[House Hearing, 110 Congress]
[From the U.S. Government Printing Office]


 
                 ACCESS TO U.S. DEPARTMENT OF VETERANS 
                 AFFAIRS HEALTHCARE: HOW EASY IS IT FOR 
                     VETERANS--ADDRESSING THE GAPS 

=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 18, 2007

                               __________

                           Serial No. 110-13

                               __________

       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     RICHARD H. BAKER, Louisiana
Dakota                               HENRY E. BROWN, Jr., South 
HARRY E. MITCHELL, Arizona           Carolina
JOHN J. HALL, New York               JEFF MILLER, Florida
PHIL HARE, Illinois                  JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania       GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada              MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado            BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas             DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana                GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California           VERN BUCHANAN, Florida
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       RICHARD H. BAKER, Louisiana
SHELLEY BERKLEY, Nevada              HENRY E. BROWN, Jr., South 
JOHN T. SALAZAR, Colorado            Carolina

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

                               __________

                             April 18, 2007

                                                                   Page
Access to U.S. Department of Veterans Affairs Healthcare: How 
  Easy is it for Veterans--Addressing the Gaps...................     1

                           OPENING STATEMENTS

Chairman Michael H. Michaud......................................     1
    Prepared statement of Chairman Michaud.......................    27
Hon. Shelley Berkley.............................................     8
Hon. Jerry Moran.................................................     3
Hon. John T. Salazar.............................................     4

                               WITNESSES

U.S. Department of Health and Human Services, Marcia Brand, 
  Ph.D., Associate Administrator, Rural Health Policy, Health 
  Resources and Services Administration..........................     5
    Prepared statement of Dr. Brand..............................    28
U.S. Department of Veterans Affairs, Gerald M. Cross, M.D., 
  FAAFP, Acting Principal Deputy Under Secretary for Health, 
  Veterans Health Administration.................................    24
    Prepared statement of Dr. Cross..............................    41

                                 ______

American Legion, Shannon Middleton, Deputy Director for Health, 
  Veterans Affairs and Rehabilitation Commission.................    16
    Prepared statement of Ms. Middleton..........................    34
Disabled American Veterans, Adrian M. Atizado, Assistant National 
  Legislative Director...........................................    19
    Prepared statement of Mr. Atizado............................    37
National Rural Health Association, Andy Behrman, Chair, Rural 
  Health Policy Board, and President and Chief Executive Officer, 
  Florida Association of Community Health Centers................    14
    Prepared statement of Mr. Behrman............................    30

                       SUBMISSIONS FOR THE RECORD

Brown, Hon. Corrine, a Representative in Congress from the State 
  of Florida, statement..........................................    46
Brown, Hon. Henry E., Jr., a Representative in Congress from the 
  State of South Carolina, statement.............................    46
Miller, Hon. Jeff, Ranking Republican Member, and a 
  Representative in Congress from the State of Florida, statement    46

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions for the Record:
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, to 
      Dr. Michael Kussman, Acting Under Secretary of Health, 
      Veterans Health Administration, U.S. Department of Veterans 
      Affairs, letter dated May 2, 2007..........................    48
    Hon. Joe Donnelly to Dr. Michael Kussman, Acting Under 
      Secretary of Health, Veterans Health Administration, U.S. 
      Department of Veterans Affairs, letter dated May 2, 2007...    55
    Hon. Jeff Miller, Ranking Republican Member, Subcommittee on 
      Health, to Dr. Michael Kussman, Acting Under Secretary of 
      Health, Veterans Health Administration, U.S. Department of 
      Veterans Affairs, letter dated April 27, 2007..............    57
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, to 
      Maurice Huguley, Legislative Analyst, Office of Deputy 
      Assistant Secretary for Legislation for Human Services, 
      U.S. Department of Health and Human Services, letter dated 
      May 2, 2007 (forwarding question from Hon. Phil Hare)......    68
    Hon. Michael H. Michaud, Chairman, Subcommittee on Health, to 
      Joe Violante, National Legislative Director, Disabled 
      American Veterans, letter dated May 2, 2007................    73
    Andy Behrman, Chair, NRHA Rural Health Policy Board, National 
      Rural Health Association, to Hon. Michael H. Michaud, 
      Chairman, and Hon. Phil Hare, Subcommittee on Health, 
      Committee on Veterans' Affairs, letter dated June 5, 2007..    69
    Steve Robertson, Director, National Legislative Commission, 
      American Legion, to Hon. Michael H. Michaud, Chairman, 
      Subcommittee on Health, Committee of Veterans' Affairs, 
      letter dated November 28, 2007.............................    72


                 ACCESS TO U.S. DEPARTMENT OF VETERANS 
                   AFFAIRS HEALTHCARE: HOW EASY IS IT 
                   FOR VETERANS--ADDRESSING THE GAPS 

                              ----------                              


                       WEDNESDAY, APRIL 18, 2007

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 2:20 p.m., in 
Room 334, Cannon House Office Building, Hon. Michael H. Michaud 
[Chairman of the Subcommittee] presiding.

    Present: Representatives Moran, Snyder, Hare, Berkley, 
Salazar.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. Sorry for the delay. We got called for a vote 
so we will start. I would ask unanimous consent that all 
written statements be made part of the record. Without 
objection, so ordered.
    I also ask unanimous consent that all Members be allowed 5 
legislative days to revise and extend their remarks. Without 
objection, so ordered.
    I apologize for a lot of the Members not being here. We 
have a lot of Committee meetings that are going on and we just 
broke up from a vote and Members will be drifting in and out 
throughout the hearing.
    The Subcommittee on Health has a lot of issues that we have 
to deal with this upcoming session. The issue of providing 
rural healthcare affects each of our States in a very different 
way. In California, rural communities make up 92 percent of the 
land mass and 8 percent of the population. In my own State of 
Maine, over 40 percent of the population lives in rural areas. 
It is estimated that 60 million Americans, one in five, live in 
areas that have been classified as rural.
    Rural populations tend to be older than urban populations 
and they tend to exhibit poor health behaviors. Economic 
factors also add to the challenges facing rural populations. 
Rural veterans make up 41 percent of the U.S. Department of 
Veterans Affairs' (VA's) patient workload. Access and resources 
present serious challenges to providing high quality care for 
these veterans. VA care can be second to none. Unfortunately 
the quality of care is not always the same throughout the VA 
system. For many veterans living in rural States like Maine, 
accessing that care is a significant challenge. For certain 
more complex procedures veterans in northern Maine must endure 
4 days of travel to and from the VA facility in Boston to 
receive care.
    Addressing the distance to care and the travel burden in 
rural areas is extremely important. However, given the smaller 
population and frequency of certain complex procedures it does 
not make sense for VA to maintain a daily in-house capacity in 
every facility for something that is used on an infrequent 
basis.
    This problem is not unique to VA. It is a problem facing 
many rural areas across the country while smaller patient 
population limit the resources available to rural hospitals, 
which in turn limits the services that hospitals can support 
and provide. Rural areas face difficulties in providing what 
has been termed ``core healthcare services'' by the Institute 
of Medicine. These services include primary care in the 
community, emergency medical service, hospital care, long-term 
care, mental health and substance abuse services, oral 
healthcare, and public health services.
    For a variety of reasons, rural areas also face a greater 
problem recruiting and retaining healthcare professionals. 
These problems must be addressed because the demand of services 
from our veterans in rural areas is only going to increase. We 
have an aging population that will need long-term care. Over 40 
percent of the new generation of veterans returning from 
Afghanistan and Iraq are from rural areas. They have their own 
unique needs including loss of limb, traumatic brain injury, 
and mental health concerns.
    One important approach to providing access to care is the 
VA system and Community-Based Outpatient Clinics (CBOCs) which 
currently number more than 650. We have five CBOCs in Maine. 
The Capital Asset Realignment for Enhanced Services (CARES) 
Commission recommends a sixth CBOC in the Lewiston, Auburn area 
along with five part-time health access points. Only one of 
these facilities is close to opening while the CBOC is not 
expected to open until 2008 at the earliest.
    During the CARES process, 250 CBOCs were identified by the 
VA as being needed, of which 156 were designated as priority. 
Since the CARES decision, VA has opened 12 of the 156, less 
than 8 percent. At this pace it will take VA over 30 years to 
open all the priority clinics. VA has also opened 18 clinics 
not on the CARES priority list, which calls into question the 
decision process and the ability of CARES to assist in 
decisions in the future.
    The VA has also designated facilities as Veterans Rural 
Access Hospitals designed to provide inpatient service to 
veterans in rural areas in which these services can be 
supported. The VA has made great strides in exploring the use 
of telemedicine and other technological means of providing 
healthcare services. I would like to hear how these efforts are 
improving care and how we can help.
    One of the problems we face in the area of recruitment and 
retention is the isolation that is often felt by healthcare 
professionals working in rural communities. I would like to 
explore how technology might be used to overcome these feelings 
of isolation and thus improve recruitment and retention.
    Is the VA, and our rural communities, ready to meet the 
increasing and changing needs of our veterans and their 
families? What is the VA in rural America going to look like in 
the future? We must keep in mind that VA healthcare does not 
operate in a vacuum but it is an integral part of our national 
healthcare system. I would also like to know when the priority 
CBOCs are going to be built or if the VA no longer intends to 
follow the CARES process.
    Today the Subcommittee hearing will provide us with the 
opportunity to begin this exploration, to begin to examine 
issues concerning access and the provision of care and the 
proper expectation of veterans in rural areas regarding the 
care that they can expect from the VA system.
    At this point in time I would like to recognize the Acting 
Ranking Member, Mr. Moran.
    [The prepared statement of Chairman Michaud appears on p. 
27.]

             OPENING STATEMENT OF HON. JERRY MORAN

    Mr. Moran. Mr. Chairman, thank you very much. I appreciate 
you recognizing me. I am delighted to be here this afternoon, 
although I have several meetings that are intruding. I am happy 
to be here to support your efforts. And I would like for you, 
Mr. Michaud, to consider me an ally. We share many similarities 
in our districts despite one is in New England and one is in 
the middle of the country, Midwest. I represent a district of 
approximately 60,000 square miles. There is not a VA hospital 
in the district. And we very much are interested in trying to 
find ways to improve access for our veterans.
    Your remarks about CBOC I think are right on point. I am 
very interested in knowing what the plans are by the Department 
of Veterans Affairs to increase the number of CBOC. We have 
significant needs in that regard and are particularly troubled 
to learn about the issue of not being on the priority list and 
still having CBOC when those that are on the priority list are 
still waiting.
    I also would encourage you and the Subcommittee to take 
seriously a piece of legislation that I introduced earlier this 
year, the Rural Veterans Access to Care Act, giving veterans 
the opportunities of utilizing their local healthcare 
providers, both hospitals and physicians, clinics, in the 
circumstances when a VA hospital is miles, hundreds of miles 
away from where the veteran lives and where the CBOC is as 
well.
    And I am hopeful that this Committee will take that form of 
legislation, that theory behind that legislation seriously and 
work with me to see that we address the needs of our veterans 
who are miles away. I spoke on the House floor recently about 
this topic, veterans who are told to drive 260 miles to get 
their prescriptions for their eye glasses when there's an 
optometrist on Main Street three blocks away.
    We need assistance when it comes to filling prescriptions 
and issuing the script. The idea that our veterans must travel 
hundreds of miles, particularly our World War II veterans at 
ages 80 and 90, to simply have an examine so that their 
prescription can be refilled in many cases it is physically not 
possible.
    I also am interested in hearing what Dr. Petzel has to say 
in his role as Director of VISN 23 in regard to the Project 
Hero. And that VISN includes six Kansas counties and I am 
interested in knowing the status and findings of that pilot 
program.
    Last December, legislation was signed creating the VA 
Office of Rural Healthcare. And I have not heard from the VA as 
to the status of the implementation of that office. Whether it 
is being staffed and what role it is now playing or is foreseen 
to play. And finally I would raise a point that we have been 
pushing for a long time, the opportunity access also includes, 
particularly in rural America, the access to other providers 
than a physician and chiropractic care continues to be 
inadequate in many of our VISNs across the country. And, I hope 
to be here to ask some questions of our Department of Veterans 
Affairs witnesses.
    Again, Mr. Michaud, you have been a champion in regard to 
rural healthcare. I would like to be your ally, and look 
forward to working with you to see that we accomplish the goal 
of meeting
the needs of veterans who live across the country, regardless 
of whether they are in the same community as a VA hospital. 
Thank you.
    Mr. Michaud. Thank you very much, Mr. Moran. I will work 
very closely with you on these issues, and I agree with your 
comments. We have scheduled a hearing, I don't know if the 
notice has been sent to your office yet, for one of your bills 
on April 26th at 10 o'clock. And we will be sending you a 
notice to testify.
    Mr. Salazar?

           OPENING STATEMENT OF HON. JOHN T. SALAZAR

    Mr. Salazar. Thank you, Mr. Chairman. And I thank you, Mr. 
Moran, for your fine comments. I associate myself with both of 
your comments. I think all of us share some commonalities in 
that we all represent some very rural areas in our distant 
communities in Kansas and in Colorado for example.
    But I want to thank you, Mr. Chairman, for you calling this 
important hearing. I think that a 2004 study by the Under 
Secretary of Veterans Health found that veterans living in 
rural areas in fact are in poor health, in poorer health than 
those living in urban areas. And because of the distances, as 
Mr. Moran referred to, and other difficulties associated with 
obtaining care, many rural veterans put off preventative 
healthcare.
    I think last Congress the Office of Rural Health and the VA 
was created to better focus on our veterans in rural areas. I 
am looking forward to today's testimony. But in reality, over 
25 percent of the veterans, I believe, live in rural areas. And 
I believe it is a fair expectation that the men and women who 
sacrifice for us are taken care of.
    I am heartened today that we got notice from Secretary 
Nicholson that, it is not really CBOC, but it is called a 
Community-Based Outreach Center which is actually going to be 
installed in Craig, Colorado, one of the remotest areas in 
Colorado. Veterans have to travel 5 hours over the mountains to 
try to get to Grand Junction for healthcare.
    I want to thank the Secretary for that. We do indeed share 
many, many issues when it comes to veterans' healthcare. I 
think, though, that if we find that the VA is incapable of 
providing that care to all of our veterans, that we can't 
afford it, then I think we must look for a new direction. And I 
agree with Mr. Moran on possibly looking at trying to address 
the issues of allowing our veterans to obtain healthcare from 
our local physicians.
    But I want to thank you, Mr. Chairman, once again. And I 
look forward to today's testimony. Thank you.
    Mr. Michaud. Thank you, Mr. Salazar. On our first panel is
Dr. Marcia Brand who is Associate Administrator for Rural 
Health Policy, Health Resources and Services Administration, of 
the U.S. Department of Health and Human Services. Dr. Brand.
    Dr. Brand. Thank you.
    Mr. Michaud. Thanks for coming this afternoon. I look 
forward to hearing your testimony.

  STATEMENT OF MARCIA BRAND, PH.D., ASSOCIATE ADMINISTRATOR, 
      RURAL HEALTH POLICY, HEALTH RESOURCES AND SERVICES 
  ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Dr. Brand. Mr. Chairman, Members of the Subcommittee, thank 
you for the opportunity to meet with you today on behalf of Dr. 
Elizabeth Duke. She is the Administrator of the Health 
Resources and Services Administration. Thank you. We welcome 
this opportunity to discuss rural health access issues and what 
is being done to meet the healthcare needs of the Nations rural 
populations. We appreciate your interest in and support for 
rural healthcare and access to healthcare for rural veterans.
    The Health Resources and Services Administration, which I 
will call HRSA, is the primary Federal agency for improving 
access to healthcare services for people who are uninsured, 
isolated, or medically vulnerable. HRSA grantees provide 
healthcare to the uninsured, people living with HIV and AIDS, 
and pregnant women, mothers and children. They train health 
professionals and improve systems of care in rural communities.
    For HRSA, the Health Center Program, the National Health 
Service Corps, and rural healthcare needs are priorities. For 
more than 40 years, the Health Center Program has been a major 
component of the healthcare safety net for the Nation's 
indigent populations. Health Center's lead the Presidential 
initiative to increase healthcare access in the Nation's most 
needed communities. Health Centers provide regular access to 
high quality, family oriented, comprehensive primary and 
preventative healthcare regardless of one's ability to pay.
    President Bush's initiative to expand the Health Centers 
began in 2002. The initiative will significantly effect over 
1,200 communities through the support of new or expanded access 
points. In 2001 HRSA funded 3,317 Health Center sites across 
the Nation. We expect the number of Health Centers sites to 
grow to 4,053 by the end of 2008.
    Just over half of all the Health Center grantees serve 
rural populations. Besides the new access points, HRSA has 
distributed 385 grants to expand the medical capacity of our 
existing delivery sites and another 340 grants to existing 
grantees to add or expand oral health, mental health and 
substance abuse services. And these are special challenges for 
our rural communities.
    Through these efforts, the number of patients treated 
annually with Health Centers has grown from 10.3 million in 
2001 to an estimated 16.3 million patients by the end of 2008. 
The National Health Service Corps improves the health of the 
Nation's underserved by uniting communities in need with caring 
health professionals. Currently more than half the National 
Health Service Corps doctors, dentists, nurses, and mental 
health and behavioral health providers serve in Health Centers 
around the Nation. And about 60 percent of them work in areas.
    HRSA's Office of Rural Health Policy is charged with 
informing and advising the Department of Health and Human 
Services on matters effecting rural hospitals and healthcare. 
We coordinate rural healthcare activities and maintain a 
national rural health and human services information 
clearinghouse. HRSA, with the Office of Rural Health Policy, is 
the leading Federal proponent for better healthcare services 
for the 55 million people who live in rural America.
    ORHP promotes State and local empowerment to meet the 
country's rural health needs in several ways. I would like to 
highlight a couple of our grant programs. We manage the 
Medicare Rural Hospital Flexibility Grant Program which 
provides funding to State governments to work with 1,300 small 
rural hospitals. We work with the State Office of Rural Health. 
There are 50 State offices of Rural Health.
    Additionally, we support a number of community-based grant 
programs that increase access to primary care or improve rural 
healthcare services. As you can see, HRSA administers a range 
of programs that serve rural communities. HRSA also provides 
staff support to the Department's cross-cutting rural efforts. 
This includes the HHS Rural Taskforce which has representatives 
from each of HHS's agencies and staff offices.
    Effective, coordinated healthcare improves the health and 
well-being of American's, regardless of where they live. 
However, effective coordination is especially critical in rural 
communities where services and providers are limited and 
resources are scarce. The challenges of providing healthcare 
for rural communities is compounded by higher rates of poverty, 
a lack of insurance. Rural people are a little bit older and 
they have higher rates of chronic disease. And there are 
significant transportation barriers.
    We take great pride in the work that we do to provide 
better healthcare services for our rural populations. However, 
we are humbled by the significant challenges that remain for 
healthcare in rural areas and the underserved. We are pleased 
that the Department of Veterans Affairs is establishing an 
Office of Rural Health to assist the Under Secretary in issues 
affecting rural veterans.
    We have contacted the individuals who are creating this 
Office and their charge sounds very familiar. With 20 years of 
experience, we have some expertise around rural and 
policymaking and research. And we look forward to collaborating 
with the new Office. And we offer our assistance.
    And, I would be pleased to answer any questions at this 
time, sir.
    [The prepared statement of Dr. Brand appears on p. 28.]
    Mr. Michaud. Thank you very much, Doctor, for your 
testimony. You had mentioned that the Office of Rural Health, 
which is getting under way within the VA System, and the fact 
that HHS has 20 years of experience in this area. What would 
you tell the VA would be the number one problem that your 
agency encountered in dealing with rural healthcare issues as 
far as access goes?
    Dr. Brand. I think that it would be difficult to say that 
there is a single issue that is most challenging around access. 
In rural communities we face a lot of the challenges that we 
face nationwide in access--it's just that much more difficult 
because it is rural. It is harder to recruit and retain 
providers because infrastructure is not there and the folks who 
use those services have higher healthcare needs and lower rates 
of insurance.
    Mr. Michaud. Okay.
    Dr. Brand. It has over the past several years become 
clearly a significant problem to provide mental health services 
for rural communities and also to provide oral healthcare. It 
is very difficult to recruit and retain providers.
    Mr. Michaud. Has it been a problem trying to find qualified 
staff to work in the rural healthcare arena?
    Dr. Brand. There are a number of different programs that 
seek to improve recruitment and retention of providers for 
rural communities. A number of them focus on the fact that 
folks who are from rural communities are more likely to go back 
there and practice. And so a number of State programs and 
several of the Federal programs try to recruit folks from rural 
communities, encourage them to go to health profession schools, 
and then return to practice in those areas.
    Also the National Health Service Corps. Roughly 60 percent 
of the folks in the National Health Service Corps practice in 
rural communities. So that is another affect of Federal 
program.
    Mr. Michaud. You are familiar with the CARES process that 
the VA went through a number of years ago?
    Dr. Brand. Sir, I read the materials in preparation for 
this hearing, but I wouldn't consider myself familiar with it.
    Mr. Michaud. A lot of time and effort went into the CARES 
process, and I commend everyone who put all the effort in 
there. My concern is that that is pretty much it. We haven't 
seen, at least in VISN 1, any movement or much movement in that 
particular area.
    My question is, when you look at rural healthcare, what you 
are doing at HHS and if you look at what the CARES process 
actually recommends, a lot of--there are a lot of areas that 
are very similar. Do you think that that is something that your 
agency could work very closely with the VA to actually speed up 
the process under the CARES process?
    And a good case in point is, one of the clinics under the 
CARES process that was recommended in Maine, the VA actually 
was working with the local hospital, was working with the 
healthcare clinic in the region. And at the very last minute 
they decide to go it alone.
    So now we have a situation where we have a hospital that is 
expanding in a rural area. You have a Federally qualified 
healthcare clinic that is building a new facility in a rural 
area. And then you have the VA building a new facility in the 
rural area in the same town, which I think is a waste of 
Federal dollars. And I think there should be some collaboration 
going on.
    So I hope you would actually look at the CARES process as 
far as where they are recommending clinics or CBOCs and see how 
you might have facilities out there where we used additional 
Federal dollars in other areas to be able to help collaborate 
with the VA and to move forward in a collaborative way so we 
can take care of veterans in rural areas. At the same time it 
will help out rural healthcare providers as well.
    Dr. Brand. I think that we have a significant investment in 
expanding the Health Centers and certainly there are 
opportunities for collaboration with the Health Centers. There 
are also 3,500 Rural Health Clinics located in those areas. And 
somewhere around 1,300 small rural hospitals that we call 
Critical Access Hospitals. And given the fact that resources in 
rural communities are so scarce, it would be--I would be 
hopeful that we would be able to find ways to collaborate more 
effectively. And we are certainly willing to try to do that.
    Mr. Michaud. Great. Well thank you very much, Dr. Brand. 
Mr. Salazar.
    Mr. Salazar. Thank you, Mr. Chairman. Dr. Brand, my 
questions are similar to Mr. Michaud's questions. It just seems 
to me to make a lot of sense that if you have to transport 
veterans over a 250 mile range, that it would make more sense 
to be able to provide them the same opportunity as normal 
residents have in rural communities, for example.
    What are the obstacles to VA refunding or making the 
payments for a patient who is a veteran who would go to a local 
hospital to get the same kind of treatment? Is there a 
rulemaking process that has to take place or is it just rules 
within VA or is it something that the Members of Congress could 
actually do to change the----
    Dr. Brand. I can speak to the Health Centers and certainly 
to small rural hospitals. Our Health Centers, frankly at this 
moment don't ask veterans' status. And so they do not know who 
is a veteran. And similarly I think for many small rural 
hospitals when someone presents either through the outpatient 
departments or coming through the emergency department it is 
not asked.
    And, so I think that frankly opportunities to improve 
collaboration are missed because Health Centers and Critical 
Access Hospitals don't know who is a veteran and who might be 
eligible for benefits. I think also it is important to note 
that the Health Centers will see someone regardless of their 
ability to pay or their veteran status. So if they present at 
the Health Center, they would be seen.
    Mr. Salazar. Well what about preventative healthcare? Like, 
for example, just to be able to go to the local primary care 
physician--do you have any mechanism for veterans in rural 
areas to be able to do that?
    Dr. Brand. They could certainly present at any of those 
facilities. Whether or not those would be reimbursed by the 
Veterans--through their veterans benefits, I think is just 
depending upon a pre-existing relationship. And I am sure my 
colleagues from Veterans Affairs could speak to that more 
effectively than I can in terms of what those relationships 
might be.
    Mr. Salazar. Okay. Thank you.
    Mr. Michaud. Thank you, Mr. Salazar. Ms. Berkley?

