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




                       LEGISLATIVE HEARING ON
            H.R. 92, H.R. 315, H.R. 339, H.R. 463, H.R. 538
          H.R. 542, H.R. 1426, H.R. 1470, H.R. 1471, H.R. 1527
                 H.R. 1944, AND DISCUSSION DRAFT OF THE
               ``RURAL VETERANS HEALTHCARE ACT OF 2007''
=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 26, 2007

                               __________

                           Serial No. 110-17

                               __________

       Printed for the use of the Committee on Veterans' Affairs







                     U.S. GOVERNMENT PRINTING OFFICE

35-636 PDF                 WASHINGTON DC:  2008
---------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing
Office  Internet: bookstore.gpo.gov Phone: toll free (866)512-1800
DC area (202)512-1800  Fax: (202) 512-2250 Mail Stop SSOP, 
Washington, DC 20402-0001























                     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 26, 2007

                                                                   Page
Legislative Hearing on H.R. 92, H.R. 315, H.R. 339, H.R. 463, 
  H.R. 538, H.R. 542, H.R. 1426, H.R. 1470, H.R. 1471, H.R. 1527, 
  H.R. 1944, and Discussion Draft of the ``Rural Veterans 
  Healthcare Act of 2007''.......................................     1

                           OPENING STATEMENTS

Chairman Michael H. Michaud......................................     1
    Prepared statement of Chairman Michaud.......................    45
Hon. Jeff Miller, Ranking Republican Member......................     2
    Prepared statement of Congressman Miller.....................    45

                               WITNESSES

U.S. Department of Veterans Affairs, Gerald M. Cross, M.D., 
  FAAFP, Acting Principal Deputy Under Secretary for Health, 
  Veterans Health Administration.................................    38
    Prepared statement of Dr. Cross..............................    94

                                 ______

Altmire, Hon. Jason, a Representative in Congress from the State 
  of Pennsylvania................................................    21
    Prepared statement of Congressman Altmire....................    73
American Legion, Shannon Middleton, Deputy Director for Health, 
  Veterans Affairs and Rehabilitation Commission.................    26
    Prepared statement of Ms. Middleton..........................    74
American Veterans (AMVETS), Kimo S. Hollingsworth, National 
  Legislative Director...........................................    27
    Prepared statement of Mr. Hollingsworth......................    77
Brown-Waite, Hon. Ginny, a Representative in Congress from the 
  State of Florida...............................................     6
    Prepared statement of Congresswoman Brown-Waite..............    47
Disabled American Veterans, Adrian M. Atizado, Assistant National 
  Legislative Director...........................................    28
    Prepared statement of Mr. Atizado............................    79
Filner, Hon. Bob, Chairman, Full Committee on Veterans' Affairs, 
  and a Representative in Congress from the State of California..    24
    Prepared statement of Congressman Filner.....................    74
Latham, Hon. Tom, a Representative in Congress from the State of 
  Iowa...........................................................    19
    Prepared statement of Congressman Latham.....................    72
Moran, Hon. Jerry, a Representative in Congress from the State of 
  Kansas.........................................................    22
Ortiz, Hon. Solomon P., a Representative in Congress from the 
  State of Texas.................................................    10
    Prepared statement of Congressman Ortiz......................    48
Paralyzed Veterans of America, Carl Blake, National Legislative 
  Director.......................................................    30
    Prepared statement of Mr. Blake..............................    84
Pearce, Hon. Steve, a Representative in Congress from the State 
  of New Mexico..................................................     2
    Prepared statement of Congressman Pearce.....................    46
Rothman, Hon. Steven R., a Representative in Congress from the 
  State of New Jersey............................................    14
    Prepared statement of Congressman Rothman....................    71
Solis, Hon. Hilda L., a Representative in Congress from the State 
  of California..................................................    18
Veterans of Foreign Wars of the United States, Dennis M. 
  Cullinan, Director, National Legislative Service...............    32
    Prepared statement of Mr. Cullinan...........................    89
Vietnam Veterans of America, Richard F. Weidman, Executive 
  Director for Policy and Government Affairs.....................    33
    Prepared statement of Mr. Weidman............................    92

                       SUBMISSIONS FOR THE RECORD

American Academy of Neurology, statement.........................   100
Brown, Hon. Corrine, a Representative in Congress from the State 
  of Florida, statement..........................................   101
Hinojosa, Hon. Ruben, a Representative in Congress from the State 
  of Texas, statement............................................   101



















 
                       LEGISLATIVE HEARING ON
            H.R. 92, H.R. 315, H.R. 339, H.R. 463, H.R. 538
          H.R. 542, H.R. 1426, H.R. 1470, H.R. 1471, H.R. 1527
                 H.R. 1944, AND DISCUSSION DRAFT OF THE
               ``RURAL VETERANS HEALTHCARE ACT OF 2007''

                              ----------                              


                        THURSDAY, APRIL 26, 2007

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

    The Subcommittee met, pursuant to notice, at 
10:02 a.m., in Room 334, Cannon House Office Building, Hon. 
Michael H. Michaud [Chairman of the Subcommittee] presiding.

    Present: Representatives Michaud, Snyder, Hare, Miller, 
Stearns, Moran.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I would like to thank everyone for coming here 
today and 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 
five legislative days to revise and extend their remarks. 
Without objection, so ordered.
    Today's legislative hearing will be the first of many this 
Subcommittee plans on holding to provide Members of Congress, 
veterans, the VA, and other interested parties with the 
opportunity to discuss legislation within the Subcommittee's 
jurisdiction in a clear and orderly process.
    I do not necessarily agree or disagree with the bills 
before us today, but I believe that this is an important 
process that will encourage frank discussions and new ideas. We 
have 11 bills before us and one discussion draft.
    The discussion draft represents some of my ideas to improve 
the quality of care available to our rural veterans and the 
ability to access care, such as establishing mobile vet 
centers, improving information technology and technology 
sharing between the VA and non-VA providers, establishing a 
Rural Veterans Advisory Committee, creating Centers of 
Excellence to encourage research in innovative healthcare to 
address the needs of rural veterans, and encourage more 
healthcare professionals to work in rural areas.
    I look forward to hearing the views of our witnesses and to 
a discussion on this and the other bills before us.
    I also look forward to working with everyone here to 
improve the quality of care available to our veterans.
    [The prepared statement of Chairman Michaud appears on p. 45
.]
    Mr. Michaud. At this time, I would recognize Ranking Member 
Miller.

             OPENING STATEMENT OF HON. JEFF MILLER

    Mr. Miller. Thank you, Mr. Chairman, for holding this 
legislative hearing.
    I also want to say thank you to the Members who brought 
these bills before us this morning and to all the witnesses 
that are going to be appearing here today.
    I look forward to engaging in a productive discussion about 
the legislation that will help us provide the best care for our 
veterans, whether it is through contract care or requiring more 
VA medical centers to provide chiropractic services, and I 
yield back.
    [The prepared statement of Congressman Miller appears on
p. 45.]
    Mr. Michaud. Thank you, Mr. Ranking Member.
    Mr. Hare, do you have an opening statement?
    Mr. Hare. No, Mr. Chairman. I will have some questions 
later though. Thanks.
    Mr. Michaud. Okay. Thank you.
    At this time, I would like to welcome two of our Members 
who are here today to present testimony. I know, Mr. Pearce, 
you have another hearing you need to go to. So why don't we 
start with you?

 STATEMENT OF HON. STEVE PEARCE, A REPRESENTATIVE IN CONGRESS 
                  FROM THE STATE OF NEW MEXICO

    Mr. Pearce. Thank you, Mr. Chairman.
    I would like to thank Chairman Filner, Ranking Member 
Buyer, Subcommittee on Health Chairman Michaud, and Ranking 
Member Miller for the opportunity to discuss this issue that is 
critical to the veterans of the State of New Mexico.
    Today I am asking for you and the Members of the Veterans' 
Affairs Committee to consider my legislation, House Resolution 
315, the ``Help Establish Access To Local Timely Healthcare For 
Your Healthy Vets Act.''
    In New Mexico's rural communities, many of our veterans are 
deprived of accessible medical facilities and face the high 
cost of gasoline to travel and to obtain care. My legislation 
would require the Secretary of Veterans' Affairs to contract 
with local doctors and hospitals on a case-by-case basis to 
provide medical services including primary care for those 
veterans who live far away from the Veterans Affairs medical 
facilities.
    This would expand the capability of our local health 
providers in southern New Mexico to provide more convenient, 
efficient medical services for veterans who live in areas that 
are far away from established VA facilities.
    Currently veterans residing in southeast New Mexico must 
drive between four and six hundred miles round trip to receive 
care at New Mexico's only VA hospital located in Albuquerque, 
New Mexico.
    Just for example, it is 305 miles from my front door to 
Albuquerque. Now, you might think I live at the end of the 
Earth, but it is actually 40 miles further south to Jal, New 
Mexico. So those people have an even longer drive.
    I consistently hear stories from my constituents about the 
detrimental impact this long-distance drive has on their 
ability to access timely care and overall health.
    One Marine veteran amputee began having uncontrollable 
drainage from his good foot and was making two to three trips a 
week to the Albuquerque VA hospital. This equates to 18 hours 
of drive time a week. After 4 months, he finally lost his foot.
    Several local civilian healthcare experts feel the 
unfortunate travel marathon contributed to the failure to save 
his foot.
    Another 87-year-old Bataan veteran developed a serious 
bladder infection and was directed to make the 6-hour, round-
trip drive along with his 85-year-old wife. Halfway through his 
treatments, prostate cancer was found and additional trips had 
to be made for chemotherapy. After 7 months of trips, he died 
and his wife's health was seriously damaged after the strain of 
such long-distance care.
    My father is in his eighties. He is a veteran and I will 
guarantee you he is not able to make a 5-hour drive one way.
    Today I know that you will hear from several National 
Veteran Service Organizations who may not support my bill and 
others under consideration today. That is because many of these 
groups have committed themselves to the goal of keeping VA 
dollars inside the VA. I understand this concept and believe at 
first glance it sounds like a commonsense approach to VA 
budgeting.
    But following this logic, the only way to get more 
localized access to care for veterans in my district would be 
to build new facilities in areas closer to their homes. I 
believe there is a need for a full-service veterans' health 
center in south New Mexico and would love to see that come to 
fruition.
    However, I am realistic as are the veterans living in rural 
New Mexico. With the tight budgetary constraints that our 
Nation faces and the smaller population in States like New 
Mexico, that idea is much easier said than done.
    This is a reality veterans living in rural areas have been 
forced to accept. Since that solution is not realistic at this 
time, we must work to find other solutions to this problem that 
is hurting our veterans with every 6- to 8-hour, round-trip 
journey to the hospital.
    Unfortunately, the idea of expanded contracting authority 
raises flags with certain Veteran Service Organizations that 
see it as a step toward privatization. Yet, if they understand 
what is going on, we are spending dollars for gasoline and 
mileage and we are not paying it for the healthcare for our 
veterans.
    I will tell you that the Federal Government and the VA are 
not adequately living up to their commitment in serving my 
constituents in the rural parts of New Mexico.
    John Taylor, life member of the Military Order of the 
Purple Heart and life member of Disabled American Veterans, 
lives in Roswell, New Mexico, which is approximately 200 miles 
away from Albuquerque. In a letter John wrote to me, rural 
veterans in New Mexico are dying and losing body parts because 
of a 6-hour, round-trip drive to the nearest VA hospital in 
this State.
    Our VSO legislative representatives from the DAV have no 
experience or do not live in contact with this issue as they 
are from large urban areas with massive facilities and 
infrastructure for support. The classic response to invitations 
requesting visits to our rural areas has historically been we 
will try. But it takes time to get there and we have a very 
busy schedule.
    I submit the same time that is an inconvenience to 
executives is the same time that is killing my fellow veterans 
or at least causing serious exacerbation of their medical 
problems.
    U.S. Army retired Lieutenant Colonel Charlie Revie, a 
member of the Uniformed Services Disabled Retirees, noted that 
the drive from Las Cruces to our only major VA facilities is a 
250-mile, one-way trip.
    The notion that providing contracted care to veterans 
through local doctors at non-VA hospitals is somehow a way to 
finagle them out of caring for them is absurd. Under my 
legislation, the VA will clearly still pay for the care of 
veterans obtained at non-VA hospitals.
    Veterans in my district and across rural America have been 
hearing politicians talk about increasing access for years. It 
is simply imperative that Congress take these issues seriously.
    Mr. Chairman, I will submit the rest of my statement, but I 
do appreciate the opportunity to come and testify before you 
today and yield back the balance of my time.
    [The prepared statement of Congressman Pearce appears on
p. 46.]
    Mr. Michaud. Thank you, Mr. Pearce. Rural healthcare for 
our veterans is very important to me, coming from the great 
State of Maine. I appreciate your testimony.
    Mr. Miller.
    Mr. Miller. I may have missed it in your comments, and it 
may be in the text of the legislation, but do you define 
geographically inaccessible?
    Mr. Pearce. Would you state the question again, Mr. Miller?
    Mr. Miller. Do you define geographically inaccessible? How 
do you define that in your legislation?
    Mr. Pearce. The definition, I think, is over 120 or 150 
miles. I will have to check on that. But, yes, we do have a 
definition.
    Mr. Miller. Okay. Very good.
    Thank you, Mr. Chairman.
    Mr. Michaud. Mr. Hare, any questions?
    Mr. Hare. Congressman Pearce, just a quick question. In 
terms of the total number of veterans that are having a 
difficult time getting to--you mentioned the long drives and 
things of that nature. Is there an estimate of how many folks, 
how many veterans in your district, in your State are having 
this problem?
    Mr. Pearce. Oh, Mr. Hare, I would guess that it is probably 
in the 20,000 range. In other words, most of the veterans in 
the southern district are a long way from a hospital. And the 
VA hospital in Albuquerque serves also Texas, so it reaches to 
the extremity.
    Some of the places in the second district are within an 
hour or two, but most are at least 3 hours one way. The rest 
are 4 to 5 hours one way. Again, my home is 5 hours one way 
from the time I leave the front door. So it is probably in the 
20,000 range. And we are just simply requesting that the 
Secretary consider on a case-by-case basis that people be 
allowed to get some care. We have had veterans talk about 
driving to Albuquerque 5 hours away one way, 5 hours back to 
take a blood test. And when they got there, they were told I am 
sorry, that has been rescheduled. These are the sorts of 
problems that the people who come from large metropolitan areas 
just are not familiar with.
    I will tell you that we have had a significant improvement 
in the relationship with the veterans hospital administrator. 
He has actually not this past Saturday, but about two Saturdays 
ago came and met with me and local veterans in Roswell. That is 
still 120 miles north of my hometown and still 40 miles from 
the southern edge of our district.
    And keep in mind, I am on one side and there is another 
side. He was about 7 hours from the sites that are equivalent 
to us on the other side, New Mexico Square. Albuquerque is 
about two-thirds through the middle. So when he was over here 
with us, he is 7 hours from those people over here.
    But at least he is coming down. We could never get the 
former administrator of the hospital to do that. So we are 
having some discussion, but he needs the flexibility to allow 
these people to go to local providers to do commonsense things.
    Mr. Hare. Well, my district is very rural too. And one of 
the things we have done, and I was just wondering if you have 
any of these, we have three veterans' outpatient clinics 
because, for example, we have people who have to go from 
Quincy, Illinois, to St. Louis or drive to Iowa City which was, 
you know, a tremendous hardship on them and people getting in 
vans and taking them to get prescriptions or a blood test or 
something.
    Are there any VA outpatient clinics in your district?
    Mr. Pearce. We do have clinics. And I will tell you that 
the clinic in Artesia, New Mexico, has a big sign that says we 
are not an emergency facility, meaning if you have an emergency 
go somewhere else. That is extraordinarily disruptive.
    So sometimes they do those things like the blood tests. 
Sometimes they do immunizations. Sometimes they say, no, we are 
too busy, you have got to go to Albuquerque.
    Mr. Hare. So you had a veteran drive 5 hours----
    Mr. Pearce. Yes.
    Mr. Hare [continuing]. For a scheduled blood test only to 
find out that----
    Mr. Pearce. Absolutely.
    Mr. Hare [continuing]. They canceled it and you had to 
drive--so 10 hours for absolutely nothing?
    Mr. Pearce. Yes. And that is one of the things that we had 
the VA hospital administrator, he said he would commit that if 
they are going to start cancelling people's appointments, they 
would at least do it the day before or 2 days before.
    Some of these people have to go on their own money. There 
is no hotel compensation allowed and they have to go on their 
own money. And they may leave a day and a half early because 
the drive is so hard.
    I will tell you that I suffer from varicose veins and they 
have recently gone in because I had this pooling of blood 
problem. And the worst thing you can do is drive with that 
situation. And to be describing this Marine veteran that was 
having to drive 5 hours with a foot that is leaking is to me 
the worst thing that you could do. And, sure enough, he ends up 
losing his foot.
    They tell me sitting on the airplane, though it is 9 hours 
for me to commute home from here to Washington, they tell me 
the worst thing I can do is sit in the airplane and, yet, that 
was the prescription for him.
    Mr. Hare. Thank you, Congressman.
    Mr. Michaud. Mr. Stearns, any questions?
    Mr. Stearns. No.
    Mr. Michaud. Dr. Snyder.
    Mr. Snyder. No.
    Mr. Michaud. Now I am pleased to recognize an honorable 
Member of this Committee, Mrs. Ginny Brown-Waite.
    Once again, Mr. Pearce, thank you very much.
    Mr. Pearce. Thank you, Mr. Chairman. You have been very 
gracious.
    Mr. Michaud. Thank you.

   STATEMENT OF HON. GINNY BROWN-WAITE, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF FLORIDA

    Ms. Brown-Waite. Thank you, Mr. Chairman, and thank you, 
Ranking Member and the Members who care enough to attend. I 
know that many people have simultaneous hearings going on that 
they also have to be to as I do, so I will be leaving after the 
testimony.
    I appreciate the opportunity to testify on House Resolution 
92, the ``Veterans Timely Access To Healthcare Act.'' When I 
first came to Congress in 2003, I introduced this measure after 
hearing of the long wait times facing some veterans in need of 
healthcare.
    We recently checked with the VA and the VA is saying that 
96 percent of the patients seeking primary care can get an 
appointment within 30 days. I think that every Member of 
Congress, if they were polled, knows that they are hearing 
otherwise. I do not know where the VA is getting their figures 
from, but we hear otherwise.
    The stories that many of us have heard about these delays 
are unacceptable. The holdups can worsen the veteran's health 
and pose a greater financial hardship on everyone involved. In 
some situations, these waits can be the difference between life 
and death.
    Events in Iraq and Afghanistan also remind us of the urgent 
matter at hand. With thousands of soldiers returning from the 
front lines, many will require immediate healthcare. VA medical 
facilities face a difficult task. Unless Congress takes action, 
wait times will only grow.
    My legislation would help ensure that our Nation's veterans 
receive timely healthcare. For veterans seeking primary care 
from the VA, the bill would establish a 30-day timeframe as the 
standard for access to medical services. This standard would 
cover from the time the individual schedules a visit until they 
actually see a medical provider. In the event this standard is 
unachievable, the VA would have authorization to contract for 
care from a private provider.
    At the same time, my bill also grants the VA some 
flexibility in meeting the standard. For those facilities in 
geographic areas that have a 90-percent or greater rate of 
complying with this requirement, the contracting provisions 
would not be necessary.
    Finally, Mr. Chairman, this legislation would establish 
comprehensive reporting requirements on wait times for 
individuals seeking care at VA medical facilities.
    As Members of Congress, we have an extraordinary 
responsibility to veterans. These brave men and women answered 
the call in our time of need and it is only fitting that we 
take care of them at their time of need.
    I look forward to working with my colleagues on the 
critical issue of wait times, and I would be happy to take any 
questions regarding the legislation.
    When I first got elected, I contacted all of the clinics in 
my area and asked what the wait times were. It did not jive 
with what I was being told by veterans. I then said I want you 
to tell me the real wait times that they have.
    Mr. Chairman, I am embarrassed to tell you that there was a 
big difference between their quick and dirty analysis and the 
true wait times that the veterans had to wait for the primary 
care.
    This is unacceptable, and because we have stayed on top of 
it, those numbers are somewhat within the acceptable range, but 
still not where they should be. Everybody in Congress wants to 
make sure that our veterans are taken care of and timely access 
to healthcare is very important.
    And with that, I yield back the balance of my time.
    [The prepared statement of Congresswoman Brown-Waite 
appears on p. 47.]
    Mr. Michaud. Thank you very much, Ms. Brown-Waite.
    Mr. Miller.
    Mr. Miller. To my colleague from Florida, I think you have 
already answered the question, do you have any confidence in 
VA's numbers in regards to wait times?
    Ms. Brown-Waite. No, sir, I do not. I honestly do not. I 
question it and every Member of Congress who hears from their 
veterans has to also question it. I know you have a large 
number of veterans and that you are very much on top of their 
needs as we all are. That is not what we hear.
    I am known as the nag in the 5th District. And I am fine 
with that because unless you nag the VA and let them know that 
you track those numbers, they do get out of control. And also 
they play games. They will schedule an appointment within ``30 
days'' and on the 25th day perhaps cancel it. So it is not 
really an appointment within 30 days. So we need to constantly 
question their numbers.
    Mr. Miller. You also talk in your legislation about 
requiring that veterans be referred to private physicians. What 
about the instance of the veteran that says he is willing to 
wait and go ahead and go through the system as normal? It does 
not preclude them from continuing on through VA?
    Ms. Brown-Waite. If they are willing to wait, they 
certainly would have that flexibility.
    Mr. Miller. That is all, Mr. Chairman.
    Mr. Michaud. Mr. Hare.
    Mr. Hare. I was just interested in where the VSOs are 
coming down on the legislation and if you could tell me why, 
from your perspective, there is opposition to the bill.
    Ms. Brown-Waite. Most of the VSOs that represent the 
veterans up here want to make sure that all the healthcare 
resides within the VA. And that certainly is their job. 
However, I think each of us when we go back home hear different 
from the veterans who want a much more timely access.
    Historically the VSOs have always wanted to contain the 
healthcare only within the VA system. And in a perfect world, 
that would be the ideal because of continuity of care. But we 
also do not want the veteran waiting inordinate amounts of time 
and the VA playing games with the wait times.
    Mr. Hare. Could you give me an example or two of what you 
have seen in terms of wait times. I know you mentioned a little 
bit about it, but maybe from in your district because, as you 
said, when we go back and we hear from the veterans, I just 
wondered if you had an instance or two that you could----
    Ms. Brown-Waite. Certainly. Mr. Chairman, if I may respond. 
I have had veterans tell me exactly this situation that I just 
described of, yes, they had an appointment within 30 days, but 
on the 21st or the 25th day, VA called to reschedule it 30 days 
later. That is not timely access and that is not serving the 
veterans.
    Certainly the VA clinics, and we are fortunate we have many 
in Florida, the VA clinics do all that they can, but they are 
also having trouble hiring for positions that are open. They do 
not have enough doctors. They do not have enough of the nurses 
and the medical technicians there.
    We are expanding clinics regularly, but people are still 
having trouble with the primary care access.
    Mr. Hare. Thank you very much.
    Mr. Michaud. Mr. Stearns.
    Mr. Stearns. Yeah. Thank you, Mr. Chairman.
    My colleague from Florida has been a leader on this ever 
since she came to Congress and I commend her for it and for 
particularly in an informal basis to try and understand the 
facts.
    Ginny, you had indicated that it takes 30 days, that that 
is the question. But have you looked at once a person gets the 
appointment and then has to come back sometimes and it is not 
just the first appointment that takes a long time, it is coming 
back for the second and third? And I heard complaints that they 
can get within the 30 days, but then when they come to get the 
referral sometimes takes longer. And I just wonder if you had 
any experience on that.
    Ms. Brown-Waite. Mr. Stearns, it depends whether or not the 
second appointment is for specialty care. I know that there is 
a much longer wait for specialty care. I recently heard from a 
veteran seeking dermatology care and that was an inordinate 
amount of time that he had to wait.
    As you all know in Florida, dermatologists are, even in the 
private sector, there is a long wait for the dermatology 
appointment. But very often they will get that first 
appointment and then there is a delay in the followup 
appointment. So, yes, I am hearing that as are other Members of 
Congress.
    Mr. Stearns. Yes. That is what I hear that some complain, 
well, okay, I can get into the front door, but I cannot get any 
response beyond that.
    I do not know. I heard you talk about your informal 
investigation. What did you find was the real time when you 
talked to these veterans themselves? What have they been 
telling you? Like some of my veterans have told me well beyond 
45, 50 days.
    Ms. Brown-Waite. Oh, absolutely. I hear well beyond that, 
as much as 2 months and longer that they are waiting. And that 
is just not acceptable and, yet, the VA tell us that overall 96 
percent are being seen within that 30-day period. I guess it is 
in, you know, dog years that they are counting it because it is 
not 30 days in human days.
    Mr. Stearns. Just your option you talked about, about the 
referral of veterans to private physicians if a network fails 
to meet the standards of access. I guess the question is, is 
your intention not to give an individual veteran the option of 
waiting to receive it or just, in other words, the veteran 
could decide, okay, I will wait 45, 50 days or is it a mandate 
that he has to go to a private physician?
    Ms. Brown-Waite. No, sir. Obviously the veteran could wait 
for the VA care if that is their choice.
    Mr. Stearns. Yeah. Mr. Chairman, I think it is important to 
point out that the legislation is not a mandate to go private, 
but giving the veteran the choice which is what I think 
ultimately the veteran wants to have.
    And I thank you.
    Mr. Michaud. Thank you.
    Dr. Snyder, any questions?
    Mr. Snyder. Thank you, Mr. Chairman.
    I did not realize we had such Florida domination of the 
Veterans Committee until this very moment.
    Ms. Brown-Waite, I guess just two comments or questions, 
and I like what you said about nagging. I think that is what we 
all do sometimes on different issues. And I think it is really 
important that we all do that.
    The concern I have about this bill and some of the other 
bills is there is no new source of funds in this bill and if we 
pass any kind of language that requires the VA to hit this mark 
or we have to pull money out of our system, that money is going 
to be pulled from some place. And if you magnify that all over 
the country or at some point, then they say, well, we need to 
lay off a primary care doctor because we got to pay these bills 
down the road.
    And it seems like we dealt with this a few years ago and I 
think there was a decision made that trying to find healthcare 
in the private sector because we do not like what is going on 
in the VA system that we love so much, at some point, it leads 
into a spiral of funding problems for the underlying system.
    How do you respond to that? I mean, I applaud you. I mean, 
this is kind of a sophisticated form of nagging you are doing 
here this morning. I think it sends a message that we, I agree 
with you 100 percent, we need to be working on these problems. 
But how do you respond to that criticism that we have heard 
through the years and which I have agreed with, by the way?
    Ms. Brown-Waite. Dr. Snyder, as you know, we have increased 
funding. This is my fifth year here and we have increased 
veterans' funding for healthcare substantially during that 
time. It has been over 40 percent in those 5 years that the 
funding has been increased.
    We need to continue to increase that funding. No, this bill 
itself does not have a pricetag attached to it. That would be 
certainly part of the appropriations process.
    Mr. Snyder. Yeah, which I think has some problems.
    Then the other, there is this other issue, too, which I 
think the VA system, as we all know, gets accolades for things 
that it does better than the private sector, but I was nagging 
one of my employees not long ago about I thought he had a 
dermatological thing he needed to have checked out and he 
finally succumbed to my verbal pressures. And it was like it 
was going to be almost, I think, like 2 months before he could 
get in. I said that is not acceptable. So then he was calling 
around and he finally did find somebody.
    But the standard at a private community on some of these 
specialty things is not all that great either for getting in. 
But thank you.
    Thank you, Mr. Chairman.
    Mr. Michaud. Thank you, Dr. Snyder.
    And, once again, thank you, Ms. Brown-Waite for your 
testimony.
    Ms. Brown-Waite. Thank you, Mr. Chairman.
    Mr. Michaud. Next on is Mr. Ortiz. I want to thank you for 
coming here today as well and to present your legislation.

