there with the doctor.
And the fact that they don't have to travel 250-plus miles
to get there. Basically, the way that I can explain that, the
veteran was traveling to Togus to see a psychiatrist, all
uptight and wound up. Spent 20 minutes with the psychiatrist,
got calmed down. And then got all uptight and wound up to
travel home 250 miles. It was defeating its purpose. Now the
longest they travel in Aroostook County is about 60 miles.
Now, in the beginning when the VA went to the CARES and
they said 30 miles or 30 minutes, at the VISN level meeting at
the BigMac, I said that don't apply to Maine. More like 60
miles, 60 minutes would fall in for us. Our road system doesn't
go in a straight line. The VA figures things out from Togus,
say, to Madawaska using the road going up there. But in the
wintertime, they don't travel Route 11. They take the longer
way around. Also, they take the longer way around in the spring
and the fall so they don't lose their life hitting a moose or a
deer.
Mr. Miller. If you need help thinning out the moose and
deer herd, I volunteer.
Mr. Wallace. Well, there's over 100 of them dead along 95
now because they are out there eating.
Mr. Miller. Mr. Wallace, I have also found in my 24 hours
here that even your straight roads aren't straight.
I yield to my colleague, Mr. Allen.
Mr. Michaud. And Mr. Miller and the staff had a great
opportunity to see what the potholes were like as well.
Mr. Wallace. Do you really like that Moxie? Because I
don't.
[Congressman Miller held up and crushed the empty Moxie
can.]
Mr. Bachelder. Mr. Chairman, the one thing that I wanted to
also comment on was that the travel pay, when I went up to
Togus a week ago, the deductible was increased also. I
appreciate your looking into it.
Mr. Michaud. Yes, and that's one thing. I know the
Secretary told the Committee that it is waived, and Mr. Miller
had mentioned that there was a letter or a memo saying that the
Secretary misspoke. Actually, we haven't seen that memo, so we
will definitely want to look at that memo. That was not the
intent.
Mr. Wafford. Yes, sir. It is waived on a case-by-case basis
is what came down from the national headquarters, sir.
Mr. Michaud. Mr. Allen?
Mr. Allen. Thank you, Mr. Chairman. I have just one
question for all of you.
What do you hear about traumatic brain injury or PTSD from
the members of your organizations? I mean, can you just give us
a flavor of problems you may see, just a fairly concise
statement about what it is you are hearing these days about
those 2 kinds of injuries.
Mr. Wafford. Yes, sir.
Mr. Allen. You know, what we need to do about them.
Mr. Wafford. The DAV, we have done--we have partnered with
a lot of other organizations on these issues. We also feel that
they are so intertwined at times, they cannot be separated. And
with the rating system designed like it is, it is a 10 percent
rating under Diagnostic Code 8517. So, that limits the amount
that a veteran may be rated unless it is rated under the
residuals of a traumatic brain injury.
We need to look at the rating schedule. We need to--we need
to separate it out. I understand about pyramiding where you
cannot rate a condition on top of a condition if it is in the
same area. But TBI is definitely intertwined with this, and we
need to re-look at the rating schedule on that.
I just had a young man call me from Walter Reed last week.
He came home to Sabattus on Tuesday. He has been in Walter Reed
for the last 10 months. He is waiting on his Medical Evaluation
Board (MEB) to be finalized. So this young man's coming home
for the help under the Wounded Warrior program. He will be
getting some treatment at Brunswick Naval Air Station, but they
are very limited. So he will have a problem with this traumatic
brain injury getting services through Togus because he is not
discharged.
Mr. Allen. I think he is the young man I saw at Walter
Reed.
Mr. Wafford. It may have been, sir, because he did say he
was in touch with our Congressional, and I advised him to come
and see me this week.
But he is a very good case to base the TBI on where he has
had treatment and we are trying to get him converted over. He
hasn't been totally discharged yet. We need to do the
continuity of care. But when the VA gets to rate this young
man's case, you know, he deserves more than 10 percent under
that diagnostic code. And so, yeah, we do. And they look under
that diagnostic code, PTSD is one of the things that are listed
in there. We need to break it down, we need to upgrade 38
C.F.R. Sec. 4.71. Thank you.
Mr. Allen. Mr. Wallace?
Mr. Wallace. At the last BigMac meeting in Bedford, Mass.,
they gave us a thing on traumatic brain injury and what the VA
is doing now. They asked them I believe it was 3 or 4
questions, and if they can answer yes to those 3 or 4
questions, they are then treated for traumatic brain injury
instead of PTSD. The biggest thing I remember when they said
that, I asked them--I said, then what are you doing about those
Vietnam veterans because I can answer yes to all those
questions. Does that mean I have been misdiagnosed all these
years? They've got a long way to go.
Mr. Allen. Jim?
Mr. Bachelder. The VFW, along with all these other
organizations, if you read their magazines, they are very
concerned about traumatic brain injury. The post traumatic
stress disorder is life-threatening to the individual if
suicide is an active symptom. Traumatic brain injury is life-
threatening just in itself because if it is not diagnosed, the
brain can have problems, swelling. It could be caused from
other things, of actual bone material that has broken from
these bombs that we have that is causing it.
So, it is a major concern that the Department of Defense
has not built a clinic, is not examining these individuals to
find out that they have a medical problem, they are not being
diagnosed, it can end their life. And we need the Department of
Defense to take responsibility to make sure that these
individuals that have been through these roadside bombs, that--
and it could be from not just that, it can be just from being
in an explosion from a grenade or a missile that came by you
that could cause a brain injury that will end your life when
you come back home. And where is the responsibility for the
military to care for these individuals before they are being
released?
Mr. Simoneau. Traumatic brain injury is something new. It
is something that we have dealt with for years, but we haven't
seen in the proportions that we are today. Traumatic brain
injury/PTSD are 2 separate items, but they are linked. We need
to make sure that the VA and the Department of Defense take a
very close look at this because this traumatic brain injury is
something that is just hiding behind that person, and we never
know where that is going to be. We need to step forward. We
need to make sure that these young men and these young ladies
that are dealing with this are taken very good care of.
It is hard to admit, anybody, that they need help. It is
hard for any of those soldiers to say I have had some things
happen to me. But if you look at the past record, whether it is
a Vietnam veteran or whether it is a World War II veteran, or
anybody else, when they come home they want to go on with life.
They don't want to say, I've got a problem. We have to reach
out. We have to make guidelines that they fit and guidelines
that work for it, and I believe that's a way to start. Thank
you.
Mr. Allen. Thank you. I yield back, Mr. Chairman.
Mr. Michaud. Thank you. Once again, I would like to thank
all 4 of you for your testimony this morning and thank you for
your service to this great Nation of ours. Thank you.
Our last panel is Brian Stiller, who is the Center Director
for Togus Medical Center, the Department of Veterans Affairs. I
want to thank you, Mr. Stiller, for coming here this morning. I
look forward to your testimony. I know you have only been at
the VA for a year or a little less, so welcome to Maine.
STATEMENT OF BRIAN G. STILLER, CENTER DIRECTOR, TOGUS VETERANS
AFFAIRS MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS
Mr. Stiller. Thank you, Mr. Chairman, and Members of the
Subcommittee. Can you hear me? Is this on? There we go. Thank
you very much.
On behalf of the employees and the volunteers at the Togus
VA Medical Center and its outlying clinics, I thank you for the
opportunity to discuss the care and services we provide Maine
veterans. I will focus my remarks today on our ongoing efforts
to improve access to care in a largely rural setting with an
emphasis on meeting mental health and women veteran healthcare
needs.
It is important to recognize that since 1999, we have grown
from 19,000 veterans to 52,000 enrollees, with 38,000 of those
enrollees accessing our VA healthcare system. Today, those
veterans receive their care at Togus and 6 community-based
outpatient clinics. These clinics are located in Bangor,
Caribou, Lincoln, Calais, Rumford, Saco, and a part-time access
point in Fort Kent. The new Bangor clinic plans include
physical therapy, dental, optometry, radiology, part-time
limited specialty services, as well as compensation and pension
rating exams.
In addition to the Medical Center and its outlying clinics,
we further provide care in rural and residential settings using
home-based primary care. We have home-based primary care teams
operating out of Togus in Portland. The home-based primary care
teams provide primary care, nursing, social work services to
the veterans with complex chronic diseases who are seeking to
maintain an independent living situation. New home-based
primary care teams are authorized for Caribou and Lincoln, and
recruitment for these new positions is ongoing.
Togus leadership is working on the newest approaches to
improving access as exemplified by the establishment of the VA
Office of Rural Healthcare. We are working with the Office of
Rural Healthcare to identify and address the needs and
challenges of providing healthcare in rural areas. The Office
of Rural Healthcare is leveraging rural health expertise from
public and private sectors and is working on several rural
health initiatives.
While recognizing our efforts to expand rural healthcare
access, we also need to further improve and expand access to
qualified healthcare professionals. Working with community
educators and healthcare providers, Togus is recommitted to
enhancing existing affiliations with State and national medical
educational facilities, as well as establishing new
affiliations. In October of 2008, we plan to host a ``Medical
Education and Research'' symposium for medical education,
healthcare and research organizations.
At Togus, we are using technology to improve access for
rural veterans as well. We are currently providing 150 veterans
with adjunct care via home telehealth. Staff use these devices
to review medication, assess wounds, complete psychosocial
assessments, and conduct follow-up reviews for medication
changes. These devices provide timely, accurate data to provide
healthcare while minimizing veteran travel.
Togus continues to be a leader in healthcare by identifying
and employing new technologies. Maine recently received a $25
million dollar Federal grant to develop telemedicine services
throughout New England. Togus is coordinating with other Maine
healthcare organizations to determine how best to further
deploy and utilize this healthcare technology.
I would like to proudly share with you some of our
accomplishments and successes in mental healthcare. Through the
VA Mental Health Initiative process, during the period of
fiscal year 2004 to fiscal year 2007, our mental health staff
grew from 54 to 74, an increase of 39 percent. With additional
staffing, we are able to provide better access to veterans and
develop new programs in the areas of treatment.
Care for veterans in rural Maine improved with all our
northern CBOCs having telepsychiatry connectivity and many
having in-home videophone connections. All Maine CBOCs have an
on-site specialized mental health provider, and mental health
clinics are located in Bangor and Portland. We strive to
provide intensive specialized mental healthcare and residential
support for veterans in rural areas, particularly homeless
veterans, those in extended PTSD treatment, and those with
substance abuse problems.
To better serve OIF/OEF combat veterans, Togus reorganized
its PTSD program into a 1-week intensive outpatient program.
This program utilizes a new evidence-based treatment that
focuses on the needs of new veterans who have careers,
families, and cannot attend a longer program. It provides a
basis for follow-up care as necessary. This program is well-
received with very favorable feedback. Moreover, 2 programs
have already been conducted solely for women veterans to
appropriately support their needs.
Women comprise about 14 percent of the active duty, Guard
and Reserve forces with approximately 1,700 Maine women
veterans receiving VA healthcare. Togus' women's clinic
provides primary care, gynecology, and mental health services.
Maternity care is provided via fee-basis by a community
provider of the veteran's choice. Mammography is provided via
fee-basis at any FDA approved site.
The VA has 2 performance measures which are specific to
women's healthcare: Breast cancer screening and cervical cancer
screening. In both of these measures, Togus exceeded the
national benchmark. Veterans are surveyed with a clinical
reminder regarding military sexual trauma and treatment
services are available through Togus, CBOCs, Vet Centers and
fee-basis as appropriate.
We have plans to purchase additional equipment to expand
care for women veterans this year. VISN 1 is evaluating women's
healthcare educational and equipment needs at CBOCs with the
goal of providing increased access to routine gender-specific
healthcare. Togus has a dedicated women veterans program
manager. And to enhance their outreach efforts, Togus hosts an
annual Women Veterans Information Fair and hosts Women Veterans
of America meetings.
Mr. Chairman, as you know, I am relatively new to Maine.
But as I have shared before, I remain impressed with the work
being accomplished by the veterans organizations, the Maine
National Guard, and other State programs. I look forward to
continuing our work with them to better serve Maine.
Mr. Chairman, we must continue to closely monitor and meet
the needs of Maine veterans. Our veterans have earned the right
to the best care available, and it is our privilege to provide
them with that care. We appreciate your interest and support in
helping VA to successfully accomplish our mission of providing
world-class care to all of those who have so honorably served
our great country.
Thank you.
[The prepared statement of Mr. Stiller appears on p. 62.]
Mr. Michaud. Thank you very much, Mr. Stiller, for your
testimony.
We appreciate all the work that you are doing and have done
for our veterans both at your previous job and here at Togus.
I know Mr. Miller has a flight that he has to catch, so I
will recognize him first for questions.
Mr. Miller. Thank you, Mr. Chairman. I actually have a
quick stop at Portsmouth first, the Naval Shipyard, and then on
to the airport. So, if I do step out, it is not because I
didn't want to stay through the entire hearing. I thank you for
the invitation.
Mr. Wafford, from DAV, expressed concern about the CBOC not
being constructed in Dover-Foxcroft. What are you doing in
regards to access to healthcare for people in that general
vicinity now?
Mr. Stiller. Currently, Mr. Congressman, we have put forth
a series of plans which would include Farmington as well as a
number of other areas, as well as Lewiston-Auburn (LA), and
that gets into the circumference area.
And one of the other things that we are looking at is we
have recently applied for a grant, and we are waiting to know
if we have been approved, to go to a mobile clinic. What we
want to do, as we have had success in the past with mobile
clinics, is use the storefront approach coupled with that
mobile clinic to address the needs of the veterans in that
area.
Mr. Miller. I know one of the biggest needs in rural
healthcare is recruiting physicians and healthcare
professionals into the area. Do you find the same problems
here? What are you doing or what is the VA doing, I guess, to
help overcome these obstacles?
Mr. Stiller. Well, I think larger--I can't speak to VA
other than from my experience in VA, and that obviously the
recent pay changes, Physician Pay Acts have helped
significantly.