           OPENING STATEMENT OF HON. SHELLEY BERKLEY

    Ms. Berkley. Thank you very much, Mr. Chairman. I am very 
glad that we are here to discuss access to VA healthcare, which 
is obviously a very important issue to our veterans across the 
country.
    As you are aware I represent a very urban district and I 
just want to emphasize that access to healthcare is not, for 
our veterans, is not only a rural issue. With 218,000 veterans 
in southern Nevada, we have no VA healthcare facilities. And of 
course because of the CARES study, finally the CARES Commission 
determined that with 218,000 veterans and no healthcare 
facilities, that perhaps Las Vegas ought to have it's own 
healthcare facility.
    So many of my veterans, aside from the fact that they have 
got 80-year old veterans standing in 110 degree temperature 
waiting for a shuttle to take them from one temporary location 
to another awaiting the building of our VA hospital, outpatient 
clinic, long-term care facility. So many of my veterans that 
have more specialized problems have to continue to go to Long 
Beach to get their healthcare needs taken care of. And it is 
just so difficult because oftentimes they are in a very low-
income bracket. Their families cannot afford to accompany them. 
They go there by themselves. Many of them are Korean War 
veterans and World War II vets. And this is an issue that is 
bigger than our rural areas. It is pervasive across the United 
States.
    I have got 1,600 Nevada veterans who have just returned 
from Iraq and Afghanistan. And we are estimating that there 
will be at least another 2,100 coming back in the next year or 
two. I can't be here for the third panel, but I think what I 
would ask you as Chairman if you could please ask the third 
panel how is the VA preparing to meet the needs of the growing 
number of returning servicemembers who will need increased 
healthcare and mental healthcare as well?
    Right now in Las Vegas, we don't have facilities to handle 
what we have. In 2011, which is when they are anticipating that 
the facilities will be completed, is an awfully long time to 
have to wait if you are a World War II vet, if you are a 
disabled vet and have to keep going to Long Beach or if you are 
returning from Afghanistan or Iraq and it is 2007. And you are 
coming home to nothing.
    So those are the questions that I would like addressed and 
I am just sorry I won't be here to hear the answers. But I 
thank you very much for letting me talk to you about my 
extraordinary frustration and, frankly, shame that we send 
young men and women to war and when they come back, we don't do 
what we have promised that we are going to do, and don't 
adequately fund this VA healthcare center. As I have said, the 
healthcare system--as I have said before, veterans healthcare 
and other benefits is the cost of war. And we ought to be 
taking this into account because the men and women that are 
coming back from Iraq and Afghanistan we are going to be taking 
care of their healthcare needs and mental healthcare needs for 
many decades to come. And we can't handle the load we have now.
    So I would like to know how the VA intends to take care of 
these people. Thank you, Mr. Chairman.
    Mr. Michaud. Thank you very much. You have been a true 
advocate for veterans. Your questions are the same that a lot 
of us have as well, and you can be assured that they will be 
asked. Thank you.
    Mr. Hare?
    Mr. Hare. Thank you, Mr. Chairman. Thank you very much for 
having the hearing.
    Dr. Brand, I just have a couple questions. One, you know, I 
represent an area, a congressional district, with a lot of 
rural areas. And you know you were talking about 
transportation. And you mentioned in your testimony that there 
are significant transportation barriers that affect the 
coordination of services. And I am wondering if you could 
elaborate on that and what HHS has done to address the issue of 
providing transportation to rural patients?
    Dr. Brand. Transportation is a significant challenge in 
rural communities. And HHS has a process to try to improve 
coordination and collaboration around transportation. And it 
would be my pleasure to submit that information to you after 
the hearing, sir.
    [The information was provided by the U.S. Department of 
Health and Human Services to Mr. Hare in the post hearing 
questions for the record, which appears on p. 48.]
    Mr. Hare. Thank you very much. And then you were talking 
about hospital care. You said that out of the 2,000 hospitals, 
I believe 1,500 have fewer than 50 beds.
    Dr. Brand. Yes, sir.
    Mr. Hare. And just a couple of questions. Can you describe 
the type of care that is provided there and have you run into 
problems finding qualified people to staff and to work at the 
small hospitals?
    Dr. Brand. Of the 2,000 hospitals, about 1,500 have less 
than 50 beds. And those hospitals typically provide some access 
to primary care through outpatient services and then standard 
services such as laboratory, radiology. They have an emergency 
department, they meet Medicare conditions of participation, but 
most of the patients that are seen are those patients with less 
complex conditions. And historically, lots of those places are 
places where individuals come and are first assessed and then 
it is important to have a good relationship with the next level 
of hospital, the referral hospital for those conditions that 
are more complex.
    And so there are----
    Mr. Hare. Thank you.
    Dr. Brand [continuing]. Part of a system or a network of 
hospitals.
    Mr. Hare. And then specifically, what do you think are the 
benefits and the disadvantages of running a hospital that has 
fewer beds?
    Dr. Brand. I beg your pardon, sir?
    Mr. Hare. What are the benefits and disadvantages of 
running a hospital with fewer beds from your perspective?
    Dr. Brand. I think that the benefits are that you could 
have contact--you can have an access point closer to where 
people live. That they don't necessarily have to drive 50, 100 
miles to get to a hospital. The challenges of a small rural 
hospital are that with a limited, a low volume, it is always 
hard to ensure that you have that financially you are in the 
positive margin, because you don't have a lot of patients to 
provide care for.
    Mr. Hare. Okay. And I am sorry, Doctor, I think you 
answered this and I was jotting a note. Have you found it 
difficult to staff hospitals? To find people to staff at the 
smaller hospitals?
    Dr. Brand. Yes, sir.
    Mr. Hare. Okay.
    Dr. Brand. It is difficult to recruit and retain physicians 
and nurses. It is a challenge to effectively staff your 
business office and your housekeeping and your dietician 
department. It is the same challenge that all small rural 
hospitals face----
    Mr. Hare. Sure.
    Dr. Brand [continuing]. In retaining workers.
    Mr. Hare. Any ideas from your end on how we can do a better 
job of doing that or how we can----
    Dr. Brand. A number of the States have been very innovative 
in the programs that they have developed for recruiting and 
retaining providers using their academic Health Centers and 
their community colleges.
    The National Health Service Corp is another fairly 
effective tool for getting folks out into those communities. I 
suspect that as long as there are remote areas, we are going to 
struggle to find ways to staff up those facilities.
    Mr. Hare. Okay. Thank you, Doctor. I yield back.
    Mr. Michaud. Thank you, Mr. Hare. Dr. Snyder?
    Mr. Snyder. Thank you, Mr. Chairman. Dr. Brand, I am 
curious what is your Ph.D. in?
    Dr. Brand. My Ph.D. is in higher education. My original 
discipline was dental hygiene, but I couldn't sit still.
    Mr. Snyder. Oh, yeah. Yeah. I see it. About half the time 
people with Ph.D. either don't know what the subject field is 
or simply don't understand the title of the theses. But I am 
always trying to educate myself.
    I have two questions. When we had our discussion in the 
Armed Services Committee, one of the issues that we had 
difficulty with about 2, 3, or 4 years ago with the TRICARE 
system was an adequate number of obstetricians that had signed 
up to provide TRICARE services to military families.
    And I think a lot of it was a reimbursement problem. And I 
think that has dramatically improved, at least our TRICARE 
contractors are saying it has dramatically improved. And I 
think it was something they learned from our Committee system.
    So when they testified from our Committee hearings over the 
last couple of years, so when they testified in the last month 
and I asked them, where do they see their gap is now? They 
testified they think their biggest gap is in mental health 
services. To the point that they have just gone out and 
contracted with a provider for full time, that they would 
assign to different geographic areas because they just can't 
find services in such an area.
    And that shouldn't be--I am sure that is not a surprise to 
you as somebody who works in rural health a lot. Because before 
we had the war in Iraq or Afghanistan we had, I think, big gaps 
in mental health services throughout the country, both urban 
and rural. Would you agree with that? Yeah.
    And now this niche of people, we have military veterans and 
military families with these mental health things. I may have 
missed it in your written statement, but I didn't really see 
much of a discussion about mental health. And because it seems 
to me the challenge we are talking about making it easier for 
veterans but we are trying to do that in a system that has big 
gaps in care for non-veterans also.
    When you talk about the mental health, where do you see 
that going?
    Dr. Brand. Yes, sir. One of the grants----
    Mr. Snyder. Would you pull that in a little closer? Maybe 
it is just my old ears or something.
    Dr. Brand. Is this better?
    Mr. Snyder. Yeah, it is.
    Dr. Brand. Sorry. One of the programs that we manage in our 
Office is an Outreach Services Grant Program and it provides 
resources for communities to define what their need is and then 
they write to that particular program need rather than being 
categorical like so many of the grants.
    And if you look at the applications that the community 
submits the gap that they are trying to fill, is the mental 
health services gap. A significant number of them try to fill 
that gap. It is--I have heard it suggested that, you know, our 
jails become the waiting rooms for our mental health facilities 
in rural communities because there is just not enough care to 
provide folks who meet those challenges.
    One of the things that HRSA is hopeful to do is improve the 
whole location of primary care and mental health services. And 
there has been a significant expansion of Health Centers and 
mental health services. And the idea is if you can have both of 
those services provided in the same facility it is much easier 
for the patients and for the clients. And frankly, in the rural 
communities where there is significant stigma, you can pull 
your car up in front of the clinic and no one knows if you are 
taking your child in for a well baby visit or if you are 
accessing the mental health services.
    So you are right, sir, the recruitment of providers and the 
provision of mental health services is a significant challenge.
    Mr. Snyder. I don't think it has helped at all by this. 
What I think is just an invisible public health policy that a 
lot of private insurance companies take in terms of their 
reimbursement on mental health services. There is not much of 
an incentive for a small rural--well a typical rural practice 
of three to five physicians and maybe a nurse practitioner and 
maybe a deal. There is not much incentive to put in a full-time 
mental health worker with very poor reimbursement for the kinds 
of services that people could benefit from.
    I notice we had this occur with regard to the Iraq War was, 
as Guard members and Reserve component members were being 
activated, and then their families were being put on to TRICARE 
as their healthcare system, they were then going to their local 
doctor and finding out that the doctor just didn't accept 
TRICARE. A lot of times I think it was because they just didn't 
know that there were people in their area that would benefit 
from that.
    Is that an issue that you have dealt with at all or do you 
have any kind of--I think it has gotten better as word has 
gotten around to physicians. They really do need to sign up for 
this program in the spirit of patriotism.
    Do you have an information network that you could 
disseminate information out there to providers about, here's 
the, you know, consider this, sign up for this?
    Dr. Brand. I believe that the Health Centers have a way of 
communicating. They have sort of a list serve system. And a 
number of the small rural hospitals do. In terms of whether or 
not they have been encouraged to participate in TRICARE and 
other programs, I don't know.
    Mr. Snyder. One of the problems that we had with that was 
hospitals signed up, but there were no physicians that had 
signed up.
    Dr. Brand. I see.
    Mr. Snyder. And so there was no one to take care of them 
while they were there. Thank you, Mr. Chairman.
    Mr. Michaud. Thank you very much, Dr. Snyder. And just to 
follow up on your last question about TRICARE, I know there is 
an issue regarding reimbursement rates, particularly as they 
relate to Critical Access Hospitals getting lower 
reimbursements. This is a problem.
    But I do want to thank you once again, Dr. Brand, for your 
testimony. There will probably be additional questions----
    Dr. Brand. Yes, sir.
    Mr. Michaud [continuing]. For you to answer in writing and 
look forward to our continuing working relationship. And on a 
closing comment, as you heard from Mr. Moran and other Members 
here and from those Members who aren't here, access to 
healthcare in rural areas is a big concern. It is an extremely 
big concern about the CARES process moving so slowly to a point 
where I have heard other Members talking about authorizing 
another agency to do delivery on the CARES process versus the 
VA.
    So I look forward to working with you and thanks again for 
your testimony.
    Dr. Brand. Thank you, sir.
    Mr. Michaud. At this time I would like to welcome the 
second panel, Andy Behrman, who is Chairman of the Rural Health 
Policy Board for the National Rural Health Association; Shannon 
Middleton, who is Deputy Director for Health for the American 
Legion; and Adrian Atizado, who is the Assistant National 
Legislative Director for the Disabled American Veterans.
    I want to thank our panelist for coming today and look 
forward to your remarks. And we will start off with Andy.

 STATEMENTS OF ANDY BEHRMAN, CHAIR, RURAL HEALTH POLICY BOARD, 
  NATIONAL RURAL HEALTH ASSOCIATION, AND PRESIDENT AND CHIEF 
  EXECUTIVE OFFICER, FLORIDA ASSOCIATION OF COMMUNITY HEALTH 
    CENTERS; SHANNON MIDDLETON, DEPUTY DIRECTOR FOR HEALTH, 
   VETERANS AFFAIRS AND REHABILITATION COMMISSION, AMERICAN 
 LEGION; AND ADRIAN M. ATIZADO, ASSISTANT NATIONAL LEGISLATIVE 
              DIRECTOR, DISABLED AMERICAN VETERANS

                   STATEMENT OF ANDY BEHRMAN

    Mr. Behrman. Mr. Chairman, distinguished Members of this 
Subcommittee, I am Andy Behrman, President of the Florida 
Association of Community Health Centers and the Chair of the 
National Rural Health Associations Rural Health Policy Board. I 
am also a veteran. And I have proudly served the United States 
Navy. I want to thank you for the opportunity to speak and 
testify on behalf of the National Rural Health Association and 
for my fellow veterans.
    NRHA is a national, non-profit and non-partisan membership 
organization and our mission is to improve the health of rural 
Americans and to provide leadership on rural health issues. 
NRHA members have long maintained concern for the health and 
mental healthcare needs of rural veterans.
    Since our Nation's founding, rural Americans have always 
answered the call when America has gone to war. And whether 
motivated by their values, patriotism, or economic concerns the 
picture has not changed much in 230 years. Simply put, rural 
Americans serve at rates higher than the proportion of the 
population. Though only 19 percent of the Nation lives in rural 
areas, 44 percent of our recruits are from rural America and 
nearly one-third of those who died in Iraq are from small towns 
and communities across the Nation.
    There is a national misconception that all veterans have 
access to comprehensive care. This is simply not true. Access 
to the most basic primary care is often difficult, sometimes 
impossible, in rural America. Combat veterans returning to 
their rural homes in need of specialized care due to war 
injuries, both physical and mental, likely will find access to 
that care extremely limited.
    What this means is that because there is a disproportionate 
number of rural Americans serving in the military, there is a 
disproportionate need for veterans care in rural areas. 
Additionally, we must all be mindful of long-term needs. And 
while NRHA is pleased that both the House and the Senate for 
fiscal 2008 budget calls for greater increases in VA medical 
care spending than in past years, long-term healthcare planning 
is critical. The wounded veteran who returns today won't need 
care for just the next few fiscal years, they will need care 
for the next half century.
    To meet those long term needs, the NRHA respectfully makes 
the following recommendations to the Committee. One: Increase 
access by building on current successes. CBOCs opened the door 
for many veterans to obtain primary care services within their 
home community and outreach Health Centers help meet the needs 
of many rural veterans.
    NRHA applauds these efforts and supports the expansion of 
these successful programs.
    Two: Increase access by collaborating with non-VHA 
facilities. Many rural veterans cannot access VHA care simply 
because the facilities are too far away. Linking quality VA 
services with rural civilian services can vastly improve access 
to healthcare for rural veterans. As long as quality standards 
of care and evidence-based medicine guide treatment for rural 
veterans, the NRHA supports collaborative efforts with a number 
of organizations.
    First, Federally Qualified Community Health Centers. 
Community Health Centers serve millions of rural Americans and 
provide high quality community-based primary care and 
preventative healthcare. And most importantly they are located 
where most rural veterans live.
    A limited number of collaborations between the VHA and 
Community Health Centers already exist and have proven to be 
prudent cost effective solutions to serving veterans in rural 
areas. These successful models should be expanded to reach all 
of rural America.
    Critical Access Hospitals. These facilities provide 
essential comprehensive services to rural communities. If these 
facilities were linked with VA services and model the quality, 
access to care would be greatly enhanced for thousands of rural 
veterans.
    And Rural Health Clinics. These clinics serve populations 
in rural medically underserved areas. And in many rural and 
frontier communities these clinics are the only source of 
primary care available.
    The third recommendation is to increase Traumatic Brain 
Injury care. Unfortunately it appears that traumatic brain 
injuries, TBI, will most likely become the signature wound of 
the Afghanistan and Iraqi wars. Such wounds require highly 
specialized care. The current VHA TBI Case Managers Network is 
vital, but has limited access for rural veterans. We need to 
expand this program.
    Four: Target care and services to rural veterans. Rural 
veterans have an especially strong bond with their families. 
Returning veterans adjusting to disabilities and the stresses 
of combat need the security and support of their families in 
making their transition back into civilian life.
    Vet Centers do a tremendous job in assisting veterans, but 
their resources are limited. The NRHA supports increases in 
funding for counseling services for veterans and their 
families. And more women today serve in active duty than any 
other time in our Nation's history. And unfortunately, more 
women are then wounded or are war casualties then ever before 
in our Nation's history.
    We must target care for today's women veterans and 
culturally competent care to meet the unique needs of rural 
minority and female veterans.
    And finally, Mr. Chairman, the NRHA calls on the Congress 
and the Veterans Administration to fully implement the 
functions of the newly created Office of Rural Veterans to 
develop and support ongoing mechanisms for study and articulate 
the needs of rural veterans and their families.
    Mr. Chairman, thank you again for this opportunity. The 
National Rural Health Association looks forward to working with 
you and this Committee to improve rural healthcare access for 
the millions of veterans who live in rural America. Thank you.
    [The prepared statement of Mr. Behrman appears on p. 30.]
    Mr. Michaud. Thank you very much, Mr. Behrman. Ms. 
Middleton?

                 STATEMENT OF SHANNON MIDDLETON

    Ms. Middleton. Mr. Chairman and Members of the 
Subcommittee, thank you for this opportunity to present The 
American Legion's views on access to quality healthcare for 
veterans in rural communities.
    Research conducted by the Department of Veterans Affairs 
indicated that veterans residing in rural areas are in poorer 
health than their urban counterparts. It was further reported 
that nationwide, one in five veterans who enrolled to receive 
VA healthcare lives in rural areas. Providing quality 
healthcare in a rural setting has been--has proven to be very 
challenging, given factors such as a limited availability of 
skilled care providers and inadequate access to care.
    Even more challenging would be VA's ability--excuse me--to 
provide treatment and rehabilitation to rural veterans who 
suffer from the signature illness of the ongoing Global War on 
Terror--traumatic blast injuries and combat-related mental 
health conditions.
    VA's efforts need to be especially focused on these issues. 
A vital element of VA's transformation in the 1990's was the 
creation of CBOCs, or Community-Based Outpatient Clinics, to 
move access closer to the veterans communities. A recent VA 
study noted that access to care might be a key factor in why 
rural veterans appear to be in poorer health.
    CBOCs were designed to bring care closer to--I'm sorry. I 
already said that. Over the last several years VA has 
established hundreds of CBOCs throughout the system, and today 
there are over 700 that provide healthcare to the Nation's 
veterans.
    CBOCs have been very successful, however, of concern to The 
American Legion is that many of the CBOCs are at or near 
capacity and many still do not provide adequate mental health 
services to veterans in need.
    One of the recommendations of the Capital Assets 
Realignment for Enhanced Services or CARES was for more, not 
less, CBOCs across the Nation. The American Legion strongly 
supports this recommendation, especially those identified for 
rural areas. However, limited VA discretionary funding has 
limited the number of new CBOCs each fiscal year.
    There is great difficulty serving veterans in rural areas. 
Veterans in States such as Nebraska, Iowa, North Dakota, South 
Dakota, Wyoming, and Montana face extremely long drives and a 
shortage of healthcare providers and also bad weather. The 
Veterans Integrated Service Networks or VISN, rely heavily upon 
CBOCs to close this gap.
    The provision of mental health services in CBOCs is even 
more critical today with the ongoing war in Iraq and 
Afghanistan. It has been estimated that nearly 30 percent of 
the veterans who are returning from combat suffer from some 
type of mental stress. Further, statistics show that mental 
health is one of the top three reasons our returning veterans 
seek VA healthcare.
    The American Legion believes that VA needs to continue to 
emphasize to the facilities the importance of mental health 
services in CBOCs. And we urge the VA to ensure the adequate 
staffing of mental health providers in the CBOC setting.
    CBOCs are not the only avenue with which VA can provide 
access to quality healthcare to rural veterans. Enhancing 
existing partnerships with communities and other Federal 
agencies such as the Indian Health Service will help to 
alleviate some of the barriers that exist, such as the high 
cost of contracting for care in the rural setting.
    Coordinating services with Medicare or with other 
healthcare systems that are based in rural areas is another way 
to help provide quality care.
    In the July 2006 report entitled, ``Health Status of and 
Services for Operation Enduring Freedom and Operation Iraqi 
Freedom (OEF/OIF) Veterans After Traumatic Brain Injury 
Rehabilitation,'' the Department of Veterans Affairs Office of 
Inspector General examined the Veterans Health Administration's 
ability to meet the needs of OIF and OEF veterans who--sorry--
who suffered from traumatic brain injury.
    Fifty-two patients from around the country were interviewed 
at least 1 year after completing inpatient rehabilitation from 
a Lead Center. Some of them did reside in States with rural 
populations. Many of the obstacles for the TBI veterans and 
their families remain, they were very similar. Forty-eight 
percent of the patients indicated that there were resources in 
the community--there were few resources in the community for 
brain injury-related problems. Thirty-eight percent indicated 
that transportation was a major obstacle. And 17 percent 
indicated that they did not have money to pay for medical 
rehabilitation and injury related services.
    Some of the challenges noted by family members who care for 
these veterans in rural settings include the necessity for 
complicated special arrangements and the absence of VA 
rehabilitative care in their communities. Case managers working 
at Lead Centers and several secondary centers noted a limited 
ability to follow patients after discharge to rural areas and 
lack of adequate transportation.
    These limitations placed undue hardship on the veterans 
families as well. Those contributing to the report, as well as 
veterans who have contacted The American Legion, have shared 
many examples of the manner in which families have been 
devastated by caring for TBI injured veterans. They have 
sacrificed financially, they have lost jobs that provided the 
sole income for family and have endured extended separations 
from children.
    Vet Centers are another important resource, especially for 
combat veterans experiencing readjustment issues who do not 
live in close proximity to a VA medical facility. Because Vet 
Centers are community-based and veterans are assessed the day 
they seek care, they receive timely care and are not subjected 
to wait lists. Some of the services provided include individual 
and group counseling, family and marital counseling, military 
sexual trauma counseling, and bereavement counseling.
    Realizing the value of Vet Centers to those who may 
encounter obstacles when seeking mental healthcare in the VA 
Medical Centers, The American Legion decided to get a glimpse 
of services and needs of Vet Centers nationwide. The American 
Legion's 2007 System Worth Saving report will focus on Vet 
Centers as well as the polytrauma centers.
    The American Legion's staff selected a sample of Vet 
Centers that were located near the demobilization sites 
throughout the country to ascertain the effects of the number 
of returning veterans on the services provided by the Center. 
The report will illustrate the types of veterans utilizing 
their respective Vet Centers as well as services requested by 
these veterans and outreach services offered.
    The American Legion believes veterans should not be 
penalized or forced to travel long distances to access quality 
healthcare, because of where they choose to live. We urge VA to 
improve access to quality primary and specialty healthcare 
services using all available means at their disposal for 
veterans living in rural and highly rural areas.
    And although access is a very important issue, The American 
Legion believes timeliness of access is just as critical. For 
example, VA establishes it's own acceptable access standard for 
primary care at 30 days. But to most Americans with private 
healthcare plans, 30 days would not be acceptable. 
Unfortunately, the continued disparity between demands for 
services and available resources continues to cause delays in 
the delivery of healthcare.
    The current Global War on Terror has placed many more 
demands on VA healthcare, the VA healthcare system to meet its 
obligations to the men and women of the armed forces, past, 
present, and future. As a grateful Nation welcomes with open 
arms the newest generation of wartime veterans, veterans of 
previous conflicts and the Cold War are being denied enrollment 
and, therefore, access to their healthcare delivery system of 
choice.
    By 2003, former VA Secretary Anthony Principi decided the 
enrollment of any new priority veterans--sorry--decided to 
terminate the enrollment of any new priority veterans, 
therefore, prohibiting access to VA medical care to hundreds of 
thousands of Priority 8 veterans due primarily to limited 
resources.
    The American Legion disagrees with the decision to deny 
access to any eligible veterans and many of these veterans are 
Medicare-eligible or have other third-party health insurance 
that can reimburse VA's reasonable charges for services 
rendered. Yet, little has been done to improve third-party 
reimbursements from private insurers and nothing has been done 
to allow VA to begin receiving third-party reimbursements from 
the Nation's largest healthcare insurer; the Centers for 
Medicare and Medicaid Services.
    The restriction of enrollment for Priority 8 veterans 
creates another ``access gap'' for recently separated veterans 
who did not serve in the combat setting. Some recently 
separated veterans must wait until their VA disabilities claims 
are approved in order to enroll. For others, unless they are 
economically indigent, they are prohibited from enrolling. 
Those recently separated veterans that successfully transition 
may very well never be eligible for enrollment in the Nation's 
best healthcare system.
    None of these situations are very welcoming messages to the 
men and women currently serving in the Nation's armed forces
    Mr. Michaud. Could you quickly summarize? I notice your 
time is running out.
    Ms. Middleton. Yes, sir.
    Mr. Michaud. Or ran out, I should say.
    Ms. Middleton. Okay. Thank you, Mr. Chairman, for giving 
The American Legion the opportunity to present views on such 
important issues.
    This hearing was very timely and we look forward to working 
with the Subcommittee to bring an end to the disparities that 
exist in access to quality care in rural areas. Thank you.
    [The prepared statement of Ms. Middleton appears on p. 34.]
    Mr. Michaud. Thank you very much for that excellent 
testimony. Mr. Atizado?

                 STATEMENT OF ADRIAN M. ATIZADO

    Mr. Atizado. Mr. Chairman, Members of the Subcommittee, 
thank you for the opportunity to provide testimony on behalf of 
the Disabled American Veterans and the Independent Budget 
Veterans Service Organizations regarding the issue before us 
today, access to VA medical care particularly on access to care 
in rural areas.
    We would like to thank Congress, the hard work of and 
commitment of this Subcommittee and the Full Committee in 
having provided VA additional funding in the previous two 
fiscal years. But we do remain concerned about access to VA 
speciality care as well as to care in rural areas.
    We are especially concerned about how VA plans to address 
rural veterans needs in the coming years, given that about 44 
percent of all veterans returning from Operations Enduring and 
Iraqi Freedom reside in rural communities. After having served 
their country, these veterans should not have to be neglected 
for their healthcare needs simply because they live in rural or 
remote areas.
    Provisions in Public Law 109-461 represents the most 
significant advances to date to address the healthcare needs of 
rural veterans and the needs of returning OIF/OEF veterans. 
Notably, however, the final legislative language failed to 
include a Rural Veterans Advisory Committee to help harness the 
knowledge and expertise of representatives from outside the 
Department.
    We hope that Congress will reconsider this mandate and we 
do urge the Secretary to use existing authority to establish 
such a Committee as well as to include representatives from our 
organizations as part of it's membership. And although we 
acknowledge benefits of the Public Law, it also raises concerns 
about unintended consequences it may have on the VA Healthcare 
System regarding the use of VA purchased medical care.
    We believe this tool should be used judicially so as not to 
endanger VA's full range of specialized services. Putting 
additional budget pressure on the specialized system of 
services without making specific appropriations available for 
new rural VA Healthcare Programs could only exacerbate 
problems.
    This new legislation also holds the VA accountable for 
improving rural veterans access to care, by requiring the 
development and implementation of a plan using CBOCs and other 
access points. The Capital Assets Realignment for Enhanced 
Services process, known as the CARES, includes a May 2004 
decision by the Secretary which identifies 156 priority CBOCs 
to address outpatient care. Furthermore, as part of the CARES 
Initiative the VA employed Medicare's Critical Access Hospital 
model as the guide to establish a new VA policy to govern many 
of VA's rural and remote facilities now designated as Veterans 
Rural Access Hospitals in addressing rural acute inpatient 
care.
    We note that VA receives no appropriations dedicated to 
support the establishment of rural CBOCs or Veterans Rural 
Access Hospitals. And thus VA must manage any additional 
expenses from within generally available medical services 
appropriations. We, therefore, urge Congress to include 
specific funding in fiscal year 2008 to address at least some 
of these needs in rural areas and to avoid the scavenging of 
resources.
    In addition to the lack of resources to meet the healthcare 
needs of rural veterans, health worker shortages and 
recruitment and retention of healthcare personnel remains a key 
challenge to rural veterans access to care as well as quality 
of that care. The 2005 IOM report titled, ``The Future of Rural 
Health,'' recommended that the Federal Government renew it's 
efforts to enhance the supply of healthcare professionals 
working in rural areas.
    To this end, we believe VA's academic affiliation as well 
as health professions education programs possess special 
attributes that could be brought to bear in improving the 
situation in VA facilities as well as in the private sector.
    Another often overlooked component of improving veterans 
access to medical care is VA's beneficiary travel program. As 
you are aware, sir, the mileage reimbursement rate of 11 cents 
a mile has not been changed in almost 30 years, even though 
Congress has delegated authority to the Secretary to make rate 
changes when warranted. DAV and several other service 
organizations have a long-standing resolution to reinstate the 
effectiveness of the travel program. We support legislation 
that has been introduced in Congress and we urge approval and 
enactment of this legislation this year.
    Given the cost of transportation in 2007, including record-
setting gasoline prices and reimbursement rates unchanged since 
1977, pales in comparison to the actual cost of travel.
    Mr. Chairman, thank you for the opportunity to provide 
testimony on these very important issues which relate to access 
to VA healthcare services. In the Independent Budget for fiscal 
year 2008, our organizations have made a number of 
recommendations in this document to Congress as well as VA that 
are relevant to the issues discussed today.
    We do invite you to review these recommendations. And as 
always, I would be happy to answer any questions you may have.
    [The prepared statement of Mr. Atizado appears on p. 37.]
    Mr. Michaud. Thank you very much. And once again, I want to 
thank the entire panel for your testimony. It has been very 
helpful.
    A quick question for the DAV. You heard from Mr. Behrman of 
the National Rural Health Association. In his testimony he 
talked about building upon the successes that VA has had with 
approaching rural healthcare by collaboration, whether it is 
with the Federally Qualified Healthcare Clinics, Critical 
Access Healthcare Clinics. And I heard your testimony saying 
you didn't really disagree with that, but you said it should be 
used judiciously.
    How do you determine judiciously? Because one of my 
concerns is the fact that if you are a veteran in a rural area, 
and I can state this from DAV members in Maine, where some were 
pleased with what the VA did, some disapproved with what VA did 
as far as the clinic in Lincoln.
    How do you determine judiciously, and how far should the VA 
deal with contracting for services, particularly in rural 
areas?
    Mr. Atizado. Mr. Chairman, as part of my written testimony, 
we do outline current authority with regards to the use of 
contract care as well as fee-based care. Just on the outright I 
would like to clarify that we are not opposed to the judicial 
use of collaboration. We are opposed--we are advocating for 
judicial use of the purchased care.
    As far as a current criteria that VA has to use or is 
required to use for contract care, as well as fee-based care, 
we think that those criteria set out specifically to protect 
VA's core services. The reason why purchased care can become 
dangerous is because it is considered an open access point. In 
other words, if VA will agree to pay for services at a local 
facility or a private facility, that is an access point that 
can be challenging with regards to quality of care, and also 
with making sure that the veterans come into the VA system for 
tertiary or specialty care.
    It is very important that when these tools are used to make 
sure that not only the quality but the continuum of care that 
VA is known to provide remain intact.
    Mr. Michaud. Okay. I would ask Ms. Middleton to answer that 
same question. And I would also ask Mr. Behrman afterward.
    Ms. Middleton. Sir, your question was how do you determine 
what is judicial?
    Mr. Michaud. I can understand the VSOs concerns with 
contracting out services because one of the concerns is that 
they don't want the VA to become an insurance agency----
    Ms. Middleton. Yes.
    Mr. Michaud [continuing]. Which I agree with. However, at 
the same time, my concern is veterans being able to access that 
care. Good quality care is important, but you need to have 
access to that quality care.
    How does The American Legion feel about the remarks that 
you heard this afternoon from the National Rural Health 
Association as far as utilizing critical access, hospitals and 
rural healthcare clinics? What is The American Legion's 
reaction to that?
    Ms. Middleton. Well, as you said, we also feel that the VA 
should not be an insurance agency just, you know, handing out 
money. But we definitely believe that veterans who require 
care, especially if they are in rural areas, they should be 
provided that care. If it is not available through the VA then, 
what is near them is best.
    We have been in contact with a few veterans who have 
actually had very traumatic injuries and there was no care near 
them and their families. As I said in my testimony, they have 
gone through hardship just trying to get this care. But if it 
was local then it wouldn't be such a hardship on the family.
    So only when necessary. And if it is not necessary, the VA 
can provide it, that is one thing. But if the veteran is going 
to experience a hardship especially if he is not able to 
physically take the travel, then it would be necessary and we 
believe that that is the best way.
    Mr. Michaud. Okay. Mr. Behrman, how do you think the VA can 
move forward with the recommendations that you mentioned while 
at the same time address some of the concerns that we hear from 
some of the VSOs?
    Mr. Behrman. Thank you, Mr. Chairman. Well, first I think 
we have established that there is a hardship already. That is 
part of the reason that we are having these hearings. Excuse 
me.
    But the reality is, first it has got to be about the 
patient, what the patient's needs are, where are they going to 
get their service. That would be the first thing. And I am sure 
the VA looks at that as the most important criteria first.
    Secondly, there needs to be a little bit more understanding 
of what these organizations are about and what they do. When we 
mentioned quality of care, this is a critical component of 
Federally Qualified Health Centers and Critical Access 
Hospitals. Most of the Community Health Centers in this country 
are JCAHO accredited.
    So quality of care is a important issue that has to be 
reviewed. Certainly the VA would be looking at an 
organizational structure that would have to have at least the 
quality of care that is being provided at a VA institution.
    The second thing about this, in particular, when it relates 
to Rural Health Clinics and Community Health Centers, is that 
primary care is what they do. This is what they are about. A 
continuum of care needs to be considered where you can take 
certain pieces and this may be the judiciary part that we are 
talking about. Where it makes sense to provide primary care in 
a medical home in a community where the veteran lives, they 
will be comfortable. They know the individuals in a lot of 
these small towns who are providing the services, the 
healthcare services.
    So there may not be the necessity to travel 150 or 200 
miles to get primary basic care, comprehensive care. And 
preventative care as well. A lot of the mental health issues, 
alcoholism, substance abuse, all of these things come into 
play. Community Health Centers have to have these services 
available to them.
    I agree that a judicious review of how services would be 
purchased is important. Nobody wants to double pay for things. 
Certainly we don't want to do that. But we also don't want to 
make--we also want to make sure that there is care available, 
quality care available and these access points that I would 
think could be worked through some process so that the VA--I 
mean these organizations could figure out who does what so we 
don't duplicate services.
    Mr. Michaud. Thank you very much. Mr. Salazar?
    Mr. Salazar. Well, thank you, Mr. Chairman. Just a brief 
question to Ms. Middleton. In your written testimony under 
inpatient bed requirements you state that the, ``VA continues 
to ignore the Federal mandate for inpatient care, especially in 
the areas of long-term. The American Legion believes that the 
VA is focused on shifting long-term care from VA to State 
Veterans Homes and private nursing home industry.''
    Could you expand on that, please?
    Ms. Middleton. That is in reference to the number of beds 
that have been established as mandatory under law. And at this 
moment I don't have the number, but I know that each year the 
number has been below that has been--has been available has 
been below that number.
    I mean it comes up in our testimony every year. But----
    Mr. Salazar. Was this----
    Ms. Middleton [continuing]. This side----
    Mr. Salazar. Was this an issue of basically funding? Maybe 
the VA can actually respond to that.
    Ms. Middleton. I am not sure if it is an issue of funding, 
but I do know that each year the number of beds that are 
mandated by law have not been available. And by doing this that 
is--by not having them available that is how the long-term care 
has been shifted to the State Veterans Home, because it is not 
they are not available--the number of beds are not available.
    Mr. Salazar. Okay. Thank you. Mr. Atizado, is that the way 
you pronounce the name, Mr. Michaud?
    [Laughter.]
    I have messed it up so.
    Mr. Michaud. You can pronounce it any way you want to. It 
is probably easier just to call him Adrian.
    Mr. Salazar. Okay. Adrian, well the only question I have 
for you is that you mentioned the issue of providing healthcare 
for veterans and I guess there is a mechanism already in place 
for remote rural areas where a veteran can go to local 
hospitals or primary healthcare physicians, right?
    Doesn't it make more sense to you to look at the economy or 
the numbers and try to figure out the economies scale to where 
maybe it will save the VA money by providing these services 
where there are already local hospitals or local doctors?
    Mr. Atizado. Well let me first be clear. We are not 
opposing the use of VA to purchase care. What we are concerned 
about is the amount that may end up being used to care for 
rural veterans.
    With regard to--let me give an example. With regard to 
contract care, generally it is a very good program on the 
outset for VA. But what we have seen is that the out years 
after the first 2, 3, 4 years of the contract it becomes a much 
higher dollar amount for that contract. So the out years become 
very, very much out of control for VA financially. For fee-
based care, as mentioned earlier, it is much like TRICARE where 
these payments are really at a reduced rate. So it becomes 
disadvantageous for a physician, not only in an urban area, but 
more so in a rural area where the cost of care can be that much 
higher. Hence, the Critical Access Hospital model that Medicare 
uses, which is a cost-based reimbursement, that actually 
provides higher than normal Medicare reimbursement rates simply 
because to have that kind of a facility and that kind of 
medical care out in the rural community does cost more.
    In other words, our concern is these tools may be used to 
the point where they lose control such that core services at 
the facility may be in danger. And that is what we don't want 
to happen. We want to make sure that if they do use this that 
it is with a thought of making sure that other services that 
they provide are protected.
    Thank you.
    Mr. Michaud. Mr. Hare.
    Mr. Hare. Mr. Chairman, in the interest of time, I know we 
have votes. If it would be okay with you, Mr. Behrman, I have 
three questions but if I could submit them to you and maybe 
have you get them back to me regarding rural healthcare and 
access to healthcare for Vets if that would be okay I would 
appreciate that.
    Mr. Behrman. Yes, sir.
    Mr. Hare. Thank you very much. I yield back.
    Mr. Michaud. Thank you, Mr. Hare. I would like to thank the 
panel once again. We will follow up with additional questions.
    I would like to ask the last panel to come up. Dr. Gerald 
Cross who is Acting Principal Deputy Under Secretary for 
Health. He is being accompanied by Dr. Robert Petzel, Dr. Adam 
Darkins, and Patricia Vandenberg.
    Yeah. And Dr. Cross if you could try to summarize your 
remarks, we will try to move this along quickly, hopefully 
before the votes.