    STATEMENT OF HON. SOLOMON P. ORTIZ, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Ortiz. Thank you, Mr. Chairman, Ranking Member, and 
Members of the Committee, for this opportunity to speak to you 
on behalf of south Texas veterans and help this Subcommittee 
understand the urgent need for a veterans' hospital for the men 
and women who fought for us.
    We have this map before you because I will be addressing 
the Rio Grande Valley. The valley is way at the bottom with a 
population of close to 600,000 people, but the nearest hospital 
is about 6 hours away.
    I would like to echo what my good friend, Mr. Pearce, 
testified to about the distance. Here with me today are the 
Veterans Alliance of the Rio Grande Valley so you can see the 
faces of the south Texans affected by the lack of a hospital.
    The Rio Grande Valley is the southern-most tip of my 
district. And these young men fought bravely for us in 
different wars, from the Korean War to the Vietnam War, and 
some of them still fighting the Iraqi and Afghanistan War.
    Here with me today is Jose Maria Vasquez, Ruben Cordova, 
Max Belmarez, Polo Uresti, Frank Albiar, and Mr. Felix 
Rodriguez. They wanted to be here today to put a face to the 
problem that we face in south Texas.
    My legislation gives the government flexibility in 
establishing a way to deal with hospital services in south 
Texas, but the only real solution, my friends, and I know you 
understand this problem, is a hospital.
    Most of the clinics that we have do not have any inpatient 
care. All they do is have outpatient care. We did try to 
contract out, but 10 beds is not sufficient. The bottom line is 
veterans' inpatient healthcare must be available where the 
veterans reside, not several hours away.
    Part of the healing process is for the family to be able to 
be close to their loved ones who are recuperating from wounds. 
Now we are beginning to see wounds that we did not see before 
because our young men and women are surviving this war because 
they have body armor and better equipment.
    These guys have fought, bled, sacrificed for this Nation. 
They need something that belongs to them, a hospital that gives 
them the care that they need where they reside.
    And we know that the VA plays the numbers game, but the 
numbers do not reflect the need, particularly in the Rio Grande 
Valley.
    When the VA commissioned the CARES study, they recognized 
the far south area of south Texas was in need of acute, 
inpatient care. They decided to meet this demand through 
contracting and leasing beds with the local hospitals, an 
approach that we tried but simply did not work.
    Veterans are still traveling in large numbers to San 
Antonio for care. And for many who are treated for emergencies 
at area hospitals, the bills go unpaid.
    Before, you can imagine this, these young men went and 
fought a war thinking that we as a government were going to 
take care of their problems. Now they have a five and a half 
hour drive, and do not even have vans. They do not have an 
ambulance. They have to get volunteers, my friends, to drive 
them for five and a half hours to the nearest VA hospital which 
is in San Antonio.
    Some of the Second World War veterans are bedridden and no 
ambulance to drive them and are dependent on volunteers to 
drive them. They have a van. How in the world can you see the 
Second World War veteran on a van when he is bedridden? Some of 
them just simply do not go to the hospital anymore or to the 
clinics that we have.
    Many of the veterans are so disgusted by the level of VA 
healthcare that they just simply do not sign up anymore. They 
have given up.
    You have heard me describe the conditions of south Texas 
veterans today, but they want to show you experience of 
veterans themselves, veterans who shed blood for our Nation.
    What I have done and what they wanted to do was give you 
testimonies, and it is a stack this high, of some of the 
sacrifices that they have gone through to go five and a half 
hours to get a 15-minute checkup because the locals do not have 
the equipment, because the locals just cannot do it. They go up 
there for 15 minutes. They drive five and a half hours. Then 
they come back another five and a half hours' drive.
    Some of them, the older people are having prostate 
problems, in the eighties. They go there just to see that their 
appointment was canceled. Then they have to drive back again, 
and they say come back in 6 months.
    This is just something that I cannot understand. You know, 
we can find money to go fight a war, into the billions of 
dollars, but for some reason we cannot find enough money to 
take care of the promises that we made.
    I am a veteran. I served. We must give them what they 
fought for. And Vic and I, you know, we served, Congressman 
Snyder and Jeff Miller. This is something that we do every day. 
We talk about readiness, about military, about personnel, and 
about funding into the billions of dollars.
    I am afraid that what we are doing today is going to have a 
huge impact if we do not try to resolve some of these problems 
on retention and recruitment.
    I was at a fair that we had for veterans and I see this 
older man on crutches with his two young grandsons. And as I 
was talking to him, he says do you think I am going to 
recommend for my grandsons to go join the military when you 
look at my condition and they have not been able to take care 
of me?
    This is why we need something to address the needs of our 
soldiers, people who have fought, people who have bled, many 
have died, have never come back.
    We just had a recent young man come back from Iraq. He was 
shot in the back. His spinal cord is gone. He cannot walk 
anymore. He says I remember when I was in Iraq and I saw those 
young men lose their legs and I felt sorry for them, you know, 
and I still do. But you know what? Those young men who lost 
their legs can walk because of prostheses. There are a lot of 
us coming back with spinal injuries with our legs, but we 
cannot walk.
    When he was coming out of anesthesia, my friends, he was 
fighting. He thought they were taking him prisoner. We need 
competent people, trauma care, who understand what they are 
faced with. And this is something that we do not have.
    I have a large testimony, but I know that time is limited. 
Look at my legislation. I will leave with you some letters that 
you can read about the sacrifices that they go through.
    Thank you so much for listening to us. Hopefully you will 
take a look at my bill, and I will give you the testimony that 
the veterans and some petitions because this is something. I 
have been in Congress 25 years. I have been fighting for a 
hospital for the last 24 years.
    What they have done in the past is to consolidate some of 
the clinics, shut down some hospitals, and now we are getting 
more and more soldiers coming back with different wounds from 
Iraq and we need to take care of that.
    Thank you so much.
    [The prepared statement of Congressman Ortiz appears on p. 
48. The petition submitted by Congressman Ortiz is being 
retained in the Committee files.]
    Mr. Michaud. Thank you, Mr. Ortiz. And do you have a copy 
of that map, so we can have it for the record?
    Mr. Ortiz. We do. We are going to pass you a copy of the 
map with the testimonials of several of the veterans.
    Mr. Michaud. Okay. Great. I appreciate it.
    And it is my understanding that under the Capital Asset 
Realignment for Enhanced Services (CARES) process there is no 
hospital, but we will check with VA to make sure.
    Mr. Miller.
    Mr. Miller. Solomon, I assume that the closest DoD facility 
to south Texas is Corpus Christi. Is there a Navy hospital 
there at the Naval Air Station?
    Mr. Ortiz. We had a Naval hospital. It was shut down. And 
sometime back, I testified before the VA Appropriations 
Subcommittee. They came down and they looked at the hospital. 
Again, the lack of funding. And then they came down and they 
said this hospital is obsolete, you know, does not conform to 
the American Association Guidelines. So we do not have a 
facility.
    Another problem that we have is the influx, you know, we 
have a lot of winter tourists, veterans that live in the area 
for 4 to 6 months, they are vets who need treatment, about 
20,000. We have about 140,000 people, soldiers who have served 
in the military. We do not have a facility. We tried 
contracting out with the local hospitals.
    One young man was having a cardiac arrest and he called his 
people at the VA, who say go to the hospital, go to the nearest 
hospital. He did. Then he got a bill for $10,000 that he still 
has not been able to pay.
    These are the problems that we face on an everyday basis. 
There is not a hospital. It is all outpatient care.
    Mr. Miller. You said that the contracting side was not 
working. Is it not working in regards to them being able to get 
the care? Is the breakdown just in paying for the bills? Where 
is the breakdown?
    Mr. Ortiz. It is both, because when you have 140,000 
eligible people and you only have about 10 beds, you know, 
either they are full, they cannot take anybody, or if they take 
somebody else, they do not have room, then they charge the 
patient coming in.
    So this is why the system, we tried it before, it is not 
working. And when I meet with a veteran, they say, you know, 
when I enlisted, they told me that they were going to take care 
of my health and now I am back and I have to wait 6 months for 
an appointment. I cannot get inpatient care. It is all 
outpatient care.
    Mr. Michaud. Mr. Hare.
    Mr. Hare. Congressman, let me just say thank you for two 
things. One, first and foremost, for introducing this 
legislation. You know, you were absolutely right. I was 
listening to your testimony and the amounts of money that we 
spend, you know, $11 million an hour on this war and, yet, I 
sat at this Committee and I keep hearing people say how are we 
going to afford this. And my answer has always been the 
question is not can we afford, the question is how can we 
afford not to do this.
    So, Congressman, I would be honored to be a cosponsor of 
this bill. I think it is something that your veterans need and 
you have been a champion for veterans. And so I just want you 
to know that.
    And we will find the money. We have got it. You know, and I 
said before maybe we ought to take it out of Paris Hilton's tax 
break. I do not know. But we will get it.
    But let me just suggest this to you, too, or thank you for 
this too. I thank you for taking the time to come in. Lane 
Evans is my predecessor as you know. And I want to thank you 
for coming in helping us complete the Hero Street Memorial with 
your help.
    And for those of you who do not know what that is, that is 
a Hispanic area in my district, one street where five young men 
gave their lives in World War II.
    And thanks to you, Congressman, that memorial is now 
finished. And I want to, on behalf of the people of Hero 
Street, I have not had a chance to thank you yet, but I want to 
thank you for doing that.
    And, again, thank you for introducing the legislation and I 
will do everything I can on my end to help you with it. And, 
you know, you are right. When you bring veterans in and you put 
a face on it, you know, I think it is a wonderful thing to do 
because sometimes we look at charts and numbers, but we are 
talking about people here.
    And from my perspective, I cannot think of anything more 
important to do than to support this bill. So thank you for 
taking the time.
    Mr. Ortiz. Thank you so much for your comments. Thank you, 
sir.
    Mr. Michaud. Dr. Snyder.
    Mr. Snyder. I have no questions.
    Mr. Michaud. Well, once again, thank you very much, Mr. 
Ortiz, for bringing the legislation forward.
    Mr. Ortiz. Thank you so much.
    Mr. Michaud. The last panelist for this panel is Mr. 
Rothman.

   STATEMENT OF HON. STEVEN R. ROTHMAN, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Rothman. Thank you, Mr. Chairman.
    Ranking Member, Members of the Committee, thank you for 
having me here today.
    I am here to testify today about the moral responsibility 
and national security obligation of the Federal Government to 
honor its commitment to all veterans, namely the commitment to 
provide them with quality, affordable healthcare.
    It is a moral responsibility because the American 
Government makes a promise to every veteran. We say that you 
volunteer to put your life on the line for freedom, because you 
are willing to sacrifice yourself for the good of all 
Americans, because of this courage, we will take care of you 
when you leave the service.
    We do not make that promise with our fingers crossed. We do 
not tack on fine print or attach a bunch of strings to the 
promise. We make that promise freely because our veterans gave 
freely of themselves in the service.
    It is a national security obligation because without 
question, the morale of a young soldier, I believe, is 
seriously hurt when he meets a 35-, 45-, 55-year-old veteran, 
combat veteran who is battling cancer or who had a heart attack 
but had no health insurance and was banned by his government 
from getting healthcare through the VA. It is outrageous.
    As a representative for more than 156,000 veterans, I have 
heard story after story from veterans in Bergen, Hudson, and 
Passaic counties of New Jersey who tell me that their 
government has broken its promise to them. That is because in 
January of 2003, the Bush Administration decided to cut costs 
by telling veterans designated as Priority 8 that they are 
banned from enrolling in the VA health system and will no 
longer have access to VA hospitals, clinics, or medications.
    The Administration defended its decision by saying that 
Priority 8 veterans make too much money to be worth the added 
expense to the system. Just so you know, the amount of money 
they said was too much was anything over $26,902. I say that 
Priority 8 is wrong and that the Bush Administration has the 
wrong priorities.
    We made a promise to those men and women to take care of 
them and there is absolutely no justification for breaking our 
word. Those veterans often live in areas where the cost of 
living more than eats up the $26,902 of income that the Bush 
Administration seems to think is so great.
    In Bergen County, New Jersey, we have the second highest 
concentration of veterans in the State of New Jersey and the 
largest number of Priority 8 veterans. There are 73,000 
Priority 8 veterans in New Jersey alone, 273,000 Priority 8 
veterans throughout the country, 273,000 veterans who have been 
told they make too much money making $26,902.
    So an example, if you served in combat in Iraq or 
Afghanistan for a number of years, three, four deployments, 
five deployments and thank God you come home without any 
physical injuries, 5 years later you get cancer, you cannot use 
the VA if you make more than 26,000 bucks. In my district, the 
number is a little bit higher, but it is certainly not enough 
to cover the costs of healthcare.
    Turned away, 273,000 veterans turned away from the VA. What 
is the message we are sending to our soldiers? We are saying 
that even though the government made this promise, even though 
all Americans believe that this is the case that if we serve, 
we are going to be taken care of, that is not the case. It is a 
lie.
    The President may promise to love veterans and love people 
in the Armed Forces, but that is not what he is doing. He had 
this Congress or he had his Administration come forth with a 
plan that has cut 273,000 veterans from healthcare through the 
VA. We need to keep our promises to our veterans.
    Mr. Chairman, Mr. Ranking Member, and Members of the 
Committee, again, we did not make those promises with our 
fingers crossed or our hands behind our back. They deserve this 
healthcare.
    And one of my colleagues was asking where we get the money. 
In my book, I think the way most Americans feel is this is an 
obligation, this is a promise we made. It is a moral imperative 
that we live up to our promise to those who put their lives on 
the line for us. It is a national disgrace, a national 
dishonor.
    Where should we get the money? Well, you know, if you have 
a lot of different needs, you take care of the most urgent need 
and the promise to those who did the most, that would fall into 
this category. And if, my goodness, because the health of the 
veterans' healthcare system cannot take care of all of its 
veterans because this Administration will not provide the 
money, then maybe we ought to rethink our healthcare system. 
Oh, my goodness.
    The first thing we need to do, though, is live up to our 
promises to our veterans and take care of them if they get sick 
when they come home.
    Thank you, Mr. Chairman, Mr. Ranking Member, Members of the 
Committee.
    [The prepared statement of Congressman Rothman appears on
p. 71.]
    Mr. Michaud. Thank you very much for your testimony.
    Mr. Miller.
    Mr. Miller. Thank you very much for your testimony, and I 
think we all agree that there are many things that we can work 
on and do better. Certainly the VA system gets that from this 
Committee and Subcommittee all the time.
    Are you aware, Mr. Rothman, that an Operation Iraqi 
Freedom/Operation Enduring Freedom (OIF/OEF) combat veteran 
can, when they come home, get 2 years of healthcare, so they do 
have that. I do not know if there is a lie being perpetrated on 
those veterans at all, and I do not think that is what you were 
trying to characterize, but----
    Mr. Rothman. Thank you for the clarification. But with 
regards to those veterans whose service preceded Iraq and 
Afghanistan, if they get a heart attack, if they get cancer and 
they do not qualify for Medicare because they are too young, 
they are under the age, they are in their thirties or forties 
or fifties, they are out of luck. They do not get any 
healthcare. And that is a lot of folks, 273,000 in the United 
States.
    Mr. Miller. I concur. Again there is an issue, but I think 
a lot of times while we are at war, we use current stories 
about veterans as they are returning home and there is a clear 
distinction in regards to their ability.
    Mr. Rothman. I accept that distinction and I appreciate 
that.
    Mr. Miller. Thank you for your testimony, Steve.
    Mr. Michaud. Mr. Hare.
    Mr. Hare. I would just concur with you. I mean, a promise 
made to veterans is a promise that we have to keep and for the 
life of me I continue to shake my head because even if we did 
not care about the health of the veteran, which should be first 
and foremost, I do not know how we are going to recruit other 
people to go in when they see the kind of treatment, or lack 
thereof, that we are giving to the current veterans.
    I really applaud you for doing this because I do not care 
what category you are, it just seems to me if you served this 
country, you are honorably discharged, this country makes a 
promise, and, as you said Congressman, we did not make it with 
fingers crossed or wink and a nod. We made the promise. So if 
we are going to make it to veterans we have to keep it. And for 
those two hundred and how much? I am sorry.
    Mr. Rothman. Two seventy-three.
    Mr. Hare. Two hundred and seventy-three thousand veterans, 
I mean, what does that say for the service that they have given 
to this country?
    Mr. Rothman. If I may, Mr. Chairman.
    Mr. Michaud. Absolutely.
    Mr. Rothman. There are a lot of our service men and women 
who are not in combat as defined under the law that my friend 
from Florida referred to. Nonetheless they are in harm's way. 
There are terrorists who would seek to blow up any 
servicemember in uniform or out of uniform. And so there is a 
justified distinction in those who served in combat, but I 
think every veteran deserves the right to, especially after 9/
11, to, and before, to get this kind of care.
    And by the way, if you ask yourself is this not so sad and 
shocking for veterans, is it not sad and shocking for an 
industrialized nation, the richest in the world, if one of the 
people that served in the military gets a heart attack or 
cancer and they cannot afford health insurance, they are going 
to suffer in the United States of America?
    Mr. Hare. I just want to say, Congressman, you know, when 
people are sworn in to any branch of the service, they swear 
that they are going to protect this country and they do. And 
once they are discharged, I think we have a moral obligation to 
protect them.
    And for the life of me, I do not know why the 
Administration decided they were going to do this unless it was 
a cost-saving factor and even if that was the excuse, that is 
about as lame as it gets. So I think we have to restore this. I 
think your bill does that.
    And, again, I think, and I know one of the Members on the 
other side, what do you want to do, do you want to cover 
everybody? The answer is, yes, I do. And I think it is 
something that is terribly important.
    And, again, this Committee, and I love this Committee a 
great deal, we have been able to do some wonderful things. We 
have a great Chairman, great Subcommittee Chairman, great 
Members, and I think we finally decided that enough already. We 
have put the brakes on this.
    And I look forward to working with you on this because I 
think it is a moral obligation that we have as a country.
    I yield back.
    Mr. Rothman. Thank you. I hope you will consider my bill, 
Mr. Chairman, Mr. Ranking Member. I appreciate your service for 
all of the veterans. We need to do more and to find the money 
to do it.
    Mr. Michaud. Thank you very much, Mr. Rothman, for your 
testimony.
    And since there are no further questions, I would ask that 
the next panel come up.
    We will be having votes shortly, so what we will do is have 
the next panel give their testimony before we ask questions. 
Keep in mind that we do have votes, and we have two more panels 
after this panel.
    I would ask unanimous consent that Chairman Filner be 
invited to sit at the dais for the Subcommittee hearing today. 
Hearing no objection, so ordered.
    I would like to welcome the second panel with us here this 
morning. And what we will do is start with Congresswoman Solis 
and move down the line.
    Congresswoman.