What we have done locally is we have actually employed a
Title 38, if you will, headhunter recruiters I call them. And
we also have 2 contracts now since my arrival that address the
challenges of recruiting the specialty care providers.
I think it is incumbent on us in the State of Maine, as far
as the Veterans Healthcare System, to educate the future
students. So, affiliations is going to be a huge piece of this.
I have been quoted as saying, ``We want our medical center and
CBOCs crawling with students.'' Obviously, it is part of our
mission, and I think we have great opportunities to bring those
future healthcare providers in and entice them into the
practice of rural healthcare.
Mr. Miller. I think you said, you talked about having
students all over the campuses. One thing that the statistics
do show is when medical students come to an area to do their
residency and do some of their original practice work, they
stay there.
Mr. Stiller. Yes.
Mr. Miller. That is something that I know Maine will want
to look forward to as well.
You've got an opportunity to take a shot at any one of us
up here. Is there anything that Congress can do? I mean,
obviously everybody is saying give more money, appropriate more
money, but from the standpoint of outreach, what else can we do
to help you reach out to the veteran population?
Mr. Stiller. Sir, I think that is an awesome question
because right now our big stress, at least in the State of
Maine, is we have a great relationship with the National Guard
and getting to these young men and women who are coming home.
We are there when they muster out and when they return from
deployment.
Where we run into difficulties is with the Reservists. The
young men and women who come home with the Reserve, we do not
have one central contact that we can go to to find out when
these units return to their drilling areas. So, if we had one
central contact for the State of Maine, and it may be the same
in other parts of the country, that would be extremely
beneficial.
Mr. Miller. Thank you.
Mr. Michaud. Mr. Stiller, just to follow-up on that.
Mr. Stiller. Yes, sir.
Mr. Michaud. We heard a lot this morning about the CARES
process and how that would actually help with a lot of the
problems that we have been hearing about veterans getting
access to the care that they need, and you mentioned Dover-
Foxcroft, Bangor.
Where does Togus, the remaining clinic that was recommended
in the CARES process, how far along are you with moving that
process forward?
Mr. Stiller. Right now, sir, as you know, we have submitted
the LA, and it is in headquarters, and I believe it is going
across the street to the Office of Management and Budget, as I
understand. We are in the process, the first step of seeking a
contractor for the Bangor replacement clinic. As I said, we are
in a 2-step process for, first, applying for the grant, if you
will, for the mobile clinic. But then the storefront for Dover-
Foxcroft will be separate. The other ones are still in the
planning stage and have not been submitted up the ladder, if
you will.
Mr. Michaud. You have heard earlier as well, it is very
important for the different VISNs to move forward projects that
they need, and ultimately it is up to Congress to provide the
adequate funding.
How do you go about the process of moving up to the VISN
level? Will you be able to get everything you need here for
Maine to take care of our veterans, or is there push-back from
the VISN 1 level?
Mr. Stiller. No, sir. Actually, VISN 1 has been extremely
helpful in helping us complete the financing, complete the
business plans because of the technical acumen that is needed
to complete these plans. So, they have been very successful and
there has been no dropping off, if you will, and repeating
them.
Mr. Michaud. Is the VA/Togus looking at expanding specialty
services and inpatient services at Togus to a full tertiary
care facility for our veterans?
Mr. Stiller. I know that we have opportunities to continue
to expand specialty care within Togus. I think what we have to
balance is the number of surgeries. I am not a medical
professional, but in my training there is a certain amount, a
certain number you want to hit for proficiency. We are trying
to take care of all of the key ones such as urology, neurology,
and then the more specialized services are better accomplished
in Boston or Maine Medical or wherever we can purchase it.
Mr. Michaud. Would you provide to the Subcommittee how many
veterans you are moving to or shipping to Boston for services
at a later date?
Mr. Stiller. Yeah, I can get you the exact number, sir. I
don't have that on the top of my head.
Mr. Michaud. And what type of services that they are going
to Boston for.
Mr. Stiller. If I could, I would like to get you the exact
pieces of that. I don't have that with me.
Mr. Michaud. No problem.
[The information from VA follows:]
Question: How many patients are being sent to Boston VAMC
and Massachusetts General from Togus VAMC? (VHA)
Response: In FY 2007, 37,796 patients received healthcare
services at the Togus VAMC. During this same time period, Togus
VAMC sent 1,096 patients to the Boston VAMC. Togus VAMC does
not refer patients to Massachusetts General Hospital.
Question: What types of services are being provided via fee
basis at these hospitals (Boston VAMC and Massachusetts
General)?
Response: Togus VAMC fee bases out gastroenterology,
urology, cardiology and audiology to Maine Medical and Eastern
Maine Medical Center. Patients are also referred to Boston VAMC
as clinically appropriate. Togus does not fee out or refer
patients to Massachusetts General.
Mr. Michaud. And my last question is, can you tell me what
the hardest female medical service is for your agency to
provide rural healthcare needs for our female veterans?
Mr. Stiller. I think that it would be the specialized care,
and not any different than the private industry and that
gender-specific specialized care. I have Dr. Hayes in the
audience. She may be better able to speak to the specifics. The
specifics, well, for the gender-specifics as you get further
into rural America, it does get difficult.
Mr. Michaud. One more issue, actually. We just established
the Office of Rural Health. How closely have you been able to
work with the Office of Rural Health, and have they been
responsive? Should we look at additional help in that office in
your opinion?
Mr. Stiller. They have been really responsive. Sir, just
anecdotally off to the side, after we had talked about--after
you had visited the Medical Center and we had talked about the
importance of reaching rural veterans, I had the luck of going
to a training class and meeting Kara Hawthorne, the new
director, and approached her. At the same time, your letter hit
her office. So, we have begun a good dialog and we continue
to--in fact, we are going to meet today to talk about some
interesting things that we are going to try to accomplish.
Mr. Michaud. Mr. Stiller, thank you very much. Mr. Allen?
Mr. Allen. Thank you, Mr. Chairman. Thank you, Mr. Stiller,
for the good work you are doing, and I was very impressed when
I was last up there.
How many counselors do you have doing military sexual
trauma issues?
Mr. Stiller. We have one major military sexual trauma
coordinator who then, as I understand it, we provide the
specialized training to the primary care physicians and the
mental health providers to cover it. And so, like, in the CBOCs
to be in the position to provide the services that the veterans
would need.
Mr. Allen. And is it one person?
Mr. Stiller. One person initially coordinates it, and then
there is a training template and there is an intensive training
program.
Mr. Allen. And she does the training of the physicians who
provide the care?
Mr. Stiller. As I understand it, sir, yes.
Mr. Allen. Okay, thank you. Lots of people sat at that
table today and testified. Was there anything that you heard
that you need or want to respond to to shed more light on, or
was there anything that struck you in terms of the testimony
that you wanted to comment on?
Mr. Stiller. I was pleased by the testimony. The one thing
I am curious to continue to work on is that's the access.
Access is critical. But the challenges we face in rural
healthcare is availability, the specialty doctors. And I think
the best way for us to address that is through bringing more
education programs and affiliations into the VA Medical Center
at Togus, and we will see significant improvement in the areas
of access.
But compared to where we were 3 years ago, which was some
of the time lines, I am not quite sure that they would find
that same experience. We do have some areas where we certainly
will improve. But overall, it has been looking pretty promising
in my opinion.
Mr. Allen. Well, all I want to say on that conclusion is, I
remember what it was like when I was first elected, and let's
just say relations between Togus and the VSOs were stormy. And
I understand that the funding was inadequate and we were being
squeezed, both at the Federal level and by the VISN. And a lot
has changed.
Mr. Stiller. Thank you, sir.
Mr. Allen. Thank you very much for your testimony, and I
would like to thank everyone else as well.
Mr. Stiller. Thank you, sir, for your support.
Mr. Michaud. Once again, Mr. Stiller, I want to thank you
for your service to the country, but also thank you very much
for what you are doing at Togus. I know you have only been
there a short while, but from what I have seen so far, you are
definitely a go-getter. You think outside the box. And as I
told the Secretary at the beginning, your performance has been
great.
As you heard testimony as well from the VSOs here this
morning, there is still work that has to be done with access
issues. Part of it you can do. I think part of it has to be on
Congress to make sure that we do provide the adequate funding
for VA healthcare, but also make sure that it is in a timely
manner. That is our job, and we will do the best job that we
can. We will continue to work with you and your staff, and we
want to thank your staff as well for all the hard work that
they do.
Once again, I want to thank Congressman Miller for his time
and willingness to have a Congressional hearing here in Maine.
I hope that you enjoyed your Moxie. We have some more available
for you for your flight back to Florida.
I also want to thank Congressman Allen for his time and
effort to come out this morning, and especially for the
audience. We look very much forward to working with each and
every one of you, especially the Office of Rural Health in
dealing with issues for access. I want to thank Kara for your
time coming up here as well. Hopefully you heard a lot from our
veterans here today, and look forward to working with you and
Mr. Stiller to make sure that every veteran has the opportunity
to access good, quality healthcare when they need that
healthcare.
So, once again, thank you everyone. This hearing is
adjourned.
[Whereupon, at 12:27 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Michael H. Michaud,
Chairman, Subcommittee on Health
The Subcommittee on Health will come to order. I would like to
thank everyone for coming today.
Today, we will examine the Department of Veterans Affairs programs
regarding rural veterans, women veterans, and other special needs
populations.
I am very happy to be here in Sanford, Maine, this morning. Sanford
is the home of longtime veteran advocate, and someone who I was honored
to call a friend, Roger Landry. Roger worked in the legislature and in
the VSO community here in Maine and was very well liked and respected
by all. Roger served his country and his community with great pride and
honor. Roger died last year and he is sorely missed. I would like to
dedicate this hearing to Roger Landry in honor of his work with and for
veterans.
It is appropriate that we are having this hearing in my home State
of Maine this morning. Maine is a very rural State and because of this
we face many unique challenges in providing health care to our
veterans. Many have to travel long distances for care, creating a
significant burden for veterans and their families.
The VA has instituted some innovative programs to provide much
needed services to rural veterans. I look forward to hearing from our
panel today about their ideas to improve access and decrease the travel
burden for our veterans living in rural communities across the United
States.
At this hearing, we will also hear about women veterans. Women make
up about 14 percent of active duty military, and consequently they are
making up more and more of our veteran population. Women have some
unique health needs. I look forward to hearing today about the unique
needs of women veterans and to hear ideas about how the VA can improve
their services targeted at women.
When the United States made a commitment to care for veterans, we
made the commitment to care for all veterans--male and female, urban
and rural. Today, I hope that we will learn how VA is meeting the needs
of these populations, what challenges are on the horizon and what we
can do to provide these veterans with the best possible care available.
Prepared Statement of Dana Doliber, Sanford, ME (Veteran)
In 1971 in an attempt to address increasingly debilitating mental
health circumstances I sought assistance from the VA at Togus VA
Hospital. While there I filed a claim for what was termed then as a
``nervous condition''. Associated with the ``nervous condition'' was a
record of poly substance drug abuse. The emphasis that the VA chose to
take was to emphasize the poly substance drug abuse as the cause of the
``nervous condition'' which they were incorrect as the poly substance
drug abuse was an attempt at self-medication on my part to try to deal
with my so called ``nervous condition'' as it was called as there was
no terminology of PTSD at the time and interestingly enough while at
Togus VA the emphasis on treatment besides group and individual
psychiatric therapy was drug therapy with Thorazine, Elavil and a host
of other mood altering drugs. My claim was denied. In 1985 after losing
my first marriage and coming close to losing my second marriage, at the
pleading of my second and present wife, many jobs and the loss of many,
if not all friends and abject social isolation, recently being laid-off
from my job and trying to work at the Navy Yard at Kittery, Maine, in
the apprentice program, my depression reached an unbearable point where
on the urgent request of my wife I sought help from a counseling
service in Sanford and began seeing Mr. Robert Paige, LCSW.
I was diagnosed with PTSD at that time and upon seeing Dr. John
Scammon, Psychiatrist at the counseling service, who concurred with Mr.
Paige's diagnosis. Upon seeking assistance from the State of Maine
Veterans Service Representative, Mr. Campbell Colton, a claim was filed
with the VA at Togus VA Regional Center. Subsequent claims for medical
conditions, all service connected, were filed in later years. From 1985
to 1992 claim after claim was denied. I provided documentation, ships'
logs from my ship, USS Richard S. Edwards (DD950), USS Newport News
(cruiser), USS Saint Paul (cruiser), USS Collette (destroyer) that not
only detailed firing on coastal defenses, gunfire support missions,
harassment and interdiction fire but of receiving fire from various
units of the enemy both from Vietnam but also islands off of the coast
of Vietnam and north of the DMZ. Letters from shipmates (buddy letters)
were also provided that corroborated my previous testimony. Photographs
were provided showing wounded being high-lined to hospital ships such
as Repose and Sanctuary. Because the ships log was incomplete and
inaccurate the VA used that as a basis for denying my claim. I had to
further provide a stressor was the VA primary qualifier.
It reached a point that I felt that unless I had the serial number
of the round going past that I would never win. There was even one
occasion in the process that the VA paperwork reflected that I was in
the Army in 1971 with a previous record of being in trouble with the
law and trouble in school while being born on July 3, 1952. The
opposite was the true story, I was born in July 3, 1947, was in the
Navy and had no problems with the law or school. This was all in one
document. Even though my brother had no claim filed with the VA, the VA
had my brother and I mixed up. This dual portrayal was not designed to
help my claim but to cast doubt on the validity of what the evidence
was. On one occasion I had an interview with a Psychiatrist because the
VA failed to provide him with stressor documentation I had already
provided made an other than PTSD diagnosis but after the documentation
was provided a panel of Psychiatrists, a diagnosis of PTSD was reached.