  STATEMENT OF GERALD M. CROSS, M.D., FAAFP, ACTING PRINCIPAL 
      DEPUTY UNDER SECRETARY FOR HEALTH, VETERANS HEALTH 
ADMINISTRATION, U.S DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED 
    BY PATRICIA VANDENBERG, MHA, BS, ASSISTANT DEPUTY UNDER 
      SECRETARY FOR POLICY AND PLANNING, VETERANS HEALTH 
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; ROBERT A. 
PETZEL, M.D., DIRECTOR, VA MIDWEST HEALTHCARE NETWORK, VETERANS 
INTEGRATED SERVICES NETWORK 23, VETERANS HEALTH ADMINISTRATION, 
 U.S. DEPARTMENT OF VETERANS AFFAIRS; AND ADAM DARKINS, M.D., 
   MPH, FRCS, CHIEF CONSULTANT, OFFICE OF CARE COORDINATION, 
  VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

    Dr. Cross. Good afternoon, Mr. Chairman and Members of the 
Subcommittee. And thank you for the opportunity to discuss our 
ongoing efforts to provide safe, effective, efficient, and 
compassionate healthcare to veterans residing in rural areas.
    And I am accompanied today by Patricia Vandenberg, VHA's 
Assistant Deputy Under Secretary for Policy and Planning; Dr. 
Adam Darkins, VHA's Chief Consultant for Care Coordination. And 
you can read into that telehealth--telemental health. And I am 
especially pleased to have Dr. Robert Petzel of VHA's Network 
Director for VISN 23.
    And I should say that by profession as was brought up 
earlier, I am a Board Certified Family Physician. Grew up in a 
rural environment on a farm. Did home visits by training. And I 
am a veteran as well.
    My remarks will briefly review the national challenge 
presented by rural healthcare and VHA's strategic direction in 
the initiatives that we have underway. Among the entire 
enrolled VA population almost 39 percent were classified as 
rural at the end of FY 2006. And among the entire enrolled VA 
population a little bit less than 2 percent, about 1.6 percent 
were classified as highly rural.
    Researchers have studied this population and a number of 
articles have looked at the VA care in the rural environment as 
well. First, studies have found that veterans living in rural 
areas tend to be slightly older, have lower income, and these 
same veterans will also be less likely to be employed. The 
studies agree that rural veterans had slightly more physical 
health problems, but fewer mental health problems as compared 
to suburban and urban veterans.
    VHA's strategic direction is to enhance non-institutional 
care with less dependence on large institutions. Instead we are 
providing more care at home and in the community. VHA now has 
717 Community-Based Outpatient Clinics or CBOCs. Of this total, 
320 or 45 percent of these are located in rural or highly rural 
areas. But we have done much more than that. We created the 
Consolidated Mail Out Patient Pharmacies, CMOPPs so that 
medications are delivered to the patients home instead of 
having the patient travel to the hospital.
    We provide home-based primary care where the folks go to 
the patients home directly. Devoting more than $175 million in 
this program in FY 2008 and more than $95 million for other 
home-based programs, we are using telemedicine and telemental 
health to reach into the veterans homes and into community 
clinics. This allows us to evaluate and follow patients without 
them having to travel to large medical centers.
    We are far along with our Mental Health Enhancement 
Initiative that will add resources and greater mental health 
expertise in primary care clinics. We are also using special 
Internet sites to provide information to veterans in their home 
including the ability to refill prescriptions from home. Here 
is a key point as to how we are doing: At the end of FY 2006, 
92.5 percent of the 5.4 million patients enrolled were within 
60 minutes of VA Healthcare Facilities, and 98.5--98.5 percent 
were within 90 minutes.
    And among those who live outside the 60-minute range, some 
veterans are in highly rural areas living in tribal areas and 
so forth. A study on veterans satisfaction, and this is another 
result, in 2006 compared rural versus urban veterans finding 
that rural patients in the VA system were actually more 
satisfied with their care than their urban counterparts.
    And here is one more result: We looked at the quality of 
care comparing rural versus urban clinics. We looked at 40 
standard measures of quality, they were virtually identical 
across the range. Rural versus urban.
    To continue this strategic support for access in rural 
healthcare, we have approved 24 CBOCs in 2007. Forty-three 
percent of these CBOCs are in highly rural areas. And I am 
pleased to share with Congressman Salazar that the Secretary 
advised me today of the approval of the Colorado Outreach 
Clinic.
    In addition to these clinics, the VA is implementing more 
care coordination home telehealth in rural areas. And since 
January of 2004, we have trained over 3,500 staff to provide 
this telehealthcare.
    Our Vet Centers support our veterans including rural 
veterans. Vet Centers provide quality readjustment counseling 
and remove unnecessary barriers to the care for veterans and 
their family members. And they engage in remarkable community 
outreach to the veteran community and to other aspects of the 
community as well. And we are continuing to expand our Vet 
Centers.
    By the way, the Vet Centers also maintain nontraditional 
hours to accommodate veterans traveling in from greater 
distances. And in accordance with Public Law 109-461, we 
continue to develop our Office of Rural Health within our 
Office of Policy and Planning.
    VHA recognizes the importance and the challenge of service 
to our rural areas. And we believe our current and planned 
efforts are addressing these concerns.
    Mr. Chairman, thank you.
    [The prepared statement of Dr. Cross appears on p. 41.]
    Mr. Michaud. Thank you very much. Mr. Salazar do you have 
any questions?
    [No response.]
    Okay. I have several questions, Dr. Cross, but 
unfortunately we have to vote and looking at all the votes we 
have we will be tied up over there for probably well over an 
hour or so. And I don't want to hold the panel here.
    So we will submit our questions in writing and hopefully 
you will be able to respond in a timely manner so we can move 
forward. But I want to thank you for your time this afternoon 
along with the other panels for your efforts as we move forward 
on rural access to healthcare for our veterans. We have to do 
better and I know the VA is intending to do better. Hopefully 
with the new budget that was just passed we will be able to 
improve access for our veterans.
    So, once again, I would like to thank this panel. Are there 
any other questions? Mr. Salazar.
    Mr. Salazar. I just wanted to thank the Secretary for his 
continued diligence on trying to provide access to rural 
healthcare. So if you would convey that to him, I would 
appreciate that.
    Dr. Cross. I will certainly do that, sir. Thank you.
    Mr. Salazar. Thank you. Thank you, Mr. Chairman.
    Mr. Michaud. Thank you. With no further questions, this 
hearing is adjourned.
    [Whereupon, at 3:50 p.m., the Subcommittee was adjourned.]














































                            A P P E N D I X

                              ----------                              

                  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.
    The issue of providing rural healthcare is one that affects each of 
our States and in very different ways. In California, rural communities 
make up 92 percent of the landmass, and 8 percent of the population. In 
my own State of Maine, over 40 percent of the population lives in rural 
areas.
    It is estimated that 60 million Americans, one in five, live in 
areas that have been classified as rural. Rural communities tend to be 
older than urban populations, and they tend to exhibit poorer health 
behaviors. Economic factors also add to the challenges facing rural 
populations.
    Rural veterans make up 41 percent of VA's patient workload. Access 
and resources present serious challenges to providing high quality 
healthcare for these veterans.
    VA care can be second to none. Unfortunately the quality of care is 
not always the same throughout the VA system, and for many veterans 
living in rural States like Maine, accessing that care is a significant 
challenge.
    For certain more complex procedures, veterans in northern Maine 
must endure 4 days of travel to and from VA facilities in Boston to 
receive care. Addressing the distance to care and the travel burden in 
rural areas is extremely important.
    However, given the smaller population and infrequency of certain 
complex procedures, it does not make sense for VA to maintain a daily 
``in-house'' capacity in every facility for something that is used on 
an infrequent basis.
    This problem is not unique to VA. It is a problem facing many rural 
areas across the country where smaller patient populations limit the 
resources available to rural hospitals which in turn limits the 
services that hospitals can support and provide.
    Rural areas face difficulties in providing what have been termed 
``core healthcare services'' by the Institutes of Medicine. These 
services include primary care in the community, emergency medical 
services, hospital care, long-term care, mental health and substance 
abuse services, oral healthcare, and public health services.
    For a variety of reasons, rural areas also face a greater problem 
recruiting and retaining healthcare professionals.
    These problems must be addressed because the demand for services 
from our veterans population in rural areas is only going to increase.
    We have an aging population that will need long term care.
    Over 40 percent of the new generation of veterans returning from 
Afghanistan and Iraq are from rural areas. They have their own unique 
needs, including loss of limb, traumatic brain injury and mental health 
concerns.
    One important approach to providing access to care is the VA's 
system of Community-Based Outpatient Clinics, which currently number 
more than 650.
    We have five CBOCs in Maine. The CARES Commission recommended a 
sixth in the Lewiston-Auburn area along with five part-time health 
access points. Only one of these facilities is close to opening while 
the CBOC is not expected to open until 2008 at the earliest.
    During the CARES process, 250 CBOCs were identified by the VA as 
being needed, of which 156 were designated as ``priority.'' Since the 
CARES decision, VA has opened 12 of the 156, less than 8 percent. At 
that pace it will take VA over 30 years to open all the priority 
clinics.
    VA has also opened 18 clinics not on the CARES priority list, which 
calls into question the decision process and the ability of the CARES 
to assist in decisions in the future.
    The VA has also designated facilities as ``Veterans Rural Access 
Hospitals,'' designed to provide inpatient services to veterans in 
rural areas where these services can be supported.
    The VA has taken great strides in exploring the uses of 
telemedicine and other technological means of providing healthcare 
services. I would like to hear how these efforts are improving care and 
how we can help.
    One of the problems in the area of recruitment and retention is the 
separation from other healthcare professionals often felt by those 
working in rural communities. I would like to explore how technology 
might be used to overcome this feeling of isolation and thus improve 
recruitment and retention.
    The questions I would like to start to answer today are: Is the VA, 
and really are our rural communities, ready to meet the increased and 
changing needs of our veterans and their families? What is the VA in 
rural America going to look like in the future?
    And we must keep in mind that VA healthcare does not operate in a 
vacuum, but is an integral part of our national health system.
    I would also very much like to know when the priority CBOCs are 
going to be built or if VA no longer intends to follow CARES.
    Today, the Subcommittee hearing will provide us with the 
opportunity to begin this exploration, to begin to examine issues 
concerning access, the provision of care, and the proper expectations 
of veterans in rural areas regarding the care they can expect from the 
VA.

                                 
       Statement of Marcia Brand, Ph.D., Associate Administrator
   Rural Health Policy, Health Resources and Services Administration
              U.S. Department of Health and Human Services
    Mr. Chairman, Members of the Subcommittee, thank you for the 
opportunity to meet with you today on behalf of Dr. Elizabeth Duke, 
Administrator of the Health Resources and Services Administration 
(HRSA), to discuss rural access issues as they affect the Nation and 
what is being done to meet the healthcare needs of the rural 
populations in this country. We appreciate your interest and support of 
rural healthcare and access to care for rural veterans.
    The Health Resources and Services Administration (HRSA) is the 
primary Federal agency for improving access to healthcare services for 
people who are uninsured, isolated or medically vulnerable. HRSA 
grantees provide healthcare to uninsured people, people living with 
HIV/AIDS, and pregnant women, mothers and children. They train health 
professionals and improve systems of care in rural communities. For 
HRSA, the Health Center Program, the National Health Service Corps and 
rural healthcare needs are priorities.
    The Health Center Program, a major component of America's 
healthcare safety net for the Nation's indigent populations for more 
than 40 years, is leading the Presidential initiative to increase 
healthcare access in the Nation's most needy communities. Health 
Centers provide regular access to high quality, family oriented, 
comprehensive primary and preventative healthcare, regardless of 
ability to pay, and improve the health status of underserved 
populations living in inner cities and rural areas.
    President Bush's initiative to expand the Health Centers, begun in 
FY 2002, will significantly affect over 1,200 communities through the 
support of new or expanded access points. In FY 2001, HRSA funded 3,317 
Health Center sites across the Nation. After distributing 514 New 
Access Point grants over the past few years, that count had grown to 
3,831 sites by the end of 2006. We expect the number of Health Center 
sites to grow to 4,053 by the end of FY 2008. Just over half of all 
Health Center grantees serve rural populations.
    Besides the 514 new access points, HRSA has also distributed 385 
grants to expand the medical capacity of existing service delivery 
sites; and another 340 grants to existing grantee organizations to add 
or expand oral health, mental health and substance abuse services. 
Through these efforts the number of patients treated annually at Health 
Centers has grown from 10.3 million in 2001 to 14.1 million in 2005, a 
37 percent increase. Of those 14.1 million patients, 5.6 million were 
uninsured, 1.6 million more than were served in 2001 (a 40 percent 
increase). We anticipate that Health Centers will serve an estimated 
16.3 million patients by the end of 2008.
    The National Health Service Corps (NHSC) is committed to improving 
the health of the Nation's underserved by uniting communities in need 
with caring health professionals and supporting communities' efforts to 
build better systems of care. The NHSC provides comprehensive, team-
based healthcare that bridges geographic, financial, cultural, and 
language barriers.
    Health Centers need committed staff and the National Health Service 
Corps plays an important role in the Health Center expansion. Currently 
more than half of the NHSC's doctors, dentists, nurses and mental and 
behavioral and other healthcare professionals serve in Health Centers 
around the Nation. Some 60 percent of all NHSC clinicians--about 2,700 
healthcare professionals--currently work in rural areas.
    HRSA's Office of Rural Health Policy (ORHP) is charged with 
informing and advising the Department of Health and Human Services on 
matters affecting rural hospitals and healthcare, coordinating 
activities within the Department that relate to rural healthcare, and 
maintaining a national information clearinghouse. HRSA, through ORHP, 
is the leading Federal proponent for better healthcare services for the 
55 million people that live in rural America.
    ORHP specifically promotes State and local empowerment to meet 
rural health needs in several ways: by supporting State Offices of 
Rural Health, by encouraging the formation of State Rural Health 
Associations, and by working with a variety of State agencies to 
improve rural health. Through our Medicare Rural Flexibility (Flex) 
Grant Program, funding is provided to State governments to strengthen 
rural health. The Small Rural Hospital Improvement Program (SHIP) 
provides funding to small rural hospitals through the States to help 
them pay for costs related to the implementation of the Prospective 
Payment System, comply with provisions of HIPAA and reduce medical 
errors and support quality improvement. The State Office of Rural 
Health Grants are designed so the States can help their individual 
rural communities build healthcare delivery systems by collecting and 
disseminating information, providing technical assistance, helping to 
coordinate rural health interests Statewide and by supporting efforts 
to improve recruitment and retention of health professionals.
    Additionally, the Rural Healthcare Services Outreach Grant Program 
increases access to primary healthcare services for rural Americans. 
The Rural Health Network Development Grant Program helps rural health 
providers develop community-based, integrated systems of care. Grants 
support rural providers for up to 3 years who work together in formal 
networks, alliances, coalitions, or partnerships to integrate 
administrative, clinical, financial, and technological functions across 
their organizations. The Network Development Planning Grant Program 
provides 1 year of funding to rural communities that seek to develop a 
formal integrated healthcare network and that do not have a significant 
history of collaboration. We also support grants to the eight States in 
the Mississippi Delta for network and rural health infrastructure 
development and a cooperative agreement supporting targeted activities 
focusing on frontier extended stay clinics. The Small Healthcare 
Provider Quality Improvement Grant Program (SHCPQI) is designed to 
assist rural providers with the implementation of quality improvement 
strategies, while improving patient care and chronic disease outcomes. 
The Rural Access to Emergency Devices (RAED) Grant Program provides 
funding to rural communities to purchase automated external 
defibrillators (AEDs) and provide training in their use and 
maintenance. As you can see, HRSA administers a range of programs that 
serve rural communities.
    HRSA also provides support staff to the Department's cross-cutting 
rural efforts. The HHS Rural Task Force is made up of representatives 
from each of the HHS agencies and staff offices and meets quarterly to 
discuss HHS programs and policies that affect the provision of 
healthcare and human services for rural Americans. Another cross-
cutting rural effort supported by HRSA is the National Advisory 
Committee on Rural Health and Human Services (NAC). The NAC is a 21-
member citizens' panel of nationally recognized experts that provide 
recommendations on rural health and human services issues to the 
Secretary.
    Effective, coordinated healthcare improves the health and well-
being of Americans, regardless of where they live. However, effective 
coordination is especially critical in rural communities, where 
services and providers are limited and resources are scarce. The 
challenges of providing healthcare for rural communities are compounded 
by higher rates of poverty and lack of insurance. Rural people are a 
little older and they have higher rates of chronic disease. There are 
significant transportation barriers. To provide for their needs, there 
are about 2,000 hospitals, nearly 1,500 of these with less than 50 
beds. There are 3,500 Rural Health Clinics. These facilities are 
located in rural areas and are authorized for special Medicare and 
Medicaid payments. And there are nearly 2,000 Federally Qualified 
Health Centers which includes approximately 1,000 health center 
grantees. Fifty-two percent of these some 1,000 centers are located in 
rural areas.
    HRSA takes great pride in the work we do in providing better 
healthcare services for the rural population. However, we are humbled 
by the significant challenges that remain for healthcare in rural areas 
and to the underserved.
    We are pleased that the Department of Veterans Affairs is 
establishing an Office of Rural Health to assist the Under Secretary 
for Health in addressing issues affecting veterans living in rural 
areas. We have contacted the individuals who are creating this Office 
and their charge sounds familiar. With 20 years experience, we have 
some expertise regarding research and policymaking in this area. We 
look forward to collaborating with the new Office and offer our 
assistance.
    I would be happy to answer any questions at this time.

                                 
      Statement of Andy Behrman, Chair, Rural Health Policy Board
          National Rural Health Association, and President and
   Chief Executive Officer, Florida Association of Community Health 
                                Centers
    The NRHA is a national nonprofit, nonpartisan, membership 
organization with approximately 12,000 members that provides leadership 
on rural health issues. The Association's mission is to improve the 
health of rural Americans and to provide leadership on rural health 
issues through advocacy, communications, education and research. The 
NRHA membership consists of a diverse collection of individuals and 
organizations, all of whom share the common bond of an interest in 
rural health.
    I am Andy Behrman, President and Chief Executive Officer of the 
Florida Association of Community Health Centers, and the chair of the 
NRHA Rural Health Policy Board. I am also a veteran of the United 
States Navy. On behalf of the Association, I appreciate the opportunity 
to testify before this Committee.
    The members of the National Rural Health Association have 
maintained a special concern for the health and mental healthcare needs 
of rural veterans for many years. The NRHA was one of the first non-
veteran service organizations to develop a policy statement on rural 
veterans and this policy work is evidence of our memberships' concern 
for rural veterans.
    My testimony discusses current VA successes in providing quality 
care for rural veterans, and suggestions for further improvements in 
quality of care. NRHA respectfully requests that the Committee give 
consideration to the following steps that would improve quality and 
access to care for rural veterans:

    1.  Increase the numbers of Veteran Centers, Outreach Health 
Centers, and Community-Based Outreach Centers (CBOCs) in rural areas.
    2.  Increase healthcare access points for rural veterans by 
building upon current successes of both VA service approaches and 
existing rural health approaches. Fully implement the contracting of 
services from the VA to Federally Qualified Health Centers (FQHCs) in 
rural areas. Develop approaches to link VA services and quality to 
existing rural health providers willing to provide care to rural 
veterans that follow standards of care and evidence-based medicine, 
including Critical Access Hospitals (CAHs), Rural Health Clinics 
(RHCs), and mental health providers.
    3.  Increase the number of Veterans Hospital Administration 
Traumatic Brain Injury Case Managers in predominately rural States.
    4.  Use the high quality VA system to provide targeted and 
culturally competent care to rural, minority, and female veterans and 
train future rural health providers in these rural VA facilities.
    5.  Fully implement the functions of the newly created Office of 
Rural Veterans and establish a national advisory committee on rural 
veterans.

    The following is additional background information and discussion 
of our recommendations.
Overview
    Since the founding of our country, rural Americans have always 
responded when our Nation has gone to war. Whether motivated by their 
values, patriotism, and/or economic concerns, the picture has not 
changed much in 230 years. Rural individuals--along with American 
Indians, urban African Americans and Hispanics--serve at rates higher 
than their proportion of the population. Though only 19% of the Nation 
lives in rural America, 44% of U.S. Military recruits come from rural 
areas and nearly one-third of those who died in Iraq are from small 
towns and communities across the Nation.\1\
---------------------------------------------------------------------------
    \1\ ``Iraq War Takes Uneven Toll at Home,'' April 3, 2004: NPR All 
Things Considered.
---------------------------------------------------------------------------
    Where in rural America are veterans from? According to the most 
recent census, rural and non-metropolitan counties reported the highest 
concentration of veterans in the civilian populations aged 18 and 
over.\2,\ \3\ The proportion of veterans living in rural areas in 18 
States is higher than the national average of 12.7 percent. These high-
concentration States span the country, and include such geographically 
varied States as Montana (16.2%), Nevada (16.1%), Wyoming (16%), Maine 
(15.9%), West Virginia (14.4%), Arkansas (14.2%), South Carolina 
(14.2%), and Colorado (14.1%).\4\
---------------------------------------------------------------------------
    \2\ ``Veterans: 2000 Census Brief,'' p. 7.
    \3\ http://factfinder.census.gov/servlet/SAFFP.
    \4\ ``Veterans: 2000 Census Brief,'' p. 5.
---------------------------------------------------------------------------
    The disproportionate number of rural Americans serving in the 
military has created a disproportionate need for veteran's care in 
rural areas and yet rural areas are less likely to have VA services 
available to them.\5\ More than 22,000 soldiers have been wounded in 
Iraq. For those wounded veterans returning to their rural homes across 
the country, access to the specialized services they will need may be 
limited. Often access to the most basic of primary care is more 
difficult in rural America. Combat soldiers who need specialized care 
to assist with their readjustment to civilian life or adaptation to 
living with war injuries (both physical and mental) will likely find 
access to that care extremely limited.\6\
---------------------------------------------------------------------------
    \5\ Veterans Health Administration, April 2000, ``A Report By The 
Planning Systems Support Group, A Field Unit of the Veterans Health 
Administration Office of Policy and Planning--Geographic Access to 
Veterans Health Administration (VHA) Services in Fiscal Year 2000: A 
National and Network Perspective.
    \6\ Alvarez, L. and Lehren, A., ``3,000th Fatality in Iraq, 
Countless Tears at Home.'' (New York Times, January 2, 2007) Miller, 
Laura J., June 2001, ``Improving Access to Care in the VA Health 
System: A Progress Report,'' Forum, A publication of the Veterans 
Administration Office of Research & Development.
---------------------------------------------------------------------------
    It is also important to note that both differences and disparities 
exist in the health status of rural and urban veterans. The Veterans 
Administration's Health Services and Outreach Network has reported that 
rural veterans ``have worse physical and mental health'' than their 
urban counterparts and concluded that ``policymakers should anticipate 
greater healthcare demand from rural populations. . . .'' \7\
---------------------------------------------------------------------------
    \7\ Demakis, JG., Jan. 2000, ``Rural Health-Improving Access to 
Improve Outcomes,'' Management Brief Health Services Research & 
Development Service, No. 13: 1-3.
---------------------------------------------------------------------------
    There is a national misconception that all veterans have access to 
comprehensive care because they are served by the Veterans 
Administration.\8\ While this may be true for many veterans, it is not 
true for many small town veterans, rural veterans or those veterans who 
choose to be isolated due to the complicated symptoms of Post-Traumatic 
Stress Disorder.\9\ The Veterans Hospital Administration (VHA) provided 
care to 4.5 million of the 7.2 million enrolled veterans in fiscal year 
2003. While the quality of VHA care is equivalent to, or better than, 
care in other systems,\10\ it often is not accessible to many rural and 
frontier veterans.
---------------------------------------------------------------------------
    \8\ Weeks, WB., et al. March 2004. Differences in Health Status in 
Rural and Urban Veterans. Presented to the 22nd National Meeting of 
HSR&D. Washington, D.C.
    \9\ Sorenson, G., ``Hinterlands are home, not a hideaway, for 
Vietnam veterans,'' Vet Center Voice, Vol. VI, No. 9, October 1985, p. 
1.
    \10\ The Independent Budget for 2005: Medical Care. Veterans 
Service Organizations. http://www.pva.org/independentbudget/index.htm.
---------------------------------------------------------------------------
    While the NRHA is pleased that both the House and Senate FY 2008 
budgets call for greater increases in VA medical care spending than in 
past years, we all must be mindful that appropriations for the last 
decade have not kept up with the cost of maintaining current 
services.\11\ Policymakers must not only make up for past funding 
deficits, they must appropriately plan for long-term funding--because 
the wounded soldiers who return today won't need care for just the next 
few fiscal years, they will need care for the next half century.\12\
---------------------------------------------------------------------------
    \11\ The Independent Budget for 2005: Medical Care. p. 44.
    \12\ The Independent Budget for 2005: Medical Care. p. 45.

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NRHA RECOMMENDATIONS

    1.  Increase Healthcare Access Points for Rural Veterans to Build 
on Current Successes

    NRHA recognizes and appreciates the successes of veteran centers 
and healthcare outreach centers in meeting the needs of rural veterans. 
We should seize the opportunity to build upon this success and further 
improve quality of and access to care.
    Community-Based Outreach Centers (CBOCs) open the door for many 
veterans to obtain primary care services within their home community. 
While outcomes research on CBOCs is mixed, some findings suggest that 
CBOCs have been successful in improving geographic access, an important 
objective of expanding community-based care to veterans.'' \13\ The VHA 
has improved procedures for planning and activating CBOCs and 
established consistent criteria and standard expectations for the over 
450 CBOCs created since 1995.\14\ CBOCs have also been successful in 
some States, such as West Virginia; however, Directive 2001-06 made 
this solution less available to more rural and remote veterans and 
other rural providers by raising the ceiling on the number of priority 
users in a given area. Outreach Health Centers provide an appropriate 
model to deal with the loss of CBOC eligibility to smaller and more 
remote rural areas, and their expansion should be considered. 
Furthermore, outreach efforts with rural veterans that focus on benefit 
education and psycho-social education of veterans and their family 
members can increase the effectiveness of services currently available 
through the VA system.
---------------------------------------------------------------------------
    \13\ Maciejewski, M., et al. CBOC Performance Evaluation Report 2, 
VA HSR&D, March 2000. http://www.hsrd.research.va.gov/publications/
internal/cbocrpt2/cboc_performance_report2.htm.
    \14\ ``VHA Handbook 1006.1,'' April 11, 2003. Department of 
Veterans Affairs, Veterans Health Administration. Washington, D.C.