STATEMENT OF HON. HILDA L. SOLIS, A REPRESENTATIVE IN CONGRESS 
                  FROM THE STATE OF CALIFORNIA

    Ms. Solis. Thank you very much, Mr. Chairman, Ranking 
Member Miller, for holding this very important hearing.
    I feel real privileged with this opportunity to present, I 
think, a case that has not been stated very clearly here in the 
Congress and it is with respect to a bill that I have 
introduced, Culturally Competent Veterans' Care, House 
Resolution 542.
    The bill requires that the Department of Veterans Affairs 
conduct a thorough assessment identifying non-English languages 
that are likely to be encountered and ensure that such services 
are available in both English and a language in which a veteran 
is proficient.
    And as you will see by the posterboard here, these are 
servicemen that have actually come from the district, served in 
Afghanistan or Iraq. Unfortunately, they did not come home. 
There are 14, so some are missing. But if you can see their 
faces, you can tell that they are predominantly of Latino 
background.
    One of the cases that came to my attention when the war 
began was one of our fellow soldiers who had fallen. I went to 
visit the family. The mother was not proficient in English. The 
son was about 20 years old, passed away, was killed in Iraq. 
And the mother had no idea about the information that the 
military was relaying to her. We tried to get them an 
interpreter.
    What they ended up doing was actually getting another 
service officer, about 18, 19 years of age, to try to interpret 
what choices the family had in terms of burial services and 
life insurance and everything else, all the details that you 
would think somebody would be proficient and competent in.
    When I came to realize that, I saw a serious gap, but it 
kept repeating itself. And so different families that I would 
encounter in my district in LA, and this is typical of the 
southwest where you see a large concentration of Hispanic 
communities serving our military, you are finding these 
households, whether it is the family itself or the soldier, who 
is proficient in another language, which is in this case, I am 
arguing, Spanish, but it could be Asian, it could be Filipino, 
it could be Asian-Pacific Islander, because we have those 
individuals, too, serving in combat.
    And what I am finding is that upon calling the VA to ask 
them about services that could be provided in their language so 
that there is less resistance and more understanding and 
sensitivity in applying for services through the VA, that that 
should be a part of what the VA does.
    Well, apparently what they do is they receive grants and 
they decide what languages they want to provide information. 
And in many cases, I do not think a booklet or a piece of paper 
goes far enough. We need to have staff out there. And you 
cannot rely on another soldier who might be misinterpreting 
information, who is not trained properly to give that 
information to a family member, to a spouse, or to the soldier, 
him or her self. And we have encountered this situation 
multiple times.
    Upon inquiring with the VA, they said, well, we do not have 
enough staff available. We know that there are guidelines that 
we are supposed to be abiding by, they say, and, yet, in most 
of their facilities, I am told that only 43 percent of the 
entire VA services it is supposed to be providing the service 
is actually being applied.
    So I have a serious, serious concern and that is why I have 
introduced the bill. I think it goes a long way and I would 
just ask for your consideration and support.
    In addition, while you may see male members here, I have 
met several times with many of our recruits in our district and 
there is a large Latino population as well. And there are 
special circumstances there where women also need to be treated 
differently with respect to service-related benefits that they 
may have.
    So I think that that is something that we have to keep in 
mind as well, and I will gladly work with the Committee and 
hope that you may somehow incorporate our efforts here, if not 
possibly see the bill come through your Committee.
    But I thank you for the opportunity to be here this 
morning.
    Mr. Michaud. Thank you very much for your testimony.
    Mr. Latham.

STATEMENT OF HON. TOM LATHAM, A REPRESENTATIVE IN CONGRESS FROM 
                       THE STATE OF IOWA

    Mr. Latham. I thank the Chairman and the Ranking Members, 
Members of the Subcommittee.
    I am honored to have the opportunity to testify before you 
today regarding House Resolution 1426 which is the ``Veterans' 
Access to Local Healthcare Options and Resources Act,'' also 
known as the ``VALOR Act.''
    I introduced this legislation in response to a growing 
concern expressed by veterans in my district regarding access 
to VA healthcare. Veterans who live in rural parts of my 
district must travel long distances to VA medical facilities to 
receive the healthcare that was promised to them.
    Oftentimes they have to wait for months to get an 
appointment. They are frequently forced to give up a full day 
sometimes in fragile condition to travel for healthcare.
    Despite the remarkable improvement in the quality of VA 
healthcare during the past decade, the fact remains that not 
all America's veterans have equal access to these services.
    One example of this inequity is the story of a Vietnam Army 
veteran from Fort Dodge, Iowa. He is a recipient of the Bronze 
Star and is service disabled. And he estimates that he has made 
the 4-hour round trip from Fort Dodge to the VA medical 
facility in Des Moines more than 100 times in the past 3 years. 
Because he cannot drive, he relies like most veterans on a 
shuttle graciously provided by one of the Veteran Service 
Organizations which takes up to 10 or more veterans to Des 
Moines at a time.
    Since they have to wait for the last appointment to return, 
the trip takes an entire day, sometimes starting at 5 a.m. and 
returning late in the evening.
    Countless similar cases have been reported to me by 
veterans in my district. This situation leads me to ask the 
question, can we really say that we are providing top-quality 
care for our veterans when so many have limited access to it?
    Out of nearly 8 million veterans enrolled in the VA 
healthcare system last year, only 5 million veterans actually 
receive VA healthcare. Recent reports show that the VA 
healthcare system continues to match or outrank private-sector 
healthcare in overall quality and consumer satisfaction.
    Out-of-pocket costs are extremely low, in particular for 
service-connected veterans, so why are less than two-thirds of 
the veterans enrolled in the system actually using it? I 
believe that access problems account for a great deal of this 
disparity. For millions of veterans, VA healthcare is simply 
not readily accessible, and again especially in rural areas.
    VA-funded research conducted by Dr. William Weeks and his 
colleagues from the VA Outcomes Group highlights the urgent 
need for action to increase healthcare access for our rural 
veterans. This research supports the conclusion that, compared 
to their urban counterparts, rural veterans have a higher 
prevalence of mental and physical problems and the least access 
to the VA healthcare system.
    I am concerned that this disparity will continue to grow 
over time unless we do something now about it. First, rural 
residents are over-represented among veterans. The VA Outcomes 
Group found that 22 percent of veterans are rural compared to 
14 percent among the general population.
    Furthermore, rural veterans are over-represented among 
those serving in Iraq and Afghanistan due to the increased use 
of the National Guard and Reserve units. These units are often 
dispersed in rural areas far from large urban centers or 
concentrations of veterans where VA facilities tend to be 
located.
    As I previously mentioned, rural veterans are already 
likely to experience more health problems. While large numbers 
of these veterans return from combat, the need for VA 
healthcare in rural areas will increase dramatically in the 
coming years.
    The ``VALOR Act'' aims at meeting this need by providing 
veterans with an option, and I will emphasize it is an option, 
they are not mandated to do anything, to receive healthcare 
that they would otherwise be eligible to receive in a VA 
facility at the local hospital or a physician's office.
    To provide this option, the legislation builds on the 
existing VA system for contracting with non-VA providers known 
as fee-basis care. The VA already has specific statutory 
authority to contract with non-VA facilities for medical care, 
but it is subject to way too many restrictions.
    The ``VALOR Act'' would require an expansion of fee-basis 
care to allow greater access to VA-funded healthcare in our 
local communities.
    Under the bill, covered services would include hospital 
care, medical services and rehabilitative services and 
preventative health services that a veteran would be eligible 
to receive at any VA facility. It also clarifies that VA drugs 
can be obtained with prescriptions written by contract 
physicians.
    Mr. Chairman, I see my time is up and I want to submit the 
rest of it for the record. But let me just say this is the 
number one veterans' issue in my district. I hear about this 
all the time. So many of these people are World War II, Korean 
veterans and it is just virtually impossible for them to 
withstand a 5 o'clock in the morning to 8 o'clock, 9 o'clock at 
night situation just to get healthcare.
    And I appreciate the opportunity to testify, and I look 
forward to answering any questions.
    [The prepared statement of Congressman Latham appears on
p. 72.]
    Mr. Michaud. Thank you very much. I really appreciate it.
    The next is Mr. Altmire who is a freshman Member of 
Congress. I want to thank you for your willingness to become 
very active in veterans' issues and look forward to your 
testimony as well.

 STATEMENT OF HON. JASON ALTMIRE, A REPRESENTATIVE IN CONGRESS 
                 FROM THE STATE OF PENNSYLVANIA

    Mr. Altmire. Thank you, Mr. Chairman, Ranking Member 
Miller, for the opportunity to testify before the Committee 
today.
    My bill, House Resolution 1944, the ``Veterans Traumatic 
Brain Injury Act of 2007,'' is bipartisan. And I introduced 
this legislation to increase the screening and treatment for 
traumatic brain injuries (TBI), for our Nation's veterans.
    TBI is an impending crisis in this country. Our brave 
service men and women are returning from Iraq and Afghanistan 
with TBI at an alarming rate. Of those treated just at Walter 
Reed Army Medical Center, it is estimated that 65 percent have 
been diagnosed with TBI as a primary or co-morbid diagnosis. 
Many now consider TBI to be the signature injury for those 
returning from Iraq and Afghanistan.
    And I am concerned that the VA health system may not be 
properly identifying and treating TBI among our Nation's 
veterans. It is estimated that more than half of all combat 
casualties have associated brain injuries. Most of them include 
mild TBI which is often missed in initial exams as physicians 
attend to other more visible injuries.
    My bill improves the coordination of TBI care for our 
Nation's veterans by requiring the VA to screen veterans for 
symptoms, develop and operate a comprehensive program of long-
term and post-acute TBI rehabilitation, establish TBI 
transition offices at all polytrauma network sites, and create 
and maintain a veterans' TBI health registry.
    And I do want to take the opportunity to commend the work 
of this Committee and the full Committee under Chairman 
Filner's leadership for the work that has been done in just the 
first 4 months on veterans' healthcare.
    The 110th Congress is taking enormous strides in meeting 
its commitments to veterans. Here in the House, we voted for 
more than $11 billion in increased funding for veterans' 
healthcare and we passed the ``Wounded Warrior Assistance Act'' 
to provide for the management of their medical care.
    And I know every Member of this Committee agrees that no 
group should stand ahead of our Nation's veterans when it comes 
time to make Federal funding decisions.
    We owe no greater debt than to our veterans and while we 
have made some progress, more needs to be done. To this end, 
the bipartisan ``Veterans Traumatic Brain Injury Treatment 
Act,'' House Resolution 1944, will allow us to properly screen 
America's returning heros for TBI and improve their treatment.
    I would be happy to answer any questions that you have, and 
I do thank the Committee for allowing me to testify today.
    [The prepared statement of Congressman Altmire appears on
p. 73.]
    Mr. Michaud. Thank you very much, Mr. Altmire.
    Next is Mr. Moran who is a distinguished Member of this 
Committee.

  STATEMENT OF HON. JERRY MORAN, A REPRESENTATIVE IN CONGRESS 
                    FROM THE STATE OF KANSAS

    Mr. Moran. Mr. Chairman, thank you very much. I am pleased 
to be on this side of the table this morning with you and 
Chairman Filner, Ranking Member Miller for the opportunity to 
testify.
    This is a topic that you have heard me speak about in the 
Committee before and it in many ways mirrors the comments of 
Mr. Latham, the gentleman from Iowa. We share the same kind of 
challenges when it comes to a rural district.
    I represent a congressional district that is about the size 
of the State of Illinois. It is almost 60,000 square miles and 
although there are 75 hospitals in my congressional district, 
there are no VA hospitals.
    And so the veterans, just as Mr. Latham described, have 
long distances to travel. We have been successful in bringing 
Community Based Outpatient Clinics (CBOCs) to the congressional 
district and I am very grateful for that, but I am convinced 
there will never be enough construction dollars to justify 
enough new clinics to serve the needs of veterans who live in 
the remote areas of Kansas and really across the country.
    I want to share just a couple of stories with you, again a 
World War II veteran. This letter comes from his wife. My 
husband has been a resident of a long-term care facility for 2 
years and is unable to drive the 65 miles it takes to get a 
physical at the Hayes VA Clinic as is required by the VA to 
receive his prescription drug benefit. They stopped filling his 
prescription medicine.
    Veterans like Ralph gave several years of their lives for 
our country and I feel that he is being treated in a very 
ungrateful way.
    Another example, Hoxie, Kansas, in which the gentleman, the 
elderly veteran needed a new pair of eyeglasses. The veteran 
was told he must travel 4 hours to Wichita to the VA hospital 
to receive his new pair of glasses, a distance of about 260 
miles, yet his hometown has an optometrist who is unable to 
meet his needs because he is not part of the VA.
    This does not make sense to me and I know that it does not 
make sense to many of my colleagues. It is long drives, bad 
weather, limited financial resources and ailments that make it 
very difficult for our veterans to make that trip and, 
therefore, many of them, I would say most forego getting 
treatment.
    It is no wonder that studies highlight the poor health of 
America's rural veterans. It is not right that we penalize 
veterans because of their choices of where they live.
    This legislation, the ``Rural Veterans Access To Care 
Act,'' has the goal of stopping these disparities in access. 
The legislation would give our country's most underserved 
veterans, those who live the farthest from VA facilities the 
choice to receive care closer to home at a local hospital or 
physician's office.
    This legislation requires the VA to coordinate care with 
the Department of Health and Human Services and to contract 
with qualified providers. These rural providers already supply 
healthcare, quality healthcare to America's rural population.
    To further ensure quality standards for the veterans' care, 
the VA should write quality criteria into contracts, monitor 
the service delivery, and put in place mechanisms to share 
healthcare information.
    The legislation would also require the VA to fill 
prescriptions written by outside physicians for eligible 
veterans.
    And I understand there are concerns. Mr. Michaud, I chaired 
this Subcommittee at one point in time and I promoted this 
legislation for a long time. It is not always supported by the 
Veteran Service Organization community. And I understand the 
concerns that are raised about the budgets and that there is a 
fear that if we enhance contracting that our VA hospitals will 
suffer.
    And I believe that it is important that we do both, fund 
the hospitals and CBOCs as well as provide contracting for our 
most rural veterans the outreach that they need.
    This legislation has not been scored, but I believe in 
order to lessen its budgetary impact, we can create criteria 
which the bill does. A veteran must live at least 60 miles from 
a VA primary care facility like a CBOC when seeking such 
outside care or 120 miles from the VA hospital or 240 miles 
from a VA tertiary care facility.
    So we have placed mileage restrictions in this legislation 
to minimize the budgetary impact. These requirements are based 
upon the VA's own care system in which they establish the goals 
for service to veterans and using their criteria of distance 
and time for veterans that they desire to serve.
    Mr. Chairman, I believe that allowing highly rural veterans 
to take advantage of the convenience of an existing rural 
healthcare infrastructure is a commonsense solution to 
providing VA care when it is not otherwise available.
    I am not suggesting we abandon the VA healthcare system, a 
system that has served veterans well and continues to improve, 
but I do request that we put in place practical reforms to 
account for the reality of those who live on the fringes of the 
VA's ability to care for them.
    I ask the Committee's full consideration of this 
legislation and would work with others to supply other ideas 
and suggestions of how it can be improved or altered so that 
our veterans will finally have the access that we have promised 
them years ago.
    Thank you, Mr. Chairman.
    Mr. Michaud. Thank you very much, Mr. Moran, for your 
testimony.
    And the final panelist is our distinguished Chairman of the 
full Committee on Veterans' Affairs, and I would like to thank 
you, Mr. Chairman, for assisting us in having this hearing on 
several pieces of legislation that are important to veterans 
and individual Members of Congress. So thank you, Mr. Chairman.

   STATEMENT OF HON. BOB FILNER, CHAIRMAN, FULL COMMITTEE ON 
 VETERANS' AFFAIRS, AND A REPRESENTATIVE IN CONGRESS FROM THE 
                      STATE OF CALIFORNIA

    Mr. Filner. Thank you. Mr. Chairman, thank you for your 
leadership. There are a lot of good bills here.
    Mr. Altmire, before you leave, I just want to thank you for 
your leadership on the traumatic brain injury situation. We are 
going to have a national symposium on brain injury and bring in 
a lot of creative and outside ideas about treatment to deal 
with it. And your bill will be there to be considered, so we 
thank you for that.
    And I thank also Mr. Latham and Mr. Moran. We are going to 
address a rural health agenda for our Nation's veterans and we 
look forward to having your bills to look at as we proceed. So 
thank you for your leadership here.
    I have two bills on our agenda today, H.R. 1470 and H.R. 
1471, and I appreciate the opportunity to speak on these bills.
    I think a special opportunity presents itself in that over 
40 percent of the medical problems for returning servicemembers 
from Iraq and Afghanistan are what we call musculoskeletal and 
many can undoubtedly benefit from chiropractic care. As one 
American who has benefited from chiropractic care, I can 
promote it in absolutely good faith.
    H.R. 1470 which was introduced in the last Congress by 
former Congressman Jeb Bradley, who was a Member of this 
Committee from New Hampshire, is called the ``Chiropractic Care 
Available to All Veterans Act.'' It requires that chiropractors 
are phased into the VA with not fewer than 75 medical centers 
by the end of December 2009 and all of our centers by the end 
of 2011.
    House Resolution 1471 is the ``Back Our Veterans Health 
Act,'' which means better access to chiropractors to keep our 
veterans healthy. It requires that veterans have direct access 
to chiropractic care at the VA hospitals and clinics so that 
veterans do not have to go through a general practitioner, or 
gatekeeper, as this doctor is sometimes called.
    We must remember that since the creation of the VA 
healthcare system, the Nation's doctors of chiropractic have 
been kept outside and all but prevented from providing proven, 
cost-effective, and much-needed care to our veterans. So, we 
are grateful that access is becoming greater.
    The support for VA chiropractic care is bipartisan and you 
may recall that the previous Secretary of the VA, Anthony 
Principi, released a policy directive before his departure 
regarding the true and full integration of chiropractic care in 
the VA.
    I hope that Secretary Nicholson will be equally open to 
this and, of course, both Republican and Democratic Members of 
this Committee have supported this bill.
    I have worked very closely with chiropractic patients, 
including our Nation's veterans, on these bills as well as the 
American Chiropractic Association and the World Chiropractic 
Alliance. I see members of both groups here today. Thank you 
for your support and your energy in promoting these important 
concepts.
    Hopefully the VA will do some of this administratively, but 
I think we have to pass this legislation to make sure that 
there is direct access for our Nation's veterans to this proven 
healthcare.
    And I thank the Chairman.
    [The prepared statement of Congressman Filner appears on
p. 74.]
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Are there any questions of the panelists that are 
remaining?
    Mr. Moran. Mr. Chairman, I would only suppose any Member of 
the Committee should compliment Chairman Filner. It is probably 
the political thing to do, but I appreciate his continued 
effort in regard to chiropractic care.
    I introduced legislation that ultimately became law 3 or 4 
years ago, 5 years ago maybe, in requiring that the VA develop 
a chiropractic care protocol. And it is a slow process by which 
the VA has integrated chiropractic care.
    And I would join with Mr. Filner in trying to encourage 
that to occur and look forward to working with you to see that 
that is accomplished.
    Mr. Filner. Thank you.
    We have passed three important bills in the last 5, 6 years 
and each time, we have gotten more direct because the VA just 
has not cooperated. So we continue to make sure, and we will 
have also oversight to make sure, that it does occur.
    Mr. Moran. Thank you.
    Mr. Michaud. Dr. Snyder.
    Mr. Snyder. Mr. Chairman, I want to ask questions of the 
Members that are not here because I will find that less 
stressful.
    Just a couple comments on Ms. Solis' bill and I have not 
studied the bill, but I am sure my family doctor back down 
here, she is dealing with primarily counseling and mental 
health treatment issues with people who were raised in other 
countries or cultures and so their language skills are 
different than those of us who are native born.
    And I think at first blush, someone may say, well, they are 
veterans, they are in the service, what do we have to do that 
for. Well, just remember that the skills that are required to, 
you know, drive a striker or shoot or go on patrol are a whole 
lot different kind of language skill requirement than the kind 
of language that you need to talk about your relationship with 
your wife, your relationship with your children, what is going 
on with your feelings in terms of the rage that you may feel or 
fears that you may feel. There are just levels, different kinds 
of language skills and different cultural sensitivities.
    Like I said, I do not know if her bill is the answer to 
this and I do not know what the current VA policy is with 
regard to these issues, but I have, you know, worked in refugee 
camps where you try to provide mental health services to people 
that you do not have good language communication with and it is 
a challenge.
    And the second issue is with Mr. Altmire's bill on TBI. We 
have talked about this issue before, but I hope in the mix, we 
will be sure that we are doing a good job of funding all the 
good research opportunities that are out there on traumatic 
brain injury because that is going to be a huge issue as Mr. 
Altmire pointed out.
    Thank you for your indulgence.
    Mr. Michaud. Thank you very much.
    I would like to ask the third panel to please come up. On 
the third panel we have Shannon Middleton, Deputy Director of 
Healthcare for the American Legion; Kimo Hollingsworth, 
Legislative Director for American Veterans; Adrian Atizado, 
Assistant National Legislative Director for DAV; Carl Blake, 
Legislative Director for Paralyzed Veterans of America; Dennis 
Cullinan, Director of the National Legislative Service of VFW; 
and Rick Weidman who is the Executive Director of Vietnam 
Veterans of America.
    And I would like to thank all of you for coming here. I 
look forward to your testimony. Why don't we start with Ms. 
Middleton and I would ask you to try to keep within the time 
limits because we do have to go vote here pretty quickly.
    Ms. Middleton.