From 1992 to the year 2000 the claim was pursued for increased
rating and retroactivity. The decision for that was reached in December
2000. This was agreed upon as a result of my agreeing to not pursue my
claim of CUE (clear and unmistakable error) that were a result of the
VA Togus previous rulings being thoroughly vacated by the BVA in
Washington and the Federal Appeals Court for the VA. During this claim
process and evidence gathering process I requested assistance from the
VA in acquiring evidence. It is my understanding that if the veteran
request side from the VA in seeking records the VA is supposed to help.
This assistance was not forthcoming. As I understand it the VA also
gives the veteran the ``benefit of the doubt'' and that if the VA
cannot provide a preponderance of evidence to counter the veteran's
claim then they must rule in the veteran's favor. This didn't happen.
Only when I found out from a shipmate that we had been awarded the
Combat Action Ribbon did the VA relent. From that point on it was a
matter of my filing claim after claim for percentage increases and
retroactivity. During that time I felt it was necessary to retain
counsel but in 1998 due to changes provided by legislation provided by
Congress the VA regs created a situation where I had to give up counsel
and after a time I asked the AMVETS for their assistance.
It needs to be noted that during the time between 1985-2000 in
pursuing my claim I received help from Senators Cohen and Mitchell and
Representative Tom Allen, Mr. Robert Paige LCSW (counselor) and
contacted to provide information Judge Greene, United States Court of
Veterans Appeals, Attorney General of the United States Janet Reno,
Richard B. Standefer, Vice Chairman Dept. of Veterans Affairs Board of
Veterans Affairs and sought confirmation of ships' activity from the
Republic of Vietnam office at the UN. When I was finally awarded the
100 percent P&T for chronic and severe PTSD I lost the percentages that
I had for medical disabilities previously awarded and the disability
for hearing loss was removed from my medical record I just recently
learned after seeking again treatment for sores and skin rashes that I
associate with Agent Orange exposure that I filed a claim for in 1991.
The VA acknowledges Chloracne and Acne form disease as indications
of Agent Orange exposure but blue water Navy isn't acknowledged by the
VA as being exposed to chemical agents while offshore. I would have
thought that the VA could make the leap from ``sores and skin rashes''
to Chloracne and Acne form disease. Apparently they can't. In their
most recent action in that regard titled: VA Adjudication Procedures
Manual, M21-1; Rescission of Manual M21-1 Provisions Related To
Exposure to Herbicides Based on Receipt of the Vietnam Service Medal an
interesting item the VA uses to discount blue water NAVY from being
exposed is that because chemical agents used as herbicides when heated
as on board ship to desalinate seawater for drinking, cooking, showers
becomes concentrated much more than when diluted in seawater. The VA
position is that it doesn't know if ships used desalinators while at
sea to convert sea water to fresh. This borders on ludicrous. There are
ships systems that require fresh water, people require freshwater. The
ship I was on operated in I Corps and north of the DMZ. I was there in
1967-'68. I Corp was one of the heaviest sprayed areas in Vietnam. The
years of the heaviest spraying for I Corps is 1966-'69. My ship was
anchored in DaNang harbor and on one occasion went up river that is
mentioned in the ship's log. The conclusion I would draw from this is
that we were subject to exposure to chemical herbicide agents.
The VA has several areas it could improve: 1) Claim processing with
and for the veteran; 2) Abiding by the law as passed by the Congress,
is: the HAAS case be Proactive FOR Veterans; 3) Medical: There are 100
percent Disabled veterans that doctors have asked for tools from the VA
Togus to help with medical conditions that are being withheld. Veterans
that should receive the gold standard in medical care whether having
heart surgery or colon cancer surgery or treatment for peripheral
neuropathy, traumatic brain injury whether in West Roxbury, Togus VA
Hospital or whereever. Be more proactive in the VA medical care of its
veterans with regard to budget requirements. Provide counseling, in-
house--to veterans just after surgery for rehab services. My own
brother recently had colon cancer surgery and was sent home 5 days
later instead of going to a rehab facility. While at home the following
day with coughing and sneezing and throwing up, all his stitches broke
and his guts came out. After being taken to a hospital after being
stabilized he was operated on again twice. Once to debride and remove
the guts to clean and put them back and a couple of days later to close
the wound leaving a space for the wound to heal from the inside out. He
is scared to death of going back to Togus VA but tomorrow morning the
18 of April he is going. He was told that if he didn't go to the VA
hospital the VA would not pay for his hospital care. He also is 100
percent disabled.
It is my hope that by providing this testimony that it in some way
it helps. Either the VA can provide some relief to its veterans or the
ironclad legislation necessary to compel the VA to do what is necessary
for veterans should be forthcoming. The VA history regarding Agent
Orange and the HAAS case is yet another example of the VA shirking
their responsibility to the veteran. Add to this the attempt of the VA,
at present time, to reinterpret the DSM IV protocol for PTSD to the
benefit of the VA and not the veteran demonstrates a level of hubris
that is amazing. The 900 lb. gorilla in the room that may prevent any
good coming from this is money or rather, the lack of it. America's
veterans providing the freedoms that we have deserve no less than the
full support of the VA. The American people understand the need to
support our veteran population. Servicemen and women understand and
expect that if they need help when they come home the help will be
there. We should not disappoint them by a lack of action. The one thing
I ask from this Committee at this time is their assurance there will be
no retribution against me or my family by the VA regarding my
testimony. I submit as well a copy of suggested legislation designed to
address Agent Orange legislation for blue water Navy.
Thank You.
Prepared Statement of Peter W. Ogden, Director,
Bureau of Veterans' Services, State of Maine, Augusta, ME,
and Secretary, National Association of
State Directors of Veterans Affars
Chairman Michaud, Congressman Miller, Congressman Allen and
distinguished members of the committee, thank you for this opportunity
to speak today on three extremely important issues for Maine's
veterans; access to healthcare, women veterans, and outreach to
veterans on their benefits. My testimony today comes from three
prospectives: as the Director of the Bureau of Maine Veterans'
Services, the Secretary of the National Association of State Directors
of Veterans Affairs (NASDVA), and as a disabled combat veteran who uses
the VA healthcare system in Maine.
We greatly appreciate the leadership of Chairmen Akaka and Filner,
Ranking Members Craig and Buyer and the entire membership of the Senate
and House Veterans' Affairs Committees for their past and continued
support of our veterans and the VA. Because of the War on Terror, we
are now serving a new generation of veterans while we are struggling to
bring our elderly WW II and Korean war veterans into the VA system. The
new veterans are going to need our help as they return to civilian life
while our elderly veterans need primary and long-term healthcare. We
believe there will be an increased demand for certain benefits and
services and the overall level of healthcare funding must meet that
demand while continuing to serve those veterans already under VA care.
Maine is a unique State in several ways: In 2000 Maine had the
largest per capita veteran population in the Nation and is still at
number two or three; the Togus Medical Center is the oldest VA hospital
in the Nation; and Maine's aging veteran population is geographically
dispersed across a large land area. We have a saying in Maine, ``ya
can't get there from here,'' while you can get to the one VA Medical
Center at Togus from about anywhere in Maine it can take you five to
six hours to travel up to 260 miles to reach Togus.
Maine presently has the distinction of being the oldest State in
the Nation with a median age of 40.6 years old. \1\ When you look at
the age of Maine's veterans you will find that 65 percent or 93,780
veterans are aged 55 and older. \2\ These are the veterans that are
most likely to need and use the VA healthcare system. Access for
Maine's aging veterans is of extreme importance.
---------------------------------------------------------------------------
\1\ Churchill, Chris. Maine: The gray State, Maine now has highest
median age in the U.S., Kennebec Journal, March 11, 2005. Page A-1.
\2\ Numbers were taken from the Veterans Administration's
Demographics Program VetPop2007 for the year ending September 2007.
---------------------------------------------------------------------------
Any conversation about aging veterans and access to healthcare
should include the importance of the State Veterans Homes program and
the services they provide to our veterans in long-term, residential,
skilled, dementia and respite care. Maine is fortunate that we have the
Maine Veterans Homes with their six facilities spread across the State
that provide the best care at the most reasonable cost. While Maine has
the maximum number of beds available by VA demographics standards, many
other States do not and Congress should continue to fund the State
Veterans Home Construction Program until they have the capacity to
provide long-term care to their veterans.
Maine's aging veteran population coupled with our rural geography
presents problems to elderly veterans trying to access VA healthcare
especially in Maine's severe winter months. Maine has a limited
transportation infrastructure and this compounds the access issue. The
CARES market plan (Far North Market) developed in VISN 1 recognized
Maine's unique geographic characteristics, limited transportation
infrastructure and rural nature. The resulting CARES Commission Report
made several points about access to VA healthcare in Maine (Far North
Market) that are relevant to this hearing.
``In the Far North and North Markets, less than 60 percent of
enrolled veterans are currently within the VA's access standards for
hospital care. The CARES standard is 60 minutes for urban areas; 90
minutes in rural areas; and 120 minutes in highly rural areas.
Inpatient medicine workload is projected to increase . . . The Far
North Market has the largest projected increase, with 209 percent over
baseline by FY 2012.'' \3\
---------------------------------------------------------------------------
\3\ CARES Commission Report, Chapter 5 VISN Recommendations, Page
5-15.
---------------------------------------------------------------------------
``. . . the Far North Market is currently below the standard for
access to primary care. Currently only 59 percent of the veterans
residing in this largely rural area are within the CARES guidelines set
for access to primary care services.'' \4\ The CARES definition for
``Access to Primary Care'' is ``70 percent of veterans in urban and
rural communities must be within 30 minutes of primary care; for highly
rural areas, this requirement is within 60 miles.'' \5\
---------------------------------------------------------------------------
\4\ CARES Commission Report, Chapter 5 VISN Recommendations, Page
5-18.
\5\ CARES Commission Report, Appendix A, Glossary of Acronyms and
Definitions, Page A-3.
---------------------------------------------------------------------------
``The VISN had proposed five new CBOCs, (Community Based Outpatient
Clinics) all in the Far North Market. These new CBOCs would be located
across Maine in order to improve access to care and thus address
current deficiencies in access in this market. . . . These CBOCs are
also crucial to the VISN's plan to expand inpatient capacity at Togus,
by reclaiming old inpatient space that has been converted to outpatient
services.'' \6\
---------------------------------------------------------------------------
\6\ CARES Commission Report, Chapter 5 VISN Recommendations, Page
5-18, 19.
---------------------------------------------------------------------------
The following table shows the aging of Maine's veteran population
over the next 25 years. As you can see we will continue to have the
majority of our veteran population over age 55 for many years to come.
------------------------------------------------------------------------
Veteran Percent of Veteran
Year Population* Veterans > 55 Population
------------------------------------------------------------------------
2007 144,007 93,780 65 percent
------------------------------------------------------------------------
2010 138,551 91,200 66 percent
------------------------------------------------------------------------
2015 129,091 86,700 68 percent
------------------------------------------------------------------------
2020 115,506 80,925 70 percent
------------------------------------------------------------------------
2025 104,650 73,047 70 percent
------------------------------------------------------------------------
2030 94,582 63,633 67 percent
------------------------------------------------------------------------
* Based on projections from VA Demographics Program VetPop2007
Rural access to VA healthcare in Maine will greatly improve if and
when the CARES Plan is fully implemented. Even if fully implemented in
Maine today, we will still face challenges as the CARES Plan only
addresses 70 percent of the veteran population which means that 30
percent or 43,202 veterans (2007 numbers) will still be outside of the
CARES standard for healthcare access. New initiatives by the VA such
as: home-based healthcare, telemedicine, tele-mental health, will help
alleviate the access to care for these veterans.
While we would like to see additional Vet Centers in Maine to
provide the necessary readjustment counseling to the large number of
returning combat veterans to the State, we applaud VA's efforts to
reach out to these individuals by establishing access points for mental
health counseling outside of the Vet Centers.
The Veterans Administration at Togus does a remarkable job of
taking care of Maine's veterans with their limited resources. I will be
the first to tell you, we do have problems that arise occasionally but
in my time as State Director they been extremely responsive to
resolving issues that have been identified to them.
The recent influx of new veterans from Iraq and Afghanistan are
being serviced well by Togus but this does have an impact on how they
can take care of the older veterans that we are identifying and
enrolling in the VA healthcare system. While the VA staffing continues
to grow, it still takes a long time to credential employees and this
does have an impact at the delivery of services level. In Maine we will
continue seeing an increasing number of our aging veterans enrolling
and seeking assistance from the VA. Currently we have over 52,000 or 36
percent of our veterans enrolled with about 38,500 who actively use the
VA healthcare system in Maine.
Continued development of CBOCs has greatly improved veterans'
access to VA healthcare. A shining example is the Lincoln clinic that
opened last year and is providing primary care to more than 800
veterans. We continue to encourage rapid deployment of new priority
clinics/access points over the next few years with the corresponding
budget support to the corresponding VA Medical Centers. VA needs to
quickly develop these additional clinics, to include mental health
services. We support VA contracting-out some specialty care to private-
sector facilities where or when access is difficult. CBOCs provide
better access, leading to better preventive care, which better serves
our veterans.
In short, to improve rural access for veterans to VA healthcare in
Maine and the Nation, implement CARES in Maine and other States and
implement it sooner than later.
According to the VA's demographics program VetPop2007 Maine has
over 10,000 women veterans with less than 1,800 using VA healthcare.
Quality or availability of types of care for women veterans does not
seem to be as much of an issue as access and outreach. Approximately 40
percent of the women veterans using VA healthcare receive it at the
CBOCs. The addition of new CBOC in the Lewiston/Auburn area and the
access points in Houlton, Dover-Foxcroft, and Farmington will allow
more women veterans to receive care closer to home and this will
increase usage numbers.
While growth has occurred in VA healthcare due to improved access
to CBOCs, many areas of Maine and the country are still short-changed
due to geography and/or due to veterans' lack of information and
awareness of their benefits. VA and State Departments of Veterans
Affairs must reduce this inequity by reaching out to veterans regarding
their rights and entitlements. Maine and NASDVA support implementation
of a grant program that would allow VA to partner with the State
Department of Veterans Affairs to perform outreach at the local level.