    2.  Increase Healthcare Access Points for Rural Veterans to Expand 
---------------------------------------------------------------------------
Access

    Time and distance prevent many rural veterans from getting their 
healthcare benefits through a VHA facility. There are approaches 
readily available in the VA system and in the rural health landscape 
that could improve this situation. These approaches include Vet 
Centers, Outreach Health Centers, and CBOCs, as mentioned above, as 
well as Federally Qualified Health Centers (FQHCs), Rural Health 
Clinics (RHCs), Critical Access Hospitals (CAHs), and mental health 
providers. Policy regarding services to rural veterans needs to provide 
access through a variety of existing rural health facilities and access 
points because not all rural communities have access to all types of 
facilities. Quality through consistent applications of standards of 
care and evidence-based medicine, however, must guide all approaches to 
care for rural veterans.
    Federally Qualified Community Health Centers (CHCs) serve millions 
of rural Americans, but most veterans cannot use their VA health 
benefits to receive care at these CHCs. These centers provide community 
oriented, primary and preventive healthcare and are located where rural 
veterans live. Congress has passed legislation encouraging 
collaborations (P.L. 106-74 and P.L. 106-117 Sec. 102(e), The Veterans 
Millennium Healthcare and Benefits Act). Despite the legislative 
intent, however, a national policy advocating VHA-CHC collaboration has 
not emerged in an effective way.
    A limited number of collaborations between the VHA and CHCs already 
exist and have proven to be prudent and cost-effective solutions to 
serving eligible veterans in remote areas. Successful contracts exist 
in Wisconsin, Missouri, and Utah. In other States, contracts were 
successful but were discontinued for reasons not related to operational 
success. This model of collaboration between VHA and CHCs might do well 
in other rural States and with other rural providers and systems of 
care and should be implemented further.
    Critical Access Hospitals provide comprehensive and essential 
services to rural communities and are specific to rural States. This 
model provides a great opportunity for policymakers to expand services 
to rural veterans in communities where CAHs are located. For instance, 
Montana has 45 Critical Access Hospitals and the highest percentage of 
veterans in the Nation. Working through these existing access points of 
care in many frontier communities in rural Montana by providing 
linkages with VA services and models of quality could greatly enhance 
care for rural veterans.
    Designation as a Rural Health Clinic (RHC) provides enhanced 
reimbursement for Medicare and Medicaid services for private physicians 
who provide enhanced services to rural communities. RHCs are often 
physician-owned or sometimes owned by small, rural hospitals, including 
Critical Access Hospitals. In many rural and frontier communities, RHCs 
represent the only source of primary care available.
    The literature provides much evidence that linking the quality of 
VA services with civilian services provides opportunities to improve 
the quality of healthcare services for all citizens. Linkages can 
improve the use of evidence-based medicine in chronic disease 
management, in screening and diagnosis, and in treatment of many health 
conditions. Linkages also provide greater opportunities for the 
dissemination of VA supported research. These are additional benefits 
of any collaboration between VHA and the existing rural health safety 
net infrastructure.

    3.  Increase Traumatic Brain Injury Care

    Throughout our history all citizens in our Nation have benefited 
from medical research focused on the signature wounds of war. 
Currently, it appears that Traumatic Brain Injury (TBI) will most 
likely become the signature wound of the Afghanistan and Iraqi wars. 
While the VA is gearing up for returning veterans with this condition, 
the importance of the TBI Case Manager Network and other services in 
the provision of quality care for these rural veterans cannot be 
understated.
    The Defense and Veterans Brain Injury Network of nine VA and one 
civilian center provides the needed and highly specialized services 
that these disabled veterans require. However, only three of these 
network centers are located in two of the 18 States with high rates of 
rural veterans, Virginia and Florida. Eleven western States with many 
rural and frontier veterans, and the other southern States with high 
numbers of rural veterans have very limited access to these centers 
once discharged from inpatient care. Therefore, the VHA TBI Case 
Managers Network is vital to these veterans and their families. A 
review of the number and location of TBI case managers finds them very 
limited in coverage in States with high numbers of rural veterans--
expansion is needed.

    4.  Target Care to Rural Veterans

      A.  Needs of the Rural Family. Rural individuals value their 
families and have strong bonds and ties to their homeplace and home 
communities. Our returning veterans adjusting to disabilities and the 
stresses of combat need the security and support of their families in 
making their transitions back into civilian life and to manage 
lifestyle changes due to disabling conditions. The Vet Centers do a 
tremendous job in assisting veterans with this readjustment, but the 
demand for services is too great for current funding levels. The NRHA 
supports increases in funding for counseling services for veterans' 
families and significant others.

      B.  Needs of Rural Women Veterans. Additionally, the NRHA 
supports better assessment of the needs of women and minority women 
veterans. Currently women make up approximately 15 percent of the 
active military force. Thirty-seven percent of these women are African 
American. These women serve in all branches of the military, and are 
eligible for assignment in most military occupational specialties 
except for direct combat roles. The highest number of women in history 
to serve in a war zone is currently serving in Iraq and Afghanistan. 
Our Nation is also seeing the highest numbers in history of female 
wounded and war casualties.\15\
---------------------------------------------------------------------------
    \15\ news.yahoo.com/s/afp/20070306/
lf_afpwomensusirapmilitary_070306170626-33k-March 15, 2007.

    According to the Center for Women Veterans, by the year 2010, the 
women veteran population is projected to be over 10 percent of the 
total veteran population. The breakdown on these women by rural and 
urban residence is not readily available, however, it is reasonable to 
assume that a higher number of both genders from rural areas go into 
military service. The VA is beginning to address changes needed to 
serve an increased female veteran population, but more can be done. 
Targeted and culturally competent care for today's women veterans is 
needed. Additionally, the VA offers a golden opportunity to train rural 
providers through rural rotations in all VA facilities and programs, 
thereby exposing our future rural providers to the unique needs of 
---------------------------------------------------------------------------
rural, minority, and female veterans.

    5.  Improve Office of Rural Veterans

    The NRHA calls on Congress and the Veterans Administration to fully 
implement the functions of the newly created Office of Rural Veterans 
to develop and support an ongoing mechanism to study and articulate the 
needs of rural veterans and their families. Additionally, the NRHA 
supports collaboration of this office with the Federal Office of Rural 
Health Policy within HRSA to better meet the access needs of rural 
veterans. Finally, the NRHA urges this office to establish a National 
Advisory Committee on Rural Veterans to provide information to 
policymakers on the needs of this population as it ages.
Conclusion
    While NRHA recognizes the purpose of this hearing is not to discuss 
specific legislation, we do recognize that H.R. 5524, the Rural 
Veterans Healthcare Act of 2006, introduced in the last Congress, 
includes many of the items long recommended by NRHA. H.R. 5524 calls 
for expansion and improved quality of services provided by Vet Centers, 
Outreach Health Centers, and CBOCs in rural areas; a heightened focus 
on the needs of rural minority veterans; a focus on rural medical 
education for VA residents, and new research and outreach efforts. We 
hope similar legislation will again be introduced in the 110th Congress 
and eventually be enacted into law.
    Mr. Chairman, thank you for the opportunity to testify.

                                 
       Statement of Shannon Middleton, Deputy Director for Health
    Veterans Affairs and Rehabilitation Commission, American Legion
    Mr. Chairman and Members of the Subcommittee:
    Thank you for this opportunity to present The American Legion's 
views on access to quality healthcare for veterans in general and 
veterans in rural communities in particular. Research conducted by the 
Department of Veterans Affairs (VA) indicated that veterans residing in 
rural areas are in poorer health than their urban counterparts. It was 
further reported that nationwide, one in five veterans who enrolled to 
receive VA healthcare lives in rural areas. Providing quality 
healthcare in a rural setting has proven to be very challenging, given 
factors such as limited availability of skilled care providers and 
inadequate access to care. Even more challenging will be VA's ability 
to provide treatment and rehabilitation to rural veterans who suffer 
from the signature ailments of the ongoing Global War on Terror--
traumatic blast injuries and combat-related mental health conditions. 
VA's efforts need to be especially focused on these issues.
Community-Based Outpatient Clinics (CBOC)
    A vital element of VA's transformation in the 1990's was the 
creation of CBOCs to move access closer to the veterans' community. A 
recent VA study noted that access to care might be a key factor in why 
rural veterans appear to be in poorer health. CBOCs were designed to 
bring healthcare closer to where veterans reside. Over the last several 
years, VA has opened up hundreds of CBOCs throughout the system and 
today there are over 700 that provide healthcare to the Nation's 
veterans. By and large, CBOCs have been pretty successful; however, of 
concern to The American Legion is that many of the CBOCs are at or near 
capacity and many still do not provide adequate mental health services 
to veterans in need.
    One of the recommendations of the Capital Assets Realignment for 
Enhanced Services (CARES) was for more, not less, CBOCs across the 
Nation. The American Legion strongly supports this recommendation, 
especially those identified for rural areas; however, limited VA 
discretionary funding has limited the number of new CBOCs each fiscal 
year.
    There is great difficulty serving veterans in rural areas. Veterans 
in States such as Nebraska, Iowa, North Dakota, South Dakota, Wyoming, 
and Montana face extremely long drives, a shortage of healthcare 
providers and bad weather. The Veterans Integrated Services Networks 
(VISNs) rely heavily upon CBOCs to close the gap.
    The provision of mental health services in CBOCs is even more 
critical today with the ongoing wars in Iraq and Afghanistan. It has 
been estimated that nearly 30 percent of the veterans who are returning 
from combat suffer from some type of mental stress. Further, statistics 
show that mental health is one of the top three reasons a returning 
veteran seeks VA healthcare. The American Legion believes that VA needs 
to continue to emphasize to the facilities the importance of mental 
health services in CBOCs and we urge VA to ensure the adequate staffing 
of mental health providers in the CBOC setting.
    CBOCs are not the only avenue with which VA can provide access to 
quality healthcare to rural veterans. Enhancing existing partnerships 
with communities and other Federal agencies, such as the Indian Health 
Service, will help to alleviate some of the barriers that exist such as 
the high cost of contracting for care in the rural setting. 
Coordinating services with Medicare or with other healthcare systems 
that are based in rural areas is another way to help provide quality 
care.
    The Presidential Task Force to Improve Healthcare Delivery for Our 
Nation's Veterans made several recommendations for DoD and VA, one of 
which: VA and DoD should declare that joint ventures are integral to 
the standard operations of both Departments. (Recommendation 4.8) Since 
this Task Force's final report in May 2003, none have materialized--yet 
there are military bases in many rural communities.
Traumatic Brain Injury Patients
    In a July 2006 report entitled Health Status of and Services for 
Operation Enduring Freedom and Operation Iraqi Freedom Veterans after 
Traumatic Brain Injury Rehabilitation, the Department of Veterans 
Affairs Office of Inspector General examined the Veterans Health 
Administration's ability to meet the needs of OIF/OEF veterans who 
suffered from traumatic brain injury (TBI). Fifty-two patients from 
around the country--including Montana, Colorado, North Dakota, and 
Washington State--were interviewed at least 1 year after completing 
inpatient rehabilitation from a Lead Center (Minneapolis, MN; Palo 
Alto, CA; Richmond, VA; and Tampa, FL) including those who lived in 
States with rural veteran populations.
    Many of the obstacles for the TBI veterans and their family members 
were similar. Forty-eight percent of the patients indicated that there 
were few resources in the community for brain injury-related problems. 
Thirty-eight percent indicated that transportation was a major 
obstacle. Seventeen percent indicated that they did not have money to 
pay for medical, rehabilitation, and injury-related services.
    Some of the challenges noted by family members who care for these 
veterans in rural settings include: the necessity for complicated 
special arrangements and the absence of VA rehabilitative care in their 
communities.
    Case managers working at Lead Centers and several secondary centers 
noted limited ability to follow patients after discharge to rural areas 
and lack of adequate transportation.
    These limitations place undue hardship on the veterans' families as 
well. Those contributing to the report, as well as veterans who have 
contacted The America Legion, have shared many examples of the manner 
in which families have been devastated by caring for TBI injured 
veterans. They have sacrificed financially, have lost jobs that 
provided the sole income for the family, and have endured extended 
separations from children. It is The American Legion's belief that VA 
needs to continue to improve access to quality primary and specialty 
heathcare services for veterans residing in rural and highly rural 
areas.
Vet Centers
    Vet Centers are another important resource, especially for combat 
veterans experiencing readjustment issues who do not live in close 
proximity to a VA medical facility. Because Vet Centers are community-
based and veterans are assessed the day they seek services, they 
receive timely care and are not subjected to wait lists. Some of the 
services provided include: individual and group counseling; family and 
marital counseling; military sexual trauma counseling; and, 
bereavement.
    Realizing the value of Vet Centers to those who may encounter 
obstacles when seeking mental healthcare in the VA medical facilities, 
The American Legion decided to get a glimpse of services and needs of 
Vet Centers nationwide. The American Legion's 2007 System Worth Saving 
report, a compilation of information gathered from site visits 
conducted by field service representatives and the System Worth Saving 
Task Force members, will focus on Vet Centers, as well as polytrauma 
centers. The American Legion staff selected a sample of Vet Centers 
that were located near demobilization sites throughout the country to 
ascertain the effects of the number of returning veterans on the 
services provided by the centers. The report will illustrate the types 
of veterans utilizing the respective Vet Centers, as well as services 
requested by these veterans and outreach services offered.
    The American Legion believes veterans should not be penalized or 
forced to travel long distances to access quality healthcare because of 
where they choose to live. We urge VA to improve access to quality 
primary and specialty healthcare services, using all available means at 
their disposal, for veterans living in rural and highly rural areas.
    Although ``access'' is an important measure, The American Legion 
believes ``timeliness of access'' is just as critical. For an example, 
VA established its own acceptable access standard for primary care at 
30 days, but to most Americans with private healthcare plans--30 days 
would be unacceptable. Unfortunately, the continued disparity between 
demand for services and available resources continues to cause delays 
in the delivery of healthcare. The current Global War on Terror has 
placed even more demands on the VA healthcare system to meet its 
obligation to the men and women of the armed forces--past, present, and 
future. As a grateful Nation welcomes with opened arms the newest 
generation of wartime veterans, veterans of previous conflicts and the 
Cold War are being denied enrollment and, therefore, access to their 
healthcare delivery system of choice.
    Since the decision within VA to begin transformation from an 
inpatient-based healthcare delivery system to an integrated healthcare 
delivery system in the early 1990s and Congress' enactment of 
eligibility reform in 1996, access to VA healthcare has increased 
dramatically. In 1990, the patient population of the VA medical system 
was somewhere in the neighborhood of 2 million. Today, VA's patient 
population is closer to 6 million with a total enrollment of 
approximately 8 million veterans.
    In fact, by 2003, former VA Secretary Anthony Principi decided to 
terminate the enrollment of any new Priority Group 8 veterans; 
therefore, prohibiting access to VA medical care to hundreds of 
thousands of Priority Group 8 veterans due primarily to limited 
resources. The American Legion disagrees with the decision to deny 
access to any eligible veterans. Many of these veterans are Medicare-
eligible or have other third-party health insurance that could 
reimburse VA reasonable charges for services rendered. Yet little has 
been done to improve third-party reimbursements from private insurers 
and nothing has been done to allow VA to begin receiving third-party 
reimbursements from the Nation's largest healthcare insurer, the 
Centers for Medicare and Medicaid Services (CMS).
    Both the Department of Defense (DoD) medical system and Indian 
Health Services (IHS) are authorized to bill, collect, and receive 
third-party reimbursements from the Centers for Medicare and Medicaid 
Services, yet VA continues to face the restriction from billing CMS. 
Repeatedly, VA's average cost-per-patient remains well below Medicare's 
average cost-per-patient (and the billions of dollars VA saves Medicare 
is not even calculated into Medicare's final funding levels).
    The restriction of enrollment for Priority 8 veterans creates 
another ``access gap'' for recently separated veterans who did not 
serve in a combat setting. Some recently separated veterans must wait 
until their VA disability claims are approved in order to enroll. For 
others, unless they are economically indigent, they are prohibited from 
enrolling. Those recently separated veterans that successfully 
transition may very well never be eligible to enroll in the Nation's 
best healthcare delivery system. None of these situations are very 
welcoming messages to the men and women currently serving in the 
Nation's armed forces.
    Over the years, VA has transformed itself into the Nation's best 
healthcare delivery system and probably the most cost-efficient as 
well. There are many reasons why the VA healthcare system has become 
the best healthcare option for eligible veterans:

      Quality of care,
      Patient safety,
      Electronic medical records,
      Cost-efficient formulary,
      Accessibility,
      World-class specialized services,
      State-of-the-arts medical and prosthetics research, and
      Minimal fraud, waste, and abuse.

    For these and many other intangible reasons, VA is a ``healthcare 
magnet'' attracting veterans, many of which have never used the VA 
healthcare delivery system before. As the veteran population continues 
to age and the healthcare industry evolves, more and more veterans on 
fixed incomes turn to VA as their best healthcare option--even those 
with other healthcare options such as Medicare, TRICARE, or private 
health insurance coverage. Many of these veterans are combat veterans 
of World War II, Korea, and Vietnam. Although their transition from 
active-duty to civilian life may have been ``seamless'' for many years, 
they now believe their individual healthcare needs would be better met 
by VA.
Returning Operation Enduring Freedom and Operation Iraqi Freedom (OEF/
        OIF) Veterans
    The American Legion fully supports the decision to provide recently 
separated veterans from OEF/OIF to access to the VA healthcare delivery 
system for 2 years after separation. However, now that they have been 
presented with conditions having delayed onset, like Post-Traumatic 
Stress Disorder (PTSD) and symptoms of Traumatic Brain Injury (TBI), 
The American Legion supports extending those 2 years to 5 years. The 
American Legion also believes that VA must ensure that it makes every 
effort to outreach to eligible Reservists components, who sometimes 
endure multiple deployments, to keep them aware of their eligibility 
for access to the VA healthcare system and provide them with timely 
access to care.
    Although they were promised priority due to their combat service, 
OEF/OIF veterans are encountering obstacles when trying to access the 
system. We are beginning to hear stories. One veteran was told to call 
back the following week for an appointment, only to be told when he 
called back, that he had to wait 30 days later for an appointment. 
Another OIF veteran reported having his appointment cancelled and 
rescheduled 30 days later. Many conditions experienced by these 
veterans may not qualify as emergencies, but are urgent enough to 
require immediate care.
Inpatient Bed Requirements
    VA continues to ignore the Federal mandate for inpatient care, 
especially in the area of long-term care. The American Legion believes 
VA is focused on shifting long-term care from VA to the State Veterans' 
Homes and private nursing home industry. Access to long-term care is 
often translated into being placed on a waiting list that may very well 
exceed the life expectancy of the veteran placed on the list. The 
Veterans' Millennium Healthcare Act clearly set the bar, but VA seems 
to have ignored this Federally mandated statute.
    During the CARES process, long-term care and mental health were not 
included in the initial decisionmaking process. In other words, two 
critical elements were included after rather than during the final 
recommendations for the future infrastructure of VA. The American 
Legion was extremely critical of that decision, especially when the 
closing recommendations revealed medical facilities with primarily 
long-term care and mental health missions. In addition, the facilities 
were primarily in rural communities.
    Again, thank you, Mr. Chairman, for giving The American Legion this 
opportunity to present its views on such an important issue. The 
hearing is very timely and we look forward to working with the 
Subcommittee to bring an end to the disparities that exist in access to 
quality healthcare in rural areas.

                                 
                     Statement of Adrian M. Atizado
  Assistant National Legislative Director, Disabled American Veterans
    Mr. Chairman and Members of the Subcommittee:
    I am pleased to appear today at the request of the Subcommittee to 
offer testimony on behalf of the Disabled American Veterans (DAV) 
related to access to medical care services in the Department of 
Veterans Affairs (VA) healthcare system, particularly on access to care 
in rural areas. I offer this statement on behalf of The Independent 
Budget (IB) for fiscal year 2008, a product of the joint efforts of 
DAV, Veterans of Foreign Wars of the United States, Paralyzed Veterans 
of America and AMVETS.
    Congress provided VA additional funding in fiscal years 2006 and 
2007, for which we are very grateful, but we continue to hear from 
veterans that their access to VA specialty care is often delayed for 
months. Likewise, access to VA care in rural areas of the country has 
been--and continues to be--a challenge for many veterans. We are 
especially concerned about how VA plans to address rural veterans' 
needs in the coming years, given reports that 44 percent of all 
veterans returning from Operations Enduring and Iraqi Freedom (OEF/OIF) 
reside in rural communities. After serving their country, veterans' 
healthcare needs should not be neglected by VA simply because they live 
in rural or remote areas at a distance from major VA healthcare 
facilities.
    Without question, sections 212 and 213 of Public Law 109-461, 
signed into law by the President on December 22, 2006, represent the 
most significant advances to date to address healthcare needs of 
veterans living in rural areas. Under this legislation, the VA is 
mandated to establish an Office of Rural Health within the Veterans 
Health Administration (VHA). This office must carry out a series of 
steps intended by Congress to improve VA healthcare for veterans living 
in rural and remote areas. This legislation is also aimed importantly 
at better addressing the needs of returning veterans who have served in 
OEF/OIF. Among its features the law requires VA to conduct an extensive 
outreach program for veterans who reside in these communities. In that 
connection VA is required to collaborate with employers, State 
agencies, Community Health Centers, Rural Health Clinics, Critical 
Access Hospitals (as designated by Medicare), and the National Guard, 
to ensure that returning veterans and Guard members, once completing 
their deployments, can have ready access to adequate VA healthcare. The 
legislation also requires an extensive assessment of the existing VA 
fee-basis system of private healthcare, and eventual development of a 
VA plan to improve access and quality of care for enrolled veterans who 
live in rural areas.
    Rural veterans, veterans service organizations and other experts 
need a seat at the table to help VA consider important program and 
policy decisions such as those being discussed here that would 
positively affect veterans who live in rural areas. The final 
legislative language of Public Law 109-461 failed to include a Rural 
Veterans Advisory Committee to help harness the knowledge and expertise 
of representatives from federal agencies, academic affiliates, 
veterans, and other rural experts, to recommend policies to meet the 
challenges of veterans' rural healthcare. We hope that Congress will 
reconsider this mandate, but the VA Secretary retains the authority to 
establish such an Advisory Committee without specific statutory 
authorization. The IBVSOs urge the Secretary to take this action, and 
to include representatives of our organizations in the membership of 
that Committee.
    Although the authors of the Independent Budget acknowledge this 
legislative measure will be beneficial to veterans living in rural and 
remote areas, the legislation also raises potential concerns about the 
unintended consequences it may have on the mainstream VA healthcare 
system. In general, current law places limits on VA's ability to 
contract for private healthcare services to instances 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 existence of a medical emergency prevents a 
veteran from receiving care from 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 of certain scarce medical specialists. Beyond these 
limits, there is no general authority in law to support broad-based 
contracting for the care of populations of veterans, whether rural or 
urban. The authors of the IB believe VA contract care for eligible 
veterans should be used judiciously and only in circumstances 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, brain and 
spinal cord injury, or chronic mental health problems. Putting 
additional budget pressure on this specialized system of services, 
without making specific appropriations available for new rural VA 
healthcare programs, could only exacerbate the problems currently 
encountered.
    The VA has had continuing difficulty securing sufficient funding 
through the Congressional discretionary budget and appropriations 
process to ensure basic and adequate access for the care of sick and 
disabled veterans. Congress repeatedly has been forced to provide 
additional funds to maintain VA healthcare services. Also, VA receives 
no Congressional appropriation dedicated to support the establishment 
of rural Community-Based Outpatient Clinics or to aid facilities VA 
designated as ``Veterans Rural Access Hospitals'' (VRAH), and thus VA 
must manage any additional expenses from within generally available 
Medical Services appropriations. VA has established and is operating 
717 Community-Based Outpatient Clinics (CBOCs) as sources of primary 
care. VA considers 320 of these clinics to be in rural or ``highly 
rural'' areas. Given current financial circumstances within VA 
healthcare, we are skeptical that VA can continue to cost-effectively 
establish additional facilities in areas with even sparser veteran 
populations.
Rural Hospitals
    Under the federal Medicare program, a ``Critical Access Hospital'' 
(CAH) is a private hospital that is certified to receive cost-based 
reimbursements from Medicare. The higher reimbursements that CAHs 
receive under this program compared to urban facilities are intended to 
improve their financial security and thereby reduce rural hospital 
closures. In other words, the Centers for Medicare and Medicaid 
Services (CMS) policy is to financially aid struggling rural hospitals 
in hopes that the additional support can help them survive. Also the 
CAH facilities are certified under Medicare ``conditions of 
participation'' that are more flexible than those used for other acute 
care hospitals. As of March 2006 (the latest data available), there 
were 1,279 certified CAH facilities in rural and remote areas.
    As a part of the VA's Capital Assets for Enhanced Services (CARES) 
initiative, the VA employed Medicare's CAH model as a guide to 
establish a new VA policy to govern operations of, and planning for, 
many of VA's rural and remote facilities, now designated VRAH. In 2004, 
however, the CARES Advisory Commission questioned whether VA's policy 
was adequate and recommended VA ``. . . establish a clear definition 
and clear policy on the CAH [now VRAH] designation prior to making 
decisions on the use of this designation.''
    Following this guidance from the CARES Commission, on October 29, 
2004, VA issued a directive that is still in force setting a 
significant number of parameters for VRAH designations, but that 
directive seems pointed in the opposite direction from that of Medicare 
for the CAH facilities in the rural private sector. Illustrative of our 
concern is the basic definition of VRAH, as follows:

          ``A VRAH is a VHA facility providing acute inpatient care in 
        a rural or small urban market in which access to healthcare is 
        limited. The market area cannot support more than forty beds. 
        The facility is limited to not more than twenty-five acute 
        medical and/or surgical beds. Such facilities must be part of a 
        network of healthcare that provides an established referral 
        system for tertiary or other specialized care not available at 
        the rural facility. The facility should be part of a system of 
        primary healthcare (such as a network of Community-Based 
        Outpatient Clinics (CBOCs)). The underlying principle is that 
        the facility must be a critical component of providing access 
        to timely, appropriate, and cost-effective healthcare for the 
        veteran population served. The activation and operation of a 
        VRAH will be similar to that of any other VHA hospital. The 
        designation of a facility as a VRAH will not remove or diminish 
        that facility's responsibility in meeting appropriate VHA 
        requirements, directives, guidance, etc.'' (VHA Directive 2004-
        061, October 29, 2004)

    We believe VA must carefully monitor the scope and quality of 
services performed at its smaller, rural facilities, specifically for 
those procedures that are complex in nature. Further, as medical care 
advances in the use of high technology and thereby elevates the 
standard of care, small VA inpatient facilities may find it 
increasingly difficult to effectively maintain, and actually use these 
new tools, to provide healthcare at its most sophisticated levels. 
However, we believe VA must maintain a safe and high quality healthcare 
service within each of its facilities, and to the greatest degree 
possible offer a comprehensive health benefit to veterans at each of 
its facilities, whether rural, suburban or urban.
    The IBVSOs remain concerned about whether VA's VRAH policy fully 
considers the implications of large-scale referrals from rural VA 
Medical Centers in continuing to provide high quality healthcare in 
those locations, particularly when veterans are referred to other far 
off medical centers within a Veterans Integrated Service Network 
(VISN), or to private facilities. VA must also consider patient 
satisfaction, continuity of care, family separation and travel burdens 
in the criteria they use for determining which rural facilities should 
retain acute care services. If acute care beds are to be retained in 
one facility because of distances that veterans must travel to access 
inpatient care or receive specialized services, we believe this logic 
should be standardized and used systemwide to the greatest extent 
possible.
Community-Based Outpatient Clinics
    The new legislation discussed above holds VA accountable for 
improving access for rural veterans through CBOCs and other access 
points by requiring VA to develop and implement a plan for improving 
veterans' access to care in rural areas. The May 2004 Secretary's CARES 
decision identified 156 priority CBOCs and new sites of care 
nationwide. The VA Secretary is also required to develop a plan for 
meeting the long-term and mental healthcare needs of rural veterans. We 
urge Congress to include specific funding in fiscal year 2008 to 
address at least some of these needs in rural areas without eroding 
VA's Medical Services appropriation.
Workforce
    Health worker shortages and recruitment and retention of healthcare 
personnel are a key challenge to rural veterans' access to VA care and 
to the quality of that care. The Future of Rural Health report 
(National Academy of Science, Institute of Medicine, Committee on the 
Future of Rural Health Care, 2005) recommended that the federal 
government initiate a renewed, vigorous, and comprehensive effort to 
enhance the supply of healthcare professionals working in rural areas. 
To this end, VA's deeper involvement in health professions education of 
future rural clinical providers seems essential in improving these 
situations in VA facilities as well as in the private sector. Through 
VA's existing partnerships with 103 schools of medicine, almost 28,000 
medical residents and 16,000 medical students receive some of their 
training in VA facilities each year. In addition, more than 32,000 
associated health science students from 1,000 schools--including future 
nurses, pharmacists, dentists, audiologists, social workers, 
psychologists, physical therapists, optometrists, respiratory 
therapists, physician assistants and nurse practitioners, receive 
training in VA facilities. These relationships of VA facilities to 
health professions schools should be put to work in aiding rural VA 
facilities with their personnel needs.
Beneficiary Travel Program
    Another component of making sure that veterans get access to the 
care they need relates to the VA beneficiary travel program. This 
program is intended by Congress to assist veterans in need of VA 
healthcare to gain access to that care. As you are aware, the mileage 
reimbursement rate is currently fixed at 11 cents per mile, but actual 
reimbursement is limited by law with a $3.00 per trip deductible capped 
at $18.00 per month. The mileage reimbursement rate has not been 
changed in almost 30 years, even though the VA Secretary is delegated 
authority by Congress to make rate changes when warranted. The law also 
requires the Secretary to make periodic assessments of the need to 
authorize changes to that rate. Unfortunately, no Secretary has acted 
to make those changes, despite the obvious need to update the rate of 
reimbursement to reflect rises in travel and transportation costs.
    In 1987, the DAV, in coordination with VA's Voluntary Service 
program, began buying and donating vans to VA for the purpose of 
transporting veterans for outpatient care. Since that time, the DAV 
National Transportation Network has become a very significant and 
successful partnership between VA and DAV. We have donated almost 1,800 
vans to VA facilities at a cost exceeding $20 million. These vans and 
their DAV volunteer drivers and medical center volunteer transportation 
coordinators have transported nearly 520,000 veterans over 388 million 
miles. We plan to continue and enhance this program, not only because 
the VA beneficiary travel rate is so low, but also we have found our 
transportation network serves as a truly vital link between rural 
veterans and crucial VA healthcare. Its absence would equate to the 
actual denial of care for eligible veterans because many of them have 
no means to substitute.
    DAV, along with several others, has a longstanding resolution (DAV 
Resolution 212) supporting repeal of the beneficiary travel pay 
deductible for service-connected veterans and to increase travel 
reimbursement rates for all veterans who are eligible for 
reimbursement. Additionally, we support legislation that has been 
introduced in Congress to repeal the mandatory deductible and increase 
the rate veterans are reimbursed for their authorized travel to and 
from VA services. We believe H.R. 963 (introduced by Mr. Stupak); H.R. 
1472 (introduced by Mr. Barrow, with Mr. Baca, Mr. Burton of Indiana, 
Mr. Boswell, Ms. Bordallo, Mr. Boucher, Mr. Abercrombie, Mr. Boren and 
Mr. Courtney); and S. 994 (introduced by Senator Tester and Senator 
Salazar), all termed the ``Veterans Travel Fairness Act,'' offer a fair 
and equitable resolution to this dilemma about which we have been 
concerned for many years. We urge this Committee and your Senate 
counterpart to approve and enact legislation this year to reform the VA 
beneficiary travel program. Given the cost of transportation in 2007, 
including record-setting gasoline prices, a reimbursement rate 
unchanged since 1977 pales in comparison to the actual cost of travel.
Mental Healthcare
    As indicated above, given that 44 percent of newly returning 
veterans from OEF/OIF live in rural areas the IBVSOs believe that they 
too should have access to specialized services offered at VA's 
Readjustment Counseling Service's Vet Centers.
    Vet Centers are located in communities outside the larger VA 
medical facilities, in easily accessible, consumer-oriented facilities 
highly responsive to the needs of local veterans. These centers present 
the primary access points to VA programs and benefits for nearly 25 
percent of veterans who receive care at the centers. This core group of 
veteran users primarily receives counseling for military-related 
trauma. Building on the strength of the Vet Centers program, VA should 
be required to establish a pilot program for mobile Vet Centers that 
could better outreach to veterans in rural and remote areas.
Homelessness
    Helping homeless veterans in rural and remote locations recover, 
rehabilitate, and reintegrate into society is complex and challenging. 
VA has no specific programs to help community providers who focus on 
rural homeless veterans. The rural homeless also deserve attention from 
VA to aid in their recoveries. Likewise, Native American, Native 
Hawaiian, and Native Alaskan veterans have unique healthcare needs that 
VA needs to address with additional outreach and other activities.
    Mr. Chairman, thank you for the opportunity to provide testimony on 
these very important issues related to access to VA healthcare 
services. In The Independent Budget for fiscal year 2008, our 
organizations made a number of recommendations to Congress and VA that 
are relevant to the issues discussed today in this testimony. We invite 
you to review these recommendations, reprinted below.
                            Recommendations
    VA must fully support the right of rural veterans to healthcare and 
insist that funding for additional rural care and outreach be 
specifically appropriated for this purpose, and not be the cause of 
reductions in highly specialized urban and suburban VA medical programs 
needed for the care of sick and disabled veterans.
    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 healthcare services.
    The VA Secretary should use existing authority to establish a Rural 
Veterans Advisory Committee, to include membership by the veterans 
service organizations.
    VA rural outreach should include a special focus on Native 
American, Native Hawaiian, and Alaska Native veterans' unmet healthcare 
needs.
    Through its affiliations with health professions schools, VA should 
develop a policy to help supply health professions clinical personnel 
to rural VA facilities and to rural areas in general.
    Mobile Vet Centers should be established, at least on a pilot 
basis, to provide outreach and counseling for veterans in rural and 
remote areas.
    VA must focus some of its homeless veteran program resources, 
including contracts with, and grants to, community-based organizations, 
to address the needs of homeless veterans in rural and remote areas.