 STATEMENTS OF SHANNON MIDDLETON, DEPUTY DIRECTOR FOR HEALTH, 
              VETERANS AFFAIRS AND REHABILITATION 
 COMMISSION, AMERICAN LEGION; KIMO S. HOLLINGSWORTH, NATIONAL 
  LEGISLATIVE DIRECTOR, AMERICAN VETERANS (AMVETS); ADRIAN M. 
      ATIZADO, ASSISTANT NATIONAL LEG- ISLATIVE DIRECTOR, 
 DISABLED AMERICAN VETERANS; CARL BLAKE, NATIONAL LEGISLATIVE 
 DIRECTOR, PARALYZED VETERANS OF AMERICA; DENNIS M. CULLINAN, 
  DIRECTOR, NATIONAL LEGISLATIVE SERVICE, VETERANS OF FOREIGN 
 WARS OF THE UNITED STATES; AND RICHARD F. WEIDMAN, EXECUTIVE 
DIRECTOR FOR POLICY AND GOVERNMENT AFFAIRS, VIETNAM VETERANS OF 
                            AMERICA

                 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 several pieces of legislation being 
considered by the Subcommittee.
    Providing quality healthcare in a rural setting has proven 
to be very challenging given the factors such as limited 
ability of skilled care professionals and inadequate access to 
care.
    The American Legion commends the Subcommittee for holding a 
hearing to discuss these very important and timely issues. My 
comments will address just a few of these bills.
    House Resolution 92, the ``Veterans Timely Access to 
Healthcare Act,'' seeks to establish standards of access to 
healthcare provided by the Department of Veterans Affairs. The 
American Legion believes that setting standards for timeliness 
in the delivery of healthcare and requiring VA to report on how 
these standards were executed will provide a realistic 
illustration of the ongoing challenges for rural veterans in 
gaining timely access to care. It will also allow VA and 
lawmakers to determine the best ways to improve timely access 
for rural veterans.
    House Resolution 315, the Help Establish Access to Local 
Timely Healthcare for Your Veterans bill would require that VA 
contract with community healthcare providers to improve access 
to healthcare for veterans in highly rural areas.
    The American Legion believes where there is limited access 
to VA healthcare, it is in the best interest of veterans 
residing in highly rural areas that local care be made 
available to them. This would alleviate the unwarranted 
hardship rural veterans encounter with seeking care.
    House Resolution 463, the ``Honor Our Commitment to 
Veterans Act,'' discussed lifting the healthcare enrollment 
restriction on Priority 8 veterans. The American Legion 
supports removing the healthcare enrollment restriction to 
Priority 8 veterans.
    We believe that it is a more effective method to ensure 
that VA can continue to provide quality healthcare by assuring 
that there is sufficient funding to care for the veterans' 
needs, not limiting access to those who have incomes that fall 
above the means tests thresholds.
    And, finally, House Resolution 1944, ``Veterans Traumatic 
Brain Injury Treatment Act of 2007,'' seeks to have certain 
veterans screened for traumatic brain injuries and discusses 
the creation of a comprehensive program for long-term care and 
rehabilitation that includes residential, community, and home-
based components.
    The American Legion believes that the provisions in this 
bill are both necessary and timely. Symptoms of traumatic brain 
injury may not be obvious and may be dismissed or may occur 
over time. Screening those who were known to have been 
subjected to blast trauma in theater, even if they have no 
visible physical wounds, would aid in diagnosing injuries more 
quickly and improve the chances of a successful rehabilitation.
    Again, thank you, Mr. Chairman, for giving the American 
Legion this opportunity to present its views on such important 
issues. We look forward to working with the Subcommittee to 
bring an end to the disparities that exist in access to quality 
healthcare in rural areas.
    [The prepared statement of Ms. Middleton appears on p. 74.]
    Mr. Michaud. Thank you very much.
    Mr. Hollingsworth.

               STATEMENT OF KIMO S. HOLLINGSWORTH

    Mr. Hollingsworth. Mr. Chairman, Members of the 
Subcommittee, I am pleased to appear to offer testimony on 
behalf of American Veterans for the pending legislation.
    The central problem for veterans with regards to the VA 
healthcare system in a timely fashion has generally been 
access. Over the years, VA has become increasingly effective in 
providing timely access, although problems still do remain.
    Regarding the legislation before this Subcommittee, we 
would like to reaffirm our commitment that service-connected 
disabled veterans should have the highest priority healthcare 
and that these services should be of the highest quality. We 
believe VA does provide that service today.
    Many of today's proposals do risk some unintended 
consequences to include quality control, safety, and potential 
adverse impacts on some mandated programs that VA is required 
to keep.
    Overall, the proposals seem to move VA toward higher cost. 
The escalating costs of healthcare in the private sector are 
well documented and, quite frankly, VA is doing a pretty good 
job at keeping healthcare costs down.
    We believe the central question to all of these contract 
proposals is whether or not Members of Congress believe the VA 
healthcare system is a national asset worth preserving or 
abandoning.
    This in turn is reliant upon appropriate levels of funding 
to hire staff, operate facilities, and clinics, and provide 
unique and specialized services. Appropriate levels of funding 
would also allow VA to open outpatient clinics where needed and 
provide other contractual arrangements to provide VA-sanctioned 
healthcare.
    Many of these proposals have some triggering mechanism that 
would mandate the Secretary contract care. These triggering 
mechanisms appear to be a one-time event that authorizes 
veterans to essentially opt out of the system and have VA pick 
up the cost.
    VA was mandated to establish an office of rural healthcare 
within VHA and we would encourage Congress to fully fund the 
office and allow VA to conduct the mandated assessment.
    The issue of nonservice-connected veterans accessing VA 
care is not new and obviously we would support open enrollment 
to the VA healthcare system. If veterans want to use the system 
and they are willing to bring their dollars to receive 
healthcare, we believe they should have that opportunity.
    Very briefly on the capital asset realignment for 
enhancement of services, it was a systemwide process to do an 
assessment of VA infrastructure. In short, with regards to VA 
construction, AMVETS supported the CARES Commission process.
    Regarding legislation on the English language, we believe 
that veterans earn benefits and services and are granted access 
to the system by virtue of qualifying military service. This 
should continue to be the overriding principle when discussing 
veterans' issues.
    And for Congress to pass a law and mandate the Secretary to 
provide these services when, in fact, they are starting to do 
this internally would create division and separation among 
veterans that took an oath to uphold and defend the 
Constitution of the United States in English.
    Mr. Chairman, with regards to chiropractor care, the 
program has been pretty successful at DoD. There was some 
resistance at VA initially getting the program started. We 
would like to see similar results within VA that appeared in 
DoD.
    This concludes my testimony. I will be happy to answer any 
questions.
    [The prepared statement of Mr. Hollingsworth appears on p. 
77.]
    Mr. Michaud. Thank you very much.
    Mr. Atizado.

                 STATEMENT OF ADRIAN M. ATIZADO

    Mr. Atizado. Mr. Chairman, Members of the Subcommittee, on 
behalf of the 1.3 million members of the DAV and its auxiliary, 
I wish to express my appreciation for the opportunity to 
present our views on healthcare legislation before us today.
    As a majority, the bills for consideration seek to address 
access to VA medical care whether it is time or distance that 
it takes a veteran to get to a facility or the time it takes a 
veteran to receive the care when needed.
    The DAV is encouraged with this hearing and the number of 
bills introduced that Congress believes as we do that through 
their extraordinary sacrifices and contributions in military 
service, these veterans have earned the right to VA healthcare 
as a continuing cost of national defense.
    Operating on a limited resource environment, there is a 
cost to improving access to VA care. And in addressing this 
issue, it is incumbent upon us to ensure that VA receives on 
time sufficient funding to plan and meet the growing need of 
enrolled veterans' healthcare including rural veterans' care as 
well as for VA to be held accountable for meeting the need in a 
timely manner.
    Equally important that all of this be done without 
disrupting the delicate balance by the erosion of VA's patient 
resource base and eventually what has been recognized as 
America's best healthcare value.
    For the sake of brevity, I will highlight some measures in 
my oral testimony and refer you to my written statement for 
greater detail on our position and commentary on any of these 
measures.
    DAV opposes both House Resolution 92 and 339. Both contain, 
as my colleague mentioned, a trigger mechanism that would 
require VA to utilize its contracting care authority in the 
provision of medical care. This is in line with our 
organization's opposition to any initiative that would turn VA 
into a primary insurer rather than provider of healthcare to 
veterans.
    In line with this, Mr. Chairman, our concern is this hard 
trigger, using limited resources, particularly without 
appropriate controls to protect from erosion the critical mass 
of VA patient over time as I had mentioned earlier.
    House Resolution 463 would overturn the policy to close 
enrollment and deny access to Priority 8 veterans. DAV believes 
that the manner by which this is accomplished in this bill 
would eliminate accountability over the Secretary's 
responsibility to establish and operate a system of annual 
enrollment for VA healthcare.
    Similarly, DAV opposes ``Rural Veterans Healthcare Act,'' 
which would provide veterans access to VA care at the expense 
of worsening VA's financial situation. We urge the confidence 
in the VA healthcare system displayed in this measure to remain 
and be used within the VA healthcare system, not outside, not 
without.
    Veterans' geographic inaccessibility of VA care is a direct 
result of limited VA resources. This bill would not improve 
this financial situation nor does it address the higher cost of 
rural care and in the end would not serve veterans well.
    DAV members support the systemwide availability of 
chiropractic services within the VA as contemplated under House 
Resolution 1470. However, 1471 would establish chiropractic 
services' practitioners on the same level as VA medical doctors 
in the direct provision of primary care services.
    DAV believes access to chiropractic services should be 
provided in consultation with VA primary care providers 
responsible for maintaining the overall health of patients 
assigned to them. Thus, we oppose House Resolution 1471.
    As this Committee is aware, the cost of providing care in 
rural and remote areas is higher than in urban areas. In much 
of our deliberation on this issue, we struggle to find a way to 
fill the indeterminate gap between limited resources and the 
demand for rural healthcare.
    Accordingly, we ask due consideration be given to the cost-
effectiveness of the mobile vet center program in the draft 
bill titled ``Veterans Rural Healthcare Act.'' This is a 
concern for such a program serving in rural areas and must be 
addressed accordingly.
    Much of the content of this bill is consistent with the 
recommendations on the Independent Budget. Further, we believe 
this measure is a good first step in addressing the healthcare 
needs of rural veterans and a good complementary step to the 
Public Law passed late last year. Therefore, DAV fully supports 
the purposes of this bill.
    Mr. Chairman, much of the content of the ``Veterans 
Traumatic Brain Injury Act of 2007'' is consistent with the 
recommendations of the IB. We have some recommendations in our 
testimony and refer you to them.
    This concludes my testimony, Mr. Chairman. I would be happy 
to answer any questions you may have.
    [The prepared statement of Mr. Atizado appears on p. 79.]
    Mr. Michaud. Thank you.
    We will have to recess at this time so we can get over and 
vote and we will recess until approximately 12:15 according to 
Mr. Tucker.
    [Recess]
    Mr. Michaud. I would like to reconvene the Committee. Sorry 
for the delay. The votes lasted longer than what Mr. Tucker 
originally thought they would last.
    We left off with Carl Blake from Paralyzed Veterans of 
America. Carl.

                    STATEMENT OF CARL BLAKE

    Mr. Blake. Mr. Chairman, thank you for the opportunity to 
testify today. It seems ironic that in the face of some 
criticism about the care being provided in VA facilities that 
demand has never been higher.
    House Resolution 92 would establish standards of access to 
care within the VA healthcare system. Access is indeed a 
critical concern of PVA as with the other organizations. The 
number of veterans enrolled in the VA is approaching 8 million 
and the number of unique users is nearly 6 million. 
Unfortunately, funding for VA healthcare has not kept pace with 
the growing demand. Furthermore, Congress has failed to live up 
to its responsibility to provide adequate resources in a timely 
manner. As long as VA continues to receive funding months into 
its fiscal year, it will never be able to properly plan to meet 
this demand. To that end, access standards without sufficient 
funding provided by the start of the fiscal year are standards 
in name only.
    PVA is concerned that contracting healthcare services to 
private facilities when access standards are not met is not an 
appropriate enforcement mechanism for ensuring access to care. 
In fact, it may actually serve as a disincentive to achieve 
timely access for veterans seeking care.
    We do think that these access standards are important, but 
we believe that the answer to providing timely care is in 
providing sufficient funding in the first place in order to 
negate the impetus driving healthcare rationing.
    Because House Resolution 315 and House Resolution 1527 
principally address the same issue, I will outline our concerns 
with these proposed bills together.
    PVA is fully aware of the challenges the VA faces every day 
to provide timely access to quality care for veterans who live 
in rural areas. However, we are concerned that in addressing 
the problem of access for these veterans, the long-term 
viability of the VA healthcare system may be threatened.
    The services provided by VA, particularly specialized 
services like spinal cord injury care, are unmatched in the 
private sector. If a large pool of veterans is sent into the 
private sector for healthcare, the diversity of services and 
expertise in different fields is placed in jeopardy.
    Ultimately PVA has serious concern about the provisions of 
this legislation that would give VA additional leverage to 
broaden contracting out of healthcare services to veterans in 
geographically remote or rural areas thereby leading to 
privatization.
    Privatization is simply a means for the Federal Government 
to shift its responsibility of caring for the men and women who 
have served and sacrificed.
    Current law limits VA in contracting for private healthcare 
services to instances in which VA facilities are incapable of 
providing necessary care, when VA facilities are geographically 
inaccessible to a veteran for necessary care, when medical 
emergency prevents a veteran from receiving care in a VA 
facility, or to complete an episode of VA care, and for certain 
specialty examinations.
    The VA could better meet the demands of rural veterans 
through more judicious application of its fee-for-service 
program. Due to the concerns that I have outlined and included 
in my written statement, PVA cannot support House Resolution 
315 or House Resolution 1527.
    PVA fully supports House Resolution 463. The provisions of 
this legislation are in accordance with the recommendations of 
the Independent Budget. However, we must emphasize that if this 
policy is overturned, additional adequate funding must be 
provided to meet this new demand. It would make no sense to 
make this change without providing that funding.
    PVA finds it difficult to comprehend the rationale for 
establishing a precedent for veterans in the VA healthcare 
system to leave the system and seek services elsewhere as House 
Resolution 1426 would do. While this legislation may be well-
intentioned, the potential unintended consequences far outweigh 
any benefit that this bill might provide.
    There would almost certainly be a diminution of established 
quality, safety, and continuity of VA care of veterans if they 
were to leave the system.
    While as a consequence of enactment of this bill some 
service-connected veterans might seek care in the private 
sector as a matter of personal convenience, they would lose the 
many safeguards built into the VA system through its patient 
safety program, evidence-based medicine, electronic medical 
records, and medication verification program.
    These unique VA features culminate in the highest-quality 
care available public or private. Also these safeguards that 
are generally not available in private-sector systems would 
equate to diminished oversight and coordination of care and 
ultimately may result in lower quality care for those who 
deserve it most.
    Mr. Chairman, we recognize that the challenges the VA faces 
in the healthcare arena are difficult. However, we must 
reiterate that the VA will struggle to meet the ever-growing 
demand of veterans, particularly rural veterans, as long as it 
does not receive adequate resources in a timely manner.
    It is unreasonable and, frankly, unacceptable to place 
expectations on the VA to meet certain types of demand if it is 
not given the resources and tools necessary.
    I look forward to working with the Subcommittee to develop 
workable solutions that will allow veterans to get the best 
quality care available.
    Mr. Chairman, I would like to thank you again for the 
opportunity to testify, and I would be happy to answer any 
questions that you might have.
    [The prepared statement of Mr. Blake appears on p. 84.]
    Mr. Michaud. Thank you very much, Mr. Blake.
    Mr. Cullinan.

                STATEMENT OF DENNIS M. CULLINAN

    Mr. Cullinan. Thank you very much, Mr. Chairman. On behalf 
of the men and women of the Veterans of Foreign Wars and 
auxiliaries, I want to thank you for including us in today's 
most important discussion.
    First under discussion today was House Resolution 92, the 
``Veterans Timely Access to Healthcare Act.'' The VFW strongly 
supports the intent of this legislation, but we do have 
concerns about the contracting aspect as well as the adverse 
impact on overall VA funding.
    Next under discussion is House Resolution 315, the 
``HEALTHY Vets Act.'' Again, the VFW supports the intent of 
this bill. We would express our concern, however, with the 
potential for over-use of contracting care as we did with House 
Resolution 92. But there are certainly areas where its use is 
proper.
    We must be mindful, though, of a demonstration project VA 
is currently undergoing, Project HERO, Healthcare Effectiveness 
through Resources Optimization. We have been supportive of the 
Project HERO's aims and think it would be wise to see how 
effective this demonstration project is and what lessons can be 
learned from it before making a sweeping legislative change.
    Next under discussion is House Resolution 339. Again the 
VFW supports the intent of this legislation, which is similar 
to House Resolution 92, in that it establishes standards of 
care for veterans waiting to receive care from VA.
    Next I will address House Resolution 463. The VFW strongly 
supports this legislation which would end the 4-year freeze on 
the enrollment of Category 8 veterans. We also urge that 
Congress keep in mind that this would have to be properly 
funded.
    Next the VFW will discuss House Resolution 542. The VFW 
supports this bill which would make mental health services 
available for veterans with limited English proficiency. There 
can be no other area where clear communication is so important 
as with respect to the provision of mental health services.
    Next I will address House Resolution 538. This bill calls 
for a study to determine whether contract care, construction of 
a VA medical facility, or sharing agreement with defense 
facility would fill the needs of veterans residing in far south 
Texas.
    Current VFW Resolution 661 which was adopted by the voting 
delegates of our last national convention calls for a medical 
center in this region.
    Next I will address House Resolution 1426. The VFW opposed 
this legislation which would allow any veteran to elect to 
receive contracted care whenever and wherever they choose. We 
have strong concerns about the viability of the VA healthcare 
system should this be enacted. Although this bill intends to 
expand coverage available to veterans, we believe it would only 
dilute the quality and quantity of service provided to new and 
existing veterans into the future.
    Next under discussion is House Resolution 1470, the 
``Chiropractic Care Available to All Veterans Act.'' The VFW 
supports this bill.
    Next under discussion is House Resolution 1471. The VFW 
opposes this legislation which would allow veterans to receive 
direct access to chiropractic services. It is important to 
remember that no other VA healthcare specialty allows for 
direct access to patients.
    Next under discussion is House Resolution 1527. We also 
support the intent of this legislation, which, like House 
Resolution 315 as discussed, allows for contracting of care to 
veterans in rural areas. Again, we urge that the Committee 
consider the results of Project HERO before going further with 
this bill.
    Also under discussion is House Resolution 1944. The VFW 
offers our strong support for this legislation which would 
require VA to implement screening programs for traumatic brain 
injuries which is the signature disability of this particular 
conflict, something with consequences going far into the 
future.
    Last under discussion is the draft bill, the ``Rural 
Veterans Healthcare Act.'' The VFW supports this bill which 
would make changes and improvements to the availability of 
veterans' rural healthcare. With over 44 percent of returning 
servicemembers living in rural areas access problems are all to 
clear and need to be addressed. We are happy to support this 
bill.
    Mr. Chairman, this concludes my testimony.
    [The prepared statement of Mr. Cullinan appears on p. 89.]
    Mr. Michaud. Thank you very much.
    Mr. Weidman.