There is no excuse for veterans not receiving benefits to which they're
entitled simply because they are unaware of those benefits. I would
encourage the Committee to support S.R. 1314, Veterans Outreach Act of
2007.
As the Nation's second largest provider of services to Veterans,
State governments' role continues to grow. We believe it is essential
for Congress to understand this role and ensure we have the resources
to carry out our responsibilities. The States partner very closely with
the Federal Department of Veterans Affairs in order to best serve our
veterans and as partners, we are continuously striving to be more
efficient in delivering services to veterans.
As I finish my testimony I would like to once again thank you for
the opportunity to speak to you today and thank you on behalf of
Maine's and the Nation's veterans for all you are doing to ensure they
receive the proper healthcare and benefits they have earned through
their service to the Nation.
Thank you.
Prepared Statement of Gary I. Laweryson, USMC (Ret.), Chairman,
Maine Veterans Coordinating Committee, Waldoboro, ME,
Commander, Military Order of the Purple Heart, State of Maine,
Judge Advocate, Marine Corps League, State of Maine, and
Aide-de-camp to Governor John Baldacci
MAINE VETERANS COORDINATING COMMITTEE
Military Order of the Purple Heart * AMVETS * Marine Corps League *
Disabled American Veterans * Korean War Veterans * WAVES *
Vietnam Veterans of America * Women Veterans of America * 40/8 *
Jewish War Veterans *York County Veterans * Paralyzed Veterans of
America * American Legion Aux * Disabled American Veterans Aux *
Honorable Congressmen:
Thank you for allowing me to testify on behalf of the Maine
Veterans Coordinating Committee. Our organization is comprised of the
above veterans service organizations and represents a united voice
working for all veterans of Maine.
As I testified on August 1, 2005, the VA's Capitol Assets
Realignment Enhanced Services (CARES) studied access to Maine's rural
veteran population and concluded more Community Based Outpatient
Clinics (CBOC's) were needed along Maine's north-south corridor and
western Maine. These CBOC's would provide Maine's rural veterans
increased access to the VA's outpatient and specialty cares.
Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) allows
the National Guard and Reserve troops to access the VA system for 5
years after return from OIF/OEF. As these current arenas of combat
continue, treatment of Traumatic Brain Injury, PTSD, amputations,
multiple injuries and illnesses, as well as, the added numbers of women
combat veterans further strains an already challenged VA system,
especially in the rural areas. High fuel prices and loss of jobs in the
rural areas have impacted the need for increased rural access to the
CBOC's as many of these veterans are now seeking care through the VA
for the first time.
CBOC's within Maine are filled to capacity and need additional
space and providers to be able to continue to provide the quality care
Maine's veterans expect and demand.
CARES studies demonstrated Maine is greater in area and veteran
population than the entire VISN 1 area. With the new OIF/OEF veterans,
Maine's veteran population has swelled from the projected 154,000 in
2004 to an estimated additional 5000 veterans eligible for care in the
VA system.
Communication of the varied VA services available to all Maine
veterans is imperative, especially to the OIF/OEF veterans. Through the
efforts of the Maine Veterans Coordinating Committee and its subsidiary
organizations, Togus VAMROC enrolled 500-700 new veterans each month
from 2003--2005. While this trend has slowed, Togus continues to enroll
new veterans each month. Many of Maine's National Guard and Reserve
components returning from Iraq and Afghanistan are returning with
illnesses and injuries requiring VA care, thus increasing the need for
improved access to the VA system.
Due to Maine's unique geographical size and the rising cost of gas,
it is difficult for Maine's rural veterans to travel to Togus and in
some instances, the existing CBOC's. Maine has no mass transit system.
Maine's veterans rely on the DAV shuttle bus for transport to Togus and
the CBOC's. However, in the northern counties, there is only one bus
available. Many of Maine's rural veterans are on a fixed income or
unemployed and unable to afford transportation to the nearest CBOC or
Togus. These veterans cannot afford health insurance or access to local
healthcare.
The Maine Veterans Coordinating Committee believes Togus should be
expanded to become a full service VA Regional Medical Center,
independent of Boston. Maine's rural veterans must now travel several
hours one way to obtain care at Togus or a CBOC. To require Maine's
veterans to travel an additional three to 8 hours to Boston to receive
tertiary care is unacceptable. Maine has one of the top Cardiac Surgery
Centers in the Nation and leads the Nation in long term care and end of
life care provided to our veterans. Sending Maine's veterans to Boston
removes the family and local veteran support systems needed to effect
recovery.
The majority of the Nation is urban or metro and growth has slowed.
Rural Maine has demonstrated a sustained growth and will continue this
trend.
During my 2005 testimony, the Maine Veterans Coordinating Committee
urged the VA to open lines of communication to all veterans, not just
in Maine. Historically, veterans have not felt the VA was user friendly
and as a result, many older veterans and those serving on active duty
have failed to avail themselves of the quality care provided by the VA
system. This has not improved.
In Maine, the veterans have banded together to educate our veterans
on the many services available to them. ``Operation I Served'' is a
joint project initiated to provide information on VA services,
educational benefits, tax relief, financial assistance, housing
assistance, long term care and end of life care available to Maine's
veterans, their spouses and families. Maine has the leading long term
care system in the Nation through the Maine Veterans Homes. ``Operation
I Served'' has been requested and shared with many other States.
On behalf of the Maine Veterans Coordinating Committee and the
Maine veterans we represent, thank you for allowing me this opportunity
to testify. The Maine Veterans Coordinating Committee looks forward to
continuing to work with Congress to enable the VA to provide quality
care to all veterans.
Respectfully submitted.
Prepared Statement of Kelley J. Kash, Chief Executive Officer,
Maine Veterans' Homes, Augusta, ME
Mr. Chairman and Members of the Committee, thank you for the
opportunity to testify today on behalf of the Maine Veterans' Homes
(``MVH'') on the topic of ``Women, Rural, and Special Needs Veterans,''
including the extremely important issue of continued access by veterans
to quality long-term nursing care.
I am the Chief Executive Officer of MVH. MVH is a public body
corporate created by the State of Maine to provide long-term nursing
care to Maine veterans. MVH operates long-term nursing care facilities
for veterans at Augusta, Bangor, Caribou, Scarborough, South Paris, and
Machias, Maine. In the aggregate, MVH currently operates 640 skilled
nursing, long-term nursing, and domiciliary beds for Maine veterans. We
are very proud of the quality long-term care nursing services that we
provide to Maine veterans.
Also, as one of the most successful State Veterans Homes systems in
the Nation, MVH provides a crucial portion of the healthcare continuum
for Maine veterans. Our facilities are each relatively small in size,
30 to 150 beds each, and this allows them to be located throughout the
State of Maine, allowing greater ease of access to our facilities by
veterans living in the most rural parts of Maine. In the future, we
hope to develop additional in-patient and out-patient services at all
of our six locations in order to offer rural Maine veterans greater
access to all of the services that the Maine Veterans' Homes, the Maine
Bureau of Veterans Services, and the United States Department of
Veterans Affairs provide.
MVH is part of a vital national system of State Veterans Homes. The
State Veterans Homes system is the largest provider of long-term care
to our Nation's veterans. As such, the State Veterans Homes play an
irreplaceable role in assuring that eligible veterans receive the
benefits, services, and quality long-term healthcare that they have
rightfully earned by their service and sacrifice to our country. We
greatly appreciate this Committee's commitment to the long-term care
needs of veterans, your understanding of the indispensable function
that State Veterans Homes perform, and your strong support for our
programs.
We especially appreciate the past support of this Committee in
providing funding to assure per diem payments by the Department of
Veterans Affairs to veterans who are residents in our State Homes.
Adequate funding is absolutely key to providing top quality long-term
care and access at affordable costs for our veterans. In addition, we
greatly appreciate your efforts to provide more funding for VA
construction grants to provide new, expanded, and more capable long-
term care services and facilities to veterans.
The Maine Veterans' Homes is a leader in this national system of
State Veterans Homes and a leader in the National Association of State
Veterans Homes (``NASVH''). The membership of NASVH consists of the
administrators and staff of State-operated veterans homes throughout
the United States. NASVH members currently operate 132 veterans homes
in 49 States and the Commonwealth of Puerto Rico. These homes provide
over 28,000 nursing home and domiciliary beds for veterans and their
dependents. These beds represent about 52 percent of the long-term care
workload for the VA, while consuming just 12 percent of the VA's long-
term care budget.
We work closely with the VA, State governments, the National
Association of State Directors of Veterans Affairs, veterans service
organizations, and other entities dedicated to the long-term care of
our veterans. Our goal is to ensure that the level of care and services
provided by State Veterans Homes meet or exceed the highest standards
available.
Role of the State Veterans Homes
State Veterans Homes first began serving veterans after the Civil
War. Faced with a large number of soldiers and sailors in critical need
of long-term care, several States established veterans homes to care
for those who served in the military.
In 1888, Congress first authorized federal grants-in-aid to States
that maintained homes in which American soldiers and sailors received
long-term care. At the time, the payments amounted to about 30 cents
per resident per day. In the years since, Congress has made several
major revisions to the State Veterans Homes program to expand the base
of payments to include nursing home, domiciliary, and adult day health
care.
For nearly half a century, State Veterans Homes have operated under
a program administered by the VA which supports the Homes through
construction grants and per diem payments. Both the VA construction
grants and the VA per diem payments are essential components of this
support. Each State Veterans Home must meet stringent VA-prescribed
standards of care, which exceed standards mandated by federal and state
governments for other long-term care facilities. The VA conducts annual
inspections to assure that these standards are met and to assure the
proper disbursement of funds. Together, the VA and the State Homes
represent a very effective and financially efficient federal-state
partnership in the service of our veterans.
VA per diem payments to State Homes are authorized by 38 U.S.C.
Sec. 1741-1743. Congress intended to assist the States in providing for
the higher level of care and treatment required for eligible veterans
residing in State Veterans Homes. As you know, the per diem rates are
established by the VA annually and may not exceed 50 percent of the
cost of care. They are currently $71.42 per day for nursing home care,
$64.13 per day for adult day healthcare, and $33.01 per day for
domiciliary care. Our State Veterans Homes cannot operate without the
per diem payments from the VA.
Construction grants are authorized by 38 U.S.C. Sec. 8131-8137. The
objective of such grants is to assist the States in constructing or
acquiring State Veterans Home facilities. Construction grants are also
utilized to renovate existing facilities and to assure continuing
compliance with life safety and building codes. Construction grants
made by the VA may not exceed 65 percent of the estimated cost of
construction or renovation of facilities, including the provision of
initial equipment for any project. State funding covers at least 35
percent of the cost. Our program cannot meet our veterans' needs
without an adequate level of construction grant funding.
In recent years, State Veterans Homes have experienced a period of
controlled growth--the result of increasing numbers of elderly veterans
who have reached that point in life when long-term care is needed. In
fact, we face the largest aging veterans population in our Nation's
history. From 2000 to 2010, the number of veterans aged 85 and older is
expected to triple from 422,000 to 1.3 million. If the State Veterans
Homes program is to fill even a part of this unmet need for long-term
care beds in certain States, and to respond to the increase in the
number of veterans eligible for such care nationally, it is critical
that the State Veterans Home construction grant program be sustained.
Traditionally, State Veterans Homes residents have been primarily
male, as the VA per diem and construction grant requirements mandate
that at least 75 percent of residents at any time be veterans. However,
more and more women veterans are being admitted to State Veterans Homes
as veterans themselves, reflecting the large and increasing numbers of
women who have served in the military since the Korean war.
While our experiences in the Gulf War and present conflicts have
given tremendous attention to post traumatic stress disorder
(``PTSD''), the reality and effects of PTSD have been present in every
conflict. While State Veterans Homes provide a common culture,
reassuring surrounding, appreciation, and understanding of the
veterans' experiences and issues, more can be learned and provided in
treating PTSD in general.
The State Veterans Home program now provides about 52 percent of
the VA's total long-term care workload. The VA recently estimated
nationally that nursing care beds in the State Homes are 87 percent
occupied. MVH beds are approximately 97 percent occupied. Many of the
State Veterans Homes nationally have occupancy rates near 100 percent,
and some have long waiting lists. The State Veterans Homes provide
long-term medical services to frail, elderly veterans at a cost to the
VA of only $71 per day, well below the cost of care in a VA nursing
home, which exceeds $560 per day.
Although there are no national admission requirements for the State
Veterans Homes, there are State-by-State medical requirements for
admission. Generally, a State will demand a medical certification
confirming significant deficits in activities of daily living (an
assessment of basic living functions) that require 24-hour nursing
care. Moreover, no per diem is paid by the VA unless and until a VA
official certifies that nursing home care is required. Veterans
qualifying for long-term nursing care at a State Veterans Home are
almost always chronically ill and elderly, and many are afflicted with
mental health conditions.
State Veterans Homes as a VA Resource
The State Veterans Homes should play a major role in meeting these
requirements and be treated as a resource integrated more fully with
the VA long-term care program. We have proposed that our beds be
counted toward the VA's overall long-term care census. Doing so would
allow the VA to meet its long-term care bed requirements. A nursing
home bed in a State Veterans Home is a very cost-effective alternative
to a nursing home bed in a VA-operated facility. Congress's goal should
be to provide long-term care to veterans in a manner that expands the
VA's capacity to provide services, while paying the lowest available
per capita cost for each eligible veteran. Including State Veterans
Homes nursing beds in the mandated VA long-term care totals could allow
the VA to meet its legislative mandate, shift some of its maintenance
care and other specialty services to the State Veterans Homes, and
ultimately increase the capacity of the VA to provide greater short-
stay, highly specialized rehabilitative care.
This goal can be accomplished by the State Homes at substantially
less cost to taxpayers than other alternatives. The average daily cost
of care for a veteran at a long-term care facility run directly by the
VA has been calculated nationally to be $563.45 per day. The cost of
care is $225.30 per day to the VA for the placement of a veteran at a
contract nursing home, which is not required to meet more stringent
State Veterans Home standards. The same daily cost to the VA to provide
outstanding quality long-term care at a State Veterans Home is far less
-- only $71.42 per day for nursing care.