                                 
               Statement of Gerald M. Cross, M.D., FAAFP
           Acting Principal Deputy Under Secretary for Health
  Veterans Health Administration, U.S. Department of Veterans Affairs
    Good Afternoon, Mr. Chairman and Members of the Subcommittee. Thank 
you for the opportunity to discuss ongoing efforts in the Veterans 
Health Administration (VHA) to provide safe, effective, efficient and 
compassionate healthcare to veterans residing in rural areas.
    In fiscal year 2006, the Department of Veterans Affairs (VA) served 
about 5.4 million patients. Approximately 39 percent of these veterans 
resided in rural areas and another 2 percent resided in highly rural 
areas.\1\ VA is fulfilling its mission by providing the highest quality 
of care to all veterans and understands that although veterans in rural 
areas face many of the same health concerns as veterans in urban areas, 
rural area veterans often face additional and unique challenges such as 
limited finances and fewer specialists. The primary challenge in 
serving veterans who reside in rural areas is to effectively address 
access to quality care in areas where veteran populations are usually 
widely distributed over a large geographical area.
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    \1\ Definitions: Urban--areas defined by U.S. Census as urbanized 
areas; Rural--all other areas excluded in U.S. Census defined urbanized 
areas; Highly Rural--any rural area within a county with less than 7.0 
civilians per square mile.
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    The VA has undergone a profound transformation in the delivery of 
healthcare over the last decade. VA has moved from a hospital driven 
healthcare system to an integrated delivery system that emphasizes a 
full continuum of care. New technology and treatment modalities have 
changed how and where care is provided with a significant shift from 
inpatient to outpatient and in-home services. Throughout that 
transformation, VA has considered our veterans who live in rural areas 
and how best the VA can enhance their access to the quality health 
services that we strive to provide to all veterans.
    VA's comprehensive approach for providing care to veterans residing 
in rural areas has proven successful. We are setting the industry 
standards for using advanced technology with our telehealth healthcare 
delivery programs. With this advanced technology, we are providing 
services directly to veterans in their homes and expanding specialized 
care in our Community-Based Outpatient Clinics (CBOCs) through 
telemedicine capabilities. We have been successful in creating greater 
access to quality services though expansion of CBOCs. Over 92 percent 
of enrollees reside within 1 hour of a VA facility, and 98.5 percent 
are within 90 minutes.
    Our veterans tell us that they are satisfied with the services and 
high quality care we are providing to them. This is substantiated by 
their high satisfaction reporting, with veterans in rural areas 
reporting comparable satisfaction to their urban counterparts.
    I share the Committee's concern for these veterans and would like 
to take a few minutes to discuss our strategic direction and current 
programs that will reveal how VA is moving toward a comprehensive plan 
with initiatives to address rural veterans' issues.
RURAL HEALTH INITIATIVES
    The strategic direction for providing services to veterans residing 
in rural areas is to provide non-institutionalized care; to bring care 
into veterans' homes. Examples of this are telehealth, mail pharmacies, 
and home-based primary care. If it is not possible to provide services 
in the home, veterans will come to one of the many access points that 
VA has established. VA has systematically undertaken a number of 
efforts aimed at addressing delivery of healthcare services to veterans 
who reside in rural areas. Central to these efforts are several major 
initiatives now being implemented throughout the VA system: 
establishing an Office of Rural Health to focus attention on issues of 
veterans who reside in rural areas; our telehealth and telemedicine 
programs, which are using new technology to bring healthcare providers 
to their patients, rather than patients to their healthcare providers; 
establishment of CBOCs to increase access to care; and utilization of 
fee-based service with private healthcare providers. I will now discuss 
these efforts and others in greater detail while providing information 
on key health concerns facing many of our veterans.
VHA's OFFICE OF RURAL HEALTH
    VHA is focusing attention on the special needs of veterans who 
reside in rural areas. In accordance with section 212 of the Public Law 
109-461, VHA is establishing an Office of Rural Health. The mission of 
the office is to promulgate policies, best practices and innovations to 
improve services to veterans who reside in rural areas of the United 
States.
TELEHEALTH--IMPACTS ON RURAL CARE
    VA is an acknowledged national leader in the development of 
telehealth. VA's telehealth programs have reached a size and complexity 
that are unparalleled elsewhere. VA continues to implement telehealth 
through further expansion of its care coordination/telehealth programs. 
This approach embeds telehealth within an appropriate, effective and 
cost-effective clinical environment. Consequently, access to care is 
expanding and enabling convenience in how veteran patients receive 
services to become a predominant consideration, one that fits with the 
overarching mission for these programs of providing the right care at 
the right time in the right setting.
    For veteran patients with chronic disease, when it is appropriate 
and their choice, the preferred setting for care is the home. Care 
coordination/home telehealth programs (CCHT) are well established in 
all 21 Veterans Integrated Service Networks (VISNs) and currently care 
for 24,921 patients. This patient census (point prevalence figure) 
already represents a 25 percent increase over fiscal year 2006 numbers 
and places VA on target to meet a projected growth in the program of 50 
percent by the end of fiscal year 2007. CCHT supports patients with 
chronic conditions such as diabetes, chronic heart failure, chronic 
obstructive pulmonary disease, post-traumatic stress disorder, and 
depression to remain living independently in their own homes. The 
program design is such that care can be delivered remotely from VA 
Medical Centers and 25 percent of CCHT patients are in rural areas and 
another 1 percent are in highly rural areas.
    The next phase of expansion in CCHT programs and ongoing extension 
into rural areas involves VA's implementation of a home telemental 
health initiative that will support veterans with PTSD and those who 
need treatment for substance abuse to be managed at home. These new 
CCHT home telemental health services are intended to support the care 
of an additional 2,000 veterans by the end of fiscal year 2008. VA 
anticipates that such services will initially develop and thereafter 
further expand in the same geographic locations as existing CCHT 
programs. VA is currently working on telecommunications strategies to 
facilitate the provision of CCHT services in rural areas, thus 
improving access to care for veteran patients and reducing their need 
to travel for services. Since January 2004, VHA has trained over 3,500 
staff nationally to provide care via CCHT. This training is done via 
distance learning techniques to enhance service development and ensure 
their sustainability in rural and remote areas.
    In fiscal year 2006, over 19,000 unique veteran patients received 
care in CBOCs and outlying VA Medical Centers via telemental health. 
Already, in the first quarter of fiscal year 2007, over 8,000 patients 
have received care via telemental health. Current projections are that 
VA will provide care in this manner to over 30,000 veterans during 
fiscal year 2007.
    The VA's Rocky Mountain Telehealth Training Center is focusing on 
making distance learning available to the providers in rural areas who 
are providing services via telehealth. Additionally, the VA 
readjustment counseling program (Vet Centers) is currently working on a 
strategy to expand services in rural areas by further expansion of its 
telehealth capacity.
    VHA has now implemented its national teleretinal imaging program to 
screen veteran patients with diabetes for diabetic eye disease. This 
program was instituted at a total of 159 image acquisition sites over 
the past 18 months. This implementation represents a 60 percent 
increase over that which was originally planned. Currently 50 percent 
of these image acquisition sites are in rural areas. Overall the 
program has provided services to 18,000 patients with a projected 
census of 110,000 by the end of fiscal year 2007 and 200,000 by the end 
of fiscal year 2008. VA's teleretinal imaging training center in Boston 
has trained the necessary image acquisition and reading staff and helps 
ensure that remote sites can be established and remain viable.
IMPROVING ACCESS THROUGH CBOCs
    CBOCs have been the anchor for VHA's efforts to expand access to 
veterans in rural areas. VHA's CBOCs are complemented by contracts in 
the community for physician specialty services or referrals to local VA 
Medical Centers, depending on the location of the CBOC and the 
availability of specialists in the area.
    VA has continued to improve access to care for veterans in rural 
areas through a variety of mechanisms. VA outpatient clinics offer 
rural veterans a full array of primary care services in communities 
where they live and work. VA has opened 717 new CBOCs since 1995.\2\ Of 
this total, 320 or 45 percent of these are located in rural or highly 
rural areas. Additionally, there are a number of rural outreach clinics 
that are operated by a parent CBOC to meet the needs of rural veterans. 
Furthermore, there are several additional outpatient clinics that, 
although located in more populated areas, are positioned to provide 
care for veterans in the surrounding rural communities. The fee-basis 
program, authorized under 38 U.S.C. 1703, also provides a local VAMC 
director with an option in meeting the needs of veterans.
---------------------------------------------------------------------------
    \2\ Nomenclature clarification: In 1995, the term used for access 
points was community-based or ambulatory clinic. In 2000, Community-
Based Outpatient Clinic or CBOC became the commonly used term.
---------------------------------------------------------------------------
    VA's current policy for the planning and activation of CBOCs 
ensures that new CBOCs meet VA's goal to improve access by current 
users by placing CBOCs in those areas where users travel significant 
distances and/or experience excessive travel time to access care.
    VA reviews and selects CBOCs through a national approval process 
based upon the proposals from VA Medical Centers and the Veterans 
Integrated Service Networks (VISNs). This process allows decisions 
regarding needs and priorities to be made in the context of local 
market circumstances and veterans' preferences.
    CBOC proposals are reviewed against national planning criteria 
including the needs of veterans living in rural areas. The planning 
criteria include items such as access standards that address veterans 
living in rural and highly rural areas, as well as additional 
considerations that include the impact of new CBOCs on waiting times, 
cost effectiveness, unique demographic or geographic considerations, 
current workload, quality of care, and enrollment decisions. As noted 
earlier, CBOC criteria do address unique demographic and geographic 
concerns such as geographic barriers, low population density, medically 
underserved or health manpower shortage areas which will enhance care 
for rural veterans. Criteria points are added for these unique 
considerations.
    VA reviews and revises its policy on the planning and activation of 
CBOCs annually and new planned CBOCs are centrally integrated into the 
annual development of resource and budget needs. VA is currently 
reviewing the CBOC criteria to emphasize those areas of the country 
that have less than 70 percent of enrollees within drive time standards 
to access care. (VA Drive Time standards recommend that 70 percent of 
market enrollees be within 30 minutes of primary care for veterans 
residing in urban and rural areas, and 60 minutes for those living in 
highly rural areas). VA will then use this information to develop 
infrastructure planning and budget needs.
MENTAL HEALTH SERVICES/SPECIAL NEEDS
    Comprehensive and effective mental healthcare is one of the top 
priorities for VA. The provision of mental healthcare in rural settings 
has historically been a challenge for all health systems and providers, 
including VA.
    VA is making changes to address these needs. In fiscal year 2005, 
VHA began an investment to improve access to mental health services 
throughout the entire VA healthcare system, in both rural and urban 
settings. Resources are funding services that are utilized by veterans 
living in rural areas, including expansion of telemental health 
programs to provide expert mental healthcare in rural areas, and 
providing an innovative rural Mental Heath Intensive Case Management 
program (MHICM-RANGE) where the population needing care was not large 
enough to require a full team.
    Some examples of VA's mental health program initiatives that will 
benefit rural veterans include:

      Integrating specialty mental healthcare into primary care 
and other medical settings;
      Continuing to expand access to specialty mental health 
services at all CBOCs, either by direct staffing, local contracts, or 
telehealth;
      Developing and piloting a model for rural areas for 
implementation of the concepts of the Mental Health Intensive Case 
Management (MHICM) programs; and
      Providing timely access for homeless veterans to mental 
health/substance abuse assessments.

    Performance Measure data indicates that as a result of our 
intensive efforts to expand services for rural veterans, veterans have 
access to service much nearer to home. In 1996, VA users of mental 
health services lived an average of 24 miles from the nearest VA 
clinic; as of 2006, they now live only 13.8 miles away (just half as 
far).
    These and other Performance Measures in Mental Health help to 
identify success related to the mental health initiatives and to 
identify areas for continued improvement. In relation to the needs of 
veterans in rural areas, we are especially committed to expanding 
telemental health resources, to provide the most effective opportunity 
for enabling even the smallest and most rural of the CBOCs to improve 
the quantity of their basic mental healthcare and also to improve 
access to more specialized mental health services when clinically 
appropriate.
HOMELESS PROVIDERS GRANT AND PER DIEM (GPD) PROGRAM
    VA Homeless Providers Grant and Per Diem (GPD) Program provides 
grants through a competitive process to community agencies providing 
services to homeless veterans. The purpose of the program is to promote 
the development and provision of supportive housing and/or services to 
help homeless veterans achieve residential stability, increase their 
skill levels and income, and independence. Efforts are made during 
funding cycles to award these grants recognizing geographic dispersion. 
Since GPD's inception, the program has funded more than 75 projects 
that are in rural locations. It is expected that these grants will 
support or create over 1,200 transitional housing beds for homeless 
veterans. Most of the grants were awarded to provide operational 
funding; however, grants were also awarded to assist in the renovation, 
acquisition, or construction of buildings to create facilities for the 
veterans who are homeless.
READJUSTMENT COUNSELING SERVICE/VET CENTERS
    The Vet Center program service mission is designed to provide 
quality readjustment counseling and to remove all unnecessary barriers 
to care for veterans and family members. The Vet Centers are community-
based facilities located at convenient locations within the community 
to promote ease of access for veterans and family members. All Vet 
Centers engage in extensive community outreach activities to directly 
contact and inform area veterans and to maintain active community 
partnerships with local leaders and service providers to facilitate 
referrals for veterans in need.
    Some Vet Centers are, by plan, established and maintained in rural 
areas, e.g., Grants Pass, OR; Caribou, ME; Missoula, MT; and Cheyenne, 
WY, to ensure that rural veterans and families have access to 
readjustment counseling services. Additionally, we have established Vet 
Center outstations in rural areas such as Cedar Rapids, IA; the 
Michigan's Upper Peninsula; and Keams Canyon, AZ on the Hopi 
Reservation. Outstations are administratively connected to a full sized 
Vet Center, utilize permanently leased space and are usually staffed by 
one or two counselors who provide full time services to area veterans 
on a regular weekly basis. The Vet Centers also maintain some 
nontraditional hours keeping the Vet Center open after normal business 
hours or on weekends to accommodate veterans traveling in from greater 
distances.
    Another important aspect of the Vet Center program for maintaining 
care for veterans in rural areas is to actively establish and maintain 
partnerships with other community providers such as State employment 
services, community substance abuse programs and healthcare providers 
such as Indian Health Service (IHS). The Vet Center program also 
maintains a contract program with over 300 private sector providers 
under contract with VA to deliver readjustment counseling to veterans 
living at a distance from existing Vet Centers. Some Vet Centers in 
rural areas have telehealth linkages to their support VAMC which 
provides veterans in more remote areas access to VA mental health and 
primary care. The Vet Centers in Santa Fe, NM; Logan, WV; and Chinle, 
AZ on the Navajo reservation are examples of such sites with active 
telehealth programs.
    Since the onset of hostilities in Afghanistan and Iraq, the Vet 
Centers have taken a lead role in providing outreach services to 
returning war veterans. Since 2003 through the first quarter of fiscal 
year 2007, the Vet Centers have provided services to 165,153 Operation 
Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) veterans. 
Following initial contact with Vet Center outreach workers at 
demobilization sites, many of these veterans disperse home to rural 
areas of the country. Without the initial Vet Center outreach contact, 
subsequent access to VA services would be far more of a challenge for 
many rural veterans.
    To further enhance services to the growing numbers of the new 
generation of returning warriors, VA announced, in February 2007, its 
plan to expand the Vet Center program. Site selections for new Centers 
were established based on evidence-based analysis of veteran 
demographic distributions. In addition, site selection for some of the 
new Vet Centers was based on special consideration for relatively 
underserved veterans residing in rural areas at a distance from other 
VA facilities. There have been 23 new Vet Centers identified to be 
opened, 8 of them, or approximately 23 percent, are in rural areas. 
Examples of Vet Centers planned to serve rural veteran populations in 
rural locations include: Grand Junction, CO; Manhattan, KS; Escanaba, 
MI; and Watertown, NY.
LTC/NURSING HOMES/DAY HEALTHCARE FACILITIES
    The demand for Long-Term Care (LTC), whether in rural or urban 
settings, has greatly increased due to the aging of the veteran 
population. VA LTC has evolved from services delivered primarily in 
geriatric clinics and inpatient nursing home settings to a well-defined 
spectrum of care, including an array of home and community-based care 
(HCBC) services.
    VA believes that LTC services should be provided in the least 
restrictive setting where services are appropriate to a veteran's 
health status, functional status, and personal circumstances, and, 
whenever possible, in HCBC non-institutional settings. We make every 
effort to identify options that maximize the veteran's ability to stay 
within the community for as long as possible. When nursing home care is 
needed, especially for a veteran residing in a rural area, VA 
identifies options for the patient from the broad spectrum of LTC 
venues available in the veteran's community, including the local State 
Veterans Home or contracted nursing home care. Contracts with rural 
community nursing homes are maintained so that beds are available when 
needed by veterans residing in rural areas.
    Newer options of VA geriatric healthcare that provide more 
opportunities for the veteran to stay close to home and family include: 
(1) Integration of Care Coordination and Home Telehealth into Home-
Based Primary Care to expand coverage into rural areas; (2) 
Collaboration with Administration on Aging and Indian Health Service 
for Home-Based Primary Care outreach and care giver support; (3) 
Promotion of Hospice-Veteran Partnerships to improve veteran access to 
community hospice care in rural areas; and (4) development of Medical 
Foster Home program, where veterans can receive an array of services 
including Home-Based Primary Care and community hospice care in a 
supportive home environment in their own community.
COLLABORATIONS
    In addition to our internal efforts outlined earlier, VA continues 
to look for ways to collaborate with complementary Federal efforts to 
address the needs of healthcare for rural veterans. We also have 
partnerships with HHS, including the Indian Health Service and Office 
of Rural Health providing healthcare in rural communities. We are also 
working to establish relationships with other entities, such as with 
the National Rural Health Association.
CONCLUSION
    Mr. Chairman, providing safe, effective, efficient and 
compassionate healthcare to our veterans, regardless of where they 
live, is the primary goal of the VHA. New technologies and better 
planning are allowing us to provide quality care in any location. VHA 
recognizes the importance and the challenge of service in rural areas, 
and we believe our current and planned efforts are addressing these 
concerns for our current and emerging veterans.
    Mr. Chairman, this concludes my statement. At this time I would be 
pleased to answer any questions that you may have.

                                 
                       SUBMISSIONS FOR THE RECORD

Statement of Hon. Corrine Brown, a Representative in Congress from the 
                            State of Florida
    Thank you, Mr. Chairman, for calling this hearing today.
    In my home State of Florida, we have a large amount of rural land 
and one of the largest populations of veterans in the country. Our 
veteran population is the oldest in the country.
    The wars we are currently fighting are using the National Guard and 
Reserves at a higher level than any other war. Many of the veterans 
coming back from OEF/OIF are not living in a traditionally military 
area. There are not a lot of retirees who served at the local base 
living nearby, creating a ready-made support group. These reserves go 
home. There are no support services nearby.
    What plans does the VA have to address these veterans 3, 4, 5 or 
more years down the road?
    We will hear from an expert from HHS which has been involved in 
rural healthcare for decades. What can the VA learn from this 
Department? Will you try to find out?
    I am pleased the VA is building a CBOC in my district in 
Gainesville. This will bring necessary mental health and other services 
to those veterans living in that area. However, we need more for them.
    I look forward to hearing the testimony from all the witnesses 
today.

                                 
  Statement of Hon. Henry E. Brown, Jr., a Representative in Congress 
                    from the State of South Carolina
    Chairman Michaud and Ranking Member Miller, thank you for calling 
this important hearing to address a continuing concern of this 
Committee: the challenges that many of our veterans face in accessing 
healthcare through the VA system. While my district is home to the 
Johnson VAMC in Charleston, a veteran from Myrtle Beach needing 
treatment or a test has to invest the larger part of an entire day for 
this visit. While treatment at our VA medical facilities is some of the 
best in the world, there is something about what I just said that 
doesn't make sense at all.
    Last Congress, when I served as Chairman of this Subcommittee, I 
was honored to travel up to Maine for a field hearing in Mr. Michaud's 
district to examine some of these very same challenges. During that 
hearing we discussed some of the serious challenges that rural veterans 
face--not because of lack of dollars--but simply because they live in 
rural areas.
    One of the messages that I came away from that hearing with is the 
need for Congress to continue to prod the VA forward in thinking 
outside the box to deliver care in innovative ways. We know the 
successful turnaround our VA hospitals have seen in the past decades. 
That turnaround required a commitment not just from Congress or the 
VA's political leadership, but a commitment from within the heart of 
the VA's bureaucracy.
    Technology certainly is a tool that can have an impact--especially 
in the case of the veteran in Myrtle Beach who now has to spend their 
entire day traveling to and from Charleston for a test. For veterans in 
Maine and other extremely rural areas, we need to look at collaborating 
further with local healthcare providers to provide care through the VA 
system. Collaboration has worked at the VAMC level across the country--
we should not be afraid of it across other areas of the VA system.
    Thank you again, Mr. Chairman, and I look forward to working with 
my colleagues and the VA to address the access needs of our veterans.

                                 
                     Statement of Hon. Jeff Miller
Ranking Republican Member, Subcommittee on Health, and a Representative 
                 in Congress from the State of Florida
    Rural America has a strong tradition of military service. According 
to the 2000 U.S. Census, rural and non-metropolitan counties have the 
highest concentration of veterans. Both my State of Florida and the 
Chairman Michaud's State of Maine are included in the top 18 States 
with a greater than average proportion of rural veterans.
    Not surprisingly, in the Global War on Terror, we continue to see a 
high rate of combat veterans from rural settings. About 41 percent of 
returning veterans from Operation Enduring Freedom and Operation Iraqi 
Freedom live in small communities.
    A study conducted by VA researchers, published in the Winter 2006 
Journal of Rural Health, ``corroborate a concern that living at a 
distance from regionalized healthcare implicitly restricts access to 
and utilization of health services. Veterans may have an additional 
healthcare option not available to the general public, but those 
veterans who live in non-metropolitan areas, far from regionalized high 
technology or specialized care, continue to experience substantial 
unmet needs, greater than those of veterans in metropolitan settings.''
    Central to VA's efforts to address access to healthcare in less 
populated settings has been the establishment of Community-Based 
Outpatient Clinic's (CBOCs). Today, VA operates about 700 CBOCs. The 
May 2004 Capital Asset Realignment for Enhanced Services (CARES) 
decision document provided a framework for prioritizing 156 new CBOCs 
to improve veteran's access to care. More than half of these new CBOCs 
were given priority because they were located in rural areas. Yet, of 
these recommended new sites of care, VA has opened only 12 and expects 
to activate only an additional 12 in 2007.
    CBOCs are important to improving geographic access to care. 
However, these primary care sites alone, cannot effectively overcome 
all the barriers that exist for rural veterans to obtain high quality 
care within their home community. Addressing the identified gaps in 
mental health services and specialty and acute hospital care, requires 
developing new approaches for delivering care. This includes the use of 
emerging technologies, partnering with existing non-VA rural healthcare 
providers and enhancing the training and recruitment of health 
professionals in rural communities.
    I thank Chairman Michaud for holding this hearing to examine how we 
can best ensure all veterans have access to services when and where 
they are needed.  With our current combat operations and an aging 
veteran population from previous wars, we can anticipate a substantial 
and rapid increase in demand for VA healthcare in rural areas. VA must 
step up to meet both the immediate physical and mental healthcare needs 
of all veterans and their families and bear in mind the special and 
unique rural healthcare delivery challenges in planning future 
services.
                 POST-HEARING QUESTIONS FOR THE RECORD

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                     Washington, DC
                                                        May 2, 2007

Michael J. Kussman, MD, MS, MACP
Acting Under Secretary for Health
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420

Dear Dr. Kussman:

    In reference to our Subcommittee on Health hearing ``Access to VA 
Healthcare: How Easy is it for Veterans--Addressing the Gaps'' held on 
April 18, 2007, I would appreciate it if you could answer the enclosed 
hearing questions by the close of business on June 5, 2007.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all full and 
Subcommittee hearings. Therefore, we would appreciate it if you would 
provide your answers consecutively and single-spaced. In addition, 
please restate the question in its entirety before the answer.

            Sincerely,
                                                 MICHAEL H. MICHAUD
                                                           Chairman
                               __________
   Questions from Hon. Michael H. Michaud, Chairman, Subcommittee on
   Health, to Dr. Michael Kussman, Acting Under Secretary of Health,
  Veterans Health Administration, U.S. Department of Veterans Affairs
        ``Access to VA Healthcare: How Easy is it for Veterans--
                         Addressing the Gaps''
    Question 1: Providing Healthcare in a Rural Setting. Forty-one 
percent of the 5.4 million veterans that VA treated in fiscal year 2006 
were from rural or highly rural areas. That is a pretty significant 
portion of the population that VA provides services to. Additionally, 
over 40 percent of the returning OEF/OIF veterans are from rural areas:

    Question 1(a): What do you believe is a reasonable expectation of 
care for these 2.2 million veterans?

    Response: The Department of Veterans Affairs (VA) believes 
reasonable expectations for healthcare for veterans who reside in rural 
areas fall into two broad categories; access and delivery of 
appropriate services.
    To ensure reasonable access, Veterans Health Administration (VHA) 
uses established guidelines of drive time to access care. For rural 
veterans: 70 percent of patients should be within 30 minutes to primary 
care, and 65 percent of patients should be with 90 minutes to acute 
care and 240 minutes to tertiary care. For highly rural areas, 70 
percent of patients should be within 60 minutes to primary care, and 65 
percent of patients should be within 120 minutes to acute care and 
tertiary care is based on the standard for that area.
    Regarding healthcare delivery, VHA is committed to providing a full 
range of services as outlined in the medical benefits package. This 
includes a standard health benefits plan available to all enrolled 
veterans. The plan emphasizes preventive and primary care, and offers a 
full range of outpatient and inpatient services within VA healthcare 
system. (http://www.va.gov/healtheligibility/coveredservices/
StandardBenefits.asp)
    VHA will continue to provide care consistent with our access 
guidelines and review these guidelines as needs change.

    Question 1(b): What level of care do you believe should be easily 
accessible to these veterans, including specific services?

    Response: VA believes primary care services, general medical and 
preventative services including mental health, should be easily 
accessible. VA supports providing high quality care balancing access 
requirements within our appropriated budget.

    Question 1(c): If you had to draw a line--where would you draw it--
and say, VA can't provide that care?

    Response: VA will honor its obligation to provide a full range of 
services to enrolled veterans within our appropriated budget. VHA will 
first provide services to enrollees through its network of healthcare 
facilities ranging from primary care services to tertiary care 
services.
    If VA is unable to provide care, care may be purchased by VA in the 
community, as determined appropriate by the VA Medical Center based on 
the particular clinical circumstance.

    Question 2: Telehealth. Your testimony elaborates on the VA's care 
coordination/home telehealth programs.