                STATEMENT OF RICHARD F. WEIDMAN

    Mr. Weidman. Mr. Chairman, Vietnam Veterans of America 
thanks you for this opportunity to present our views here 
today.
    Quite a number of these bills that are under consideration 
really revolve around a funding issue and only point up the 
need for assured funding that is predictable, that is adequate 
to meet all the needs of veterans.
    And I am sure you are familiar with this. The partnership, 
sir, which nine organizations including the six represented at 
this table have agreed upon and urge that the 110th Congress 
move to address this chronic problem and to do so before the 
end of the first session because it would obviate the need for 
many of these well-intentioned bills that just nibble around 
the edges.
    In regard to the Priority 8 veterans, in January of 2003, 
the Executive Directors, and I am that for VVA, of the six 
organizations represented before you met with Secretary 
Principi and the then Under Secretary for Health and were told 
that they were going to limit, because of the short-term 
funding problem, we are going to temporarily suspend enrollment 
of Category 8's on the basis that it was a temporary 
suspension. We backed them at great political cost, I might 
add, within our organizations.
    Five weeks later, I was in a briefing on the so-called 
CARES procedure and they flipped up a slide. I said stop, go 
back. The slide before projected 20 years out was a still 
freezing out Category 8 veterans. I said how did we go from a 
1-year, temporary freeze to a permanent barment of veterans who 
are not indigent.
    We resented that. I can assure you that I asked who 
authorized this and ended up on the 10th floor of VA saying I 
do not know how we can trust you all again because you sold us 
a pig in a poke. And this is not right. It is not right to do 
this on a permanent basis.
    If, in fact, you all asked for enough money to serve the 
veterans whom you are legally obligated to serve correctly and 
they do not give it to you, shame on the Congress. But if you 
continue not to ask for that money, then shame on you. And it 
is time once again to address the funding issue.
    Similarly to that, if I may suggest, and this also goes 
along with, VVA strongly supports the TBI bill, the screening 
bill, and at the same time would encourage you to add in that a 
requirement that as they are in the process now of redesigning 
the automated patient treatment record that VA be required, 
since they do not seem to be able to do it on their own, be 
required to take a complete military history and include it in 
the automated patient treatment record based on branch of 
service, when did you serve, where did you serve, what was your 
military occupational specialty, and what actually happened to 
you. And based on the answers to those five questions to 
automatically screen for things like traumatic brain injury as 
one example along with many other things such as post-traumatic 
stress disorder (PTSD). And it would be high time to do that.
    Doing the look-back and the proper training on TBI 
throughout VA is absolutely essential. I would bring to the 
Committee's attention that 17 percent of the active-duty troops 
serving at Fort Carson in a survey that was completed 2 weeks 
ago done by the Army that were diagnosed, most of these people 
were not diagnosed as TBI; 17 percent of those active-duty 
troops who had been in Iraq were screened and found to have 
traumatic brain injury of one degree or another.
    This is a huge problem. It is going to be a huge problem 
that unfortunately is moving from the military medical system, 
and not being adequately addressed there, into the VA 
healthcare system. And VA needs to do its part and urge that 
Mr. Snyder and those folks on Armed Services ensure that 
military medical system carries more of its load.
    On a number of the other bills, rural access to veterans 
and building a hospital in south Texas, VVA strongly favors 
that. It is a need that goes back very far and these veterans 
have been underserved for many, many years, and urge that the 
Committee move expeditiously on that and the Congress move 
expeditiously.
    Once again, we agree with our distinguished colleagues from 
the VFW in the intent of the ``Veterans Timely Access To 
Healthcare,'' ``Richard Helm Access To Healthcare Options And 
Resources Act,'' and the ``Rural Veterans Access To Care Act'' 
are well-intentioned. However, we come back to the point that 
if you are not adequately funding the system to serve folks 
within the system, where are you going to get the money in 
order to contract out?
    Mr. Snyder hit it right. At the moment, it is a zero sum 
game. And if you take away from that, then you are going to be 
taking away resources from within the system.
    We are philosophically not opposed to contracting out where 
it is in the best interest of the veteran. However, we need 
adequate funding before you start taking money out of the 
system.
    Because I am out of time, I will stop there. And the rest 
of the statement on the other bills, I think is contained 
therein. I would be happy to answer any questions, Mr. 
Chairman. Thank you.
    [The prepared statement of Mr. Weidman appears on p. 92.]
    Mr. Michaud. Well, once again, I would like to thank all 
the panelists for your testimony. It was very interesting. 
There are a lot of common themes throughout each of your 
statements.
    I just have a few questions for VFW. You mentioned Project 
HERO. This might be a more appropriate question for the VA. 
When is that report due out? Do you have any idea?
    Mr. Cullinan. I talked with our health policy person and 
there seems to be some uncertainty as to when exactly it is 
going to come out. The only thing is it is, from our 
understanding, it is gathering very valuable information with 
respect to these kinds of projects. So it is something worth 
waiting for.
    Mr. Michaud. Okay. Mr. Weidman.
    Mr. Weidman. If I may comment. Originally Project HERO was 
designed because there was a strong interest on the part of the 
Congress to standardize across Veterans Integrated Services 
Networks (VISNs) and between hospitals the cost of various 
goods and services. And this was a laudable goal on the part of 
the Congress, pointing out the fact that it was all over the 
map in terms of what we were paying for the same service or 
same good from hospital to hospital.
    So Project HERO, inappropriately named as VVA would 
maintain, was supposed to standardize that. And, in fact, the 
first draft RFP was a fire sale on clinical care across the 
board to the private sector. We said time out. What do you all 
think you are doing. This is not what the Congress intended. 
They intended you to rationalize that which you were already 
contracting out. And it has scaled back several times.
    But the problem with all of this contracting out right now 
is that you give them an inch, they take a mile. And until we 
can have confidence that the intent of the Congress is not 
going to be distorted by the way in which it is actually 
implemented, VVA has no choice but to oppose it, sir.
    Mr. Michaud. You mentioned support of the legislation 
dealing with the hospital in Texas. As you all know, VA went 
through an extensive process, the CARES process, and hopefully 
we will be able to move forward on that more aggressively than 
we have in the past.
    Do you think the Texas hospital should be put before the 
CARES process or should we follow the CARES process first?
    Mr. Hollingsworth. Mr. Chairman, AMVETS, as I indicated, 
did support the CARES process and there were some decisions. I 
think there was 18 studies. Some of those were going to require 
further analysis. To the best of my knowledge, the VA has not 
responded to some of those.
    In addition, I would like to add that during the 108th 
Congress, there was a separate study that VA, I believe, was 
mandated to do with regards to that specific region and that 
report is still supposed to be forthcoming.
    Mr. Michaud. Okay. Great.
    Mr. Weidman. Unlike our colleagues, Mr. Chairman, VVA does 
not support the CARES process in its current form. We would 
characterize it as an organized way of going wrong with 
confidence. It is based on a civilian medical formula for 
people who can afford HMOs and PPOs. They have adjusted 
somewhat for mental health and somewhat for blind and visual 
and for prosthetics, but they only adjusted a formula that is 
fatally flawed. It does not address veterans' healthcare and as 
a result is always going to underestimate the needs. Let me 
give you one example, if I may.
    That formula is predicated on one to three presentations 
per individual who walks through the door. VA averages at their 
hospitals five to seven presentations per individual who comes 
through the front door. So the burn rate, if you will, of 
clinical resources is much higher among veterans than it is 
among the civilian population who are middle class, well fed 
who that formula is based on.
    As a result of that, it is going to continually 
underestimate not only the amount of care needed but the shape 
of care needed. There is a dramatic difference between civilian 
medicine and veterans' healthcare medicine. And until we start 
to think of veterans' healthcare as a set of occupational 
healthcare entities or occupational health for a set of very 
dangerous occupations, we are going to continue to go wrong.
    So we think that the need for the south Texas facility is 
self-evident and we should move on it immediately, sir.
    Mr. Michaud. Thank you.
    And my last question, and I will preface it with some 
comments, deals with access to healthcare. And I agree with the 
comments that you have all made. We have definitely got to 
adequately fund VA which is extremely important. And I think a 
lot of problems related to the bills that we have heard today 
and ones that we will be hearing hit on that core issue about 
not adequately funding VA.
    However, even if VA was adequately funded, my concern still 
would be the access issue in rural areas. And I know in some of 
the comments, there was talk about it being more expensive and 
less cost-effective. That is probably true, but when you look 
at veterans in rural areas, if they are going to get the 
services that they need, we might have to pay a little bit more 
for those services because I do not think it would be cost-
effective to have clinics throughout all the rural areas.
    So is that a fair assumption on all the VSOs that even if 
we do adequately fund the VA, which I think we definitely have 
to do, that there still will be a need for fee-for-service 
arrangements for veterans who live in rural areas?
    Mr. Cullinan. Mr. Chairman, speaking on behalf of the VFW, 
we certainly have no philosophical or other kind of objection 
to providing contract-based care. VA has existing authority to 
do that. We would urge that they do it more judiciously, 
perhaps more liberally.
    The only thing we do not want to see is contract care 
suddenly supplanting the VA's own infrastructure. That is our 
concern and, of course the cost of all this.
    Mr. Michaud. I agree with that comment.
    Are any of the VSOs, following up on that same line of 
questioning, aware of any VISNs out there now that are abusing 
the fee-for-service contracting out services?
    Mr. Hollingsworth. Mr. Chairman, AMVETS is not aware of 
that, but some of this delves into a territory I do not think 
we want to go today which has to do with the medical care cost 
collection funds and how we fund things.
    I think overall, you know, AMVETS says, hey, we need to get 
the services that veterans are entitled to receive or that they 
are authorized to receive and we should provide those services.
    I think our overriding concern with some of the legislation 
presented today is the simple fact that the Secretary does have 
this authorization and so there is no need for separate 
legislation to do this. If the needs are not being met, then 
let us get the VA to act within their existing authorizations.
    Mr. Atizado. Mr. Chairman, if I may, with regards to the 
VISNs that make extensive use of contractor fee-basis care, I 
think if you look to the hearing with regards to Project HERO, 
it was mentioned in that hearing that the four VISNs that were 
chosen were chosen specifically for their high utilization rate 
of contracting fee care.
    With regards to rural care, I think once we all agree with 
the fact that to provide this care is going to be higher than 
what we are all used to, then we would have to shift our idea 
of cost-effective care specifically for this population.
    The concerns that all my colleagues have here on this side 
of the table is the idea that has been presented on how to deal 
with this issue. Much of them require VA, takes out 
flexibility, it is a hard trigger legislation, which, if I may 
say, we could probably look more toward a soft trigger, 
something that would allow us to be more aware of the 
situation, be more cognizant, and be more prudent as well as 
take incremental steps to really address this problem.
    This is a very huge problem, particularly for the new 
veterans from OIF/OEF. And we really should take the time to 
take a look at this instead of coming up with this potentially, 
and I say this, potentially dangerous legislation with the way 
it is written.
    Mr. Weidman. VVA is not, as I mentioned before, 
philosophically opposed to contracting out as long as it is 
done judiciously and as long as the system is adequately 
funded.
    I am keenly familiar with what you are talking about, Mr. 
Michaud. A decade following military service in Vietnam, I 
lived in northern New England and was 2\1/2\ hours if the roads 
were dry, which you cannot assume in northern New England, from 
White River Junction. And so I am familiar with the difficulty 
in receiving care from VA when you have those kinds of 
distances.
    But the real issue here is if you have adequate funding for 
the overall system and using, as our good friends from the DAV 
put it, judicious use of the already contract fee provider 
mechanism, then we would have no objection whatsoever.
    Mr. Michaud. Great. Well, once again, I would like to thank 
the panel for your testimony today. I look forward to working 
with you as we continue moving forward in this Congress to deal 
with issues important to veterans. Our door is always open. So, 
once again, thank you for your testimony.
    Sorry for the delay. And I would ask the last panel to 
please come up. On the panel is Dr. Cross, who is the Acting 
Principal Deputy Under Secretary for Health. He is accompanied 
by Walter Hall who is the Assistant General Counsel for the 
Department of Veterans Affairs.
    And, once again, I apologize for the lengthiness of the 
hearing on these pieces of legislation. Unfortunately, votes 
got in the way.
    So without any further ado, Dr. Cross, once again, welcome 
and I look forward to your comments.

  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 WALTER A. HALL, ASSISTANT GENERAL COUNSEL, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

    Dr. Cross. Good afternoon, Mr. Chairman and Members of the 
Subcommittee, and thank you for inviting me here today to 
present the Administration's views on several bills that would 
affect programs administered by the Department of Veterans 
Affairs in the provision of healthcare to veterans.
    With me today is Walter Hall. He is the Assistant General 
Counsel.
    The various bills under consideration address issues that 
include wait times, expanded access to healthcare in rural 
areas, the provision of chiropractic care, and multilingual 
outreach.
    Mr. Chairman, knowing my time is limited, I will address 
these issues collectively by subject. And I would like to 
submit my written testimony which provides additional in-depth 
information for the record.
    Mr. Michaud. Without objection, so ordered.
    Dr. Cross. House Resolution 92 deals with waiting times. 
Specifically House Resolution 92 addresses wait times for 
appointment scheduling as well as the issue of waiting room 
times. Both issues are important to VA and VA has no 
significant objection with respect to the 30-day standard for 
scheduling patients.
    We would, however, ask the Committee to change the bill 
language to clarify that it would apply only to new patients. 
It is these patients who need to be tracked to understand that 
there are difficulties accessing the VA system.
    Turning to waiting room times, we would like to submit to 
the Subcommittee results from our customer satisfaction survey 
which is independently done indicating nearly 80 percent of 
patients waiting for primary care services are seen within 20 
minutes of their appointment time and more than 70 percent of 
veterans are seen within 20 minutes of their specialty care 
appointment time.
    We feel that House Resolution 92 would not remedy the wait 
experience of the patient for a particular visit and further 
that the remedy is based on a flawed assumption that all 
private care in the community meets the proposed standards.
    House Resolution 315 and House Resolution 1527 address 
expanded access to healthcare for veterans in rural and highly 
rural areas. VA is concerned that both of these bills would 
undermine further expansion of our system to facilities in 
rural areas.
    VHA recently established the Office of Rural Health in 
accordance with Congress' mandate in the ``Veterans Benefits 
Healthcare And Information Technology Act of 2006.'' This 
office will determine how we can continue to build on what we 
have already successfully accomplished and to expand on that 
expertise in caring for our rural and highly rural veterans 
who, in fact, rate their satisfaction of care higher than their 
urban veteran counterparts.
    House Resolution 538 defines provisions of care for 
veterans in far south Texas. VA at the request of Senator Kay 
Bailey-Hutchinson has contracted to evaluate and to report on 
current needs in the south Texas region. The results from the 
study are due in July of this year.
    VA respectfully requests that the Subcommittee await the 
results of this ongoing evaluation before considering whether 
to mandate a particular means for addressing the healthcare 
needs of veterans in that area.
    House Resolution 1426 would provide enrolled veterans the 
option of receiving care outside the VA healthcare system. VA 
strongly opposes enactment of this bill. Not only could it lead 
to the undoing of a world-class VA healthcare system, but it 
would also fragment the care our veterans receive because they 
would no longer have a complete set of medical records 
reflecting their comprehensive care.
    House Resolution 463 would terminate the administrative 
freeze on enrollment of veterans in Category 8. VA strongly 
opposes this bill. The bill would render meaningless the 
prioritized enrollment system mandated by Congress in 1996. VA 
would have to add capacity to absorb the increased workload 
this bill would entail. But in the interim, the quality and 
timeliness of VA healthcare would suffer.
    House Resolution 1470 and 1471 deal with chiropractic care 
programs in the VA. VA does not oppose increasing the number of 
VA sites providing chiropractic care. However, at this time, we 
do not believe that chiropractic care at all VA medical centers 
is warranted. To date, 98 percent of our patients can receive 
chiropractic care within 30 days of their desired date.
    And VA also strongly objects to extending the field of 
chiropractic care to the treatment of other medical conditions. 
We believe that it is in our patients' best interest to 
continue having their individual primary care providers remain 
in charge of managing their care, particularly since our aging 
population exhibits complex medical conditions requiring 
intensive and highly integrated clinical management skills that 
are better managed in a primary care setting.
    House Resolution 542 would require VA services in a 
language other than English for veterans with limited English 
proficiency. We believe that we are already meeting the intent 
of this bill.
    On February 12, 2007, VHA issued a new directive updating 
the guidance previously set forth regarding services to 
individuals with limited English proficiency. Similar documents 
have also been issued by the National Cemetery Administration 
(NCA) and by the Veterans Benefits Administration (VBA).
    These action plans ensure that VA facilities and programs 
fully implement all such requirements.
    Sir, this concludes my prepared statement. Mr. Chairman, we 
are still in the process of developing cost estimates for these 
bills and we will supply them for the record when they are 
cleared. And I would be pleased to answer any questions you 
have.
    [The prepared statement of Dr. Cross appears on p. 94.]
    Mr. Michaud. Thank you very much, Dr. Cross.
    When do you think they will be cleared as far as the cost 
estimates?
    Dr. Cross. Well, I do not have a date in mind at this 
point, but this is of great interest and concern. And, sir, we 
will cooperate with you and do it as quickly as possible.
    Mr. Michaud. Okay. Great. In your written testimony, you 
also said you will provide comments on H.R. 1944, the rural 
healthcare bill as well. When do you think you will have those?
    Dr. Cross. H.R. 1944 is a bill that we have just seen. It 
just came over, I believe, and so we looked at it. It concerns 
TBI. Obviously TBI is of intense interest to us and our system 
right now.
    My view of it, and this is not official, is that the intent 
of the bill and many of the things in the bill are consistent 
with the direction that we are pursuing right now.
    Mr. Michaud. But when will you have it? You said you would 
have written testimony on those two specific bills.
    Dr. Cross. Having just gotten it, I am sure that it will 
take a couple of weeks.
    Mr. Michaud. Project HERO, when is that report due or when 
will it be ready?
    Dr. Cross. Actually, HERO is to some degree just being 
kicked off because it was announced in January and I believe 
the first RFPs just went out in, I believe, April. And so it is 
very, very early in the process.
    We are using four sites, four VISNs. The focus is on the 
effectiveness of how we do our current contracting to make it 
more effective. And I will have to get you in writing, sir, the 
answer as to exactly when the date is for that to be turned in. 
It is a 5-year pilot project.
    Mr. Michaud. And you heard from Vietnam Veterans of America 
about the enrollment ban on Priority 8 veterans, that 
originally that was put in place because of lack of funding 
within the VA and it was only supposed to be temporary. But it 
appears that the VA intends to make that permanent; is that 
correct?
    Dr. Cross. It is correct that we do not have any plans to 
change the current regulation at this time. And it is more than 
a funding issue. It is also a capacity issue and it will take 
time and funding substantially to incorporate that large bolus 
of an additional population.
    Mr. Michaud. When you talked about waiting lists I believe 
you said that we ought to look at new patients, not existing 
veterans. Why is that?
    Dr. Cross. I wanted to explain that. I am really pleased 
that you asked because we deal with a chronic disease model of 
care given the nature of the patients that we see.
    A patient who is coming in to us over a period of decades 
for their blood pressure control, for cardiac evaluation, for 
cholesterol, for PTSD, they do not necessarily need to be seen 
every month. And so we want to be careful. If you set a 30-day 
standard, we may be telling them they do not need to come back 
for 2 months or 3 months or 6 months.
    So we use something called the desired date. And I have to 
explain that to you because that is a negotiation between the 
doctor, the scheduler, and the patient as to what is 
appropriate time for them to come in and what is convenient for 
them as well, what fits into their schedule.
    And an arbitrary standard of simply 30 days measure does 
not account for that finesse within our system. The new 
patients, a hard number of 30 days is just fine, I think, 
because that person making that initial request, we want to get 
them in. There is no desired date issue. We assume that they 
want to be seen as soon as possible.
    And so that is why I made that distinction, and we would 
support that.
    Mr. Michaud. You also mentioned the Office of Rural Health. 
Have you already hired the individual?
    Dr. Cross. We have already established the office. We have 
assigned the duties to our Policy and Planning Chief, Pat 
Vandenberg, but our intent is to move forward with further 
development of that office. And I think we were given an end-
point target date of the end of the summer or the end of the 
fiscal year. And we are working hard to meet that. We will meet 
that.
    Mr. Michaud. And what are you looking for for an individual 
to run the Office of Rural Health?
    Dr. Cross. Well, I am not sure if I have the criteria all 
in mind, sir, but I would be happy to share those with you. We 
want someone who is committed in the same way that you are to 
moving this forward for our rural veterans.
    And may I please say, you know, we had the rural health 
hearing just a short time ago. This is a strategic direction 
for us. We are moving out with more and more Community-Based 
Outpatient Clinics. We are moving out with more telemedicine, 
telemental health. We want to reach out into those communities.
    But there is a new technique that we want to add in, which 
we are already doing to some degree, outreach clinics. We 
always put the CBOCs on the map and that is a big deal. But we 
want to have also clinics that are CBOCs that are part time, 
that do not really count as a full CBOC. We call them outreach 
clinics. We have about a dozen of those so far.
    And those serve that need of that very small population 
going into perhaps leased space in the community part time, 1 
day a week, 2 days a week, half day a week where we can meet 
those veterans' needs so they do not have to leave that 
community, can get their prescription refilled, can get their 
blood test done, and so forth. And that is one of our strategic 
directions.
    Mr. Michaud. You heard the testimony from my colleagues on 
both sides of the aisle this morning and unfortunately a lot of 
it relates to funding issues, and it is not only the 
Administration's lack of looking at what we need for the VA, 
but it is also Congress' lack of taking the initiative to 
provide the appropriate funding.
    I think if we do have appropriate funding, whether it is 
assured or mandatory funding, that a lot of these problems, a 
lot of the legislation we are having today, would not 
necessarily be here. Funding is a big issue, as is funding for 
rural healthcare when you look at the men and women who are 
currently serving in our military today in rural areas.
    My only concern, and hopefully you will keep this in mind, 
is even though rural healthcare might be important for some 
over at VA, I do not think that is necessarily true for all. 
And that is where a lot of us who represent rural regions are 
concerned.
    As for the CARES process, had that process been moving 
along a lot quicker than it has, I think a lot of these 
problems would not be here.
    But, again, it boils down to funding issues. A good 
example, is Maine. During the CARES process, VISN 1 had 
recommendations for a CBOC, and I believe five clinics. Yet, 
when we talked with the region one VISN Director, they never 
even requested a business plan.
    That does not give me a good feeling that the interests, 
particularly as you have heard earlier this morning from other 
Members of Congress, that if you have a VISN Director who sits 
in a metropolitan area, that they really understand what is 
happening out there with our men and women who served this 
country in rural areas. And I think it is very important that 
we do have a focus on taking care of veterans regardless of 
where they live.
    I look forward to working with you, Doctor, as we move 
forward in this Congress on a lot of the issues that we have to 
deal with. And I look forward to working with my colleagues on 
both sides of the aisle because, as I stated over and over 
again, veterans' issues are not Democratic or Republican 
issues. They are American issues.
    The situation at Walter Reed, the situation with Bob 
Woodruff, some of the articles that have come out as far as 
taking care of our men and women who are serving and who have 
served our Nation, have not been good. But the bottom line is 
good, particularly when you look at the budget that was passed 
about a month ago as it relates to VA.
    And we have to make sure that we continue onward in this 
area, and I appreciate all the work that you are doing, Doctor 
and Mr. Hall, within the VA system and I look forward to 
working with both of you as we move forward along with the 
VSOs.
    At this time, I would actually ask, since Mr. Miller was 
unable to make it back, if Counsel on either side might have 
any questions?
    Ms. Dunn. No.
    Mr. Tucker. I do have two quick questions.
    Mr. Michaud. Okay. Yes, Mr. Tucker.
    Mr. Tucker. Thank you.
    Dr. Cross, just two quick questions. One a little more 
philosophical than the other.
    You state that you are looking at outreach clinics as 
providing some of the primary care in rural areas. Is this 
similar to what HHS is doing and is there any overlap between 
what you are doing or trying to do and what HHS is currently 
doing?
    Dr. Cross. I think there is a very important distinction on 
a couple of aspects of that. The outreach clinics that we have, 
like our CBOCs, are tied into our system. For instance, they 
are tied in by our electronic health record system. That 
promotes a level of safety, for instance, in prescribing that, 
you know, I think is different from the civilian community that 
uses paper prescriptions.
    The same screening criteria, and we are very proud of this, 
this is so important as was mentioned by one of the VSOs, that 
this is a unique thing that we must do for our veterans. So we 
screen them for PTSD. We screen them now for TBI, all of the 
OIF and OEF that we see. We screen them for alcoholism and so 
forth.
    We are focused on those issues. And it is hard to explain 
sometimes what that distinction is, but I think that 
distinction is very important.
    Mr. Tucker. And my last one is more philosophical. As we 
are trying to address rural healthcare needs and trying to 
figure out the best mix of VA services and possibly other 
services and how to provide that care, how do you see the VA 
providing healthcare in the next decade or next two decades? Is 
it going to be based on the system that we have today with a VA 
medical center and a hub and spoke system with Community-Based 
Outpatient Clinics? Are we going to be looking at building more 
and more Community-Based Outpatient Clinics in rural areas to 
provide primary care and other services or how is the VA 
approaching what healthcare will be like in the next decade or 
so?
    Dr. Cross. Dr. Kussman just led a summit meeting where we 
looked at the future of VA healthcare as a group with our VISN 
Directors and Program Chiefs. VA healthcare is going to look 
very different in a lot of respects. We are going to become 
less institutionalized.
    The idea that the patient has to leave home to get medical 
care is not necessarily the way that we want to go. We think 
that much more can be done in the community and at home. Let me 
give you a couple of examples.
    Information, we have the My HealtheVet Web site so that 
they can get the information that is wholesome and reliable in 
their own home for those who have a computer and Internet 
access. We let them refill their prescriptions sitting at their 
desk at home and just log in and take care of that.
    We will download their medical records to the individual 
electronically. So if by chance we do send them off somewhere, 
we do fee-basis care in the rural environment and other places, 
they can print off and take the relevant materials with them to 
that institution that does not have electronic records.
    I think that we are going to have less focus on grand, 
large, giant institutions and much more on meeting the needs in 
other ways. We are doing that with nursing homes, moving away 
from the standard model to a less restrictive model. We are 
doing home-based primary care where we send people out to visit 
in the home. We are spending $175 million on 2008 budget for 
home-based permanent care.
    I think that is the direction, and I think it will look 
different. I think it will be innovative and I think it will 
meet the needs of our patients actually better.
    Mr. Michaud. Just one last question. I know money is an 
issue and it will help. I am also concerned that we make sure 
that we provide adequate healthcare but in a manner that is 
cost-effective. And this just is a rough idea I am throwing out 
to get your thoughts.
    When you look at what we have for a system in State 
Veterans Homes, have you looked at trying to partner with the 
State Veterans Homes, for instance, if they have a Veterans 
Home to take care of our veterans long term but also saying, 
well, maybe that might be an area where the Veterans Home might 
be able to build a CBOC or a clinic and have a community, 
veterans' community there by utilizing another entity as far as 
partnerships? Is that something that you are looking at?
    Dr. Cross. I think we are very open to that idea. I think 
that is a good idea. I think we are actually doing that in some 
locations already where we have a little campus, not 
necessarily the traditional VA campus, but elsewhere where we 
put a number of services collocated, regional office, VBA 
services, and State Veterans Homes, those kind of things.
    A number of State Veterans Homes, I believe, and I am not 
sure of the number, are located actually on campuses with the 
VA. So that works in the other direction as well.
    Mr. Michaud. Okay. Great. Once again, I want to thank both 
you, Dr. Cross, and Mr. Hall, for your testimony as well as all 
the other previous panels, and look forward to working with you 
as we move forward in this Congress. Once again, thank you very 
much.
    With no further questions, the hearing is adjourned.
    [Whereupon, at 1:23 p.m., the Subcommittee was adjourned.]














                            A P P E N D I X

                              ----------                              

             Prepared Statement of Hon. Michael H. Michaud
                    Chairman, Subcommittee on Health
    I would like to thank everyone for coming today.
    Today's legislative hearing will be the first of many this 
Subcommittee plans on holding to provide Members of Congress, veterans, 
the VA and other interested parties with the opportunity to discuss 
legislation within the Subcommittee's jurisdiction in a clear and 
orderly process.
    I don't necessarily agree or disagree with the bills before us 
today, but I believe that this is an important process that will 
encourage frank discussions and new ideas.
    We have 11 bills before us and one discussion draft.
    The discussion draft represents some of my ideas to improve the 
quality of care available to our rural veterans and the ability to 
access that care such as:

      Establishing mobile vet centers, improving information 
technology and technology sharing between VA and non-VA providers;
      Establishing a Rural Veterans Advisory Committee;
      Creating Centers of Excellence to encourage research and 
innovative healthcare to address the needs of rural veterans; and
      Encourage more healthcare professionals to work in rural 
areas.