This substantially lower daily cost to the VA of the State Veterans
Homes compared to other available long-term care alternatives led the
VA Office of Inspector General to conclude in a 1999 report: ``the SVH
[State Veterans Home] program provides an economical alternative to
Contract Nursing Home (CNH) placements, and VAMC [VA Medical Center]
Nursing Home Care Unit (NHCU) care'' (emphasis added). In this same
report, the VA Office of Inspector General went on to say:
A growing portion of the aging and infirm veteran population
requires domiciliary and nursing home care. The SVH [State
Veterans Home] option has become increasingly necessary in the
era of VAMC [VA Medical Center] downsizing and the increasing
need to discharge long-term care patients to community based
facilities. VA's contribution to SVH per diem rates, which does
not exceed 50 percent of the cost to treat patients, is
significantly less than the cost of care in VA and community
facilities.
In another example of how the VA can partner with State Veterans
Homes, the State of Maine enacted legislation earlier this month to
establish a veterans' campus at Bangor, Maine. The concept is to create
a one-stop shop for veterans to receive most of their healthcare and
social services needs. The proposed project will locate a new, larger,
and more capable VA community-based outpatient clinic next to the MVH
Bangor facility. Other veteran service organizations will be colocated
at the campus, bringing a wide range of veteran services to a single
campus and making it more efficient and convenient for veterans,
families, the State Bureau of Veterans Affairs, VA, and various
agencies and veterans service organizations that serve veterans'
healthcare and social service needs. The Bangor Veterans Campus is a
pioneering effort and the first of its kind in the Nation. Its success
should be replicated throughout the Nation.
Status of VA Regulations
In our opinion, the VA chronically has been slow to implement
enacted legislation. Section 211 of Pub. L. No. 109-461 authorized the
VA to directly place and pay the full cost of care for veterans with
service-connected disabilities rated 70 percent or greater, or for
veterans who need nursing home care as a result of their service-
connected disabilities. The same legislation authorized the VA to
provide veterans with service-connected disabilities rated 50 percent
or greater with prescription medications while residing in State Homes.
Federal law required these provisions to take effect by March 22, 2007,
yet we are still waiting for the VA regulations with no forecasted date
of implementation. The result has been tremendous confusion and
frustration for the many thousands of veterans who are waiting for
these services, and for the State Veterans Homes, which will be
required eventually to provide these services.
Section 201 of Pub. L. No. 108-422 authorized the VA to pay up to
50 percent of the cost for State Veterans Homes to implement an
employee incentive scholarship to recruit and retain nurses. While the
VA announced that its regulations and implementation instructions will
be completed this summer, Federal law required the VA to begin making
payments to States no later than June 1, 2005 -- 3 years ago!
VA Construction Grant Program
Under current law, there are strict limits and standards for
funding the construction and renovation of State Veterans Homes. The
system is working very well under the provisions of the Millennium
Bill, which establishes priorities for funding according to life/
safety, great need, significant need, and limited need.
Moreover, under the requirements of the Millennium Bill, the VA
prescribes strict limits on the maximum number of State Veterans Home
nursing beds that may be funded by construction grants. This is based
on projected demand for the year 2009, which determines which States
have the greatest need for additional beds. This process assures that
additional State Veterans Home beds are built only in those States that
have the greatest unmet need for such beds.
However, the Administration has proposed cutting State Veteran Home
construction matching-grant funding by almost 50 percent, from $165
million in FY 2008 down to $85 million for FY 2009. The backlog of
construction projects to repair, rehabilitate, expand, and build new
State Veterans Homes is now approaching $1 billion. Over $200 million
of this backlog are life-safety projects. These are critical and
immediate needs. Moreover, habitually under funding these projects puts
the State Veterans Homes and their veteran residents at risk.
Conclusion
Thank you for your commitment to long-term care for veterans and
for your support of the State Veterans Homes as a central component of
that care. In conclusion, I will reiterate the key issues facing the
State Veterans Homes.
First, thank you for your continued support of the VA per diem
payment to the State Veterans Homes. The loss or reduction of the VA
per diem would place Homes in an untenable financial position and could
lead to the closure of many State Homes, ultimately impacting our aging
veterans severely.
Second, we believe Congress must increase funding for construction
grants to State Veterans Homes to at least $200 million to address the
growing backlog of projects. Inadequate or delayed funding will
continue to grow the nearly $1 billion backlog that now exists,
including over $200 million in life-safety projects.
Third, we believe Congress must require the VA to promulgate long-
overdue regulations to strengthen State Veterans Homes and the veterans
they serve. In particular, increased payment for nursing home care and
the provision of prescription medication in State Veterans Homes for
veterans with service-connected disabilities of 70 percent or greater
and 50 percent or greater, respectively, have been delayed indefinitely
by the VA.
Fourth, we believe that the State Veterans Homes can play a more
substantial role in meeting the long-term care needs of veterans. NASVH
recognizes and supports the national trend toward
deinstitutionalization and the provision of long-term care in the most
independent and cost-effective setting. In a letter to VA Secretary
Nicholson dated April 5, 2005, NASVH proposed that we explore together
creative ways to provide a true continuum of care to our veterans, both
rural and urban, in State Veterans Homes and in the community. We would
be pleased to work with the Committee and the VA to explore options for
developing pilot programs, such as the proposed Bangor Veterans Campus,
for providing innovative care and for more closely integrating the
State Veterans Homes program into the VA's overall healthcare system
for veterans.
Prepared Statement of David Hartley, Ph.D., MHA,
Director, Maine Rural Health Research Center, and
Professor, Muskie School of Public Service,
University of Southern Maine, Portland, ME
Thank you for the opportunity to testify before this Committee. My
testimony is based on 12 years as a manager of substance abuse
treatment programs followed by 15 years as a rural health researcher,
much of which has been focused on access to mental health services in
rural America. I brought that expertise to bear when I served on the
Institute of Medicine's Committee on the Future of Rural Health which
met throughout 2004 and released its report early in 2005: Quality
through Collaboration: The Future of Rural Health (IoM 2005). Two years
ago, I testified before this subcommittee in Washington DC, and
reported that several of the recommendations of the IoM Committee were
directly relevant to the challenge of delivering high quality health
care services to rural veterans.
Since 44 percent of new recruits come from rural places (Tyson
2005), we are seeing an increase in the numbers of veterans from Iraq
and Afghanistan who are returning to rural America recovering from
complex combat-related injuries, both physical and emotional. The
Veteran's Healthcare System has unique expertise and resources to
devote to the healing of these injuries. In recent years, the VA has
opened more community based outpatient clinics or CBOCs to make this
expertise and these resources available to veterans who live at
significant distances from VA medical centers. We now have six CBOCs in
Maine.
The Department of Veterans Affairs has arguably the best integrated
health information network in the Nation. It also has extensive,
evidence-based, patient-centered performance measures and a monitoring
system to assure that all patients receive high quality, guideline
concordant care. That system gets good outcomes for those veterans who
receive care from VA clinics, and from Community-Based Outpatient
Clinics and contract providers who can meet the VA's high standards of
care. There are several reasons why a veteran in need of help might not
seek care at one of these facilities. While CBOCs have improved access
in many rural areas, there remain vast remote areas in our most rural
States, including Maine, where VA facilities are still out of reach.
Also, some veterans prefer to seek care from the non-VA system, for a
variety of reasons. The significant numbers of veterans whose combat
experience was with the National Guard are often in this category.
Citizen soldiers may be more familiar with citizen health care, and
often do not register for VA benefits. While many veterans prefer to
receive care from VA providers, others feel just the opposite. Our VA
healthcare system needs to reach out to our civilian health care system
to assure that these combat veterans get care consistent with their
needs, and concordant with the special expertise of the VA healthcare
system.
Clearly, one way the VA system can do this is by contracting with
non-VA providers in rural areas where it is not efficient to open a
CBOC. The federal government has created several programs to attract
providers to underserved areas, and to support them. These include
federally qualified health centers (FQHCs), critical access hospitals,
and rural health clinics. Some rural areas are also served by community
mental health centers. These programs were created as a federal
response to the difficulty of recruiting providers to serve remote
populations. They exist in areas that have been designated as
underserved. In many rural areas, hospitals, clinics and health centers
collaborate in recruiting efforts, often with the help of their state
office of rural health, or state hospital association. For the VA to
open a new CBOC in a community that is already served by one or more of
these entities is inefficient. Rather, I would suggest that we have the
technology and the expertise to help these rural sites provide care to
rural veterans that is of the same high quality that urban vets
receive. This can be done through tele-health, through the VistA
information system which is now available as open-access software to
all providers, through direct clinical consultation and supervision
between expert clinicians in VA medical centers and rural providers,
and through the placement of VA providers in these non-VA rural sites,
creating veterans' access points. With these resources at our disposal,
care provided in a rural site for some of these combat injuries can be
of the same high quality as that provided in a VA medical center.
My research has been in the area of rural behavioral health. The
IoM rural report found that behavioral health needs in rural America
are not being met, due to a fragmented, under-funded, non-system. Much
of my research has sought to document the lack of specialty mental
health services in rural areas, and to discover alternative models for
delivering such services in the absence of psychiatrists, psychologists
and psychiatric facilities. The need for mental health services in
rural
America has been repeatedly identified as one of the topmost issues
facing State-level officials and policymakers. It now faces the VA
healthcare system as well.
Evidence of the need for mental health services among veterans can
be found in the high rates of combat zone suicide (Army News Service
2004), post-traumatic stress disorder, often not manifesting until a
year or more after returning home, and in the VA's recently published
studies of rural-urban disparities in health-related quality of life,
both for veterans with psychiatric disorders (Wallace et al. 2006) and
for veterans in general (Weeks 2004). Lacking specialty mental health
services, rural people with psychiatric problems have typically sought
help from their primary care practitioner. Research tells us that such
care has not always been of the highest quality, and often does not
follow evidence-based guidelines for conditions such as depression,
anxiety disorders and children's mental health issues (Rost et al.
2002). Two specific conditions of veterans now returning from
Afghanistan and Iraq may not be accurately diagnosed by primary care
practitioners who are not familiar with these conditions: post-
traumatic stress disorder (PTSD) and traumatic brain injury (TBI). Once
such disorders are suspected, it may be possible to refer vets to a VA
specialist, and travel from a rural to an urban area for specialty care
may simply be the only way to get quality care. In many of our most
rural States, however, there is no VA TBI program. Moreover, the
symptoms of PTSD typically affect the whole family, and may lead to
domestic violence, child abuse, divorce, substance abuse and suicide.
Here too, the lack of services in rural areas poses a significant
barrier to effectively addressing these problems.
My research suggests that creative solutions are needed to meet the
need for mental health and substance abuse treatment in rural areas.
Behavioral health research often entails precisely designed trials of
various clinical interventions, many of which are unlikely to be
implemented in rural areas. Creative solutions to meet the behavioral
health needs of rural veterans can be found by establishing a rural
behavioral health research center charged to explore and evaluate new
models for delivering care to veterans in remote areas. This can best
be accomplished through collaboration between a VA medical center and a
federally funded rural health research center. Such a collaboration
might be facilitated by the VA Office of Rural Health and the Federal
Office of Rural Health Policy, in the Health Resources and Services
Administration, working together.
As I stated to this subcommittee two years ago, the Veterans
Administration has an opportunity to take advantage of decades of
research, policy, and programs serving rural Americans, and combine
those resources with its own, so as to improve access to quality care
for rural veterans, and to bring its unique resources for quality
improvement and information management to rural providers. We can do
this for our veterans.
References
Army News Service (2004). Army suicide rate in combat zones
elevated. March 26, 2004.
Institute of Medicine, Committee on the Future of Rural Health Care
(2005) Quality through Collaboration: the Future of Rural Health.
Washington DC: The National Academies Press.
Rost K, Fortney J, Fischer E, and Smith J (2002) Use, quality and
outcomes of care for mental health: The rural perspective. Medical Care
Research and Review 59(3): 231-265.
Wallace AE, Weeks WB, Wang, S, et al. (2006) Rural and urban
disparities in health-related quality of life among veterans with
psychiatric disorders. Psychiatric Services. 57(6):1-6.
Tyson, AS (2005) ``Youths in rural U.S. are drawn to military.''
Washington Post. November 4, 2005.
Weeks WB, Kazis LE, Shen Y, et al. (2004) Differences in health-
related quality of life in rural and urban veterans. American Journal
of Public Health 94:1762-67.
Prepared Statement of Donald A. Simoneau, Past Commander, Department
of Maine, and Member, National Legislative Council, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to present The American Legion's
views on women, special needs, and rural veterans. As more eventual
veterans return from Iraq and Afghanistan, a higher emphasis is being
placed on the Department of Veterans Affairs (VA) to provide the
highest quality of care to all veterans who have served our Nation and
earned the entitlement.
Within the veteran population, the provision of quality health care
to women veterans, special needs veterans, and rural veterans has
proven to be very challenging, given factors such as limited
availability of skilled care providers and inadequate access to care.
Other challenges such as miscommunications and misperceptions of
Veteran Health Administration (VHA) services also continue to impede
the delivery of quality care to the veteran population. The American
Legion commends the Subcommittee for holding a hearing to discuss these
vitally important issues.
Women Veterans
According to VA research, women make up approximately 15 percent of
the active force, are serving in all branches of the military, and are
eligible for assignment in most military occupational specialties
except for direct combat roles. The increase in the number of women
serving in the military significantly impacts the services provided by
the Department of Veterans Affairs (VA). VA also projects that by the
year 2010, women will comprise well over 10 percent of the veteran
population, an increase of 6 percent over current figures. The State of
Maine is comprised of approximately 9,396 of these women veterans.