    Question 2(a): What are some of the challenges that VA is facing in 
procuring equipment that is standard throughout the system for these 
programs?

    Response: The challenges that VA faces procuring technology that is 
standard for home telehealth fit into two broad categories: (1) 
equipment interoperability and (2) scalability of technology. The home 
telehealth industry is relatively small and emerging. When it is 
appropriate to do so, VA is working with the vendor community to ensure 
systems are interoperable and to extend the functionalities available 
to support the care of veteran patients in their own homes.
    VA has a very large installed base of home telehealth technologies 
with which to support the timely care of veteran patients in their own 
homes. The home telehealth network VA has created is unprecedented in 
size and complexity. As this network continues to grow, VA is working 
with the vendor community to ensure systems are robust, sustainable, 
and compatible.

    Question 2(b): Please elaborate on the telecommunications 
strategies VA is currently working on to facilitate the provision of 
CCHT services in rural areas to improve access and reduce travel times 
for veterans?

    Response: In the first phase of its national care coordination home 
telehealth (CCHT) expansion--2004-2008--VA has relied upon telephone 
connectivity to veteran's homes. This strategy was pursued because: (1) 
telephone lines were relatively ubiquitous, (2) it was the dominant 
telecommunication infrastructure chosen by the vendor community, (3) 
ease of installation for patients and staff and (4) staff and patients 
had the technical skills necessary to ``troubleshoot'' any problems. VA 
is now considering how other telecommunications modalities could help 
support the care of veteran patients when telephone lines are not 
available or adequate. Ease of use by patients and staff continues to 
remain of paramount concern as VA continues to explore such future 
options.

    Question 2(c): What is the actual number of veterans taking 
advantage of the CCHT services? What percentage does that represent in 
the overall veteran population that VA treats?

    Response: On May 5, 2007, CCHT programs in VA were supporting 
25,556 patients nationally. This number represents 0.1 percent of the 
total population VHA treats. However, this CCHT figure represents 50 
percent of the population of patients with chronic disease for which 
the program was implemented to provide care. Given the necessary 
evolution of the technology and attendant clinical and business support 
processes, a possible 1.1 million (20 percent) of veterans could 
benefit from such assistive devices in the home.

    Question 3: CBOCs. In the last CBOC report received by this 
Subcommittee, dated March 30, 2007, VA reported a growth of 8 percent 
over the last 3 years in the activation of the 156 priority CBOCs that 
were listed in the CARES Decision of May 2004. At that rate it will 
take 30 years to open these 156. Realizing that VISNs can propose the 
activation of CBOCs not in the CARES document:

    Question 3(a): Do you think that a pace of 8 percent over 3 years 
is going to be effective?

    Response: The Capital Asset Realignment for Enhanced Services 
(CARES) decision document indicated a plan to have all 156 open by 2012 
(pending availability of resources and validation with the most current 
data available). In fiscal year (FY) 2007, after data validation, only 
CARES priority Community-Based Outpatient Clinics (CBOCs), or newly 
identified CBOCs that met the CARES priority criteria were placed on 
the list to open.
    The newly identified CBOCs had to meet one of the following CARES 
priority criteria. The CBOC must be:

      Located in a market with less than 70 percent of 
enrollees within access guidelines, and having more than 7,000 clinic 
stops planned for the CBOC.
      Located in a market with less than 70 percent of 
enrollees within access guidelines, and located in a rural or highly 
rural county.
      Part of a Department of Defense (000) collaboration.
      Needed for a CARES realignment decision.
      Needed to relieve space constraints at the parent 
facility and located within 20 minutes of the parent facility.

    As of May 25, 2007, VA has opened or approved to open 88 CBOCs. The 
following list shows where they are and when they are scheduled to open 
in FY 2007 or 2008.


--------------------------------------------------------------------------------------------------------------------------------------------------------
                               VISN                                               Clinic                  State       Approved             Status
--------------------------------------------------------------------------------------------------------------------------------------------------------
   2                                                                                           Warsaw         NY          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                           Bangor         PA          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                            Dover         DE          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                          Fayette         PA          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                       Gloucester         NJ          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                      Monongalia County   WV          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                          Venango         PA          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                           Warren         PA          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   5                                                                                      Andrews AFB         MD          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   5                                                                                      Ft. Detrick         MD          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   6                                                                                                 CharlotteVAille      May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   6                                                                                         Franklin          NC         Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   6                                                                                           Hamlet          NC         Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   6                                                                                          Hickory          NC         Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   6                                                                                        Lynchburg         VA          Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   6                                                                                          Norfolk         VA          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                            Aiken          SC         May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                           Athens         GA          Mar-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                         Bessemer         AL          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                                 ChildersbALg         May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                           Goose Creek     SC         Sep-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                      Spartanburg          SC         May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                      Stockbridge         GA          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   8                                                                                                 Camden CoGAty        May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   8                                                                                         Jackson County   FL          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   8                                                                                          Putnam County   FL          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   8                                                                             Sumter--The Villages         FL          Sep-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                            Berea         KY          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                                 CovingtonTN          Sep-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                           Dupont         KY          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                         Grayson County   KY          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                          Hamblen         TN          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                         Hawkins County   TN          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                           Hazard         KY          Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                         Madison County   TN          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                  Memphis--South Clinic   TN          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                       Standiford         KY          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                        Vine Hill         TN          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                         Morehead         KY          Sep-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                                 CambridgeOH          Mar-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                  Florence/Boone City     KY          Mar-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                         Hamilton         OH          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                           Marion         OH          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                 New Philadelphia         OH          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                           Newark         OH          Mar-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                            Parma         OH          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                          Ravenna         OH          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  11                                                                                          Alpena County   MI          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  11                                                                                                 Clare CouMIy         May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  11                                                                                         Elkhart County   IN          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  15                                                                                         Daviess County   KY          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  15                                                                                          Graves County   KY          Sep-04      Opening in FY2009
--------------------------------------------------------------------------------------------------------------------------------------------------------
  15                                                                                         Hopkins County   KY          Sep-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  15                                                                                       Hutchinson         KS          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  15                                                                                       Jefferson City     MO          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  15                                                                                            Knox County   IN          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                          Branson         MO          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                                 Conroe   TX          Mar-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                            Eglin         FL          Feb-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                          Hammond         LA          Feb-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                La Place/St Johns         LA          Feb-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                       Pine Bluff         AR          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                          Slidell         LA          Feb-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  17                                                                        San Antonio--VA/DoD Joint         TX          Sep-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  18                                                                                      Miami/Globe         AZ          Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  18                                                                                        NW Tucson         AZ          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  18                                                                                        SE Tucson         AZ          Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  19                                                                                                 Cut Bank MT          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  19                                                                                        Lewistown         MT          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  19                                                                               Western Salt Lake City VallUT          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  20                                                                                                 Canyon CiID          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  20                                                                                      North Idaho         ID          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  20                                                                                     Northwest WA         WA          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  20                                                                                                 Central WWAhington   Feb-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  21                                                                                   American Samoa                     Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  21                                                                                           Fallon         NV          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  22                                                                                           Orange           CA        Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                         Bellevue         NE          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                 Bemidji--Fosston         MN          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                                 Carroll  IA          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                                 Cedar RapIAs         May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                        Holdredge         NE          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                     Marshalltown         IA          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                       Shenandoah         IA          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                      Spirit Lake         IA          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                           Wagner         SD          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                        Watertown         SD          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                           Western WI (Rice Lake)         WI          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------


    Question 3(b): What do you think the pace should be?

    Response: We believe the current pace is reasonable. It is 
important that VHA grow at a manageable rate as the organization 
continues to make significant improvements to access.

    Question 3(c): Do you believe the cumbersome planning and 
activation process currently in place at VA is a stopgap for those 
medical centers who serve the rural community?

    Response: The difficulty in opening a CBOC in rural markets is 
related to the unique challenges in providing care in remote areas. 
Staff are at times difficult to hire, and partners or other contracting 
entities are scarce. VA is constantly exploring and establishing 
alternatives to CBOCs to provide care in these rural communities such 
as outreach clinics and telemedicine capabilities.

    Question 3(d): How would you streamline the process so rural 
veterans are not waiting 25 years for a CBOC to be activated in their 
area?

    Response: As evidence of the fact that improving access in rural 
areas is a high priority for VHA, of the 156 CBOCs on the priority 
list, 103 are in rural areas. In some rural areas, as noted above, 
outreach clinics may be more appropriate than a CBOC due to the unique 
challenges in these remote areas.

    Question 3(e): What good did the prioritization of the CBOCs do if 
VA is not following their own plan? What is the role of the priority 
list if the VA opens clinics not on the priority list?

    Response: In FY 2007, only CARES priority CBOCs, or newly 
identified CBOCs that met the CARES priority criteria were placed on 
the list to be considered. As veteran populations and demographics are 
constantly changing, some of the CARES priority CBOCs will no longer 
meet the criteria, while alternative locations meet the criteria and 
the needs of the patient population served. VA will continually need to 
update the plans for establishing additional CBOCs in order to reflect 
the changes in veteran population, as well as advances in healthcare 
delivery practices.

    Question 4: Access to Transportation. The issue of access to 
transportation is vital to providing healthcare to veterans in rural 
communities.

    Question 4(a): With the veteran population aging and increasingly 
rural, how can VA better connect veterans with their ongoing healthcare 
needs?

    Response: Technological advancements are, and will continue to be, 
the primary way that VA can better connect with veterans, in their own 
homes, to deliver healthcare services. VHA's Office of Care 
Coordination oversees VA's CCHT program. This program uses a variety of 
home-telehealth technologies to monitor the care of patients with 
chronic conditions directly from their homes. The CCHT program 
encourages patient self-management and a national network of care 
coordinators in every Veterans Integrated Service Network (VISN) 
facilitates access to appropriate care across the continuum.
    VA has a variety of arrangements across the system for 
transportation assistance. VA operates more than 1,300 vans donated 
primarily by service organizations, which assist in bringing veterans 
into VHA facilities. Once donated, VA maintains these vans, assists 
with recruiting volunteer drivers, and has developed a training and 
medical clearance program for all volunteers. Today, VA has almost 
10,000 volunteers that have donated more than 1.8 million hours to 
serve as volunteer drivers.
    Further assistance in transportation is provided by the local 
healthcare system and varies depending on the ability to secure donated 
vans and volunteer drivers and the need of the veteran patient. Some 
systems use an `out-placed van' method where they have pre-determined 
pick-up stops and/or will pick up a veteran at their home to bring them 
into a VA facility for appointments or services. Others operate a 
shuttle service between their facilities, with some including stops at 
pre-determined pick-up locations.

    Question 4(b): Has the agency looked to review partnerships with 
community-based public transportation systems operating in these areas?
    Response: At the national level, a partnership with community-based 
public transportation systems has not been addressed. However, at the 
local level, VA healthcare systems work with localities to assist with 
transportation. Examples of this are providing bus and/or train passes 
for veterans needing transportation.

    Question 5: Interventions to Improve Healthcare in Rural America. 
In a study done in 2005, the Institute of Medicine found that a wide 
range of interventions are available to improve health and healthcare 
in rural America, such as education, community and environmental 
planning. Making explicit the full range of options available to rural 
communities to improve personal and population health should lead to 
more optimal allocation of scarce financial.

    Question 5(a): Has the VA implemented any interventions to improve 
personal or population health among the rural veteran population?

    Response: To address both personal and population health, VHA's 
Office of Public Health and Environmental Hazards has several strategic 
healthcare groups that have implemented programs and policies to 
improve the health of rural veterans.
    In particular, the Public Health Strategic Healthcare Group, 
(PHSHCG) has addressed the needs of enrolled veterans living with human 
immunodeficiency virus (HIV) residing in rural areas. For example, 
employing a postage paid mail-back card allowing patients to self 
report results of purified protein derivative (PPD) testing (for 
exposure to mycobacterium tuberculosis), eliminates the need for rural 
patients to make a return visit to the medical center. Care delivery 
models which allow patients in rural areas to locally access routine 
services such as blood specimen drawing through modification of CBOC 
contracts and/or linkage with community-based programs located in rural 
areas have been implemented.
    Additionally, the Women Veterans Strategic Healthcare Group, which 
is committed to providing the highest quality care to women veterans, 
has continued to advocate for access for women's gender related care, 
such as mammograms and obstetrical care must be provided within 1 hour 
drive/50 miles, using non-VA providers when necessary (Handbook 
1330.01, Proposed revisions 2007).
    Through their work in national programs to improve the health of 
all veterans, these strategic healthcare groups have implemented 
programs and policies to improve the health of rural veterans.
    The Department of Health and Human Services (HHS) and VA signed a 
memorandum of understanding (MOU) in February 2003 to encourage 
cooperation and resource sharing between the Indian Health Service 
(IHS) and the VHA to deliver quality healthcare services and enhance 
the health status of American Indian and Alaska Native (AI/AN) 
veterans.
    Outreach: Most networks are engaged in a variety of outreach 
activities, including meetings and conferences with IHS program and 
tribal representatives, VA membership in the Native American Healthcare 
Network, VA participation in traditional Native American ceremonies, 
transportation support to AI/AN, etc.
    Clinical Programs: An example of clinical collaborations involves a 
diabetes prevention program that has been developed jointly by VHA and 
IHS staff in San Diego, Albuquerque, and Greater LA. The goal is to 
reach Native Americans in their communities.
    Education: VHA provides training programs to IHS staff and the 
tribal community. In 2006, VHA delivered 145 training programs, of 
which 90 were made available using satellite technology and 55 using 
web-based technology. These educational programs will be continued in 
2007, and VHA will also provide selected IHS staff an opportunity to 
attend regional workshops.
    Behavioral Health: The Behavioral Health Workgroup developed a 
framework for AI/AN communities to assist returning Operations Enduring 
Freedom and Iraqi Freedom (OEF/OIF) AI/AN servicemembers and veterans 
reintegrate with their families and communities and readjust to 
civilian life. The objective is to promote a community health model 
that gives tools to Tribal communities and families to help returning 
veterans address emerging adjustment reactions, traumatic stress, and 
post traumatic stress disorder (PTSD), emphasizing recovery as the 
goal. The Joint Committee has developed a slide presentation to be used 
by outreach teams when addressing various Tribal veterans. There have 
been briefings using the slide presentation in Montana, with 
approximately 30 veterans now receiving services from VA.
    Expanded Healthcare Services: At the local level, 10 VHA networks 
are engaged in targeted initiatives aimed at providing a full continuum 
of healthcare services, such as; health fairs, VA/IHS advisories, use 
of health buddy, and education and/or shared services in substance 
abuse, domestic violence programs, cardiac rehabilitation, dietetics, 
behavioral medicine, etc.
    Care Coordination: The VHA-IHS Shared Healthcare Workgroup has 
drafted an Interdepartmental Coordinated Care Policy, the goal of which 
is to optimize the quality, appropriateness and efficacy of the 
healthcare services provided to eligible AI/AN veterans receiving care 
from both VHA and IHS or Tribes; and to improve the patient's 
satisfaction with the coordination of care between the two Departments.
    Telemedicine: Telemedicine has proven to be extremely effective in 
the treatment of PTSD in Alaskan Native villages. VA and IHS are 
working to spread the use of telemedicine services by AI/AN veterans, 
which will allow VA to bring physical and mental healthcare to the 
tribes, especially those in remote areas of the country.
    Traditional Healing: Some VHA facilities and vet centers have 
incorporated traditional healing ceremonies along with modern methods 
of treatment and counseling. As a national initiative, VA has sent over 
500 letters to tribal leaders to ask them to provide information on 
appropriate providers of traditional practices so that they may be 
called upon for religious/spiritual care of AI/AN veterans.

    Question 5(b): Has VA collaborated with HRSA on any of these 
interventions?

    Response: The Institute of Medicine (IOM) 2005 report Quality 
Through Collaboration: The Future of Rural Healthcare did not 
specifically recommend how rural veterans would benefit from a health 
resources and services administration (HRSA), collaboration, however, 
VHA has collaborated with Health and Human Services to address rural 
veterans in several ways; we currently have a small number of contracts 
with federally qualified health centers (FQHCs) and we have a MOU with 
IHS.
    In addition, rural veterans with HIV who live at a great distance 
from the closest VA Medical Center were informed that they were 
eligible to receive HIV/AIDS care through community-based HRSA clinics 
who were recipients of Ryan White funding, if this care would be more 
convenient for them.

    Question 6: Hospital-at-Home. Since 1994, Johns Hopkins Hospital 
has been developing a hospital-at-home model. In 2005, new research 
released suggested that many of the patients could be treated just as 
safely and effectively at home than in a hospital.

    Question 6(a): Do you believe a program like this would work in 
rural areas?

    Response: The work of Johns Hopkins Hospital in this area is 
commendable and adds to the weight of evidence supporting the direct 
provision of care in the home to acutely ill older patients, when it is 
safe and appropriate to do so. Caring for acutely ill patients via a 
hospital-at-home program is an outreach program that is geographically 
restricted to a defined radius (e.g. 25 miles) or set travel time (e.g. 
20 minutes) from a suitably equipped acute hospital. As such, hospital-
at-home models as currently conceived are not a readily deployable 
model for care in rural areas where distance, low population density 
and staff recruitment issues make them difficult to implement. VA is 
seeking to use telehealth to monitor such rural health patients and 
enable them to self-manage their condition. This approach relies upon 
early detection of patient deterioration and preemptive referral of 
patients across the continuum of care. VHA's care coordination model is 
conducive to this approach.
    Although this may not be a model for all geographic areas, staffs 
in the Office of Geriatrics and Extended Care who are charged with both 
community-based care and with acute care for the elderly are interested 
in promoting expansion of this model, as appropriate, within VA. Plans 
are underway to initiate a hospital-at-home program at the New Orleans 
VA by July 1 to partially address the shortage of VA hospital beds due 
to Hurricane Katrina. Discussions have begun to explore a similar 
undertaking in Honolulu, with possibly broader application throughout 
the Hawaiian Island chain. Rural expansion from an urban center on 
Oahu, and one based out of CBOCs as has been already discussed as a 
second phase for New Orleans, will be logical next steps for assessing 
the feasibility of migration of the model into more rural settings.

    Question 7: Partnerships. To what extent is VA working with 
existing state and federal healthcare providers, for example State 
veterans homes or CMS designated Critical Access Hospitals, in rural 
areas to coordinate and capitalize on limited resources available in 
rural communities to maximize range of services? If this is not 
occurring, is VA willing to explore coordinated efforts with these 
types of government supported healthcare providers?

    Response: VHA has united with existing State and Federal healthcare 
providers to coordinate and capitalize on resources available in rural 
communities and to maximize the range of services. Currently, VHA has a 
relationship with 122 State-owned veteran's homes, 54 domiciliaries, 4 
hospitals, and 2 adult daycare facilities. VA provides a per diem 
payment to the facilities for veterans care. Approximately 75 of VA's 
State home collaborations are in rural areas.
    VHA also collaborates with FQHCs, including Community Health 
Centers, at the local level based on the local needs. VA will continue 
to collaborate and develop partnerships with various government and 
nongovernmental organizations to meet the individual needs of veterans.
    VHA will continue to partner with other agencies, including 
collaboration by education and training on issues specific to providing 
care to veterans. Through VHA's Office of Rural Health, we will further 
explore ways to expand healthcare in rural areas.

                                 
       Questions from Hon. Joe Donnelly to Dr. Michael J. Kussman
 Acting Under Secretary for Health, U.S. Department of Veterans Affairs
    Question 8: Elkhart County CBOC. Convenient access to local 
healthcare for veterans is an important concern of both my constituents 
and of this Committee. While the CARES Commission of 2004 set out 
future priorities for facility management, CARES recommendations are 
not always followed and are sometimes altered. Through conversations my 
office and I have had with VA VISN 11 officials in Indiana, it is our 
shared expectation to soon open a CBOC in Elkhart County, Indiana. 
While an Elkhart County CBOC opening does not appear on the CARES 
priority recommendations, according to these officials, the proposal to 
open a CBOC in Elkhart County has successfully passed several 
preliminary stages within the Department and is pending final approval 
by the Secretary. VA officials in Indiana are optimistic that the 
opening of a new CBOC could begin in early FY 2008. Further, if a new 
CBOC is opened in Elkhart County, some constituents of mine are 
concerned that the VA will require some veterans who live within the 
county to receive care at a CBOC located in another county.

    Question 8(a): Is the VA considering opening a new CBOC in Elkhart 
County, Indiana? If so, at what stage in the process is this decision; 
and if approved, when can the people of Elkhart County expect the 
opening of the bidding process for management of the CBOC?

    Response: The Elkhart County CBOC has been approved. Local VA 
officials are working on the activation of the clinic. We will keep all 
stakeholders informed as this proceeds.

    Question 8(b): If a CBOC is opened in Elkhart County, will all 
Elkhart County veterans have the opportunity to choose to receive care 
at this new facility?

    Response: The service area for the proposed Elkhart County CBOC 
includes 100 percent of Elkhart County. All veterans within the county 
may request care at the CBOC and will be accommodated based on 
eligibility, clinic capacity, and the care requirements of the Veteran.

    Question 9: Peru, Indiana CBOC. The Secretary's CARES Decision 
included Peru, Indiana on the list of CBOC priority implementation. 
Officials at VA VISN 11 hope that a new CBOC could be opened in the 
Peru area during FY 2009. Is the VA considering opening a new CBOC in 
Peru, Indiana? If so, at what stage in the approval process is this 
decision; and if approved, when can the people of north central Indiana 
expect this CBOC to open?

    Response: A business plan has not been prepared by the VISN for a 
CBOC in Peru, Indiana. The earliest that a CBOC for Peru could be 
requested would be in FY 2009 and a business plan would be prepared at 
that time.

    Question 10: Fort Wayne Campus. The CARES Commission 2004 report 
proposed closing the acute care and lieu services provided at the Fort 
Wayne campus of the VA Northern Indiana Healthcare System, citing the 
availability of tertiary care at VA facilities at Ann Arbor and 
Indianapolis and initial low projections of anticipated demand for 
inpatient care. However, since the report was published, projections 
were updated and actually showed higher usage rates for the future. It 
is my understanding that, as a result, the VA is reexamining the 2004 
report's proposal regarding Fort Wayne. Many veterans in my district, 
as well as many thousands more from across northern Indiana have come 
to count on high-quality care and valuable patient-provider 
relationships formed at the Fort Wayne inpatient facilities for meeting 
their health needs. Further, directing veterans in northern Indiana to 
seek care in Ann Arbor or Indianapolis would be a significant new 
hurdle in receiving VA medical services. In light of the new 
projections for the future use of the Fort Wayne inpatient services, 
and the thousands of new Hoosier veterans who will need care connected 
to their service in Operation Iraqi Freedom or Operation Enduring 
Freedom, it seems to me that limiting the services provide by Fort 
Wayne now would be counter-intuitive.

    Question 10(a): What factors are being considered in the 
reevaluation of the 2004 recommendation on Fort Wayne?

    Response: Factors that are being considered in the analysis of 
options for Fort Wayne include:

      Access: Considers barriers whether imposed by geography, 
disability, finances, or simply a lack of available services which can 
compromise the quality, satisfaction, and coordination of care, 
resulting in poor outcomes.
      Flexibility: Measures each options ability to manage 
change in demand.
      Cost Effectiveness: Evaluates the total life cycle costs 
for a project and then compares it against other viable project 
alternatives.
      Impact on Other VA Goals/Missions: Measures the impact on 
other VA goals/Missions.
      Risk of Implementation: Assesses risk on two dimensions, 
the probability that the risk will occur and the impact of the risk. 
Twenty-five individual risk factors are identified.

    Question 10(b): When does the Department anticipate making a 
permanent decision regarding the services provided by the Fort Wayne VA 
hospital?

    Response: The contractor will be submitting their final report in 
August, 2007. The Secretary will make a decision after this time.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                     Washington, DC
                                                     April 27, 2007

Michael J. Kussman, MD, MS, MACP
Acting Under Secretary for Health
U.S. Department of Veterans Affairs
Washington, DC 20420

Dear Dr. Kussman:

    On Wednesday, April 18, 2007, Dr. Gerald Cross testified before the 
Subcommittee on Health. As a followup to the hearing, I am requesting 
the following questions be answered in written form for the record:

     1.  Please describe the process that VA undergoes to develop a new 
Community-Based Outpatient Clinic (CBOC) and obtain all necessary 
approvals. How long does each phase of that process take?
     2.  Have any new CBOCs been proposed since the May '04 CARES 
report? Please identify where they are, and when they are scheduled to 
be activated.
     3.  Have decisions been made not to proceed with any of the 156 
CBOCs proposed in the May '04 CARES report? If so, please explain 
further.
     4.  Does VA currently impose enrollment limits or caps on CBOCs? 
If so, how does that work?
     5.  How would you characterize the limitations on marketing new 
CBOC enrollments? How is that implemented logistically?
     6.  What happens if OEF/OIF veterans want to enroll in a CBOC that 
has been prevented from enrolling additional new veterans?
     7.  Some CBOCs offer mental health services through VA staff and 
others though contractor personnel. What are the criteria that 
determine who provides mental health services in a given location?
     8.  What is the average length of time it takes for a contract 
provider to be credentialed by VA? Are there any significant issues 
that cause delays in provider credentialing throughout VA?
     9.  Mr. Behrman testified that there were a limited number of 
successful collaborations between VA and Community Health Centers. 
However, the contracts were discontinued. Why were these contracts 
discontinued? Should this type of partnership be expanded to other 
rural States?
    10.  Has VA established policies whereby VA will contract with 
Critical Access Hospitals and other primary care providers in rural 
areas to provide primary and preventive healthcare to rural veterans 
who lack reasonable access to VA facilities?
    11.  Does VA have performance measures in place to evaluate how 
effective the Vet Center program is in providing quality readjustment 
counseling and removing unnecessary barriers to care for veterans and 
family members?
    12.  VA's testimony stated: ``VA continues to look for ways to 
collaborate with complementary Federal efforts to address the needs of 
healthcare for rural veterans. We also have partnerships with HHS, 
including the Indian Health Services and Office of Rural Health 
providing care in rural communities.'' Where are the current 
collaborative efforts?
    13.  What percent of rural healthcare is provided through contract 
care?
    14.  What are the challenges of providing care to the aging veteran 
population in rural areas? How is VA addressing these challenges?
    15.  How does VA differentiate between a rural veteran traveling 
over an hour to a healthcare facility, and a veteran in an urban area 
traveling over an hour to a healthcare clinic in rush hour?
    16.  Public Law 109-461 directs the Secretary to expand mental 
health services in outpatient clinics. What is VA doing to expand this 
capability? How many CBOCs had mental health capabilities in April 2005 
and how many have mental health capabilities today?
    17.  What are the challenges in providing mental health services in 
rural communities?
    18.  VA Central Office reviews waiting times. How do the waiting 
times for specialty care in rural areas compare with those in urban 
centers?
    19.  Musculoskeletal ailments (principally joint and back 
disorders) are among the top health problems of veterans returning from 
Iraq and Afghanistan according to a November 2006 VA study. Currently, 
chiropractic care is only available at about 20% of all VA facilities 
and most veterans do not have access to care, despite back issues being 
the ailment that affects the most veterans. Has the VA developed plans 
on how to further implement chiropractic care into the VA healthcare 
system?
    20.  What is the status--and, if available, the initial findings--
of the VA's Project HERO demonstration project?
    21.  The VA's March 30th report to Congress detailing CBOCs 
approved for activation only lists 6 CBOCs approved for an FY08 
opening. Will more be approved? Was the proposed VISN-approved CBOC for 
Hutchinson, KS turned down or is it still under consideration by the 
VA?

    Additionally, Dr. Petzel and Dr. Darkins accompanied Dr. Cross. I 
would request that they respond to the following for the record:

     1.  Dr. Petzel: One may consider VISN 23 as one of the most rural 
VISNs in the VA system. How has VISN 23 improved access for veterans? 
Have you been working with other VISN Directors to share some of the 
best practices from VISN 23 in providing access to veterans?
     2.  Dr. Darkins: How can telemedicine help provide access to 
veterans? What are the limitations of telemedicine? Are there any 
circumstances in which you would not recommend the use of telemedicine?

            Respectfully,
                                                        Jeff Miller
                                          Ranking Republican Member
                               __________
       Questions from Hon. Jeff Miller, Ranking Republican Member
         Subcommittee on Health, to Dr. Michael Kussman, Acting
       Under Secretary of Health, Veterans Health Administration
                  U.S. Department of Veterans Affairs
    Question 1(a): Please describe the process that VA undergoes to 
develop a new Community-Based Outpatient Clinic (CBOC) and obtain all 
necessary approvals.

    Response: Planning process. CBOC planning is a partnership between 
the Veterans Integrated Service Networks (VISN) and Headquarters' 
strategic planning process. This allows decisions regarding CBOC need 
and priorities to be made in the context of available resources, as 
well as local market circumstances and veteran preferences. During the 
Capital Asset Realignment for Enhanced Service (CARES) planning 
process, the VISNs identified 242 CBOCs to potentially address access 
and space issues. Of these 242 CBOCs, 156 were prioritized and 
published in the Secretary's CARES Decision Document in April 2004 
since they met the requirements of:

      Located in a market with less than 70 percent of 
enrollees within the access guidelines (distance a veteran is required 
to travel to receive care) and having more than 7 DoD Clinic Stops 
planned for the CBOC.
      Located in a market with less than 70 percent of 
enrollees within access guidelines, and located in a rural or highly 
rural county.
      Part of a VA/Department of Defense (DoD) collaboration.
      Needed as a result of a CARES realignment decision.
      Needed to relieve space constraints at the parent 
facility and located within 20 minutes of the parent facility.