    I look forward to hearing the views of our witnesses on this 
discussion draft and the other bills before us.
    I also look forward to working with everyone here to improve the 
quality of care available to our veterans.

                                 
                 Prepared Statement of Hon. Jeff Miller
           Ranking Republican Member, Subcommittee on Health
    Thank you, Mr. Chairman.
    I appreciate your holding this legislative hearing today and 
welcome the opportunity to discuss the 12 different legislative 
proposals before us focusing on providing better healthcare access for 
veterans.
    There has been an unprecedented demand for the Department of 
Veterans Affairs (VA) healthcare. Since 2003, the number of patients VA 
is treating has grown from 4.8 million to an expected 5.8 million in FY 
2008. In 2008, VA anticipates treating 263,000 Operation Iraqi Freedom 
(OIF) and Operation Enduring Freedom (OEF) veterans, 25.8 percent more 
than the 2007 level. This surge in demand for healthcare is expected to 
continue and creates new challenges for VA's capacity to deliver both 
primary and specialty care.
    Two of the bills we will consider today, H.R. 92, the Veterans 
Timely Access to Healthcare Act, and H.R. 339, the Veterans Outpatient 
Care Access Act of 2007, would require VA to contract for care for 
veterans who are unable to be seen in a VA facility in a timely manner. 
Since 2004, VA has reported a substantial improvement in the percent of 
veterans who receive appointments within 30 days of a patient's desired 
date, stating they are meeting their established 30 day goal for 96 
percent of primary care and 94 percent of specialty care patients. 
However, statistics mean nothing to a veteran who is delayed care 
because they are placed on a waiting list. If VA cannot meet its own 
established standard for any veteran, that patient should be given the 
choice to receive care in a non-VA facility.
    Last week, this Subcommittee held a hearing on veterans' access to 
care that highlighted our concern that veterans in rural areas face 
additional challenges to receiving healthcare as these areas are 
traditionally underserved. In the Pensacola area of Florida, in my 
district, the nearest inpatient VA facility is located approximately 
125 miles away in Biloxi, Mississippi.
    Several of the bills we will examine would specifically address the 
needs of veterans living in rural or geographically remote areas. One 
of the bills, H.R. 1527, the Rural Veterans Access to Care Act, 
introduced by our fellow Subcommittee Member, Jerry Moran, would allow 
a highly rural veteran enrolled in VA healthcare to receive services 
through a local provider if that veteran chooses to receive non-
Department care. It would also allow VA pharmacies to fill 
prescriptions written by non-Department providers for these veterans.
    In March, this Subcommittee held a hearing to assess the 
rehabilitation needs and care of our injured servicemembers with 
Traumatic Brain Injury (TBI). These injured servicemembers and their 
families are relying on VA to provide a full continuum of first class 
care and support for their complete recovery--from inpatient services 
at the Polytrauma Rehabilitation Centers, to outpatient rehabilitation 
to long-term care services in their home communities. At this hearing 
we will consider H.R. 1944, the Veterans Traumatic Brain Injury 
Treatment Act of 2007. This bill would among other requirements, 
establish a comprehensive program of long-term care for post-acute TBI 
in four geographic regions.
    Additionally, we will discuss legislation to improve the provision 
of chiropractic care through VA medical centers. According to a 
November 2006 VA study, musculoskeletal ailments are among the top 
health problems of veterans returning from Iraq and Afghanistan.
    We will also consider H.R. 463, the Honor Our Commitment to 
Veterans Act. This legislation would change the law to require the 
Secretary of Veterans Affairs to administer the VA healthcare 
enrollment system as to enroll any eligible veteran who applies. The 
President's Task Force to Improve Healthcare Delivery For Our Nation's 
Veterans, in their 2003 Final Report, issued a recommendation that 
``The present uncertain access status and funding of Priority Group 8 
veterans is unacceptable. Individual veterans have not known from year 
to year if they will be granted access to VA care. The President and 
Congress should work together to solve this problem.''
    In closing, I want to thank the Members who have brought these 
bills before us and all of our witnesses appearing here today. I look 
forward to engaging in a productive discussion about legislation that 
will help us provide the best care for our veterans, whether it is 
through contract care, or requiring more VA medical centers to provide 
chiropractic services.
    Thank you, Mr. Chairman, I yield back.

                                 
 Prepared Statement of Hon. Steve Pearce, a Representative in Congress 
                      from the State of New Mexico
    I would like to thank Chairman Filner, Ranking Member Buyer, 
Subcommittee on Health Chairman Michaud and Ranking Member Miller for 
the opportunity to discuss this issue that is critical to the veterans 
of the State of New Mexico. Today I am calling on you and Members of 
the Veterans Affairs Committee to support my legislation, H.R. 315, the 
Help Establish Access to Local Timely Healthcare for Your (HEALTHY) 
Vets Act.
    In New Mexico's rural communities, many of our veterans are 
deprived of accessible medical facilities and face the high cost of 
gasoline to travel and to obtain care. My legislation would require the 
Secretary of Veterans Affairs to contract with local doctors and 
hospitals on a case-by-case basis to provide medical services, 
including primary care, for those veterans who live far away from VA 
medical facilities. This would expand the ability of our local health 
providers in southern New Mexico to provide more convenient, efficient 
medical services for veterans who live in areas that are far away from 
established VA facilities.
    Currently, veterans residing in southeast New Mexico must drive 
between 400 and 500 miles roundtrip to receive care at New Mexico's 
only VA Hospital located in Albuquerque. I consistently hear stories 
from my constituents about the detrimental impact this long-distance 
drive has on their ability to access timely care and overall health. 
One Marine veteran amputee began having uncontrollable drainage from 
his ``good'' foot and was making 2 to 3 trips a week to the Albuquerque 
VA hospital. This equates to 18 hours of drive time a week. After 4 
months, he finally lost his foot. Several local civilian healthcare 
experts feel the unfortunate travel ``marathon'' contributed to the 
failure to save his foot.
    Another 87-year-old Bataan veteran developed a serious bladder 
infection and was directed to make the 6 hour roundtrip drive along 
with his 85-year-old wife. Halfway through his treatments prostate 
cancer was found and additional trips had to be made for chemotherapy. 
After 7 months of trips, he died and his wife's health was seriously 
damaged after the strain of such long-distance care.
    Today, I know you will hear from several National Veterans Service 
Organizations who may not support my bill and others under 
consideration today. That is because many of these groups have 
committed themselves to the goal of ``keeping VA dollars inside the 
VA.'' I understand this concept and believe at first glance it sounds 
like a commonsense approach to VA budgeting. But following this logic, 
the only way to get more localized access to care for veterans in my 
district would be to build new facilities in areas closer to their 
homes.
    I believe there is a need for a full-service Veterans Health Center 
in southern New Mexico and would love to see that come to fruition. 
However, I am a realistic man as are the veterans living in rural New 
Mexico. With the tight budgetary constraints our Nation faces, and the 
smaller population in States like New Mexico, that idea is much easier 
said than done. This is a reality veterans living in rural areas have 
been forced to accept.
    Since that solution is not realistic at this time, we must work to 
find other solutions to this problem that is hurting our veterans with 
every 6-8 hour roundtrip journey to the hospital. Unfortunately, the 
idea of expanded contracting authority raises flags with certain 
Veterans Service Organizations that see it as a step toward 
privatization. They characterize this as the Federal Government 
brushing aside its commitment to care for the men and women who have 
served our Country.
    Well I will tell you that the Federal Government and the VA are not 
adequately living up to their commitment and serving my constituents 
under the current system. John Taylor, a life member of the Military 
Order of the Purple Heart and life member of the Disabled American 
Veterans, lives in Roswell, NM which is approximately 200 miles away 
from Albuquerque. In a letter John wrote to me:

          ``Rural veterans in New Mexico are dying and losing body 
        parts because of a 6 hour, roundtrip drive to the nearest VA 
        hospital in this State. . . . Our VSO legislative 
        representatives from the DAV, etc. have no experience or live 
        in contact with this issue, as they are from large urban areas 
        with massive facilities and infrastructure for support. The 
        classic response to invitations requesting visits to our rural 
        areas has historically been, `we'll try, but it takes time to 
        get out there, and we have a very busy schedule.' I submit the 
        same time that is an inconvenience to executives is the same 
        time killing my fellow veterans or at the very least, causing 
        serious exacerbation of their medical problems.''

    U.S. Army Retired LTC Charlie Revie, a member of the Uniformed 
Services Disabled Retirees, noted that the drive from Las Cruces to our 
only major VA facility is a 250 mile one way trip--from Hobbs, the 
distance is 320 miles.
    The notion that providing contracted care to veterans through local 
doctors at non-VA facilities is somehow a way to finagle out of caring 
for them is absurd. Under my legislation, the VA will clearly still pay 
for the care veterans obtain at non-VA facilities. Veterans in my 
district and across rural America have been hearing politicians talk 
about increasing access for years. It is simply imperative Congress 
take these issues seriously this year.
    After the reports regarding conditions at Walter Reed Army Medical 
Center, the House passed the Wounded Warrior Assistance Act, which 
takes steps to shed light on the bureaucratic process that plagues the 
VA. It improves communications amongst DoD, VA and Congress and 
strengthens the process for returning soldiers transitioning into the 
VA healthcare system. All these measures are extremely important and I 
hope the Senate works to pass similar legislation. But we must not just 
be a reactionary Congress that only finds time to fix issues in light 
of displeasing media reports. Without any changes to allow veterans 
more localized access to care, many soldiers returning from Iraq and 
Afghanistan who return home to their families in southern New Mexico 
will face the extensive 400+ mile trek to the VA medical center in 
Albuquerque.
    I appreciate the opportunity to present my legislation to the 
Committee and speak on this issue which deserves the attention of 
Congress. Our veterans in rural America deserve no less.
                                 
   Prepared Statement of Hon. Ginny Brown-Waite, a Representative in 
                   Congress from the State of Florida
    Thank you for allowing me to appear before the Subcommittee today.
    I appreciate the opportunity to testify on my legislation, H.R. 92, 
the Veterans Timely Access to Healthcare Act.
    When I first came to Congress in 2003, I introduced this measure 
after hearing of the long wait times facing some veterans in need of 
healthcare at the VA. Frankly, the stories many of us have heard about 
these delays are unacceptable. These holdups can worsen the veteran's 
health and impose a greater financial hardship on everyone involved. In 
some situations, these wait times can be the difference between life 
and death.
    Events in Iraq and Afghanistan also remind us of the urgent matter 
at hand. With thousands of soldiers returning from the front lines, 
many of whom will require immediate healthcare, VA medical facilities 
face a difficult task. Unless Congress takes action, wait times will 
only continue to grow.
    My legislation would help ensure that our Nation's veterans receive 
timely healthcare. For veterans seeking primary care from the VA, my 
bill would establish a 30-day timeframe as the standard for access to 
medical services. This standard would cover from the time an individual 
schedules a visit until they actually see a medical provider. In the 
event this standard is unachievable, the VA would have authorization to 
contract for care from a private provider. At the same time, my bill 
also grants the VA some flexibility in meeting this standard. For those 
facilities in geographic areas that have a 90 percent or greater rate 
of complying with this requirement, the contracting provisions would 
not be necessary. Finally, this legislation would establish 
comprehensive reporting requirements on wait times for individuals 
seeking care at VA medical facilities.
    As Members of Congress, we have an extraordinary responsibility to 
veterans. These brave men and women answered the call in our time of 
need; it is only fitting that we take care of them in their own. I look 
forward to working with my colleagues on the critical issue of wait 
times. I would be happy to take any questions regarding my legislation.
    Thank you.
                                 
Prepared Statement of Hon. Solomon Ortiz, a Representative in Congress 
                        from the State of Texas
    Mr. Chairman, thank you for this opportunity to speak on behalf of 
south Texas veterans and help this Subcommittee understand the urgent 
need for a veterans' hospital for the men and women who fought for us.
    Here with me today are members of the Veterans Alliance of the Rio 
Grande Valley--so you can see the faces of the south Texans affected by 
the lack of a hospital . . . the Rio Grande Valley is the southernmost 
tip of my district.
    Here with me are: Jose Maria Vasquez, Ruben Cordoba, and Max 
Balamaris, Polo Uresti, Frank Albiar, and Mr. Felix Rodriguez.
    My legislation gives the government flexibility in establishing a 
way to deal with hospital services in south Texas . . . but the only 
real solution for the area is a hospital.
    Bottom line: veterans' inpatient healthcare must be available where 
the veterans live, not several hours away.
    These guys have fought, bled and sacrificed for this Nation--they 
need something that belongs to them . . . a hospital that get's them 
the care they need where they live--not 5 hours away.
    We know the VA plays the numbers game--but the numbers do not 
reflect the need . . . particularly in the Rio Grande Valley.
    When the VA commissioned their CARES study they recognized the far 
south Texas area was in need of acute inpatient care.
    They decided to meet this demand through contracting or leasing 
beds in local communities, an approach simply not working.
    Veterans are still traveling in large numbers to Audie Murphy in 
San Antonio for care, and for many who are treated for emergencies at 
area hospitals, the bills go unpaid by VA.
    Many veterans are so disgusted by the level of VA health services, 
they simply do not sign up for VA healthcare.
    You have heard me describe the conditions of south Texas vets; 
today I want to show you experiences of veterans themselves . . . 
veterans who shed blood for our Nation . . . veterans whose healthcare 
is utterly inferior.
    South Texas veterans regularly travel 5 hours there and back to a 
15 minute appointment that took months to get.
    Sometimes they need to stay overnight in San Antonio . . . 
sometimes, veterans find after the strenuous trip, their appointment 
has been canceled.
    We've scrubbed the names to prevent any retaliation for truth 
telling. . . . And my time will run out before I'm done, but I want you 
to hear the stories I hear. . . .
    A 21-year-old Iraq war veteran came home badly wounded in his 
spine.
    He's now at Audie Murphy in San Antonio.
    He was being moved by hospital staff from the bed to a wheelchair--
but they moved too quickly and damaged his spine even more.
    He has a lifetime of going back and forth to San Antonio for 
treatment . . . and his family has a lifetime of committing to take him 
there regularly.

                               __________
    One veteran underwent emergency heart surgery; his wife called the 
local clinic and she was directed to call 911; he was admitted for the 
emergency surgery locally.
    His benefits coordinator told him to follow up with a local 
cardiologist to chart his progress since there wasn't a cardiologist at 
the clinic.
    He did, but VA did not pay and on the 3rd visit, the cardiologist's 
office told him to pay upfront for all services.
    The VA clinic then told him he should have gone to a cardiologist 
in San Antonio.
    By now, his sutures were infected and leaking.
    Eventually, he got an appointment to see a VA cardiologist 5 weeks 
later.
    The stress from all this prompted his psychiatrist to increase the 
dosage on his meds.
    When he got to San Antonio, the cardiologist was surprised to learn 
he had surgery.
    He was prescribed more high blood pressure medication.
    That made him faint from low blood pressure, panicking his wife . . 
. she called a home health nurse who suggested stopping all meds and 
going immediately to the hospital.
    He did not want to go to the hospital because they had not been 
paid and he might be refused.
    He was poor--so the nurse recommended that he drink a Coca-Cola 
with crackers, which helped temporarily.
    Due to a faulty medical records system, he was prescribed too much 
medication.
    Since then, he travels to San Antonio to monitor his heart.
    He travels 5 hours, has a 10 minute procedure done, and once was 
told to return in 48 hours.
    He did not qualify for lodging so he returned to the Valley. After 
2 days he returned for a procedure that took under 5 minutes.
    That equals 2 trips to San Antonio in 2 days . . . traveling about 
25 hours . . . to be seen a total of 15 minutes.
                               __________
    A retired disabled veteran is in the midst of several surgeries to 
correct service injuries, in numerous visits to San Antonio, the 
nearest VA hospital to the Valley.
    When he had shoulder surgery, he spent the night in his car so the 
anesthesia could wear off . . . and he didn't take any pain medication 
so he could make the 4 hour drive back home. . . .
    He had to stop several times along the way to vomit from the pain.
    He also had to sleep once in his car in San Antonio to make an 
early appointment because by the time he arrived in San Antonio all the 
rooms available for veterans had been taken.
                               __________
    A constituent's brother had a triple bypass done in San Antonio 
Audie Murphy Veterans Hospital in 2005.
    During the course of his recovery at home, he developed 
complications that needed to be monitored closely.
    The VA medical provider told him that he needed to be monitored 
closely; then later that day, he got a call from the VA clinic that he 
needed to go to the nearest hospital taking veterans.
    Once there, he was moved by ambulance to another area hospital, 
where he was admitted after advising the hospital he was a veteran and 
showing his ID card.
    The hospital got the clearance from San Antonio VA and admitted 
him.
    His medical bills there have not been paid because the VA is 
claiming that ``VA facilities were feasibly available to provide the 
care.''
    The VA said his brother could have traveled to San Antonio under 
the dangerous medical problems he was having.
    His brother does not want to ``rock the boat'' because of his heart 
condition and other medical problems.
    In a sense, he is held hostage by our government.

                               __________
    A family member said this: Congress should also hear about the 
hardship that the vet's family must also endure.
    She has a full-time job but must miss work, taking leave, to take a 
loved one to San Antonio.
    She cannot let him go by himself whenever they do procedures that 
require anesthesia or manipulation of his neck or spine.
    He is usually in so much pain and/or drowsy with medication that he 
cannot drive.
    He has a hard time sitting for long periods, and San Antonio is 5 
hours away.
    They must also make arrangements for the kids if they are not 
getting back before school's out.
    A couple of times he's had to go alone because she couldn't leave 
work or find another driver.
    Then she is so worried about him driving that she cannot function 
at work, going out several times to call to make sure he is OK.
    She also notes the travel pay is woefully insufficient, given gas 
prices.
    They have to fill up twice to get there and back, plus pay for 
meals.
    She notes that hospitalized vets would be better off near friends 
and family to keep them in good spirits.
                               __________
    A Vietnam vet still being treated for post-traumatic stress 
disorder; has two sons, both active-duty military, who have served 
multiple tours in Iraq.
    After a late-night phone call from a son saying that he'd been hurt 
in an IED explosion, his post-traumatic stress surfaced . . . when he 
called to see the psychiatrist, he was told the soonest appointment was 
in 6 months.

                               __________
    The district director for the Veterans of Foreign Wars in the 
Valley says VA provides good medical care.
    The doctors and staff do the best they can with what they have.
    The problem is getting into the system to get the care.
    He says, ``We believe we've earned the right to see a doctor where 
we live.''

                               __________
    Veteran and State Rep. Aaron Pena says what isn't spoken is the 
sense that they are being ignored despite the long history of 
Hispanics' service to the U.S. military.
    We've fought in almost every American war . . . and we're still 
being ignored.

                               __________
    The disabilities of a Port Isabel veteran who served two tours in 
Vietnam are made worse by a round trip on a crowded van, and an 
overnight stay in a dirty hotel.
    Fourteen months ago he went to a private emergency room, which then 
sent him by ambulance to San Antonio to treat a kidney infection.
    VA still has not paid for the emergency visit--ironically today, 
April 26, is his deadline to pay the local hospital $10,000 since VA 
won't pay.

                               __________
    An Iraq veteran is haunted by some of the terrible things he saw in 
combat leading to depression and thoughts of suicide.
    His friend got him to go to the VA office . . . where he was 
referred to the VA hospital in Waco for evaluation for post-traumatic 
stress.
    He was told he needed to begin regular sessions, and he'd get an 
appointment in the mail.
    Three weeks later, he got a letter from VA that he could see the 
doctor in 8 months.
                               __________
    Another veteran notes: ``It's hard to hold a job when you have to 
miss work four or five times a month to travel to San Antonio for 
medical appointments.''

                               __________
    One veteran has utilized the VA healthcare systems in Reno, Nevada 
and Fargo, North Dakota, and he reports both were very good.
    Conversely, his experience with the clinics in Harlingen and 
McAllen are ``ongoing nightmares.''
    Lately he's been trying to get an appointment with the psychiatrist 
in Harlingen.
    Every time he calls, he's put on hold and eventually hangs up after 
waiting and waiting.
    He was not alone among veterans who suspect some manner of 
``Federal racism'' when our Nation is only anxious to send border 
patrol agents, but no hospital to treat military veterans who live 
here.

                               __________
    A daughter who misses her dad says her father served in the U.S. 
Army and came home needing psychological care catered to what a veteran 
experiences--and taking into consideration the stigma a Hispanic man 
feels with depression.
    She lost her father to suicide and wishes that care was available.

                               __________
    Another veteran learned the VA now accepted that Agent Orange could 
have affected sailors in the Tonkin Gulf.
    The VA did not respond to him since he was not a ``wounded 
veteran.''
    He also has diabetes for which they will not treat him.
    He believes they want to wait until he cannot care for himself at 
all rather than helping him prevent the devastation of diabetes while 
he can.

                               __________
    A former military wife said her ex-husband and daughter now live in 
San Antonio and her son has plans of retiring there too--merely to be 
closer to military medical facilities.
    Veterans are forced to choose between living near home and family, 
or living near healthcare.
                               __________
    Another veteran notes many soldiers from the Valley can not afford 
the trip, much less the expense it takes to visit these facilities.
    He notes many veterans have died never getting the medical 
attention they needed.
    He calls the VA health system in south Texas a ``disastrous 
situation.''

                               __________
    A former sergeant says: The cruel irony of extra stress on various 
disabilities caused by traveling 5 hours to a VA hospital makes 
conditions even worse.
    And like several others I heard from, he issued an invitation for 
any of my colleagues here today to join them on the 5 hour ride to San 
Antonio in the van.

                               __________
    A retired major notes local access would promote early diagnosis 
and early cure for ailments that would otherwise generate higher 
treatment costs if left untreated.
    He also has the novel suggestion of using hospital ships as a 
veteran's hospital.

                               __________
    A retired Air Force sergeant--who is covered by TRICARE benefits--
knows he is lucky to have access to local medical facilities.
    Always a soldier, he volunteered to drive the van to San Antonio.
    He would drive from Raymondville to Brownsville to pick up veterans 
at 6 a.m. then to San Benito then Harlingen and then back to 
Raymondville, where the actual trip to San Antonio commenced.
    He reiterated what many people said: It's not a straight 5\1/2\ 
hour trip since they had to stop various times for restroom breaks.
    And he was prohibited from helping the vets in and out of the van 
out of liability concerns.
    Most veterans he drove had to wait hours to be seen for just a 15 
minute visit, then they began the long trek back.