Although integrated within the ranks, these women veterans require
special treatment to ensure they have the best chance of returning to
good health. Research has shown that female veterans encounter three
large barriers when trying to access health care through VA. These
barriers include: lack of knowledge about VHA services; unaware of
eligibility for health care benefits; and the perception that VA only
caters to male veterans. During various site visits to VA Medical
Hospitals, Vet Centers, and Community Based Outpatient Clinics (CBOCs),
the American Legion met with various managers who stated their greatest
challenge was accommodating women who suffered from Military Sexual
Trauma (MST). It is imperative that VA has adequate funding and
resources, to include staffing, to ensure tools such as private
entrances are in place, thereby encouraging more women to come forward
and obtain care.
The American Legion recommends that once women veterans' needs are
identified, VA develop and implement policy to address these
deficiencies in a timely manner and conduct an extensive outreach
campaign to ensure this special population--and those who serve them--
aware of enhancements in health care services. We also urge Congress to
also appropriate adequate funding to maintain these enhancements, once
in place.
Special Needs Veterans
The American Legion is concerned with the needs of all veterans; to
add, we must reassure to all that special needs veterans (SNV) don't
slip through the cracks of the VA health care system. Recently in my
hometown here in Maine we lost one of these Special Needs Soldiers, who
served two tours of duty in Iraq but slipped through the cracks, in the
VA system. This should not have happened, to anyone, especially someone
who gave so much to us, but it is happening all across the Nation.
Special Needs Veterans, according to the Diagnostic Statistical Manual
(DSM) IV, include the chronically mentally ill, which are conditions of
schizophrenia or major affective disorder including bipolar disorder,
or Post Traumatic Stress Disorder (PTSD). Many older veterans are
dealing with PTSD and have for years and are never diagnosed. Many
returning veterans are dealing with TBI or Traumatic Brain Injury,
which is one of the newest Special Needs Veterans issues. Special Needs
Veterans also include the frail elderly or those veterans who are 65
years of age or older with one or more chronic health problems; and
limitations in performing one or more activities of daily living. The
last major group with special needs is the homeless.
The issue of homelessness affects every category of veteran. The VA
Advisory Committee on Homeless Veterans 2007 report states the need and
complexity of issues involving women veterans who become homeless are
increasingly unexpected.
The increased risks of homelessness among each of these
populations, warrant funding for special needs grants. The American
Legion strongly urges Congress to provide VA with the adequate funding,
ensuring more grants be put into place to assist those veterans with
special needs.
Special Needs Veterans also encounter barriers when trying to
access health care through VA. These obstacles include: lack of
knowledge about VHA services, not knowing that they may be eligible for
health care benefits, and a negative perception of VA.
The American Legion maintains that VA has a duty to constantly seek
new ways to bring information to veterans--ALL veterans.
Rural Veterans
The American Legion believes veterans, many of whom are elderly and
infirm or unable to travel, are isolated from the regular, preventative
medical attention they need and deserve. Providing quality health care
in a rural setting has proven to be challenging with such dilemmas as
limited availability of skilled care providers and inadequate access to
care.
VA's ability to provide treatment and rehabilitation to rural
veterans who suffer from the ``signature ailments'' of the on-going
wars in Iraq and Afghanistan (Traumatic blast injuries and combat-
related mental health conditions) will continue to be challenged if it
lacks the appropriate resources to accommodate new returning and
existing veterans. According to Title 38, United States Code, section
1703, VA has the authority to contract for services where they are
needed.
Mr. Chairman, with that measure in place, we have to persistently
ensure funding and resources are available to facilitate the needs of
veterans who reside in rural locations. We also encourage VA to
periodically assess the resources in place and match against those who
have returned. This assessment will determine the future needs of our
Nation's veterans, to include those who reside outside normal distances
of the VA Medical Center system.
The American Legion believes that where there is limited access to
VA healthcare, it is in the best interest of veterans residing in
highly rural areas to have local care made available to them. This
would alleviate the unwarranted hardships rural veterans encounter when
seeking access to VA health care services. Veterans should not be
penalized or forced to travel long distances to access quality health
care because of where they choose to live.
On October 15, 2004, the VA Office of Inspector General (VAOIG)
released the ``Evaluation of Department of Veterans Affairs Policies
and Procedures Addressing the Location of New Offices and Other
Facilities in Rural Areas.'' This report examined VA's policies and
procedures to give first priority to locating new offices and other
facilities in rural areas, as outlined in the Rural Development Act
(RDA) of 1972.
The report determined that despite not having formal policies in
place, VA did make a significant effort to improve access to VA
services for veterans living in rural areas. The American Legion
commends VA's efforts, however, we urge the Congress to ensure there
are an adequate number of resources for veterans, as well as provision
of adequate funding and care whilst VA is making efforts to accommodate
the veteran.
The American Legion believes that CBOCs serve as a vital element of
VA's health care delivery system when rural veterans are being
discussed. As is widely known, there is great difficulty serving
veterans in rural areas. According to the 2000 Census, many rural and
non-metropolitan counties across the Nation had the highest
concentrations of veterans in the civilian population aged 18 and over
from 1990-2000. The State of Maine has the fourth highest proportion of
veterans living in rural areas in the Nation at 15.9 percent. Studies
have further shown that veterans who live in rural areas are in poorer
health than their urban counterparts. In States such as Nevada,
Nebraska, Iowa, North Dakota, South Dakota, Wyoming, Montana, and
Maine, veterans face extremely long drives, a shortage of health care
providers and bad weather. In Maine we are waiting for the funding for
Lewiston, Dover/Foxcroft, Farmington and Norway/So. Paris CBOCs and
grateful for the Lincoln CBOC that opened recently. The Veteran
Integrated Services Networks (VISNs) rely heavily upon these CBOCs to
close the gaps. The American Legion urges the Congress to adequately
fund VHA to ensure an adequate number of CBOCs are constructed and
maintained.
Although effective, CBOCs are not the only avenue with which VA can
provide access to quality health care to rural veterans. VA must
enhance existing partnerships with communities and other federal
agencies to help alleviate barriers that exist, such as, the high cost
of contracted care in rural settings. The American Legion believes
coordinating services with Medicare or other healthcare systems based
in rural areas is another way to provide quality care.
In closing, providing quality health care to women veterans,
special needs veterans, and rural veterans has proven to be very
challenging, given factors such as limited availability of skilled care
providers and inadequate access to care. Other challenges such as
miscommunications and misperceptions of Veteran Health Administration
(VHA) services also continue to impede the delivery of quality care to
theses veteran populations.
The American Legion believes all veterans who are entitled to VHA
services should receive it in a timely and quality manner. Last The
American Legion urges the Congress to provide adequate funding to VA to
accommodate the modernization of all VA structures. The modernization
of VA structures would readily provide telehealth and telemedicine to
all veterans who reside in rural areas.
Again, thank you Mr. Chairman for giving The American Legion this
opportunity to present its views on such important issues. We look
forward to working with the Subcommittee to bring an end to the
disparities that exist in access to quality health care to women
veterans, special needs veterans, and rural veterans.
For God and Country.
Prepared Statement of John Wallace, President,
Maine State Council, Vietnam Veterans of America
Mr. Chairman, Ranking Member Miller, Distinguished Members of this
Subcommittee, and guests, my name is John W. Wallace. I am a combat
veteran who is presently Vietnam Veterans of America Maine State
Council President. I serve on the Maine VHA MiniMac, BigMac, and
Network Communications Council. I also serve on the Maine Veterans
Coordinating Committee, the Caribou Veterans Cemetery Committee, the
Maine Veterans Home Liaison Committee in Caribou and I participate in
the Commanders Call with the Governor/General.
Today, I will briefly discuss with you some of the health related
issues facing veterans in the State of Maine, which is home of more
than 154,000 veterans and their families.
Mr. Chairman, the Maine Department of Veterans Affairs Medical
Center is located in Togus, 6 miles east of Augusta. Opened in 1866,
Togus was the first national home for disabled volunteer soldiers. This
VA Medical Center provides medical, surgical, psychiatric, and nursing
home care. The VA operates community-based outpatient clinics in
Bangor, Calais, Caribou, Rumford, and Saco to provide better access to
care for veterans living in rural areas. In 2007, the VA opened a part-
time clinic in Lincoln. There is also a Mental Health Clinic located in
Portland.
More than 1,400 active-duty service members and veterans of the
Global War on Terror have sought VA health care in Maine. Many veterans
from the conflicts in Iraq and Afghanistan have visited VA counseling
centers in Bangor, Caribou, Lewiston, Portland, and Springvale. These
community-based Vet Centers are an important resource for veterans who,
once home, often seek out fellow veterans for help transitioning back
to civilian life. Over six million veterans live in rural areas across
America, and most fall below the poverty line. They travel hours to get
to the nearest VA medical facilities. At a hearing of the Subcommittee
on Health, Mr. Chairman, you pointed out that although 20 percent of
the Nation's populace lives in rural areas, 40 percent of veterans
returning from deployments in Afghanistan and Iraq live in rural
communities. This leads to ``significant challenges maintaining `core
health care services'.'' The average distance for rural veterans to
access care is 63 miles, according to the National Rural Health
Association.
The difficulty of accessing health care is a significant problem
for many of Maine's veterans. Although Togus is centrally located in
Augusta, the State's geographic expanse makes it a problem for many
veterans to use the hospital as their primary health-care provider. In
a 2004 report, a government commission expressed concern that only 59
percent of Maine's veterans were living within its geographic
guidelines for access to care, which ranged from 60 minutes for urban
areas to 120 for very rural areas.
Furthermore, research by the National Rural Health Association
underscores the problem. The association found that about 44 percent of
service recruits come from rural areas whose population comprises 19
percent of Americans. The disparity was far less during World War II
and the Vietnam War.
Of Maine's six CBOCs with two more planned under CARES, the closest
CBOC is over 80 miles from its hub and the farthest is 260 miles. For
primary care this is ok, but for specialty care services veterans have
to travel to Togus or Boston. The distance a veteran may have to travel
is more than 300 miles, which is clearly outside the 75-mile radius
established by the VA. To make matters worse, most rural medical care
providers, weary of the paperwork and long delays involved in the
federal benefits system, often do not accept TRICARE, the military
health insurance for active-duty soldiers and their families. The
program offers a 180-day transitional benefit for soldiers after
discharge.
There is evidence that the VA has known for some time about the
need to focus more on rural care. A 2004 VA study of 750,000 veterans
found that those living in rural areas tended to have more serious and
costly health problems than their urban counterparts. Perhaps the VA
could reach a lot of the veterans who live in rural Maine by expanding
the use of fee-basis care, in which the VA contracts its services out
to a third-party provider. Certainly, the myriad issues involved in
providing healthcare for rural veterans must be addressed by the VA's
new Office of Rural Health, which has been slow to get started.
Veterans Health Administration Office of Rural Health
In accordance with section 212 of the Pubic Law 109-461, VA
established an Office of Rural Health. The mission of the office is to
develop policies and identify and disseminate best practices and
innovations to improve services to veterans who reside in rural areas.
The law states:
Section 212c(3) ``To designate in each Veterans
Integrated Service Network (VISN) an individual who shall consult on
and coordinate the discharge in such Network of programs and activities
of the Office for veterans who reside in rural areas of the United
States.
Public Law 109-461--Sec. 822. Business Plans For Enhanced Access To
Outpatient Care In Certain Rural Areas
(a) Requirement--Not later than 180 days after the date of the
enactment of this Act, the Secretary of Veterans Affairs shall submit
to the Committee on Veterans' Affairs of the Senate and the Committee
on Veterans' Affairs of the House of Representatives a business plan
for enhanced access to outpatient care (as described in subsection (b))
for primary care, mental health care, and specialty care in each of the
following areas:
(1) The Lewiston-Auburn area of Maine.
(2) The area of Houlton, Maine.
(3) The area of Dover-Foxcroft, Maine.
(4) Whiteside County, Illinois.
(b) Means of Enhanced Access--The means of enhanced access to
outpatient care to be covered by the business plans under subsection
(a) are, with respect to each area specified in that subsection, one or
more of the following:
(1) New sites of care.
(2) Expansions at existing sites of care.
(3) Use of existing authority and policies to contract for care
where necessary.
(4) Increased use of telemedicine.
Mr. Chairman, we are in an emergency situation in Maine, and VVA is
seeking your help in Congress to expedite the provision stated in P.L.
109-461. Otherwise, our disabled veterans'--both young and old--will be
forced to continue their long-distance travel for care and treatment to
the nearest VHA Medical Center, clinic, or hospital. We pioneered the
first rural or rural-rural VA clinic as I like to call it, in the
country. It covers an area bigger than the States of Connecticut and
Rhode Island. It sits about 260 miles north of Togus VAMC. We quickly
went from 1 day a week to 5 days a week with three providers and staff
treating over three thousand veterans a month. There are also two
mental health providers on board with telemedicine health 2 days a
week. This was a great start to the VA's commitment to its veterans.
But we veterans had to fight for this every step of the way. In the
beginning we were told this would never happen.
If you travel into the farm towns of any State in the Union, you
see lots of veterans who need help and are having difficulty finding
it. Should we lose veterans who protected this Nation so honorably
because our government was unwilling to look past politics? I think
not!
Since 1982, Vietnam Veterans of America has been a leader in
championing appropriate and quality health care for all women veterans.
Additionally, although women veterans are authorized the same benefits,
services and compensation as their male counterparts, many women do not
know their rights as veterans, and they do not know how to access VA
programs. Some concerns remain in the treatment, delivery, and
monitoring of services to women veterans.
WOMEN VETERAN PROGRAM MANAGERS
The duties, responsibilities, advocacy, oversight and reporting of
the VA Women Veteran Program Managers, as defined in their handbook
(1330.2), are substantial. VVA calls for the VA to provide the Women
Veteran Program Managers with a minimum of 20 hours per week to
accomplish the responsibilities of the position. VVA believes that
these significant duties and responsibilities are essential and should
not be minimized in light of the collateral duties they usually must
perform. Further, we believe that while each VISN must designate,
support, and utilize one of its Medical Center Woman Veteran Program
Managers as the VISN Women Veteran Program Manager, we believe
additional time must be allocated for these increased duties and
responsibilities.