    Plans for activating CBOCs are included in the VISNs' strategic 
plans, and are updated with the most current data after the strategic 
plan submission at the request of the Deputy Under Secretary for Health 
for Operations and Management (DUSHOM) for the purposes of forecasting 
activation of CBOCs for budget cycles. CBOCs are primarily funded 
through existing VISN resources. As a result, planning for CBOCs is 
also dependant on fiscal year (FY) budget forecasts and allocations. 
VISN chief fiscal officers must certify that the facility can maintain 
services given current budget scenarios at the time the CBOC business 
plan is being reviewed against national planning criteria.
    Review process. The review process for new CBOCs is documented in 
the Veteran Health Administration (VHA) Handbook 1006.1 Planning and 
Activation of CBOCs and consists of the following:

      VISNs submit CBOC business plans for review against 
national planning criteria. VISNs submit plans for CBOCs that were (1) 
identified in CARES, (2) identified in the network strategic plan and/
or updates provided to DUSHOM on plans for CBOC activation. VISNs 
certify that the CBOC can be implemented within existing funds once 
approved.
      National review panels (NRP) convene to review proposals 
against national planning criteria as below:

      Located in a market not meeting VA access guidelines
      Space deficits at the parent facility
      Number of users and enrollees
      Market penetration
      Unique considerations--such as: targeted minority veteran 
populations, geographic barriers, highly rural and/or low population 
density, medically underserved, DoD sharing opportunity, parking and 
transit issues at parent facility
      Cost effectiveness of proposed site
      Impact on specialty care waiting times
      The NRP submits results of review with recommendations to 
DUSHOM.

    Approval: Business plans for new CBOCs that are recommended for 
approval by the national review panel require Under Secretary for 
Health (USH) and Secretary approvals and Congressional notification. 
The process is as follows:

      DUSHOM obtains approvals from USH and Secretary
      Office of Management and Budget (OMB) review
      Congressional notification

    Question 1(b): How long does each phase of that process take?

    Response: Timeframes involved in the review process are estimated 
below:

      Develop CBOC business plans:
                                      2-3 months
      NPR review:
                                      3 months
      USH and Secretary approval:
                                      2-3 months

    Question 2: Have any new CBOCs been proposed since the May '04 
CARES report? Please identify where they are, and when they are 
scheduled to be activated.

    Response: Since the May 2004 CARES report, VA has opened or 
approved to open 88 CBOCs. The following list shows where they are and 
when they are scheduled to open in FY 2007 or 2008.


--------------------------------------------------------------------------------------------------------------------------------------------------------
                               VISN                                               Clinic                  State       Approved             Status
--------------------------------------------------------------------------------------------------------------------------------------------------------
   2                                                                                           Warsaw         NY          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                           Bangor         PA          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                            Dover         DE          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                          Fayette         PA          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                       Gloucester         NJ          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                      Monongalia County   WV          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                          Venango         PA          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   4                                                                                           Warren         PA          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   5                                                                                      Andrews AFB         MD          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   5                                                                                      Ft. Detrick         MD          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   6                                                                                                 CharlotteVAille      May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   6                                                                                         Franklin          NC         Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   6                                                                                           Hamlet          NC         Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   6                                                                                          Hickory          NC         Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   6                                                                                        Lynchburg         VA          Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   6                                                                                          Norfolk         VA          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                            Aiken          SC         May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                           Athens         GA          Mar-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                         Bessemer         AL          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                                 ChildersbALg         May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                           Goose Creek     SC         Sep-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                      Spartanburg          SC         May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   7                                                                                      Stockbridge         GA          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   8                                                                                                 Camden CoGAty        May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   8                                                                                         Jackson County   FL          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   8                                                                                          Putnam County   FL          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   8                                                                             Sumter--The Villages         FL          Sep-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                            Berea         KY          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                                 CovingtonTN          Sep-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                           Dupont         KY          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                         Grayson County   KY          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                          Hamblen         TN          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                         Hawkins County   TN          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                           Hazard         KY          Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                         Madison County   TN          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                  Memphis--South Clinic   TN          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                       Standiford         KY          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                        Vine Hill         TN          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
   9                                                                                         Morehead         KY          Sep-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                                 CambridgeOH          Mar-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                  Florence/Boone City     KY          Mar-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                         Hamilton         OH          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                           Marion         OH          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                 New Philadelphia         OH          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                           Newark         OH          Mar-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                            Parma         OH          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  10                                                                                          Ravenna         OH          Jun-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  11                                                                                          Alpena County   MI          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  11                                                                                                 Clare CouMIy         May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  11                                                                                         Elkhart County   IN          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  15                                                                                         Daviess County   KY          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  15                                                                                          Graves County   KY          Sep-04      Opening in FY2009
--------------------------------------------------------------------------------------------------------------------------------------------------------
  15                                                                                         Hopkins County   KY          Sep-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  15                                                                                       Hutchinson         KS          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  15                                                                                       Jefferson City     MO          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  15                                                                                            Knox County   IN          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                          Branson         MO          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                                 Conroe   TX          Mar-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                            Eglin         FL          Feb-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                          Hammond         LA          Feb-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                La Place/St Johns         LA          Feb-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                       Pine Bluff         AR          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  16                                                                                          Slidell         LA          Feb-06                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  17                                                                        San Antonio--VA/DoD Joint         TX          Sep-04                   Open
--------------------------------------------------------------------------------------------------------------------------------------------------------
  18                                                                                      Miami/Globe         AZ          Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  18                                                                                        NW Tucson         AZ          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  18                                                                                        SE Tucson         AZ          Mar-06      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  19                                                                                                 Cut Bank MT          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  19                                                                                        Lewistown         MT          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  19                                                                               Western Salt Lake City VallUT          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  20                                                                                                 Canyon CiID          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  20                                                                                      North Idaho         ID          May-07      Opening in FY2008
--------------------------------------------------------------------------------------------------------------------------------------------------------
  20                                                                                     Northwest WA         WA          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  20                                                                                                 Central WWAhington   Feb-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  21                                                                                   American Samoa                     Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  21                                                                                           Fallon         NV          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  22                                                                                           Orange           CA        Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                         Bellevue         NE          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                 Bemidji--Fosston         MN          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                                 Carroll  IA          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                                 Cedar RapIAs         May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                        Holdredge         NE          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                     Marshalltown         IA          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                       Shenandoah         IA          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                      Spirit Lake         IA          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                           Wagner         SD          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                                        Watertown         SD          May-07      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
  23                                                                           Western WI (Rice Lake)         WI          Mar-06      Opening in FY2007
--------------------------------------------------------------------------------------------------------------------------------------------------------


    Question 3: Have decisions been made not to proceed with any of the 
156 CBOCs proposed in May '04 CARES report? If so, please explain 
further.

    Response: The only CARES CBOCs for which a decision has been made 
not to proceed were in VISN 9. VISN 9, along with their stakeholders, 
embarked on a reassessment of all proposed CBOCs analyzing current 
demographics and comparing to national criteria. Based on this review, 
some did not meet national criteria, and others had overlapping 
coverage. The sites in VISN 9 deleted from the CARES priority list are:

    Holston Medical Clinic, TN
    Pennington Gap Clinic, VA
    Thompson Clinic, VA
    Haysi Clinic, VA
    Davenport Clinic, VA
    Davis Clinic, VA
    West Lee County, VA
    Pontotoc County, MS
    Tunica, MS
    Grenada, MS
    Wynne-Cross County, AR
    Glasgow, KY
    Giles County/Pulaski, TN
    London, KY

    Question 4: Does VA currently impose enrollment limits or caps on 
CBOCs? If so, how does that work?

    Response: While there is no national guidelines on when a CBOC 
would be declared ``at capacity,'' a VHA facility might infrequently 
determine that they are at capacity based on the number of patients per 
physician and other local factors. In these rare instances new patients 
would be cared for at the nearest VA Medical Center. This would apply 
to new patients only and not existing patients, and would generally be 
a short term in nature lasting only until additional resources in the 
form of providers and/or space can be identified.

    Question 5: How would you characterize the limitations on marketing 
new CBOC enrollments? How is that implemented logistically?

    Response: A public announcement in the local press is made that a 
CBOC has been approved. While the site is being finalized the medical 
center prepares letters that are sent to existing veterans who reside 
in the new service area. These veterans can elect to change their 
primary care provider to the new CBOC site or remain at the parent 
site.
    Marketing new enrollment is not done, beyond the notification of an 
opened CBOC through press releases and ground breaking. New veterans 
who decide to use the VA for care complete an enrollment process. As 
part of that process they have the choice of selecting the new CBOC as 
their primary care site.

    Question 6: What happens if OEF/OIF veterans want to enroll in a 
CBOC that has been prevented from enrolling additional new veterans?

    Response: Cases in which Operation Enduring Freedom/Operation Iraqi 
Freedom (OEF/OIF) veterans are not able to be seen at the clinic of 
their choice are very rare, but in these rare cases the veteran may 
need to be seen at the nearest VA Medical Center (VAMC). A small number 
of CBOCs across the country are at capacity and are referring patients 
to the nearest medical center for treatment. For example, if the OEF/
OIF veteran has emergent care needs, the parent VAMC and CBOC will make 
every effort to accommodate.

    Question 7: Some CBOCs offer mental health services through VA 
staff and others through contractor personnel. What are the criteria 
that determine who provides mental health services in a given location?

    Response: All CBOCs must provide mental health services either by 
providing services onsite, purchasing services through a contract or 
providing telepsychiatry/telemedicine. The method for providing the 
care is determined locally based on the availability of services in the 
community, the availability of healthcare staff in the community and 
cost effectiveness.

    Question 8(a): What is the average length of time it takes for a 
contract provider to be credentialed by VA?

    Response: There is no distinction made in the credentialing of 
contract providers from other providers delivering care to veterans. 
There are approximately 15 DoD licensed independent providers appointed 
to the medical staff of VA facilities under contract or fee basis care 
authorities out of almost 61 DoD licensed independent providers.
    Contract providers can be credentialed for a full appointment, 
expedited appointment, or a temporary appointment for urgent patient 
care needs. Additionally, if a disaster is declared, contract providers 
can be appointed under the disaster credentialing and privileging 
procedures defined in facility policies.
    For initial appointment to the medical staff, the average length of 
time for the credentialing process to be completed is 6 to 8 weeks. 
This time is reduced by half for those providers who were previously 
credentialed by any VA facility through VetPro. VetPro is VHA's 
electronic credentialing file that maintains the verifications of 
education, training, licensure, certifications as well as reference and 
personal history information. Providers who have been previously 
credentialed through VetPro only need to be brought up to date from 
their last VA appointment.
    Temporary appointments to the medical staff for urgent patient care 
needs can be done in a matter of a day or two since there only needs to 
be verification of one full, current, active, unrestricted license, 
confirmation of comparable clinical privileges, and one reference 
obtained. Facilities have 45 workdays to complete the credentialing of 
these providers which is frequently expedited. Of the almost 61 DoD 
licensed independent providers, 59 have current temporary appointments 
for urgent patient care needs with 47 of them being contractors, fee 
basis or telemedicine providers.

    Question 8(a): Are there any significant issues that cause delays 
in provider credentialing throughout VA?

    Response: The largest delay in provider credentialing is the 
provider themselves submitting the complete application so that 
verification can be initiated. The ``clock'' does not start until the 
application is submitted by the provider so the 6 to 8 week period to 
credential a provider does not even begin until an application is 
complete.
    Temporary appointments for urgent patient care needs can be done 
without an application, but the provider needs to submit a complete 
application upon arrival at the medical center. VA's experience is no 
different than other organizations in that delays are encountered when 
references do not respond in a timely manner or verification must be 
obtained from overseas. VA policy does allow for documentation of a 
good faith effort in these instances. Policy states that if primary 
source documents are not received, after a minimum of two requests, 
full written documentation of the efforts to obtain verification will 
be placed in the credentialing folder in lieu of the document sought. 
It is suggested that no more than 30 days elapse between each request 
before the attempt is deemed unsuccessful. The practitioner should be 
notified and assist in obtaining the necessary documentation through a 
secondary source.

    Question 9: Mr. Behrman testified that there were a limited number 
of successful collaborations between VA and Community Health Centers. 
However, the contracts were discontinued. Why were these contracts 
discontinued? Should this type of partnership be expanded to other 
rural States?

    Response: We have worked with the National Rural Health Association 
(NRHA), whom Mr. Behrman represents, in efforts to gain more detailed 
information on the locations of the discontinued Community Health 
Centers (CHC) contracts they sited. However, the NRHA was unable to 
provide the needed information thus VHA can not address the specific 
contracts in question.
    VHA currently has a small number of contracts with the CHCs, and 
other Federally Qualified Health Centers (FQHCs). We are, and continue, 
to collaborate and develop partnerships with various government and 
nongovernmental organizations as we explore ways to expand healthcare 
in rural areas as part of our strategic initiatives in VA's Office of 
Rural Health. It is not our position that collaboration solely with 
FOHCs should be adopted at a national level, for they vary in scope, 
types of expertise and services. Rather, collaboration is best done at 
the local levels based on the needs, services and expertise available.

    Question 10: Has VA established policies whereby VA will contract 
with Critical Access Hospitals and other primary care providers in 
rural areas to provide primary and preventive healthcare to rural 
veterans who lack reasonable access to VA facilities?

    Response: VHA is currently establishing an Office of Rural 
Healthcare within the Office of the Assistant Deputy Under Secretary 
for Health for Policy and Planning. This new office will develop 
strategies for improving access to rural veterans that will be 
implemented throughout the system.

    Question 11: Does VA have performance measures in place to evaluate 
how effective the Vet Center program is in providing quality 
readjustment counseling and removing unnecessary barriers to care for 
veterans and family members?

    Response: Vet Center program services are monitored through several 
evidence-based measures to ensure ease of access for veterans and 
family members and the provision of quality readjustment counseling. 
Vet Center clinical measures include the global assessment of 
functioning (GAF) scale, quality of life measures, client waiting 
times, veteran satisfaction and employee satisfaction. Vet Centers do 
not have waiting lists and veterans who call or walk in may be seen the 
same day by a counselor for an assessment and to schedule a followup 
appointment. Vet Centers also maintain nontraditional hours in the 
evening or on the weekends when necessary to accommodate the working 
schedules of veterans and family members. Vet Centers are the gold 
standard for client satisfaction in VA. Over 99 percent of all veterans 
surveyed consistently report being highly satisfied with services 
received and that they would refer another veteran to the Vet Center. 
Based on the results of the One VA Employee Satisfaction Survey, Vet 
Center employees consistently exceed other VHA employees in outcomes. 
Results showed Vet Center employees have a significantly higher level 
of job satisfaction.

    Question 12: VA's testimony stated: ``VA continues to look for ways 
to collaborate with complementary Federal efforts to address the needs 
of healthcare for rural veterans. We also have partnerships with HHS, 
including the Indian Health Service and Office of Rural Health 
providing healthcare in rural communities.'' Where are the current 
collaborative efforts?

    Response: The Department of Health and Human Services (HHS) and VA 
signed a memorandum of understanding (MOU) in February 2003 to 
encourage cooperation and resource sharing between the Indian Health 
Service (IHS) and VHA to deliver quality healthcare services and 
enhance the health status of American Indian and Alaska Native (AI/AN) 
veterans.
    Outreach. Most networks are engaged in a variety of outreach 
activities, including meetings and conferences with IHS program and 
tribal representatives, VA membership in the Native American Healthcare 
Network, VA participation in traditional Native American ceremonies, 
transportation support to AI/AN, etc.
    Clinical Programs. An example of clinical collaborations involves a 
diabetes prevention program that has been developed jointly by VHA and 
IHS staff in San Diego, Albuquerque, and Greater Los Angeles. The goal 
is to reach Native Americans in their communities.
    Education. VHA Employee Education System (EES) provides training 
programs to IHS staff and the tribal community. In 2006, VHA delivered 
145 training programs, of which 90 were made available using satellite 
technology and 55 using web-based technology. These educational 
programs will be continued in 2007, and VHA will also provide selected 
IHS staff an opportunity to attend regional EES workshops.
    Behavioral Health. The Behavioral Health Workgroup developed a 
framework for AI/AN communities to assist returning OEF/OIF AI/AN 
servicemembers and veterans reintegrate with their families and 
communities and readjust to civilian life. The objective is to promote 
a community health model that gives tools to Tribal communities and 
families to help returning veterans address emerging adjustment 
reactions, traumatic stress, and post-traumatic stress disorder (PTSD), 
emphasizing recovery as the goal. The Joint Committee has developed a 
slide presentation to be used by outreach teams when addressing various 
Tribal veterans. There have been briefings using the slide presentation 
in Montana, with approximately 30 veterans now receiving services from 
VA.
    Expanded Healthcare Services. At the local level, 10 VHA networks 
are engaged in targeted initiatives aimed at providing a full continuum 
of healthcare services, such as; health fairs, VA/IHS advisories, use 
of health buddy, and education and/or shared services in substance 
abuse, domestic violence programs, cardiac rehabilitation, dietetics, 
behavioral medicine, etc.
    Care Coordination. The VHA-IHS Shared Healthcare Workgroup has 
drafted an Interdepartmental Coordinated Care Policy, the goal of which 
is to optimize the quality, appropriateness and efficacy of the 
healthcare services provided to eligible AI/AN veterans receiving care 
from both VHA and IHS or Tribes; and to improve the patient's 
satisfaction with the coordination of care between the two Departments.
    Telemedicine. Telemedicine has proven to be extremely effective in 
the treatment of PTSD in Alaskan Native villages. VA and IHS are 
working to spread the use of telemedicine services by AI/AN veterans, 
which will allow VA to bring physical and mental healthcare to the 
tribes, especially those in remote areas of the country.
    Traditional Healing. Some VHA facilities and Vet Centers have 
incorporated traditional healing ceremonies along with modern methods 
of treatment and counseling. As a national initiative, VA has sent over 
500 letters to Tribal leaders to ask them to provide information on 
appropriate providers of traditional practices so that they may be 
called upon for religious/spiritual care of AI/AN veterans.
    VHA's Office of Rural Health (ORH) has also established a working 
relationship with and sought consultation from HHS's Office of Rural 
Health. As the office matures, VHA's plan is to work closely with HHS 
to maximize the opportunities in a range of areas including education, 
training, research, and access.

    Question 13: What percent of rural healthcare is provided through 
contract care?

    Response: The National Fee Support Office, which oversees the 
processes of determining eligibility and payment of non-VA provided 
healthcare, does not differentiate between urban/rural care at this 
time. The Office of Rural Health will be performing an analysis of fee 
basis services and will be able to provide further data at the 
completion of the study.

    Question 14: What are the challenges of providing care to the aging 
veteran population in rural areas? How is VA addressing these 
challenges?

    Response: Frail, rural older veterans may be at particular risk of 
illness, disability, institutional placement and death if they receive 
a portion of their care from a more centralized urban VAMC. These rural 
elderly veterans, in addition to their usual burden of disability 
risks, have less access to VAMC-based care options. Moreover, non-VA 
health and social services--besides being fragmented from the client's 
perspective--are less available or nonexistent in rural areas (Dwyer, 
Lee and Coward 1990). Additional challenges include: long travel 
distances and lack of transportation services, frail, elderly primary 
caregivers with few resources, a lower level of service awareness among 
the elderly, and fewer financial resources.
    VA is addressing these challenges with its shift from a hospital-
driven healthcare system to an integrated delivery system that 
emphasizes a full continuum of care. The strategic direction for 
providing services to veterans residing in rural areas is to provide 
non-institutional care; to bring care into veterans' homes and home-
like settings. Options include:

      Integration of care coordination and home telehealth into 
home-based primary care to expand coverage into rural areas;
      Pilot program on improvement of caregiver assistance 
services;
      Collaboration with Administration on Aging and IHS for 
home-based primary care outreach and caregiver support;
      Referral to and purchase of community nursing home, home 
care, hospice and adult day healthcare services;
      Promotion of hospice-veteran partnerships to improve 
veteran access to community hospice care in rural areas;
      Development of medical foster home program, where 
veterans can receive an array of services including home-based primary 
care and community hospice care in a supportive home environment in 
their own community;
      Establishing satellite home-based primary care programs 
at remote sites such as VA CBOCs; and
      Development of a model of rural longitudinal care 
management.

    Question 15: How does VA differentiate between a rural veteran 
traveling over an hour to a healthcare facility and a veteran in an 
urban area traveling over an hour to a healthcare clinic in rush hour?

    Response: VHA Planning Systems and Support Group (PSSG) 
differentiate travel time between rural and urban by using geographic 
information software (GIS). These travel times are determined based on 
road type and are adjusted using survey data from the annual urban 
mobility report and civilian population densities. Seasonal and daily 
adjustments (e.g. rush hour or weather), cannot be taken into account 
on a national scale, thus are not reflected in the drive time analysis. 
Therefore, VA cannot calculate the effect that rush hour, or other 
daily fluctuations, may have on either urban or rural veterans commute 
time. However, the involvement of VISNs in the planning process 
provides a mechanism for this type of information to be considered.

    Question 16: Public Law 109-461 directs the Secretary to expand 
mental health services in outpatient clinics. What is VA doing to 
expand this capability? How many CBOCs had mental health capabilities 
in April 2005 and how many have mental health capabilities today?

    Response: Mental health services are currently available at all VHA 
outpatient clinics either from primary care staff, who are trained to 
manage many common mental health problems, or from mental health 
specialists, who manage the more difficult cases. To expand the 
capability for specialty mental health, VHA has distributed $42.7 
million to 301 CBOCs since FY 2005 for mental health professionals to 
those clinics where there was a need. Eight million dollars in 
telemedicine equipment has been sent to base facilities and their 
corresponding CBOCs as infrastructure to provide telemental healthcare 
where direct access to mental health specialists is unavailable. In 
addition, VHA has allocated $37.8 million in FY 2007 to 92 VA 
facilities to provide mental health specialists who will be integrated 
into existing primary care clinics.
    In April 2005 (end of the second quarter), 315 of 408 CBOCs (77 
percent) serving more than 1,500 unique veterans provided substantive 
mental health specialty services (i.e. 10% or more of the visits were 
in mental health clinics). In April 2007, 429 out of 449 CBOCs (96 
percent) had reached that standard.

    Question 17: What are the challenges in providing mental health 
services in rural communities?

    Response: While CBOCs have been the anchor for VHA's efforts to 
expand access to veterans in rural areas we have encountered some 
challenges, such as:

      Availability of qualified mental health professionals in 
small rural communities is often limited.
      Very small rural CBOCs may require mental health 
specialists too infrequently to justify even part-time on-site mental 
health staff.
      VA salaries at times are not competitive in specific 
locations, both rural and urban.
      Transportation to and from CBOCs is problematic for many 
veterans living in sparse population areas. However, telemental health 
at remote clinics, where feasible, has proven to be convenient and is 
generally well accepted by veterans.
      VHA's CBOCs are complemented by contracts in the 
community for all physician specialty services, depending on the 
location of the CBOC and the availability of specialists in the area. 
Some contract CBOCs prefer using their own mental health staff rather 
than accepting VA providers, a situation which may present 
communication barriers with veterans or with VA staffed settings.
      VHA has used fee-basis care with private healthcare 
providers in smaller or more remote communities for many years. Quality 
control of fee basis care is difficult to achieve in part because these 
providers do not have access to VA's electronic medical record system.

    Question 18: VA Central Office reviews waiting times. How do the 
waiting times of specialty care in rural areas compare with those in 
urban areas?

    Response: Appointments are made within 30 days for rural areas 96 
percent of the time. For highly rural areas 92 percent of appointments 
are made within 30 days. Urban CBOCs appointments are made within 30 
days 94 percent of the time. These data are for specialty care using 
the 47 specialty clinics out of the 50 from FY 2007 thru February 2007.

    Question 19: Musculoskeletal ailments (principally joint and back 
disorders) are among the top health problems of veterans returning from 
Iraq and Afghanistan according to a November 2006 VA study. Currently, 
chiropractic care is only available at about 20 percent of all VA 
facilities and most veterans do not have access to care, despite back 
issues being the ailment that affects the most veterans. Has VA 
developed plans on how to further implement chiropractic care into the 
VA healthcare system?

    Response: Yes. In accordance with Public Law 107-135, VA is 
providing chiropractic care in each of the 21 VISNs and presently has 
30 chiropractors across the country. Additionally, VHA established the 
Chiropractic Field Advisory Committee (FAC) to provide advice on 
clinical and administrative issues relating to chiropractic care for 
veterans and to serve as a communication channel between field-based 
practitioners and VHA Central Office. The FAC assists with identifying 
and providing data for evaluating the demographics of chiropractic 
care. Chiropractic care is included in the medical benefits package, 
the standard health benefits plan generally available to all enrolled 
veterans. When the residence of the veteran is geographically distant 
from a VHA site providing on-station chiropractic care, the outpatient 
fee-basis care program is used to provide these services through 
community chiropractors.

    Question 20: What is the status--and, if available, the initial 
findings--of the VA's Project HERO demonstration project?

    Response: VA Project HERO (Healthcare Effectiveness through 
Resource Optimization) is a demonstration project that is being piloted 
in selected VISNs to maximize the care VA provides directly and better 
manage fee care. The ultimate goal of Project HERO is to ensure that 
all care delivered by VA--whether through VA providers or through 
community partners--is of the same quality and consistency for 
veterans.
    VA issued a request for proposals (RFP) for a Project HERO 
specialty care provider network on January 12, 2007 and vendor 
proposals were received May 2, 2007 and are in the evaluation process. 
Contract award is anticipated in July 2007. This RFP applies only to 
fee care, which is care that is already being purchased and provided 
outside of the VA health system.
    The Project HERO Program Office and VA acquisitions team met with 
vendors during due diligence sessions in March 2007. Due diligence 
sessions offered potential vendors the opportunity to learn more about 
VA's requirements and to ask specific questions related to their 
proposed solution. Many industry leaders participated in the sessions 
with representatives from the participating VISNs, the Project HERO 
Program Office and other representatives from VA and VHA.
    In anticipation of the demonstration, the Project HERO Program 
Office is also conducting financial modeling activities to identify 
areas of potential cost savings under Project HERO. Using historical 
fee usage and cost data as well as projection rates from the VA 
Enrollee Healthcare Projection model, the Project HERO Program Office 
has been able to identify breakeven points for certain inpatient 
clinical areas and geographic locations (VAMCs). The outpatient model 
is currently being completed. Preliminary results from our inpatient 
financial modeling efforts indicate that there are potential areas for 
cost savings under Project HERO.
    In addition to financial modeling efforts, the Project HERO Program 
Management Office is also working with representatives from each of the 
participating VISNs to identify opportunities to standardize and 
improve fee business process and contract administration procedures. VA 
anticipates Project HERO will contribute to current efforts to 
standardize and optimize fee business processes.
    A Project HERO Governing Board, which includes senior leadership 
from VHA and participating VISNs, will oversee the demonstration to 
ensure that veterans continue to receive high quality care, and will 
review and approve any change in the terms, conditions and quantities 
of Project HERO contracts. The Project HERO Governing Board will 
regularly track and monitor Project HERO cost, quality, safety, vendor 
performance and other data relevant to the demonstration to ensure that 
Project HERO is meeting the goals and objectives outlined in Public Law 
109-305. The Project HERO Program Office will prepare quarterly and 
annual reports monitoring key elements of the demonstration including: 
costs, the quality of care provided, veteran satisfaction, impact on 
academic affiliates, clinical information sharing, and financial 
analysis.

    Question 21: The VA's March 30th report to Congress detailing CBOCs 
approved for activation only lists 6 CBOCs approved for an FY08 
opening. Will more be approved? Was the proposed VISN-approved CBOC for 
Hutchinson, KS turned down or is it still under consideration by the 
VA?

    Response: The VA's directive on establishment of new CBOCs is 
currently being revised. The Hutchinson, Kansas CBOC has been approved 
and VA anticipates its opening in FY 2008.

    Question 22: One may consider VISN 23 as one of the most rural 
VISNs in the VA system. How has VISN 23 improved access for veterans? 
Have you been working with other VISN Directors to share some of the 
best practices from VISN 23 in providing access to veterans?

    Response: VISN 23's primary method to improve rural access has been 
to establish a network of CBOCs. Since the inception of the VISN 
structure in 1995, VISN 23 has opened 36 CBOCs and/or outreach clinics. 
VISN 23 provides mental health services in all of these locations by a 
combination of telepsychiatry and on-site services. VISN 23 had 21 
additional CBOCs approved under CARES. Three of these have opened and 
three more will open this fiscal year. Several of these clinics are on 
remote American Indian Reservations in western South Dakota.
    The other major modality for us to reach rural veterans is telehome 
healthcare. This program provides for monitoring and treatment of 
patients in their homes by using remote monitoring equipment, the 
Internet and multiple voice or television communication.
    We also use case management and transportation networks operated by 
the service organizations and counties to facilitate rural veteran 
access.
    The success of the CBOCs in providing better rural access has been 
widely shared across all of the networks. Telehome health or care 
coordination, as the program is known within VHA, has a very active 
program office that has been very effective in developing and promoting 
this modality.

    Question 23: How can telemedicine help provide access to veterans? 
What are the limitations of telemedicine? Are there circumstances in 
which you would not recommend the use of telemedicine?

    Response: Telemedicine enables changes to take place in the 
location of care such that healthcare access is increased by removing 
the travel component of a clinical encounter for either the patient, or 
for the healthcare practitioner who is providing consultation/care. 
Therefore, when it is an appropriate tool to use, telemedicine can make 
healthcare needs better match the available resources and in doing so 
take services out into remote locations.
    Generally accepted limitations to telemedicine relate to the level 
of encounter that can take place between patient and healthcare 
practitioner with respect to clinical examination and restrictions that 
lack of telecommunications bandwidth imposes in providing care in 
certain areas.
    Telemedicine applications that are recommended for national 
deployment in VHA are ones in which the necessary clinical, technology 
and business processes have been resolved to ensure they are 
appropriate, safe and effective to meet the underlying patient care 
need for which they have been created. The corollary of this is that 
ones that are not deemed appropriate, safe and effective to meet a 
defined patient need would not be recommended.

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                     Washington, DC
                                                        May 2, 2007

Maurice Huguley
Legislative Analyst
Office of the Deputy Assistant Secretary for Legislation for Human 
    Services
U.S. Department of Health and Human Services
Washington, DC 20201

Dear Mr. Huguley:

    In reference to our Subcommittee on Health hearing ``Access to VA 
Healthcare: How Easy is it for Veterans--Addressing the Gaps'' held on 
April 18, 2007, I would appreciate it if you could answer the enclosed 
hearing question by the close of business on June 5, 2007.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all Full and 
Subcommittee hearings. Therefore, we would appreciate it if you would 
provide your answers consecutively and single-spaced. In addition, 
please restate the question in its entirety before the answer.