                               __________
    The widow of a Vietnam-era vet said he died 9 years ago of a heart 
attack and almost certainly from a lung problem associated with his 
exposure to Agent Orange.
    He never pursued a diagnosis because the San Antonio facility was 
too far and he was not able to make the trip.
    The one time he did for hearing loss from a mortar concussion while 
in Vietnam, he found that the number of people they were trying to 
serve was too great for quality care.
    He never went back again.
                               __________
    A captain with the 1st Cavalry in Iraq was wounded in 2003 by an 
IED that ruptured both ear drums and left his right side littered with 
pieces of shrapnel, many still remain.
    He plans to retire in the next 4 years.
    He said he's gotten good treatment while on active duty, but 
worries about the time when he retires, with no local VA hospital in 
the area.
    He talks regularly with local veterans that can not afford to make 
the drive to San Antonio because they can't afford the gas or can't 
drive or have no one to take them.
                               __________

    Another veteran echoes many voices in saying south Texas veterans 
should be treated by local medical resources.
    He lives in Corpus Christi, but worries about what the cost of 
transportation does to an aging veteran's population with higher 
poverty rates in the Rio Grande Valley.
    Extended trips place unnecessary physical stress on veterans, it 
places a financial burden on Valley veterans and their families as 
well.
    He sustained a head injury, which resulted in a visible dent in the 
skull.
    After headaches and memory issues, the VA physician sent him to 
Audie Murphy for a CT scan; and he had no option but to drive the 300 
mile round trip to the VA facility.
    That trip not only put him at risk, but the safety of other drivers 
as well.

                               __________

    Another veteran invites all of us to come experience the long and 
painful ride from south Texas to San Antonio to visit a doctor.

                               __________

    A south Texan speaks on behalf of friends married to veterans; she 
is incensed that for healthcare they must be inconvenienced financially 
(gas, food, overnight stays for vets and families) and time-wise, which 
interferes with their jobs.

                               __________

    The brother of a constituent is medically retired from the Air 
Force and must travel to San Antonio every month for his medical 
treatments.
    It takes a day out of his life and requires a long ride back and 
forth.

                               __________

    Another retired veteran chooses the expense of private care over 
the time it takes waiting at the local clinic or taking the time to 
travel to San Antonio.

                               __________

    Another veteran also speaks to the trouble and time consuming 
nature of going so far for procedures.
    He knows that by the time you arrive your problems just seem to 
increase.

                               __________

    A Corpus Christi veteran laid out the context of getting treatment 
in San Antonio: She said it is a 12 hour ordeal to get to San Antonio, 
get tended to at Audie Murphy, and return home.
    It costs two tanks of gas and a whole day of work. The $26.00 for 
travel does not cover nearly the cost.
                               __________

    Placido Salazar, State Veterans' Affairs Officer of The American GI 
Forum of Texas, tells me that some veterans from the Valley were 
recently in San Antonio for 3 days of appointments; they told him that 
a manager at the associated hotel would not release a room to them 
until 6:00 p.m., (using very abusive language); with one of the 
veterans not getting a meal in more than 24 hours.

[PETITIONS SUBMITTED BY REPRESENTATIVE ORTIZ ARE BEING RETAINED IN THE 
PERMANENT COMMITTEE HEARING FILES AND ARE NOT BEING PRINTED.]

[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


                              ----------                              

          ADDENDA--LETTERS AND STORIES OF SOUTH TEXAS VETERANS
    Last week, some veterans from the Valley that were in San Antonio 
for 3 days of appointments at Audie Murphy called me to inform me that 
one of the managers at the Oak Hill Hotel on Wurzbach Road had given 
them a hard time, in not releasing a room to them until 6:00 p.m., 
(using very abusive language) with one of the veterans not getting a 
meal in more than 24 hours.
    THAT is totally unacceptable, but I believe we got the situation 
corrected. If anybody else should have trouble at that hotel or any 
other type of problem, I will be glad to try to assist. Just call me, 
any day--any time (210) 658-9756.

                                                    Placido Salazar
State Veterans' Affairs Officer of The American GI Forum of Texas (2
                                                       10) 658-9756
                               __________
    My father served in the U.S. Army and came home to marry the girl 
next door, raise a family consisting of four kids, but never truly felt 
at peace because he suffered from what he was exposed to while he was 
in the Army.
    He needed psychological care catered to what a veteran experiences 
taking into consideration the stigma a Hispanic man must deal with for 
feeling depressed.
    He ended up committing suicide years later leaving us all behind to 
miss him dearly. Please build a complete veterans hospital in the 
Valley, our veterans deserve and need it.

            Thank you,
                                             Army Veterans Daughter
                               __________
    I am a veteran here in south Texas and would be willing to go to 
Washington next week, in order to prepare the Congressman for his 
testimony.
    I live on a fixed income but will drive if I have to be there.
    I am sure I can get at least two other vets from here to go with 
me. Please call me ASAP to speak of this.

            Thanks,
                                                              Lydia
                               __________
Congressman Ortiz,

    It is with great pleasure and honor that I congratulate you for 
your efforts to bring a veterans hospital to south Texas. While south 
Texas is one of the homes of many heroes who have given their lives in 
foreign wars for the sake of freedom in America, south Texas remains 
one of the poorest areas in the Nation where veterans have difficulties 
finding jobs and medical care. As a Navy veteran of the Vietnam War, I 
served on a destroyer for several months in the Tonkin Gulf and also on 
an expedition to the Sea of Japan during the USS Pueblo incident where 
the North Koreans boarded one of our ships and took our men prisoners.
    At some point in my life I became diabetic while no one in my 
immediate family (father, mother, or grandparents), were diabetic. For 
10 years I have addressed diabetes on my own. One day a Vietnam vet 
friend told me that I could have been affected by Agent Orange even 
though I was aboard a destroyer and that the VA was now accepting that 
Agent Orange could have affected sailors in the Tonkin Gulf. I reported 
to the VA clinic in Corpus Christi and basically they did not respond 
to my request for nothing more than diabetic medication which is 
extremely expensive.
    I am one of those individuals that will address health issues with 
or without VA assistance. However, my DD 214 clearly states that I 
served in the Tonkin Gulf and shows my veterans status, but somehow no 
one seemed to know what I was talking about when I visited the VA 
clinic in Corpus Christi. They told me they needed more documentation 
and that I was not a wounded veteran. Nevertheless, I was not looking 
for any kind of monetary compensation, but rather for help with 
medication for my diabetes only.
    The thought occurred to me that one day I will probably need 
assistance from the VA hospital in San Antonio, but will not get it 
because I am not a wounded veteran, but have been afflicted with 
diabetes that may have occurred in the Tonkin Gulf. The VA made 
available benefits for veterans of the Tonkin Gulf, but no one at the 
VA clinic seems to know that.
    While I have assisted many veterans by taking them for medical 
service at Audie Murphy, many were not wounded veterans. I suppose that 
they want to wait until I am unable to care for myself entirely to 
provide service, if any, instead of helping me now prevent the 
devastation of diabetes while I can. I have seen many veterans struggle 
with transportation to San Antonio for service and as you well know I 
provided services for many senior citizens from Kleberg for many years 
that needed to go to Audie Murphy. Now I am one of them and a veteran 
who volunteered during the Vietnam War.
    I know that many vets struggle getting to San Antonio from the 
coastal bend to receive services. A hospital closer to us would be 
appreciated by all veterans and in fact every region across America 
should have one more so we need to spend money on expanding economic 
efforts rather than basically serving special interests like oil and 
uranium mining. I for one am disappointed with the reception I received 
at the Corpus Christi VA and surely I am not going to beg for their 
attention to my need and get kicked in the face every time I ask.
    Hopefully, you will be successful in your bid for a VA hospital for 
veterans that is long overdue and maybe a revamping of existing VA 
clinics and services so that vets like myself who need assistance are 
not turned down because someone there does not understand what being 
aboard a destroyer in the Tonkin Gulf means.
    I remain your friend and supporter of many years,

                               Ben Figueroa, BA, MA, LCDC, CPS, CPM

                               __________
Dear Congressman Ortiz,

    Thank you so very much in you support of our veterans and their 
welfare. Though I am not a veteran, my daughter, son and ex-husband are 
veterans along with other family members.
    I feel that a veteran's hospital is greatly needed in the Valley. 
My ex-husband along with my daughter are now living in San Antonio and 
my son has plans of retiring there too. Why? You guessed it. . . . 
Military medical facilities.
    My ex-husband was diagnosed with cancer along with other Vietnam 
medical issues and has had to leave his immediate family and move to 
San Antonio in order to be closer to medical assistance.
    Thank you so much, again, for taking on this task. My prayers are 
with you.

            Sincerely,
                                                    Beatrice Weaver
                               __________
To whom it may concern:

    My name is Jim Hodges, Jr., a Vietnam veteran from Brownsville, 
Texas. I am the proud Past-Commander of America's Last Patrol Inc., 
Post 2. I am also the son and nephew of a couple WWII veterans. I am 
also involved in trying to get a veterans hospital in the Rio Grande 
Valley.
    My relatives served in WWII, Korea, Vietnam and every conflict our 
wonderful country has ever been involved in. They have had and have an 
extremely hard time getting the medical attention that they earned. 
Many of my relatives and friends can not go to the VA hospitals in 
Houston, San Antonio and/or Fort Bliss. Most of these soldiers are 
``POOR'' and can not afford the trip much less the expense it takes to 
visit these facilities.
    Many have past away never getting the medical attention they 
needed. I am blessed that I can go to the VA here in the Houston area 
where I live. BUT, there are many in this area who can not.
    That is why there is a ``shuttle'' to help those veterans who can 
not afford it and/or are not able to drive. How can we expect our 
veterans to make that 300 to 500 mile trip to a veterans hospital? 
Thank you for your help and attention to this ``disastrous situation.''

            In service to our country,
                                                Mr. Jim Hodges, Jr.
                                                       832-228-2758
                               __________
To whom it may concern!

    My problem with VA healthcare is the extra stress on our 
disabilities caused by traveling 5 hours to a VA hospital. That is one 
way only. Also, 24/7 medical care that is needed by service-connected 
veterans. Let the Veterans' Affairs Committee come to the Rio Grande 
Valley and travel to VA on a van?

                                                 Sgt. James Krummel
                               __________
                                                     April 21, 2007

Congressman Solomon Ortiz
3649 Leopard Street
Corpus Christi, Texas 7841

Subject: VA Hospital in South Texas

Dear Congressman Ortiz:

    It is most encouraging to hear of your fight to provide the 
veterans of south Texas with a VA hospital. Please allow me to offer 
some suggestions that may help. Among the most salient reasons for 
locating such a facility in this area are the following points:

    1.  Local access would enhance participation by some veterans who 
are discouraged by the travel distance to out-of-town VA facilities. 
This in turn would promote early diagnosis and early cure for ailments 
that would otherwise generate higher treatment costs if left untreated. 
Equally, it would also benefit those who are too seriously ill to 
tolerate the commuting stress. All of this would lead to more efficient 
expenditure of VA healthcare dollars.
    2.  With the Port of Corpus Christi's expanded terminal now able to 
handle large volume military hardware shipping, it lends itself to 
accept hospital ships that have become a major factor in saving 
military lives. At a time when America's freedoms are challenged in all 
parts of the globe, the ability to have a hospital facility that could 
accept large numbers of military patients from a waterborne hospital 
vehicle, would be strategically and economically prudent. It makes 
little sense to dock such a vehicle in outer ports and then air-
transport the patients to inland hospitals. Corpus Christi could 
service all of that need in one location, and could easily provide 
contingency plans for expansion in national emergencies. Also, the 
government could save by incorporating the ancillary services such as 
lab, X-ray, and pharmacy, in a location that could handle both active 
and retired military personnel. This would provide economy of scale in 
areas of high cost medical technology, which is a primary reason for 
escalating health costs.
    3.  A large VA hospital facility would help mend the region's 
physician shortage. Logically, some VA physicians serving the region 
would elect to remain here in private practice. This would provide 
relief in Medicare services, such as rheumatology (among other 
specialties), that are heavily skewed to a narrow panel of physicians 
who accept and treat Medicare patients in this region. Again, this 
would deliver Medicare budget economies by early diagnosis and 
treatment.

    The above three points are only a sample of the issues that stress 
a need for a VA hospital in this region. I truly hope you are 
successful in your effort. If I can be of further assistance, please do 
not hesitate to call upon me. I can be reached at 361-993-6905.

            With best personal regards,
                                                     John D. Falcon
                                                  Major, USA (Ret.)
                               __________
Dear Congressman Ortiz,

    I myself a veteran retired of 20 years serving in the U.S. Air 
Force do not need to travel the long distance being I have TRICARE 
benefits to visit local medical facilities. I was a volunteer driver 
for 8 months and at one time I drove twice a week for 2 months being 
there wasn't other drivers. The trip was to leave on Sunday and return 
on Monday. The other to leave on Wednesday and return on Thursday.
    I would drive from Raymondville to Brownsville, Texas to pick up 
veterans early in the morning, 6 a.m., to return to San Benito then 
Harlingen and then back to Raymondville. After picking up the remaining 
vets at Raymondville we started the longer trip to the VA hospital in 
San Antonio, TX.
    The trip was not a straight 5\1/2\ hours, we had to stop various 
times due to some of the vets needing to use the restrooms due to 
medical problems such as prostate illnesses and others needing to 
stretch out, as you know or can visualize a WWII veteran sitting on 
such a long trip and of course also climbing on and off a 15 passenger 
van. We as driver were not, repeat not, able to help him on or off the 
van due to liability. The veterans had to be ambulatory.
    Upon arrival, the veterans would be dropped off at the entrance and 
from then on they were on their own, able to walk on their own or not 
he or she needed to walk to report to their appointment for the same 
day or the next. Most of the veterans had to wait hours to be seen for 
just a 15 minute visit and be released for the rest of the day and wait 
to return on the 5\1/2\ hour trip.
    Before departing back to the Valley, Raymondville, Harlingen, San 
Benito and Brownsville, the veterans needed to be located from wherever 
their appointment was at, which wasn't very simple due to the other 
``many'' veterans who had similar appointments.

            Yours truly,
                                        Tsgt. Rafel M. Cisneros III
                                            U.S. Air Force, Retired
                               __________
    My name is CPT Martin Albert Longoria and I am currently serving 
with the 1st Cavalry Division which is in Iraq.
    I was wounded in November 2003 by an IED that ruptured both of my 
ear drums and left the right side of my body littered with pieces of 
shrapnel that are affecting me today. I have pieces that are in my 
hands which I am having trouble with as we speak to include my calf and 
thigh.
    The pieces that were left in me for the last 3 years are working 
their way out and some have already been removed. In the next 4 years I 
plan on retiring, but I will still have pieces of shrapnel that will 
eventually work their way out too. While being on active duty I have 
received good treatment. When a piece of shrapnel needs to be removed 
it is.
    However, the day will come when I retire and having a local VA 
hospital in the area would make a difference to those that are not as 
financially stable as others. I have talked with local veterans that 
can not afford to make the drive to San Antonio because they can't 
afford the gas and can't drive for some health reason or have no one to 
take them.
    We as local veterans have served our country when called upon to 
PROTECT IT and DEFEND IT no matter what and some have died doing it. I 
have served with many local soldiers from the south Texas area in war 
and peace, but who is going to take care of this generation of 
veterans. We as a country seem to make the same mistakes from past 
conflicts in not providing adequate healthcare for our past veterans.
    When its budget time you will not hesitate to give yourself a 
raise, but when it comes to us the veteran it seems we are put on the 
back burner for political jargon. I hope what I have expressed helps 
with this cause that is taking place and I hope it helps the veterans 
that have served as proudly as I have. Please remember this when you 
are sitting at home or in your office. We have served being away from 
loved ones and doing what is asked of us.

                               __________
    Thank you for the opportunity to provide comments on the 
availability of veterans' healthcare in south Texas. It is common 
knowledge to everyone in the region that south Texas veterans' are 
underserved as far as veterans' healthcare is concerned.
    The problem didn't occur overnight and has been a gradual process. 
No blame is being assessed. The time has come, however, to rectify the 
problem for both current and future veterans.
    The south Texas veteran population is spread over a large area with 
many veterans living in rural environments. Many south Texas counties 
have no significant metro type area and consequently are limited in any 
medical resources, much less those for the veteran populations.
    This particular concern could be addressed in Congressman Ortiz's 
bill which in part provides south Texas veterans be treated by local 
medical resources. That would insure that every veteran would have 
access to appropriate medical care in a timely manner. Often, it can 
take months for a veteran to get scheduled for what would otherwise be 
a routine medical visit. That needs to be changed.
    The Veterans' Health Administration (VHA) is well known for its 
quality care especially preventive medicine. In some cases veterans 
have to go to extraordinary lengths to receive the preventative care. 
First hand experience may illustrate some of these inequities.
    This veteran suffers from Chronic Obstructive Pulmonary Disease 
(COPD). It's a progressive lung disease with no known cure. Competent 
medical practices contend a COPD patient take a pulmonary function test 
(PFT) twice a year or at a minimum of once a year. A complete PFT takes 
around 45 minutes.
    COPD is typically diagnosed in patients at around middle age 
thereby suggesting that the COPD population is older than the rest of 
the veteran population. The pulmonary function lab at Audie L. Murphy 
Memorial Veterans Hospital in San Antonio, Texas is the only PFT 
resource available to south Texas veterans enrolled in the VHA system. 
There are, however, facilities in Corpus Christi as well as in the Rio 
Grande Valley where the test can be taken.
    The round trip for this writer is about 300 miles or maybe a bit 
more than 5 hours driving time. Therefore, it takes nearly 6 hours to 
get the test. Of those 6 hours, more than 5 are driving time. For older 
patients that becomes a real issue.
    For veterans in the Rio Grande Valley, the distance and drive time 
is slightly more than doubled. That would mean a veteran and probably a 
veteran getting up in years would be required to drive 10 or 11 hours 
for a 45-minute test. That is problematic and raises a legitimate issue 
about the burden and travel stresses on an older veteran with a 
disease, which will probably end his or her life.
    Another issue is the cost of transportation be it by private 
accommodation or some commercial means. The Valley has an aging 
veterans population according to the last census data. It also has 
higher poverty rates. In addition to an extended trip placing 
unnecessary physical stresses on veterans, it places a financial burden 
on Valley veterans and their families as well. That needs to be 
remedied.
    There are other routine procedures, which necessitate a trip to 
Audie Murphy. This veteran had sustained a head injury, which resulted 
in a visible dent in the skull. After discussing ongoing headaches and 
memory issues, the VA physician said a skull series or CT scan was 
necessary.
    That routine procedure necessitated a trip to Audie Murphy. The 
veteran had no option but to drive the 300 mile round trip to the VA 
facility. The safety of that endeavor is questionable at best. Not only 
was the veteran put at risk, but the safety of other drivers as well.
    There was about a 10-minute wait for the X-ray procedure and the 
scan itself took 6 or 7 minutes. A cup of coffee left in the car was 
still hot for the return drive home. Out of 5 hours and 15 minutes for 
the CT scan, 5 hours was driving. The same imaging could have been done 
locally or in the Valley.
    It was later learned that the injury triggered two strokes as well 
as a bifrontal hygroma. The hygroma is dead brain tissue that has 
filled with fluid. The wisdom of having a patient make that kind of 
drive is indeed questionable. Consider the patient, made maybe more 
frail making that trip from Brownsville, Texas. An argument could be 
made that such a trip would simply be reckless.
    One other trip to Audie Murphy is especially haunting. This veteran 
needed to go to the cardiac lab in San Antonio for a thallium stress 
test. That's a routine procedure for evaluation of the heart. The 
procedure was scheduled for morning.
    In order to make the appointment, it was necessary to leave Corpus 
Christi before daylight. It was soon learned that the veteran's night 
vision had deteriorated to the point of making the trip dangerous. That 
is now a new concern for Valley veterans. The thallium stress test is 
available nearly everywhere and in most communities with a hospital.
    The test itself is a simple procedure with an 8-minute protocol on 
a treadmill. At the end of the treadmill a nuclear dye is injected. 
Next, the patient waits for a period of time measured in hours for the 
dye to circulate. Then multiple images of the heart are taken.
    While waiting for the imaging in the lobby of Audie Murphy, an 
elderly man was encountered. We visited for a while. He said that he 
caught a ride in a VA van in Cameron County, Texas. He continued that 
he got on the van way before daybreak for the ride to San Antonio.
    Although the purpose of his visit is not recalled, he said only 15 
to 20 minutes of his time was needed at the hospital. Then he had to 
wait hours until 3:00 p.m. to catch the van back to Cameron County. He 
said it would probably be dark when he got back.
    He was clearly tired. He had family in Corpus Christi. We talked 
about his staying with them and then going back to Cameron County the 
day after. We called his family who thought that it was a great idea. 
He rode to Corpus Christi with this veteran.
    Ever since, there has been a concern about other Valley residents 
who have had to endure the same travel stresses. That man should have 
never been put into that position. Whatever services he needed should 
have been obtainable in or near Cameron County.
    While having to make a trip to Audie L. Murphy may be an 
inconvenience to this veteran, to Valley veterans it is a more serious 
matter. First the trip is onerous, especially on the older or frailer 
veterans. Secondly, the cost of the trip in some cases could 
conceivably cause veterans to avoid necessary medical care, simply 
because they couldn't afford the transportation.
    The current delivery of veterans' health is inadequate and in many 
cases not being made reasonably available. A case for making what would 
be customarily considered outpatient services available through 
existing private sector resources should be relatively easy to see and 
make. A veteran should be able to get procedures as those discussed 
above near his or her home town.
    A matter not clear in the bill is that of emergency room care. An 
uninsured visit to an emergency room can be financially catastrophic. 
Today, if a veteran calls facilities as the Corpus Christi Outpatient 
Clinic or even Audie L. Murphy Memorial Veterans' Hospital, the caller 
will hear a recording to the effect that if the call is an emergency, 
call 911.
    Any such medical care is at the veteran's expense. On the other 
hand, should there be a VHA hospital nearby or an ER that contracts 
with the VHA, the veteran is covered. Acute medical care should be 
available to any veteran wherever they are situated.
    Within the last several years, a sibling sustained a head injury in 
a fall. Although the sibling died after a few days, the emergency room 
and intensive care bill was around $70,000. Such could be devastating 
to a veteran's survivors.
    With or without a new hospital many of the routine medical services 
such as stress tests, pulmonary function tests and numerous 
radiological procedures can be done competently, cost effectively, and 
with fewer burdens on the veteran.
    As far as inpatient care is concerned, this veteran would prefer to 
get to a real veterans' hospital if able. It would make no difference 
if the facility were located in either the Valley or San Antonio. If it 
were an acute matter, the preference would be the first facility 
contracted with VHA if a VHA facility were not nearby.
    The ability to provide routine medical procedures as well as acute 
or emergency room care should be available in nearly every community in 
south Texas. That would necessarily contemplate the public-private 
component of the bill or some combination of the other provisions.
    Your consideration of these remarks is appreciated.