PTSD AND SUBSTANCE ABUSE
The VA counts PTSD as the most prevalent mental health malady (and
one of the top illnesses overall) to emerge from the wars in Iraq and
Afghanistan, but the VA is facing a wave of returning veterans who are
struggling with memories of a war where it's hard to distinguish
civilians from enemy fighters and where the threat of suicide attacks
and roadside bombs hovers over the most routine mission. Moreover, the
return of so many veterans from Afghanistan and Iraq is squeezing the
VA's ability to treat yesterdays' soldiers. Top VA officials have said
that the agency is well-equipped to handle any onslaught of mental
health issues and that it plans to continue beefing up mental health
care and access under the administration's budget proposal released in
mid-February.
Yet according to a Government Accountability Office (GAO) report
issued in November 2006, the VA did not spend all of the extra $300
million budgeted to increase mental health services and failed to keep
track of how some of the money was used. The VA launched a plan in 2004
to improve its mental health services for veterans with PTSD and
substance-abuse problems. To fill gaps in services, the department
added $100 million for mental health initiatives in 2005 and another
$200 million in 2006. That money was to be distributed to its regional
networks of hospitals, medical centers, and clinics for new services.
But the VA fell short of the spending by $12 million in 2005 and about
$42 million in fiscal 2006, said the GAO report. It distributed $35
million in 2005 to its 21 health care networks but did not inform the
networks the money was supposed to be used for mental health
initiatives. VA medical centers returned $46 million to headquarters
because they could not spend the money in FY'06.
More troubling, however, is the fact that the VA cannot determine
to what extent about $112 million was spent on mental health services
improvements or new services in 2006. In September 2006, the VA said
that it had increased funding for mental health services, hired 100
more counselors for the Vet Center program, and subsequently was not
overwhelmed by the rising demand. That money is only a portion of what
VA spends on mental health. The VA planned to spend about $2 billion on
mental health services in FY'06. But the additional spending from
existing funds on what the VA dubbed its Mental Health Care Strategic
Plan was trumpeted by VA officials as a way to eliminate gaps in recent
and future mental health.
Furthermore, VVA believes there is a need for increased VA research
specifically focused on women veterans' mental health issues. For
example, as of August 2006 VA data showed that 25,960 of the 69,861
women separated from the military during fiscal years 2002-06 sought VA
services. Of this number approximately 35.8 percent requested
assistance for ``mental disorders'' (i.e., based on VA ICD-9
categories) of which 21 percent was for PTSD, with older female vets
showing higher PTSD rates. Also, as of early May 2007, 14.5 percent of
female OEF/OIF veterans reported having endured military sexual trauma
(MST). Although all VA medical centers are to have MST clinicians, very
few clinicians within the VA are prepared to treat co-occurring combat-
induced PTSD and MST. These issues need to be addressed.
The VA will need to directly identify its ability and capacity to
address these issues along with providing oversight and accountability
to the delivery of their services. VVA believes that the VA has twelve
programs that address PTSD in women veterans, but they are not
exclusively for MST (some are general PTSD programs) and not all are
gender-specific programs.
A concern for the environment of the delivery of services also
exists in the residential programs of the VA. Most if not all
residential programs are designed for treatment of mental health
problems. The veterans of these programs are a very vulnerable
population. This was particularly brought to our attention in regard to
women veterans, who, in light of the high incidence of sexual trauma,
rape, MST, and domestic violence find it difficult, if not impossible,
to share residential programs with male veterans. They openly discuss
their concern for a safe treatment setting, especially on units where
the treatment unit layout does not provide them with a physically
segregated, secured area. They also discuss the need for gender-
specific group sessions, in light of the nature of some of their
personal and trauma issues. VVA asks that all residential treatment
areas be evaluated for the ability to provide this environment; that
medical center facilities develop cost plans to address this
accommodation; that these facilities report the findings for
consideration to their respective VISN and to VA Central Office, Office
of the Under Secretary for Health.
This submission points to the need for a well-conceived and well-
implemented long-range plan for healthcare services and delivery for
our women veterans. To VVA's knowledge no such plan exists. Although
the VA has taken great strides in the past 15 years toward improvement
of the quality of care for female veterans, there is always room for
improvement. While it is fair to say that the quality of care at most
VA facilities is equal to that of any other medical system in the
world, it does not help women veterans who cannot access that fine care
because services aren't available.
In closing, VVA would like your support of H.R. 4107, Women
Veterans Health Care Improvement Act, introduced by Rep. Stephanie
Herseth Sandlin (D-SD) and S. 2799 Women Veterans Health Care
Improvement Act of 2008, introduced by Senator Patty Murray (D-WA).
Mr. Chairman and members of the Subcommittee, on behalf of Vietnam
Veterans of America, and the Veterans in Maine, I thank you for your
continued hard work and dedication to this issue. I will be happy to
answer your questions.
Prepared Statement of Joseph E. Wafford, Supervisory National
Service Officer, Department of Maine, Disabled American Veterans
Chairman Michaud and other Members of the Subcommittee:
Thank you for requesting the testimony of the Disabled American
Veterans (DAV), Department of Maine, at today's field hearing of the
Subcommittee. DAV is a national veterans service organization of 1.3
million members, and is dedicated to rebuilding the lives of disabled
veterans and their families.
The topics before the Subcommittee--women, rural and special needs
veterans--are of acute interest to DAV in Maine and nationwide. Maine,
with an adult population of 970,000, is home to 155,000 veterans, who
constitute 16 percent of our adult population, among the highest
proportion of veterans in any State. Also, with so many members of the
National Guard and Reserve forces fighting the wars in Iraq and
Afghanistan, including the Maine National Guard, and with nearly half
of those serving coming from rural, remote and frontier areas, access
to Department of Veterans Affairs health care and other VA services in
rural areas is perhaps VA's most pressing challenge today, and is an
exceedingly important issue in this State. Within that set of
challenges, we are encouraging VA to do a better job of addressing the
needs of women veterans, who are playing such an important role in
these war deployments, and because of that exposure, are suffering a
degree of disability and combat-related illnesses that we have never
seen before in American military expeditions. In that regard, we urge
the Subcommittee to swiftly consider and approve a bill, H.R. 4107, the
Women Veterans Health Care Improvement Act, offered by Representatives
Herseth Sandlin and Brown-Waite, two Members of your Committee. We are
seeing a large number of rural veterans, both men and women, coming
home from these wars with severe injuries and illnesses. Therefore, we
are very pleased that the Subcommittee is turning its attention to
these issues, and urge that you maintain that strong focus.
As you know, VA operates a major regional medical center in Togus,
near Augusta. Opened in 1866, the Togus facility was the first national
home for disabled volunteer soldiers. Today, Maine's only VA medical
center plays a major role in the community and State, providing
medical, surgical, psychiatric and nursing home care. It is also a
significant employer in the Augusta community.
VA also operates community-based outpatient clinics (CBOC) in
Bangor, Calais, Caribou, Rumford and Saco, and there is a part-time
outpatient clinic in Lincoln. Also the VA's Readjustment Counseling
Service has established ``Vet Centers'' in Bangor, Lewiston, Caribou,
Portland and Springvale, and VA provides a mental health clinic in
Portland. Given the vast distances, severe weather and geographical
barriers of our beautiful State, coordination of health care and
patient referrals for subspecialty services are major, continuing
challenges, both within the VA and in the State's private sector as
well. In an effort to provide more effective health care to Maine's
veterans, the Togus Center operates a home tele-health program that
currently aids 116 veterans, and uses VA's video ``Help Buddy'' system
to monitor the health status of outpatient veterans who live at a
distance from the Medical Center.
Mr. Chairman, as you know, VA had planned to open a CBOC in Dover
Foxcroft, but those plans were shelved due to an insufficient veteran
population base to support a full time VA clinic. DAV believes that
area still needs VA's attention, and we highly recommend that Togus
provide a ``satellite van'' or a portable physician office to serve
veterans in that area. Once veterans in the Dover Foxcroft area become
aware that VA has established a health care presence for them, even on
a part time basis, this may help justify a full time clinic later on in
that community. We would appreciate the Subcommittee's making that
recommendation to the VA.
According to VA, in 2006 (latest information available), inpatient
admissions to VA health care facilities in Maine totaled 1,696, while
outpatient visits reached 325,718. Also, 17,474 veterans 65 years of
age and older received health care from VA in 2006. VA makes a wide
range of geriatric, rehabilitation and extended care services available
and offers expanded programs to meet the growing needs of this elderly
population. The Togus VA Medical Center offers elderly veterans
geriatric primary care, geriatric and gero-psychiatric consultations,
geriatric evaluation, nursing home and dementia care, as well as
palliative and respite care.
Mr. Chairman, in Maine, more than 1,400 active duty service members
and veterans of the Global War on Terror have sought VA health care.
Many veterans from the conflicts in Iraq and Afghanistan have visited
Vet Centers. These community-based Vet Centers serve as an important
resource for veterans who, once home, often seek out fellow veterans
for advice to help them transition back to civilian life.
The State of Maine operates six State veterans homes supported by
VA subsidies. They are located in Augusta (120-bed skilled care and 30-
bed residential care); Bangor (120-bed skilled care); Caribou (40-bed
skilled care and 30-bed residential care); Scarborough (120-bed skilled
care and 30-bed residential care); South Paris (62-bed skilled care and
30-bed residential care) and Machias (30-bed residential care). We are
very fortunate in Maine to have these homes available to the State's
war veterans as a continuing source of care and comfort in their
elderly period. One difficulty, however, that concerns us is that our
State Homes do not provide a rehabilitation or convalescence
capability. Given our elderly veteran population's needs, the State
Homes could offer veterans a great new service if they embraced a
rehabilitation/convalescence mission in partnership with the Togus
Medical Center. Many veterans in inpatient care at the Togus VA Center
live in Bangor, Caribou and other communities at great distance from
Togus. Following surgery or other invasive care in Togus, if they had a
local residential provider available to help them with rehabilitation,
these veterans could be placed closer to home. The State Homes are
available but do not offer rehabilitation, so often these veterans are
admitted to community nursing homes at higher cost to the VA. I
encourage VA to consider exploring such an arrangement with the Maine
Veterans Homes to see whether such a referral partnership for post-
hospital convalescence is feasible.
In general, current law limits VA in contracting for private health
care services to instances in which VA facilities are incapable of
providing necessary care to a veteran; when VA facilities are
geographically inaccessible to a veteran for necessary care; when a
medical emergency prevents a veteran from receiving care in a VA
facility; to complete an episode of VA care; and, for certain specialty
examinations to assist VA in adjudicating disability claims. VA also
has authority to contract for the services in VA facilities of scarce
medical specialists. Beyond these limits, there is no general authority
in the law to support any broad VA contracting for populations of
veterans.
The Independent Budget (IB) veterans service organizations
(Disabled American Veterans, Veterans of Foreign Wars of the United
States, AMVETS and Paralyzed Veterans of America) agree that VA
contract care for eligible veterans should be used judiciously and only
in the specific circumstances described above so as not to endanger VA
facilities' ability to maintain a full range of specialized inpatient
services for all enrolled veterans. We believe VA must maintain a
``critical mass'' of capital, human and technical resources to promote
effective, high quality care for veterans, especially those disabled in
military service and those with highly sophisticated health problems
such as blindness, amputations, spinal cord injury or chronic mental
health problems. We are concerned that in an open environment of mixed
government and private providers with tight budgets, the contracted
element (particularly if it were focused on acute and primary care to
large populations) would inevitably grow over time, and place at risk
VA's well-recognized qualities as a renowned and comprehensive
provider. We believe such a distributed program would not only become
prohibitively expensive, but also could damage VA's health professions
affiliations--the bedrock of VA quality care.
We believe the best course for most enrolled veterans in VA health
care is for VA to provide continuity of care in facilities under the
direct jurisdiction of the Secretary of Veterans Affairs. For the past
twenty-five years or more all major veterans service organizations have
consistently opposed a series of proposals seeking to contract out or
to ``privatize'' VA health care to non-VA providers on a broad or
general basis. Specific incidences of such proposals have occurred in
the States of Maryland, Minnesota, Oregon and Florida. Ultimately,
these ideas were rejected by Congress or the Federal courts. We believe
such proposals--ostensibly seeking to expand VA health care services
into broader areas serving additional veteran populations at less cost,
or providing health care vouchers enabling veterans to choose private
providers in lieu of VA programs, in the end only dilute the quality
and quantity of VA services for all veteran patients. Given the dire
financial straits VA has experienced over several recent fiscal years,
this is an important policy to sick and disabled veterans, and to those
who represent their interests.
Mr. Chairman, aside from these concerns, we know that VA's contract
workloads have grown significantly. VA currently spends more than $2
billion annually on contract health care services, from all sources.
Unfortunately, VA does not adequately monitor this care, consider its
relative costs, analyze patient care outcomes, or even establish
patient satisfaction measures for most veterans under the care of
contract providers. VA has no systematic process for contract care
services to ensure the care is safe and delivered by certified,
licensed, credentialed providers. Also, VA does not monitor continuity
of contract care or ensure that these veterans are properly referred
back to the VA health care system following private care. Records of
veterans' contract care are inadequate in documenting the associated
pharmaceutical, laboratory, radiology and other key information
relevant to the episode(s) of care, nor does VA know if the care
received is consistent with a continuum of VA care.
Several times the Independent Budget has recommended that VA
implement a program of community contract care coordination that
includes integrated clinical and claims information for veterans
currently cared for by community-based providers. VA is yet to take
these actions.
In order to meet the needs of our newest generation of veterans
with access challenges and special needs, particularly in a State such
as Maine, it will be crucial for VA to develop an effective care
coordination model that achieves VA's responsibilities to these
veterans. Developing an effective care coordination model would improve
patient care quality, optimize use of VA's limited resources, and
prevent overpayments when eligible veterans utilize contract community
care.