            Sincerely,
                                                 MICHAEL H. MICHAUD
                                                           Chairman
                               __________
             Question from Hon. Phil Hare, Subcommittee on
       Health, to Maurice Huguley, Legislative Analyst, Office of
     Deputy Assistant Secretary for Legislation for Human Services
              U.S. Department of Health and Human Services

    Question: I represent a congressional district with a lot of rural 
areas. You were talking about transportation, and you mentioned in your 
testimony that there are significant transportation barriers that 
affect the coordination of services. I wonder if you could maybe 
elaborate on that and what has HHS done to address the issue of 
providing transportation to rural patients?

    Response: The Department recognizes the special barriers rural 
residents face in obtaining needed services and addresses 
transportation issues in a variety of ways within its programs. Within 
HRSA, the Bureau of Primary Healthcare (BPHC) funds the Health Centers 
Program. Health centers address the transportation issue in various 
ways, including: providing rides to/from the health center in center-
owned vans; providing clients with public transportation vouchers; and/
or providing clients with cab fare from a ``taxi fund.'' Health centers 
are required to provide transportation services as part of the center's 
``enabling services.'' Specifically, the enabling services section of 
the health center authorizing legislation includes transportation 
within the definition of ``required primary health services.'' HRSA 
also administers the Ryan White Program. Parts A, B, and C of the Ryan 
White Program provide funding for ``support services.'' The legislation 
defines support services as those services ``needed for individuals 
with HIV/AIDS to achieve their medical outcomes (such as respite care, 
outreach services, medical transportation, and linguistic services).''
    To assure collaboration and coordination across the Department's 
Agencies and among other Federal Departments, HHS is part of the 
workgroup working on the United We Ride project. Other Departments in 
the workgroup include the Department of Transportation, Department of 
Interior, Department of Labor, Department of Education, Department of 
Veterans Affairs and Department of Agriculture. Within HHS, there is 
participation from HRSA, Centers for Medicare and Medicaid Services, 
Administration on Aging, Substance Abuse and Mental Health Services, 
and the Administration for Children and Families. The link to the 
website is http://www.unitedweride.gov/.

                                 

     Responses to Questions from Hon. Michael H. Michaud, Chairman,
   Subcommittee on Health, to Maggie Elehwany, Government Affairs and
          Policy President, National Rural Health Association

                                  National Rural Health Association
                                                     Alexandria, VA
                                                       June 5, 2007

The Honorable Michael H. Michaud, Chairman
The Honorable Phil Hare
Subcommittee on Health
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515

Dear Chairman Michaud and Representative Hare:

    Once again, I appreciated the opportunity to testify to the 
Subcommittee during an oversight hearing on the topic of ``Access to VA 
Healthcare: How Easy is it for Veterans--Addressing the Gaps'' on April 
17, 2007. On behalf of the National Rural Health Association (NRHA), a 
national nonprofit membership organization with approximately 15,000 
members that provides leadership on rural health issues, I thank you 
both for your leadership in addressing the needs of our rural veterans.
    My letter today responds to the followup questions submitted to me 
on May 2, 2007. The questions and answers follow.

    Question 1: Increase Access Points. Difficulty obtaining reliable 
transportation is a common concern. Effective, timely, inexpensive 
transportation is a pervasive problem in the rural areas. There are 
significant transportation barriers that affect coordination of 
services and providers in the rural setting.

    Question 1(a): Do you have any recommendations to address the time 
and distance issues as it relates to veterans getting to a facility?

    Response: Distance of travel to VA facilities is a significant 
concern of the NRHA. During much of my testimony, I spoke of increasing 
access points in rural communities. Two ways to increase access points 
that have been successfully utilized in rural communities to a limited 
extent are the use of Community-Based Outpatient Clinics and the use of 
collaborative models with rural health facilities that are already in 
the community, such as Federally Qualified Health Centers, Critical 
Access Hospitals, and Rural Health Clinics. We believe the expansion of 
services into the community in which the veterans live is the preferred 
method of providing care.
    The NRHA acknowledges that it may not always be possible to have 
care provided in every community. A number of new innovative approaches 
are currently being tried that would help limit the need for transport. 
Some of these, such as telehealth and distance medicine, are the 
products of new technology. Others, such as the direction of care 
through a family physician and linking payment with Medicare moneys, 
are simply new ways of thinking. But again, this may not provide care 
for every beneficiary.
    It is essential, then, that during VA outreach the issue of 
transportation be raised. Through experience with other rural 
populations we have found that transportation can be the biggest 
barrier to care and can lead to the largest gap in patient-provider 
compliance. One approach that has been successful in improving this gap 
is to consider transportation from the moment the provider, in this 
case the VA, contacts a patient. By asking simple questions--such as 
how do you plan to get to the VA facility; do you have reliable 
transportation; will someone be driving you; and are you able to afford 
the transportation costs--the facility can get a much better sense of 
the needs of that particular patient. In asking these questions and 
considering their responses, the VA should be prepared to help pay this 
transportation cost.
    The VA Office of Rural Affairs will need to monitor this 
transportation and access point question. While new collaborations and 
telehealth approaches sound promising and the NRHA strongly supports 
them, we can not be assured that these interventions are working 
without sound research. This type of followup research must be a part 
of any plan to overcome the lack of access points in rural communities.

    Question 2: Traumatic Brain Injury Care. Given that TBI is the 
``signature wound'' of OEF/OIF and that 44 percent of our returning 
veterans come from rural areas:

    Question 2(a): You state that the number and location of TBI case 
managers is limited in coverage in States with high numbers of rural 
veterans. What is the scope of ``expansion'' of the TBI case manager 
network that your organization believes is needed to meet the needs of 
the rural TBI patient?

    Response: Simply stated, it is not clear how much expansion is 
needed in the TBI case manager network to cover the needs of returning 
veterans in rural America. More research is needed to better understand 
TBI and the needs of those suffering from it. We strongly encourage 
that this research be ongoing, throughout the duration of care given to 
those returning from OEF/OIF.
    We have learned from the experience of dealing with PTSD post-
Vietnam War. As the severity of PTSD began to be realized, resources 
were poured into providing care. Like any new medical intervention, 
some worked while others did not. Had solid quantitative evidence been 
gathered from the start, perhaps less than the 15.2 percent of male 
veterans and 8.5 percent of females who served in Vietnam would 
currently be suffering from PTSD. Followup studies have shown more 
effective ways to treat PTSD and the VA has accepted these for veterans 
returning from future wars. However, when possible, research should be 
ongoing, especially in the case of TBI, where waiting for followup 
studies may mean leaving a generation of veterans with physical, 
cognitive, behavioral, emotional and social impairments.
    The evidence shows that the TBI case manager network would be more 
effective in a `spoke-and-hub' model that has more than one research 
and primary care center located across the Nation. By diffusing TBI 
care throughout the VA, every employee will see treating TBI as part of 
their core mission. Further, by using a spoke-and-hub model, more case 
managers will be available to rural veterans and will still have the 
support they need from larger research centers. We strongly encourage 
the expansion, testing, and decentralization of the TBI case managers 
to help provide rural veterans an avenue to recovery.

    Question 3: Office of Rural Veterans. Your organization would like 
a national advisory committee on rural veterans established to provide 
information to policymakers on the needs of this population as it ages.

    Question 3(a): What does your organization believe is the number 
one issue that the advisory committee should take up if it is 
established?

    Response: There are many things that the advisory committee on 
rural veterans could examine if it was established. Obviously, such a 
committee would have the opportunity to set its own priorities and may 
deal with issues that we have not even considered. However, we have 
identified a few issues that the advisory committee could take up 
immediately if established:

    1.  Research Agenda. Currently, there is not a specific rural 
research agenda for veterans' care, and rural research is not a 
priority of the general VA research projects. Since care in a rural 
environment is so different than in an urban community, the NRHA is 
very concerned about the lack of ongoing rural research. VA research 
must include rural specific issues, and an advisory committee could 
establish this priority and set the agenda.
    2.  Special Population Status. The VA has a long history of 
monitoring ``special populations'' and using the data for providing 
higher quality care. Such populations over time have included those 
with spine injuries and other difficult injuries, the homeless, and 
those of lower economic status. By monitoring those veterans living in 
rural communities, the VA may get a better sense on how to provide care 
to those furthest from VA facilities and better understand their health 
status and address barriers to care.
    3.  Field-Based Operations. Currently, the Office of Rural Veterans 
is located in one central office. For the information the Office 
collects and develops to spread throughout the VA, a more diffused 
network of offices may be needed. In addition, having field offices 
located in VA centers across the country that serve rural veterans may 
be helpful in understanding their specific needs.

    Question 3(b): What would an advisory committee offer to the VA and 
veterans that is not currently being provided?

    Response: In a different venue, the NRHA has a long history of 
working with the Federal Office of Rural Health Policy and the National 
Advisory Committee on Rural Health and Human Service. We know from 
experience that the National Advisory Committee is an important player 
in making sure that the Office of Rural Health is meeting its goals and 
identifying gaps in Federal programs. Further, the National Advisory 
Committee has helped set the agenda for a priority on rural issues 
within the Department of Health and Human Services.
    We expect a rural advisory committee for the VA to do the same. 
While the Office of Rural Veterans is a strong advocate within the 
agency, an outside voice and independent review is needed. 
Unfortunately, as we all know, internal agency politics can play a role 
in determining the priorities of any single office. In addition, 
offices can be hamstrung by set policies or internal procedures. The 
advisory committee would be able to think outside of this internal 
paradigm and articulate a vision of what the office and the entire VA 
should be doing for rural veterans. In addition, such a committee can 
help focus attention on the good things that the VA is currently doing 
on behalf of rural veterans without the inherent bias that comes with 
any self promotion. We expect that an independent voice on rural issues 
would be helpful to the VA, and provide rural veterans with another 
needed advocate for the highest possible quality of care.

    Mr. Chairman and Mr. Hare, thank you for this opportunity to 
respond to your questions on rural veterans' access to VA care. If you 
are in need of further followup or clarification, please contact Maggie 
Elehwany, NRHA Vice President for Government Affairs and Policy (703-
519-7910 or elehwany@NRHArural.org).

            Sincerely,

                                                       Andy Behrman
                              Chair, NRHA Rural Health Policy Board

                                 
     Responses to Questions from Hon. Michael H. Michaud, Chairman,
    Subcommittee on Health, to Steve Robertson, Director, National 
              Legislative Commission, The American Legion

                                                    American Legion
                                                     Washington, DC
                                                  November 28, 2007
The Honorable Michael H. Michaud, Chairman
Subcommittee on Health
Committee on Veterans' Affairs
U.S. House of Representatives
Washington, DC 20515

Dear Chairman Michaud:

    Thank you for allowing The American Legion to participate in the 
Committee hearing on the President's budget request on April 18, 2007. 
I am pleased to respond to your specific questions concerning that 
hearing.

    Question 1: Community Health Clinics. The Veterans Millennium 
Healthcare and Benefits Act (P.L. 106-117) encouraged collaborations 
between the Community Health Centers, that serve millions of rural 
Americans, and the VA.

    Question 1(a): Does your organization support these collaborative 
efforts?

    Response: The American Legion supports collaborative efforts 
between Community Health Centers and VA to provide services to rural 
veterans when VA is not capable of providing that care. In areas where 
there is very limited access to VA healthcare, it is in the best 
interest of veterans residing in rural areas that local care be made 
available to them. Some of these veterans have physical limitations due 
to age or service-connected injuries, or suffer from conditions that 
make extensive travel dangerous. Many veterans have expressed concerns/
frustrations about their limited financial resources prohibiting 
travel--citing the disparity caused by long travel distances, the 
rising cost of gas, the limitations of the mileage reimbursement rate, 
and the need to pay for overnight accommodations as huge obstacles. 
Weather and geographic obstacles are also considerations.
    Providing contracted care in rural communities--when VA healthcare 
services are not possible--would alleviate the unwarranted hardships 
that these veterans encounter when seeking access to VA healthcare.

    Question 2: Level of Care. What are your organization's 
expectations regarding the level of care VA should provide in the rural 
community?

    Response: The American Legion believes that veterans residing in 
rural communities deserve the same level of healthcare and timely 
access to care as veterans residing anywhere else.

    Question 2(a): Do you believe the VA's presence in the rural health 
community should be expanded?

    Response: Yes, when doing so would improve access to care and 
decrease travel time for veterans who travel hundreds of miles for 
care.

      If so, should the VA accomplish this by expanding 
partnerships or providing its own system of care?

    Response: Determining whether VA should accomplish this by 
expanding partnerships or providing its own system of care should be 
based on the healthcare needs of the veterans in the rural area it is 
considering, services available through the rural health community, and 
the number of veterans who would benefit from VA providing its own 
system of care in that rural area. It would be VA's responsibility to 
determine if there are any trends in needed services in particular 
rural communities, especially for specialized care.
    Many veterans move or return to rural areas following military 
service. If the services available through community health providers 
are not able to address the rehabilitative needs of those returning to 
these rural communities with traumatic brain injuries, other blast 
trauma injuries, or other service-related ailments, VA has a duty to 
make these services available. It would be ideal if--realizing that 
those requiring specialized services probably would have difficulty 
traveling and coordinating care--VA would make these services as easily 
accessible as possible.
    Another indication that VA needs to bring its services more local 
would be if a number of veterans are traveling hundreds of miles from a 
specific geographic area to receive services from the VA that they 
cannot receive in their communities due to lack of availability of 
those services.
    If needed services are available in local communities, those 
traveling hundreds of miles for care would probably benefit from an 
expansion of partnerships.

    Question 2(b): What do you believe would be an effective approach 
to providing returning veterans with the types of specialized services 
they need such as TBI rehabilitation and mental health services?

    Response: An effective approach to providing returning veterans 
with the types of specialized services they need could be providing 
more facilities, nationwide, where veterans can access these service, 
and/or developing partnerships with community providers in rural 
communities.

    Question 3: Women Veterans and Rural Health. Women are a growing 
population within the armed forces. By 2010 it is estimated that they 
will exceed 10 percent of the veteran population and 15 percent of the 
armed forces. Unlike their fellow female veterans from previous 
conflicts, this current cohort of female veterans is routinely exposed 
to combat in Operations Enduring Freedom and Iraqi Freedom.

    Question 3(a): Does your organization have any recommendations as 
to how to address the growing need for specialized services for women 
who have experienced combat?

    Response: Most importantly, we need to make sure we understand what 
specialized services these veterans will need. Outreach to women 
veterans is an important mechanism in identifying the specialized 
services women veterans will require. They will need to know where they 
can voice their needs and what services are available to them.
    Also, comprehensive research on women veterans needs to be updated 
to consider the health effects of combat on women veterans that address 
long-term physical, as well as mental effects. Information gathered 
from research would also facilitate addressing their need for 
specialized services.

    Question 4: Healthcare System of the 21st. The face of healthcare 
is changing. VA has an Advisory Committee on Genomic Medicine. The use 
of telemedicine programs is growing. Technology is advancing rapidly. 
The delivery of healthcare is going to change over the next 10, 20, 30 
years.

    Question 4(a): What does your organization believe VA should be 
focusing on in the future regarding the direction of the VA healthcare 
system?

    Response: The American Legion believes that the VA needs mandatory 
funding to ensure that its healthcare system can adequately address the 
needs of all veterans. VA should be focusing on improving access to 
care and timely delivery of care.

    Thank you once again for all of the courtesies provided by you and 
your capable staff. The American Legion welcomes the opportunity to 
work with you and your colleagues on many issues facing veterans and 
their families throughout this Congress.

            Sincerely,
                                                    Steve Robertson
                          Director, National Legislative Commission

                                 

                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                     Washington, DC
                                                        May 2, 2007

Joe Violante
National Legislative Director
Disabled American Veterans
Washington, DC 20024-2410

Dear Mr. Violante:

    In reference to our Subcommittee on Health hearing ``Access to VA 
Healthcare: How Easy is it for Veterans--Addressing the Gaps'' held on 
April 18, 2007, I would appreciate it if you could answer the enclosed 
hearing questions by the close of business on June 5, 2007.
    In an effort to reduce printing costs, the Committee on Veterans' 
Affairs, in cooperation with the Joint Committee on Printing, is 
implementing some formatting changes for materials for all Full and 
Subcommittee hearings. Therefore, we would appreciate it if you would 
provide your answers consecutively and single-spaced. In addition, 
please restate the question in its entirety before the answer.

            Sincerely,
                                                 MICHAEL H. MICHAUD
                                                           Chairman
                                             Subcommittee on Health
                               __________
   Questions from Hon. Michael H. Michaud, Chairman, Subcommittee on
         Health, to Joe Violante, National Legislative Director
                       Disabled American Veterans
    Question: Community Health Clinics. The Veterans Millennium 
Healthcare and Benefits Act (P.L. 106-117) encouraged collaboration 
between Community Health Centers, that serve millions of rural 
Americans, and the VA.

    a.  Does your organization support these collaborative efforts?

    Answer: After review of P.L. 106-117, the Veterans Millennium 
Healthcare and Benefits Act, we were unable to find any language 
addressing the question of collaboration with Community Health Centers.

    Question: Level of Care. What are your organization's expectations 
regarding the level of care VA should provide in the rural community?

    a.  Do you believe the VA's presence in the rural health community 
should be expanded? If so, should the VA accomplish this by expanding 
partnerships or providing its own system of care?

    Answer: We believe Congress should provide VA the additional 
resources it needs to expand its presence in rural areas. As we have 
often stated, veterans' healthcare is a continuing cost of war. After 
serving their country, veterans should not have their healthcare needs 
neglected by the VA because they choose to live in rural and remote 
areas far from major VA healthcare facilities particularly when 
Congress and the Administration have been aware that about 44 percent 
of today's active duty military servicemembers and tomorrow's veteran 
population list rural communities as their homes of record.
    VA's medical benefits package is the embodiment of a continuum of 
care which allows veteran patients to be clinically matched to the 
appropriate level of care in order to maximize the care they receive 
and the quality of life they lead. When providing medical care in rural 
and remote areas, there are consequences to sick and disabled veterans, 
the VA healthcare system, and the cost of such care when the 
appropriate level of care is provided based on other than medical need.
    As a direct provider of care, the VA has established and is 
operating over 700 CBOCs, of which 100 are located in areas considered 
by the VA to be rural or highly rural; however, we remain concerned 
that the VA receives no Congressional appropriation dedicated to 
support establishment of rural CBOCs but must manage those additional 
expenses from within the available Medical Services appropriation 
provided by Congress. The DAV believes that given current 
circumstances, VA cannot cost-effectively justify establishing 
additional remote facilities in areas with sparse veteran populations, 
and therefore urges Congress to act on the report it has required VA to 
provide in section 212(b) of P.L. 109-461 regarding CBOCs and 
additional access points identified in the May 2004 CARES decision.
    Recognizing the diversity of rural areas, the DAV does not believe 
that requiring VA to provide needed medical care in rural areas should 
be done solely as a direct provider or solely through expanding 
partnerships. We believe the VA's ability to provide such care should 
be given proper latitude, particularly as VA is establishing an Office 
of Rural Health and is designating an individual at each Veterans 
Integrated Service Network (VISN) to promulgate policies, best 
practices, and innovations to improve healthcare services to veterans 
who reside in rural areas.

    Question:

    b.  What do you believe would be an effective approach to providing 
returning veterans with the types of specialized services they need 
such as TBI rehabilitation and mental health services?

    Answer: The current conflicts in which our Nation is engaged are 
producing a significant number of veterans suffering from polytraumatic 
injuries, amputations, brain injuries, blindness, burns, spinal cord 
injuries, and post-traumatic stress disorder (PTSD). The DAV believes 
reforming VA's healthcare budget is of primary importance in order for 
the Veterans Health Administration (VHA) to continue to provide these 
severely disabled veterans with the lifetime of specialized healthcare 
services they will require. To its credit, VA has taken progressive 
steps to address the specialized needs of our newest disabled veterans 
and is working to provide the highest quality care possible. We believe 
VA should be given every opportunity to capitalize on its successes 
without the fiscal uncertainties that have prevented the best 
management of VA healthcare. Timely and adequate funding would make the 
management of veterans' healthcare more dependable, and stable, and 
with proper oversight would make VA's high quality medical care and 
specialized services more cost-effective and efficient.
    In an era of funding government programs through continuing 
resolutions or increased funding levels provided months into the fiscal 
year, VA facilities have had to restrict services provided to veterans, 
delay hiring of new clinical staff, institute local and regional 
freelance policies to restrict eligibility and care, and impose a 
variety of questionable--and potentially hazardous--cost-cutting 
measures just to make ends meet. It is clear that VA operates in a 
state of management paralysis, planning chaos, and structural financial 
crisis as a direct consequence of the discretionary budget process. We 
do not believe this is an effective approach to providing returning 
veterans with the types of specialized services they need such as TBI 
rehabilitation and mental health services.
    In addition to reforming the budget process, we believe the 
direction taken by VA to use the effective hub-and-spoke model of it's 
spinal cord injury service serves as a good first step to deliver 
coordinated care for our returning servicemembers. As you are aware, 
the VA established four Level I Polytrauma Rehabilitation Centers 
(PRCs) at the Defense and Veterans Brain Injury Center's (DVBIC) 
designated VA sites, Level II PRCs at each of the 21 regional Veterans 
Integrated Service Networks, as well as a multitude of local Level III 
and IV PRCs across the Nation. These new Level II centers will better 
assist VA to raise awareness of TBI issues, and the Level III and IV 
sites will provide increased access points for TBI veterans and allow 
VA to develop a systemwide screening tool for clinicians to use to 
assess TBI patients. Furthermore, clinicians and researchers are 
evaluating several approaches to ensure more effective healthcare 
delivery, such as standardizing patients' records from two distinct 
healthcare systems and treatment plans. We believe these efforts will 
provide a model of proactive care for patients with TBI and polytrauma 
and enhance standards of practice within the VA and non-VA healthcare 
systems.
    Finally, the VA needs clear guidance from Congress on how to 
proceed with new programs for the latest generation of wounded and 
disabled veterans. A number of bills have been introduced dealing with 
polytrauma, brain injury, and mental health; however, none have become 
law at this time. We ask the Committee to consult with the veterans 
service organizations as you begin to fashion these bills into law.

    Question: Women Veterans and Rural Health. Women are a growing 
population within the armed forces. By 2010 it is estimated that they 
will exceed 10 percent of the veteran population and 15 percent of the 
armed forces. Unlike their fellow female veterans from previous 
conflicts, this current cohort of female veterans is routinely exposed 
to combat in Operations Enduring Freedom and Iraqi Freedom.

    a.  Does your organization have any recommendations as to how to 
address the growing need for specialized services for women who have 
experienced combat?

    Answer: With increasing numbers of women serving in the military, 
and with more women veterans seeking VA healthcare following military 
service, it is essential that the VA be responsive to the unique 
demographics of this veteran population cohort. As we see growth in the 
number of women veterans using VA healthcare services, we also expect 
to see increased VA healthcare expenditures for women's health 
programs.
    At a recent VA National Conference: Evolving Paradigms--Providing 
Healthcare to Transitioning Combat Veterans--one track focused on women 
veterans who served in Iraq. A panel discussion by those women was very 
revealing about their unique experiences in the military and the impact 
of that service on their physical and mental health, as well as their 
existing impressions of access to VA services post-deployment. The 
women who participated in this panel, as well as other women who have 
served in combat theaters, could offer the Subcommittee greater insight 
on the impact of military experience on this new generation of women 
veterans. We understand that VA had planned to convene a focus group of 
approximately 50 women veterans of the wars in Iraq and Afghanistan to 
examine gaps in service and how VA could better meet the needs of this 
group. It is not clear whether VA still plans to convene such a group, 
but DAV believes this could stimulate an effective policy debate within 
VA and likely benefit this new generation of women veterans.
    We recommend that the Subcommittee hold a hearing on women veterans 
issues and invite women veterans from Operations Iraqi and Enduring 
Freedom (OIF/OEF), the newly appointed Acting Chief Consultant of the 
VA's Women Veterans Health Strategic Healthcare Group and a 
representative from the National Center for Post-Traumatic Stress 
Disorder, to discuss how the Department is currently addressing the 
unique healthcare needs of women veterans who have served recently in 
combat theaters.
    The National Center notes that anecdotal reports from OEF/OIF 
veterans suggest a number of unique concerns that have a more direct 
impact on women than their male counterparts returning from combat 
theaters, including lack of privacy in living, sleeping, and shower 
areas; lack of gynecological healthcare; impact of women choosing to 
stop their menstrual cycle; gender-specific differences in urinating 
leading to health concerns for women, including dehydration and urinary 
tract infection. There are also reported findings that suggest distinct 
differences at homecoming including that women may be less likely to 
have their military service recognized or appreciated; possible 
differential access to treatment services; and possible increased 
parenting and financial stress. Additionally, preliminary reports 
suggest that women may be more likely to seek help for psychological 
difficulties.
    The National Center is looking at gender differences in mental 
health, military sexual trauma (MST) in the war zone, and gender 
differences in other stressors associated with OEF/OIF service and 
homecoming. A number of research initiatives/projects are focused on 
treatment of PTSD in women, enhancing sensitivity toward and knowledge 
of women veterans and their healthcare needs among Reserve components 
of the armed forces. Testimony from principal investigators in these 
studies would also be of assistance to the Subcommittee in fashioning 
effective policy to meet the needs of women veterans.
    Finally, some women serving in the military may suffer the dual 
burden of combat exposure and MST. While the DoD has established an 
office to deal with the incidence of sexual trauma, the conditions of a 
combat theater, quartering and lack of personal security offer special 
threats to women serving. VA and DoD need to better coordinate policies 
and treatment for transitioning women veterans who suffer readjustment 
issues related to combat exposure and/or have suffered MST.

    Question: Healthcare System of the 21st. The face of healthcare is 
changing. VA has an Advisory Committee on Genomic Medicine. The use of 
telemedicine programs is growing. Technology is advancing rapidly. The 
delivery of healthcare is going to change over the next 10, 20, 30 
years.

    a.  What does your organization believe the VA should be focusing 
on in the future regarding the direction of the VA healthcare system?

    Answer: Over the last decade, the VA has dramatically transformed 
the delivery of veterans' healthcare and moved to the forefront of the 
healthcare industry in areas such as patient safety, health promotion 
and disease prevention, quality improvement, use of computerized 
patient records, telemedicine, and biomedical and health services 
research. Therefore, we believe that VA is appropriately focused to 
meet the future needs of veterans and increasing demands on its 
healthcare system.
    As the VA continues making advances in medicine to address chronic 
diseases and disabilities that are prominent in and specific to the 
veteran patient population such as diabetes, cardiovascular diseases, 
cancer, amputations, spinal cord injuries, polytraumatic injuries and 
other similar conditions, VA must be mindful of the ever closer 
association of medicine with science and technology, which presents a 
dilemma where the latter broadens the former in helping the patient, 
yet may undervalue the caring or ``art of medicine.'' We must ensure 
the VA finds a proper balance between the promising possibilities of 
modern, high-technology medicine and the actual ``high touching'' care 
of patients.
    Moreover, VA must remain sensitive to the limitations and 
capabilities of biotechnology, genetic technology, and genomics. Rapid 
technological changes occurring in the field of biotechnology coupled 
with genetics, genomics, and links between the two, proffer a 
tremendous shift in how healthcare will be provided in the future. The 
possible effects would include a change from the current population-
based medicine to personalized medicine, such as tailormade drug 
treatment for the individual patient (pharmacogenetics) as well as the 
redefinition of the concept of ``disease.''
    As medical care becomes more individualized, VA's Health-E-Vet 
automated record offers patients an opportunity to actively participate 
in their health decisions with a focus on prevention, empowerment, 
wellness and satisfaction. Since the newest generation of veterans 
tends to be more technologically inclined than veterans of prior wars, 
but will rely on the VA for their medical care for decades to come, VA 
should remain committed to this initiative.
    The changes in VHA have been profound, and the benefits have been 
and continue to be recognized by the veteran, medical, academic and 
private sector communities. VA provides better care to our Nation's 
veterans, care closer to their homes, and uses the latest technology in 
delivering safe care. VA must continue to provide the right services, 
at the right time, in the right place to our Nation's veterans in the 
future. However, we currently face significant challenges, which we 
must address to assure that our Nation maintains a comprehensive, 
integrated healthcare system able to respond to the unique problems 
that are associated with the military combat experience. In addition to 
the most important new developments in the diagnosis and therapy of the 
most common diseases, the VA must focus on how medicine in the future 
can successfully combine high-tech and high-touch, and how the emphasis 
can be placed more on the individual person, with his or her physical, 
emotional and mental health needs--an aspect that, to the detriment of 
patients, all too often is neglected in the day-to-day practice of 
high-technology medicine.
    A final concern is one that we have discussed previously in the 
Independent Budget for fiscal year 2008: the future of VA capital 
assets. The VA healthcare system operates over 1,400 centers of care, 
of which a number of the more significant VA Medical Centers were 
constructed in relatively brief periods following World Wars I and II, 
and the Korean and Vietnam Wars. Thus, aging physical plant facilities 
is a major issue for the future of VA healthcare. While it is difficult 
to make firm predictions about VA's capital infrastructure needs over 
the next 30 years, the existing trends of emphasis on ambulatory, 
outpatient care over acute and chronic inpatient hospitalization would 
seem to predict the need for smaller inpatient facilities in the 
future, treating a higher acuity of case mix for shorter periods, 
alongside significantly enlarged outpatient facilities, including those 
promoting primary care, preventative care, ambulatory surgeries, and 
other therapies that can be delivered in a same-day service setting. 
This trend coupled with the underfunding of VA's construction budget 
heightens our concern over the impact this may have on sick and 
disabled veterans needing specialized programs such as blind 
rehabilitation, spinal cord injury care, prosthetics services, and 
mental health services.
    The agency strategic and clinical planning, budget formulation and 
Congressional appropriations processes create obstacles that cause 
years, at times decades, of lag time between conception and 
construction. DAV believes that Congress should provide additional 
oversight to VA's construction and capital-facilities replacement 
policies to improve their performance, and to help prepare for the 
future of a very challenging issue. Also, we continue to question 
whether VA's capital decisions are still consonant with the Capital 
Asset Realignment for Enhanced Services (CARES) process that was 
concluded in 2004. The CARES process was designed by VA to provide a 
clear, market oriented roadmap for VA capital planning needs for the 
next several decades, but in the intervening time we have been witness 
to facility construction decisions that seem inconsistent with the 
CARES decision memorandum of a prior VA Secretary. We ask the Committee 
to provide sharper oversight of VA capital programs to ensure they are 
consistent with CARES.