Mr. Chairman, the information expressed above is the basis for the
IB recommendation on coordination of community care. Based on our
current knowledge of VA's ongoing demonstration called ``Project HERO
(Healthcare Effectiveness and Resource Optimization),'' VA is not fully
employing our recommended model in that demonstration, which has been
put in place in Veterans Integrated Service Networks (VISNs) 8, 16, 20
and 23. While this demonstration does not directly affect VA programs
in the State of Maine, it is of rising concern among veterans and
organizations that represent them in the States that are a part of this
demonstration. The Independent Budget veterans organizations are united
that whatever emerges from that demonstration, we believe as
representatives of millions of enrolled, sick and disabled veterans,
that the Veterans Health Administration (VHA) needs to closely
coordinate with our community any proposed expansion of the Project
HERO initiative.
We appreciate the recent change in VA policy on beneficiary travel
reimbursement, increasing the rate of reimbursement from eleven cents
per mile to 28.5 cents. This increase, made after over 30 years of
stagnancy, helped to ease rural veterans' ability to access VA
facilities for their care. We thank you for supporting that change, and
for providing the new funding essential to enable VA to adopt the new
policy. Unfortunately, recent dramatic gasoline price increases have
wiped out most of that improvement, but we are grateful nevertheless.
Mr. Chairman, we appreciate your Subcommittee's work in
establishing the VA Office of Rural Health (ORH) in legislation enacted
in 2006, Public Law 109-461. Veterans in Maine and elsewhere have high
expectations for that office to establish creative and effective
policies in meeting veterans' healthcare needs in rural America. The
Independent Budget for Fiscal Year 2009 made a series of
recommendations dealing with the responsibilities of this new office,
including the following:
VA must ensure that the distance veterans travel, as well
as other hardships they face be considered in VA' s policies in
determining the appropriate location and setting for providing VA
health care services;
VA must fully support the right of rural veterans to
health care and insist that funding for additional rural care and
outreach be specifically appropriated for this purpose, and not be the
cause of reduction in highly specialized VA medical programs needed for
the care of sick and disabled veterans;
VA should ensure that mandated outreach efforts in rural
areas required by Public Law 109-461 be closely coordinated with the
Office of Rural Health;
Mobile Vet Centers should be established, at least on a
pilot basis, to provide outreach and counseling for veterans in rural
and highly rural areas;
Through its affiliations with schools of health
professions, VA should develop a policy to help supply health
professions clinical personnel to rural VA facilities and practitioners
to rural areas in general. The VHA Office of Academic Affiliations, in
conjunction with Office of Rural Health, should develop a specific
initiative aimed at taking advantage of VA's affiliations to meet
clinical staffing needs in rural VA locations;
The VA Secretary should use existing authority to
establish a Rural Veterans Advisory Committee under the Federal
Advisory Committee Act, to include membership by veterans service
organizations (including those that offered the Independent Budget).
Mr. Chairman, we understand the Secretary is now considering taking
steps to establish this advisory Committee, and we applaud that
decision;
Recognizing that in areas of particularly sparse veteran
population and absence of VA facilities, the Office of Rural Health
should sponsor and establish demonstration projects with available
providers of mental health and other health care services for enrolled
veterans, taking care to observe and protect VA's role as coordinator
of care. The projects should be reviewed and monitored by the Rural
Veterans Advisory Committee. Funding should be made available to the
Office of Rural Health to conduct these demonstration and pilot
projects outside of VERA, and VA should report the results of these
projects to the Committees on Veterans' Affairs;
At highly rural VA CBOCs, VA should establish a staff
function of rural out reach worker to collaborate with rural and
frontier non-VA providers to establish referral mechanisms to ease
referrals by these providers to direct VA health care when available,
or VA-authorized care by other agencies;
Rural outreach workers in VA's rural CBOCs should receive
funding and authority to enable them to purchase and provide public
transportation vouchers and other mechanisms to promote rural veterans'
access to VA health care facilities that are distant to their rural
residences. This travel program should be inaugurated as a pilot
program, in a small number of facilities. If successful as an effective
access tool for rural, remote and frontier veterans who need access to
direct VA care and services, it should be expanded into other rural
areas; and
The ORH should seek and coordinate the implementation of
novel methods and means of communication, including use of the
worldwide web and other forms of telecommunication and telemetry, to
connect rural, remote and frontier veterans to VA health care
facilities, providers, technologies and therapies, including greater
access to their personal health records, prescription medications, and
primary and specialty appointments.
Mr. Chairman, most of these recommendations are clearly applicable
in our State. On behalf of the Independent Budget, we hope the
Subcommittee will address these recommendations with oversight and
further legislation if needed, to ensure they are implemented. Rural
veterans, whether in the State of Maine or elsewhere, deserve access to
VA health care, despite the obvious challenges we face in providing it.
Mr. Chairman, this concludes my testimony, and I will be pleased to
consider your questions on these important topics.
Prepared Statement of Brian G. Stiller, Center Director,
Togus Veterans Affairs Medical Center, Veterans Health Administration,
U.S. Department of Veterans Affairs
Mr. Chairman and members of the Subcommittee, on behalf of the 1300
employees and 400 volunteers at the Togus Veterans Affairs Medical
Center (Togus) in Maine, I thank you for this opportunity to discuss
the care and services we provide to veterans in Maine.
Togus has experienced many positive changes in the delivery of
healthcare services to veterans in Maine. One of the most significant
changes has been an increase in numbers of enrolled veterans selecting
Togus as their preferred choice for healthcare services and support. In
1999, total enrollment for healthcare was 19,000. Currently, 52,000
veterans are enrolled. Of those enrolled, 38,500 have received
healthcare services.
I want to focus my remarks today on three key factors in the
delivery of healthcare in Maine. First, I will speak on the challenge
of providing access to care in a largely rural setting. Next, I want to
share our progress in meeting the demands in the mental health area.
Finally, I will conclude with remarks on our current efforts in serving
the expanding female veteran population.
Community Based Outpatient Clinics. During the last two decades,
Maine has experienced a remarkable and sustained shift in the delivery
of healthcare services, particularly access to rural healthcare. Today,
there are six full-service Community-Based Outpatient Clinics (CBOC) in
Maine. Five of six CBOCs have expanded more than once to meet increased
demand. Our CBOCs are located in Bangor, Calais, Caribou, Lincoln,
Rumford and Saco.
The new Bangor CBOC includes physical therapy, dental, optometry,
radiology, part-time and limited specialty services as well as
Compensation & Pension rating exams. Four of our six CBOCs now offer
on-site phlebotomy services and all CBOCs have contracted locally for
X-rays and immediate lab services. To minimize travel, teleretinal
imaging services are available at Caribou. VA recently changed the
reimbursement rate from 11 cents to 28.5 cents per mile to help offset
some of the travel cost.
CBOCs are an essential part of primary care and they provide
preventive health services, health promotion and disease prevention
programs, as well as mental health services. A part-time primary care
access point is located in Fort Kent. To further provide care in rural
or residential settings, Home-Based Primary Care (HBPC) teams operate
out of Togus and Portland. These teams provide primary care and support
services to veterans requiring short term care, as well as veterans
seeking to maintain an independent living situation. New HBPC teams are
authorized for Caribou and Lincoln. Recruitment for these new positions
is ongoing.
Rural Health. VA recently instituted the Office of Rural Healthcare
(ORH) to specifically identify and address the needs and challenges of
providing healthcare to veterans living in rural areas. ORH is
leveraging rural health expertise from the public and private sectors
and is currently working on several initiatives such as the Veterans
Rural Health Advisory Committee, Veterans Integrated Service Network
(VISN) Rural Consultant Program and Rural Health Resource Centers. ORH
recently completed an analysis of outreach clinics and a Mental Health
and Long Term Care Plan. These initiatives are a few of the additional
mechanisms to enhance effectiveness and efficiency of healthcare
delivery to rural areas including Maine.
Affiliations. Togus continues to enhance existing affiliations with
State and national medical education facilities as well as establishing
new affiliations. We see the need to help grow and nurture the medical
education of students in Maine, to encourage them to stay and to
practice rural healthcare. To that end, Togus is working with the Maine
Medical Center (MMC), a private facility in Portland to provide
clinical positions for Maine medical students attending Tufts
University for their rotations or residency. Similarly, Togus is
working with the University of Southern Maine for nurse practitioner
students and the University of New England for physician assistant and
pharmacist students. As Husson College institutes its new pharmacist
program, Togus will offer training opportunities to those students.
Similar training opportunities are currently available for other
clinical disciplines such as dental, psychology, social work, and
nursing. In October 2008, we plan to host a ``Medical Education and
Research'' symposium for medical education, healthcare and research
organizations.
Additional Initiatives. Togus continues to be a leader in health
care by identifying and employing new technologies such as the latest
improvements in home healthcare monitoring. Maine recently received a
$25 million Federal Communications Commission grant to develop
telemedicine services throughout Maine. Togus is coordinating with
other Maine healthcare organizations to determine how best to further
deploy and utilize this healthcare technology.
Currently, over 150 veterans receive adjunct care via home
telehealth using a variety of devices. VA staff use these devices to
review medications, assess wounds, complete psychosocial assessments,
conduct follow-up reviews for medication changes and determine if there
are changes in health status when medications are changed. Areas of
focus are primary care, Spinal Cord Injury, specialty or acute care and
patients discharged from inpatient medical or mental health units.
These devices provide timely, accurate data to allow providers to
provide some healthcare remotely while minimizing veteran travel.
Mental Health. I'd now like to share with you some of our
accomplishments and successes in the mental health area. Togus Mental
Health Service saw sustained growth in the number of unique veterans
served from 4,230 to 5,854--a 38-percent increase from FY 04 to FY 07.
Through the VA Mental Health Initiative process, during the same
period, our mental health staff grew from 54 to 74, an increase of 39
percent. With additional staffing, we are able to care for the
increased number of veterans and develop new programs and areas of
treatment. New services include an opiate substitution (buprenorphine)
treatment program, a Suicide Prevention program, a recovery program,
our first Grant and Per Diem homeless facility, an integrated mental
health and primary care team located in the primary care area at the
Togus campus, three new clinicians for our Post Traumatic Stress
Disorder (PTSD) Clinical Team and a vocational rehabilitation staffer
for a supported employment program. Care for veterans in rural Maine
improved with all of our northern CBOCs having telemental health
connectivity and many having in-home video phone connections. All Maine
CBOCs now have on-site specialized mental health providers. There are
two VA mental health clinics located in Bangor and Portland.
To better serve combat veterans returning from Iraq or Afghanistan,
Togus reorganized its PTSD program into a one week intensive outpatient
program that uses a new evidenced based treatment approach: Acceptance
and Commitment Therapy (ACT). With clinical experience in that area, we
were asked to be consultants to the national roll-out of ACT for VA.
This program focuses on the needs of new veterans who have careers,
families and cannot attend a longer program. This program provides the
basis for follow-on care in another PTSD class and individual or group
treatment as well as a dual diagnosis treatment. This new program has
been very well received by Operation Enduring Freedom/Operation Iraqi
Freedom (OEF/OIF) veterans with favorable feedback. Moreover, two
programs were conducted solely for women veterans to appropriately
support their needs.
We are striving to provide more intensive or specialized mental
healthcare and residential support for veterans in rural areas,
particularly veterans who are homeless, who are in extended treatment
for PTSD, or who have substance abuse problems.
Partnership with Vet Centers. PTSD treatment is readily available
at Togus VAMC, six CBOCs, two mental health clinics and all five Vet
Centers located in Bangor, Caribou, Lewiston, Portland and Sanford.
Togus works in partnership with the five Vet Centers to provide mental
health services to combat veterans throughout the State. Maine's Vet
Centers have outreach locations to provide mental health services to
more rural locations.
Special Need Population. Design is nearly complete and construction
will begin this fall on the relocation and expansion of our 16 bed
inpatient psychiatry unit. The new unit will have 24 beds, with special
care areas for geriatric veterans and those more acutely ill. These
improvements will ensure care is provided in accordance with latest
industry standards to minimize risk and ensure safety for this
vulnerable patient population.
Women Veterans. Women comprise about 14 percent of active duty
Guard and Reserve forces. The ratio of enrollment for female to male
veterans has increased over the last decade. In FY 2007, women
comprised 5.2 percent of all veteran users nationwide and it is
projected the percentage will increase to 8.1 percent of all veteran
users by 2011. Approximately 42 percent of OEF/OIF women veterans are
enrolled for VA healthcare services and 28.5 percent used VA healthcare
services in 2007. Of these, 78.5 percent were under the age of 40,
which presents new challenges in addressing their unique healthcare
needs. In Maine, there are approximately 1700 women veterans receiving
VA healthcare.
VA is committed to identifying and meeting the various needs of
women veterans of all ages and at all levels. Togus' women's clinic
provides primary care, gynecology and mental health services and a bone
densitometer to screen for osteoporosis. Maternity care is provided via
Fee-Basis by a community provider of the veteran's choice. Mammography
is provided via Fee-Basis at any FDA-approved site near the veteran's
home. VA has two Performance Measures which are specific to women's
health: breast cancer screening and cervical cancer screening. In both
of these measures, Togus exceeded the national benchmark. All veterans
are surveyed with a clinical reminder regarding Military Sexual Trauma
and dedicated treatment services are available through Togus and its
various clinics, Vet Centers or Fee-Basis as appropriate.
We plan to purchase additional equipment to expand care to women
veterans this year. VISN 1 primary care is evaluating women's
healthcare educational and equipment needs at CBOCs with the goal of
providing increased access to routine healthcare that is gender
specific. Togus has a dedicated Women Veterans Program Manager (WVPM)
who is also the Lead MVPM for VISN 1. To enhance outreach efforts,
Togus hosts an annual Women Veterans Information Fair and provides a
site for Women Veterans of America meetings.
Mr. Chairman, to better serve Maine veterans, we must continue to
closely monitor and meet their needs. America's veterans have earned
the best care we can possibly provide and it is our privilege to
provide them with the highest levels of customer service. We appreciate
your interest and support in helping VA to successfully accomplish our
mission of providing world-class care to all those who have so
honorably served our great country.