                                                  Claude V. D'Unger
                               __________
To whom it may concern:

    I'm a decorated veteran who served two tours in Vietnam, 1967 
through 1969. I'm a 100% permanent disabled veteran. The 5-hour trips I 
have to make to San Antonio for any special needs the clinics can't 
perform is making my disabilities worse. The round trip is made on a 
crowded van, and the overnight stay in a dirty hotel is a hardship. I'm 
too sick to drive myself. If you are in a wheelchair you can't ride the 
vans. I'm saddened to see the old WWII veteran of 90 years old suffer 
this way as well. I went to an emergency room at a private hospital 14 
months ago and then was sent up by ambulance to the Audie Murphy 
veterans hospital in San Antonio Texas for a kidney infection. To this 
day I'm still waiting for so-called due process. I've talked to three 
different people in fee-basis with the most recent being the 
supervisor. They all told me it would be 45 days with the last contact 
on April 3rd. Well guess what, nothing yet. I'm currently being 
threatened and I have until April 26, 2007 before bill collectors are 
given the job to collect $10,000 from me, for what I shouldn't have to 
be concerned about. My credit is at risk because fee-basis is 
backlogged, so they keep saying. This is a big mess with a lot of 
stress. I truly have lost faith in this VA nightmare. Give the veterans 
what they deserve or tear down this VA system and close the doors and 
let us use our cards like (Medicare) and pick and choose our own 
doctors and hospitals. I'm not too proud being a veteran because 
there's too much disgrace and shortcomings from a broken-down system. 
Another disgruntled veteran? Maybe so but it shouldn't be this way. 
This substandard treatment for veterans in the Rio Grande Valley is 
unacceptable as it is anywhere in the U.S.A. Please let our voice be 
heard, we the people. Veterans don't want our new veterans to endure 
these shortcomings. Do what's right--PROVIDE FOR ALL WHO DESERVE.

                                                        Dan Kerkow,
                                                  Port Isabel Texas
                               __________
Honorable Sir:

    I do not know if you have heard from any of the family members of 
the disabled veterans from the Rio Grande Valley that require travel to 
San Antonio for appointments, but I believe that Congress should also 
hear about the hardship that the vet's family must also endure. I have 
a full-time job at one of the area hospitals. When my fiancee needs to 
go to San Antonio for certain procedures, I have to take time off from 
work to accompany him. It causes me to lose work time, and the only way 
I can make up that money is to use my vacation days. I cannot let him 
go by himself whenever they do procedures that require anesthesia or 
manipulation of his neck or spine. He is usually in so much pain and/or 
drowsy with medication that he cannot drive. He has a hard time sitting 
for long periods, and San Antonio is 4 hours away, and sometimes longer 
when we have to stop so that he can stretch to relieve the pain. A 
couple of times he has had to go on his own because I cannot take off 
from work and we cannot find anyone else to go with him. He has had to 
lie to the staff that he has a driver. Then I am so worried about him 
driving that I cannot even function at work, and am having to go out 
several times to call him to make sure he is OK. We also have to make 
arrangements for our kids if we are not getting back before they get 
home from school. We have had to go to San Antonio just to get a result 
of an X-ray or CT scan. This requires at least 8 hours of driving for 
an appointment that lasts 10 minutes. Where is the justice in that?
    I know several veterans that have to go to San Antonio for 
treatments or procedures; some do not have family members that can 
drive them to San Antonio or reliable vehicles or they are taking care 
of small children at home. What are they supposed to do? The van that 
is supposed to be available to these vets is not really available; it 
only runs on certain days and with limited space and with no handicap 
accommodations. Sometimes some procedures have to be scheduled for the 
weekend; like my fiancee's MRI that's scheduled for a Sunday; he also 
has another appointment scheduled for Monday for a spinal procedure. I 
cannot even make that appointment with him because I cannot take the 
time off. This means we have to call around and see who can go with 
him. What happens to those vets that have no one to take them and no 
bus available? Rescheduling appointments can take up to 6 months or 
more.
    I have heard several horror stories from these vets and I think it 
is a shame that our vets are having to sleep in their cars overnight 
because there is no room available at the designated hotel and they 
have to be there for an early morning appointment. And travel pay?? You 
have got to be kidding; with gas prices the way they are, we barely get 
enough for one tank full of gas. We have to fill up twice to get there 
and back, plus pay for meals. How about when these vets are 
hospitalized up there? Isn't it better for them to be near friends and 
family that can visit and keep him/her in good spirits? Isn't this 
supposed to be better for them, rather than being all alone away from 
everyone?
    The Valley has several thousand vets already and will have more 
when these young men and women return home from our current conflicts. 
Are they going to have to suffer the same hardships?
    Congress needs to stop turning a deaf ear and a blind eye to our 
situation in the Rio Grande Valley. Our veterans have willingly given 
their service to the United States. It is time to return that service. 
How can Congress appropriate money for every other cause except this 
one, when it means taking care of our own? These men and women deserve 
better; we all owe it to them.

            Sincerely,
                                                     Anabeth Molina
                               __________
    I am a strong supporter of establishing a veterans hospital in 
south Texas as soon as possible. Veterans who have to visit a hospital 
have to travel all the way to San Antonio, TX to take care of their 
medical needs. I venture to say that the majority of the personnel 
voting against this issue have never been in the military. I will ask 
these opponents of the medical facility in south Texas to please take a 
trip all the way from south Texas to San Antonio to visit a doctor.
    But take this trip when he/she/they are in pain or sit in a 
wheelchair for the trip and see how they like it. I dare any one of 
those opponents to try taking this trip! If he/she/they decide to do so 
please let me know so I can get the news media to cover this trip. You 
may quote me on any or all of the above statements.
                                                      Lino Trevino,
                                                   305 Beverly Dr.,
                                                  Schertz, TX 78154
                               __________
    I HAVE SEVERAL CLOSE FRIENDS WHO'S HUSBANDS ARE VETERANS AND THEY 
TELL ME, AND I CAN ALSO SEE, WHAT THEY HAVE TO GO THROUGH EVERY TIME 
THEY HAVE TO LEAVE FOR SAN ANTONIO. IT IS SUCH AN INCONVENIENCE FOR 
THEM AND THEIR FAMILY, PLUS THE COST FOR THEM AS WELL, SINCE THE COST 
OF GAS HAS GONE UP AND THEN THE COST OF A HOTEL IF THEY HAVE TO STAY 
PLUS FOOD ETC. . . .
    COULD WE NOT USE THE HOSPITAL AT THE CORPUS CHRISTI ARMY DEPOT ON 
BASE, BUILD IT UP AND MAKE IT BIGGER, HIRE THE DOCTORS AND NURSES 
NEEDED TO MAKE LIFE A LITTLE EASIER FOR ALL OUR DESERVING VETERANS.
    I AM DEFINITELY FOR A VETERAN'S HOSPITAL IN THE SOUTH TEXAS AREA.
            YOURS TRULY,
                                                     OLGA RODRIGUEZ

    Olga V. Rodriguez, CCISD Office of Food Services, 4922 Westway, 
Corpus Christi, TX 78408, (361) 844-0222, Fax: (361) 844-0226.

                               __________
The Honorable Congressman Ortiz,

    My husband is a Vietnam War veteran and my father is a World War II 
veteran. Both had injuries due to the war and both have to make trips 
to San Antonio at the Audie Murphy Hospital. My father is in his mid 
80's and it is getting harder and harder for him to make trips to San 
Antonio. My husband also has had problems getting to San Antonio. . . . 
I feel they both served their country and gave their all while doing so 
and they need to have you be their voice to tell Congress that there is 
a great need here in south Texas to have a veteran's hospital. Thank 
you for what you are trying to do for our loved ones that have served 
their country because they believe in our traditions and also served 
with honor.
    Many blessings to you.

            Sincerely,
                                                   Elizabeth Jasso,
                                          Food Service Coordinator,
                                                 Corpus Christi ISD
                               __________
Dear Congressman Solomon P. Ortiz:
    I have a brother who is medically retired from the U.S. Air Force. 
He must travel to San Antonio every month for his medical treatments. 
It takes a day out of his life and requires a long ride back and forth. 
I am also a retired veteran but choose to see my own doctors rather 
than spend a long time waiting at the local clinic or taking the time 
to travel to San Antonio. It would be a blessing to many of us veterans 
if we had a hospital here in Corpus Christi or nearby.
    I would like for you to know that I am a registered Republican but 
I started voting for you when you ran and was elected sheriff of Nueces 
County. You may remember I was an active member of Associated Clubs of 
Texas (ACT). I have voted for you each time you ran for Congress. I am 
confident that you can get the veterans hospital for us.

            Respectfully,
                                                  Richard D. Hanson
                               __________
Dear Sir:

    I appreciate this opportunity to give my opinion on veteran's care 
in south Texas. I have been a part of the VA healthcare systems in 
Reno, Nevada and Fargo, North Dakota. Both Reno and Fargo were very 
good. These were medical hospitals, not clinics. My experience with the 
clinics in both Harlingen and McAllen are ongoing nightmares. Lately I 
have been trying to simply get an appointment with my psychiatrist in 
Harlingen. Every time I call I get put on hold and eventually I hang up 
after waiting and waiting. I finally gave up but I will try again soon. 
This is just one example. I dread trying to do anything with the 
veterans care facilities here. I have tried to figure out why it is 
that an area that seems to have more veterans per capita than any other 
area of the Nation has the poorest healthcare for them. I suspect a 
type of Federal racism. I can't understand what else it might be. The 
employees in both clinics are overworked way beyond the point of 
laughability. The thought that maybe we don't need a VA hospital in 
this area is so ridiculous I feel embarrassed for whoever might be 
thinking this. Many veterans won't use the facilities here. They self-
diagnose and then pick up meds in Mexico.
    I am Douglas R. Brown. My phone is 956-579-4441. I will reveal any 
other personal information about myself if you need it. I am available 
to talk to anyone.

                               __________
Congressman Ortiz:

    We need a Veterans Administration hospital in the Rio Grande Valley 
so that we do not have to travel to San Antonio for acute care. I have 
had a couple of near-death experiences dealing with the bureaucracy of 
the Veterans Administration as it provides healthcare to us veterans.
    I underwent bypass heart surgery under an emergency basis as a 
result of a heart attack. My wife called our local clinic and she was 
directed to call 911 and that if I was service-connected the VA would 
cover. I in fact did have the surgery. I had no problem being admitted, 
but after my release from the hospital everything changed. Upon release 
we provided the VA clinic with the hospital doctors' recommended post 
surgery instructions. I was placed under new medication.
    Unfortunately, the nurse which received those medical instructions 
did not input them into my computer medical records. I was at home 
without medication and had to turn to a private pharmacist to obtain 
them. No one at the VA had requested the new medication. I went to the 
benefits coordinator and told him that I needed to follow up with a 
cardiologist to chart my progress. He told me since there wasn't a 
cardiologist at the clinic that he saw no problem if I followed up with 
the local cardiologist. I did and VA did not pay. I was taking Coumadin 
and had to be monitored weekly.
    After three visits, the cardiologist's office advised me of the 
problem with the VA and requested that I pay up front for all services. 
I called the clinic and was told that the VA says that I should have 
gone to a cardiologist in San Antonio. By this time, my sutures had 
become infected and I was leaking fluids. I went to the clinic and was 
told that they would assign a home health nurse to monitor the sutures. 
She was given very specific instructions and was limited on what she 
could do.
    I then attempted to get an appointment to see a VA cardiologist 
which had been seeing me, but was told at the local VA that they did 
not do that and I should call San Antonio directly. I did and was able 
to get an appointment 5 weeks after my release. By this time I was all 
stressed out and had to see my psychiatrist. He doubled my dosage on my 
medication in order to help me. When I arrived in San Antonio, the 
cardiologist did not know that I had had surgery.
    She was surprised because she thought that I was coming up to San 
Antonio for a heart catheterization. She thought that I had a valve 
problem and was surprised that they had found two arteries that were 
clogged. She was irritated because she did not have my up to date 
medical records. I showed her my sutures and she was visibly irritated 
because they were infected.
    She tried calling the local VA clinic but could not get the line. 
She immediately called the surgeon's office and made arrangements that 
I be seen immediately. She reviewed all my medications and made 
changes. The surgeon cleansed my sutures and told me to return to the 
surgeon that had done my surgery so that he could follow up locally. I 
returned home and continued with problems with my sutures.
    I was also prescribed more high blood pressure medication. I was 
taking so much medication that my blood pressure fell down almost to 
the point that I was fainting. There was no way to reach the VA because 
it happened on a weekend, not even the toll-free nurses number. My wife 
panicked and called the home health nurse which suggested that I quit 
taking the medications and go immediately to the hospital. I did not 
want to go because the hospital had not been paid and I might be 
refused.
    The nurse recommended that I drink a Coca-Cola with crackers, which 
I did. Thank God that the home remedy that the nurse recommended 
worked. On Monday I called San Antonio and told them what had happened 
and they took me off some medication and I was told that I was taking 
too much medication. (The reason for this is the faulty medical records 
system.) I returned to the surgeon that performed the surgery and I 
told him that the VA had sent me back to him.
    His office called the VA and I assumed it had been approved. He saw 
my sutures and was very concerned and wondered what the VA was doing. 
He immediately ordered wound therapy and I was given a 3 times a week 
regimen for about 2 months. Since then, I have had to travel to San 
Antonio to have a halter placed to monitor my heart. I traveled 5 
hours. When I arrived I had the procedure done, which took about two 
(2) minutes. I was told to return in 48 hours. I did not qualify for 
lodging so I returned to the Valley. After 2 days I returned to have it 
removed. Again I traveled 5 hours to get there. The procedure to remove 
it took 45 seconds to a minute. I had to make two (2) trips to San 
Antonio to be seen a total of 2\1/2\ to 3 minutes. Why? Because this 
procedure could not be done at the local clinic?
    On my last visit to my medical provider at the clinic I was 
assigned a new doctor. When I was being triaged, the nurse asked me if 
I had any past surgeries. I told her, hell yes, I just had a bypass, 
isn't it in the records. I told her that I even had to go to San 
Antonio to have a halter to monitor my heart. She wondered out loud as 
to why they had sent me to San Antonio for a procedure that could have 
been done locally. The doctor and I reviewed my medical and I was 
surprised that some of the medication that I had been ordered to stop 
was still on the active list. I told him that I had not refilled those 
prescriptions. He deleted them from my record. I had to update him on 
what had happened since my surgery.
    The hospital and the doctors that did the surgery have not been 
paid and I am getting medical billings from them. The fee service 
people at the VA told me that I could have gone to San Antonio for the 
medical services. They did not have any records in their files 
indicating that a VA doctor had approved the medical. I told him that 
the hospital had called and that they were given the okay or they would 
not have allowed the services. I told him that I had no choice but to 
go to a local hospital because it was an ``emergency.'' And since the 
clinic had not provided post surgery care, I had had to follow up with 
the doctors.
    I am doing fine now. I am gradually recovering from the surgery. 
But while I was suffering with the infection to my surgery and the 
delicacy of the operation I had to make two (2) trips to San Antonio, a 
total of almost 20 hours in a car. The pain and discomfort that I 
suffered made me think, why in the hell did I choose the VA for my 
medical.
    I have gone to San Antonio on previous occasions to see the 
cardiologists only to find out that the echograms and ekg's done at a 
local hospital were not available. They were not sent up there because 
the VA had not paid. The cardiologist was visibly disturbed by this and 
she ordered new ones done since I was in San Antonio already. She 
showed concern that I had traveled all the way from the Valley and that 
I would not be seen due to the lack of the medical being sent to her.
    I have had to go to San Antonio for other minor exams that took 15 
to 20 minutes. The stress test could have been done locally, the 
allergy tests could have been done locally, the breathing test could 
have been done locally, and my skin rash exams could easily have been 
done locally. But I had to travel to San Antonio for them because the 
Rio Grande Valley does not have acute care to provide healthcare for 
us.

            Sincerely,
                                                 Arturo Treto Garza
                               __________
Honorable Solomon Ortiz,

    Thank you for getting our needs in the Rio Grande Valley heard. 
Yes, we do need a hospital for us. Having to travel to San Antonio is 
just so much trouble and time consuming. Sometimes it just does not 
help, by the time you arrive your problems just seem to increase. We 
need all the help we can muster.

            Respectfully,
                                                    Jose Benavides,
                                                334 McDavitt Blvd.,
                                           Brownsville, Texas 78521
                               __________
Dear Congressman Ortiz:

    My brother had a triple bypass done in San Antonio Audie Murphy 
Veterans Hospital in 2005. He returned after a 2 week stay at Audie 
Murphy and continued with his post-surgery care. During the course of 
his recovery, he developed complications with a blood thinning 
medication called Coumadin. That medication had to be monitored 
closely. On one occasion he went to the Harlingen Outpatient Clinic 
with problems.
    His VA medical provider told him that he needed to be monitored 
closely for his PT INR and that he needed to take vitamin K. He sent 
him home while he ordered his new dosage of medication.
    He told my brother that maybe the pharmacy in McAllen might deliver 
the medication later that day. As soon as my brother arrived at his 
home, he received a call from the VA clinic that he needed to go to the 
nearest hospital immediately and was told that Dolly Vinsant Memorial 
Hospital in San Benito was taking veterans.
    My sister-in-law drove him right away to DVMH. At DVMH he was told 
that he was very sick and he was immediately transferred to Valley 
Baptist Medical Center in Harlingen, TX by ambulance. He was admitted 
because he advised the hospital that he was a veteran and showed his ID 
card. The hospital got the clearance from San Antonio VA and admitted 
him. He was given two pints of blood and was required to stay for 4 
days to recover.
    His medical billings have not been paid because the VA is claiming 
that ``VA facilities were feasibly available to provide the care.'' In 
other words, the VA felt that my brother could have traveled to San 
Antonio under the dangerous medical problems he was having.
    He barely made it to the local hospital let alone to San Antonio 
which is 4 to 5 hours away by car. The VA clinic did not tell him that 
they would provide an ambulance for him to take him to San Antonio, 
they know better. There is no such thing. What his VA medical provider 
did do and under an abundance of caution was referred him to the 
nearest local hospital.
    If the VA feels that our veterans can immediately fly or magically 
transfer themselves to San Antonio for medical care under emergency 
conditions, then I wish they would let us in on the secret.
    Once again the VA is using the excuse that medical VA facilities 
were feasibly available. The local VA clinic does not even have a 
cardiologist. VA facilities are not ``feasibly available'' for veterans 
with emergencies and or acute care problems.
    This is another reason why we need a VA hospital for the Rio Grande 
Valley. My brother does not want to rock the boat because of his heart 
condition and other medical problems which have developed. He does not 
want to jeopardize the healthcare that he does receive from the VA. In 
other words, he is in a sense held hostage by our government.

            Sincerely,
                                                       Arturo Garza
                               __________
Dear Congressman Ortiz,

    My husband, Alfonso X. Soto, an army veteran of the Vietnam War 
died 9 years ago. I believe that at the time of his heart attack he was 
also suffering from a problem with his lungs possibly due to his 
exposure to Agent Orange while in Vietnam. He never persued a diagnosis 
mainly because the San Antonio facility was too far and he was not able 
to make the trip. The one time he did go due to hearing loss from a 
mortar concussion also while in Vietnam, he found that the number of 
people they were trying to serve was too great for quality care. He 
never went back again.
    My husband is gone, but for the sake of other veterans who deserve 
our support and in light of the number of young men and women from our 
area serving in Iraq, who will need physical and psychological support 
when they return, I ask that you actively pursue a facility in the 
south Texas area. Each time I drive by the old Valley Regional facility 
just sitting there with no purpose, I wonder at the possibility of a 
veteran's hospital in Brownsville, Texas. Congressman, I know you are a 
man of vision. Please do what you can.

            Sincerely,
                                                    Neida Ruth Soto
                               __________
Mr. Ortiz:

    I am a 54-year-old black female veteran and I retired and live in 
Corpus Christi, Texas. I have 60% service-connected disability and find 
it ridiculous and cumbersome to have to travel to San Antonio for 
visits to Audie Murphy. I have to take off from work for a day as 
opposed to 1 to 2 hours to have a mammogram, an X-ray, consults which 
take all day waiting, and 10 minutes to get done.
    I usually have appointments at 12 p.m. which means I must go to bed 
early enough, to get up around 6 a.m. leave Corpus no later than 7:30 
to make sure I get to Audie 30 minutes prior to my appointment. Once I 
am checked in; and I will take my last appointments for instance, I 
wait for 1 hour to be called, and another 2 hours before I am seen. 
They reimburse me $26.00 for the appointment and we know that does not 
even fill a tank.
    I must miss a day of work of course because it is a full day 
evolution to get this completed. I work on the military base located at 
NASCC. It has a large hospital that is being used as a clinic. I do not 
know why the government is underutilizing the facility and requiring 
veterans from our surrounding cities as well as those here in Corpus to 
travel miles for services that can be provided right here. This will 
show the appreciation for the veterans, employ qualified physicians, 
get adequate services and probably allow the people that have fought 
for our country the availability to convenience in knowing what some of 
our brothers and sisters died for was not in vain.
    The last visit to San Antonio I was in a room with several other 
veterans. We all realized through conversation that we were all from 
either Corpus, Robstown, Brownsville, and other surrounding areas of 
Corpus. This was ridiculous because some had been there since 8 a.m. 
and it was already 11 a.m. and they had not been serviced. My 
appointment was 11 a.m. and I was seen at 1 p.m. and left at 4 p.m. 
This was a full day of work and not counting me driving up there and 
returning home, which by the way I arrived at 7 p.m.
    So basically from beginning to end it took me 12 hours to get to 
San Antonio, get serviced at Audie Murphy, caused me to fill my tank 
twice, going and coming, I took off a whole day of work and got 26 
dollars for my troubles and all of this could have cost nothing but 
probably 4 hours of time if I could have used the hospital already in 
Corpus or some facility that is comparable.
    I sincerely appreciate you fighting this battle for us because it 
is becoming increasing difficult to travel those miles for treatment 
that can be completed in Corpus Christi. I cannot say enough that 
finally someone is noticing that we veterans do not ask for much but 
when we do it is because we feel we need it, deserve it and it is a 
doable request.
    Thanks for the time and energy put forth for this cause.

                                         Billie P. Harvey, USN-Ret.
                               __________

    I favorably support the proposal(s) concerning the establishment of 
a VA hospital in the Rio Grande Valley, not just ``south Texas.''
    Even though I am a retired and VA-disabled U.S. Army Vietnam War 
veteran, I have not used VA facilities, other than the Disabled Veteran 
license plate benefit. Perhaps I will need their services in the 
future.
    I do, however, recognize and support the efforts of you, and our 
VA-eligible brothers and sisters, to gain relatively local access to VA 
care, other than crowded, overloaded VA clinics.
    This effort needs to be sustained to fruition even though this may 
not be the year for success.
    Carry on, sir.

            Most respectfully yours,
                                                  John M. Lawrence,
                                             1SG, U.S. Army (Ret.),
                                               26 Winterhaven Lane,
                                              Brownsville, TX 78526
                               __________

    We need all the support from you to make this recommendation become 
a reality. For several years I have seen and helped other veterans 
travel to San Antonio for their medical problems.
    It is time to open their eyes, that we do need a hospital here in 
the Valley. The Harlingen area will be getting a new outpatient clinic 
within the next few months but this will not help because we still need 
to travel to San Antonio.
    It's great but we need a hospital here. There's too many of us 
veterans who need a hospital. It's very difficulty for us to travel 
because of our illnesses and no support for our families when we are 
there. I have advised those veterans that they need to speak out so 
that our congressmen hear us.
    Our vote means a lot and if we get together we can have a great 
impact in our coming elections. Once again, thank you for your support 
and I hope that you can convince the VA Committee.

                                                      Miguel Rangel
                               __________

    My opinion on this matter is that in the Rio Grande Valley, there 
is a serious need of a VA hospital.
    There are many vets that because of the drive to San Antonio most 
of them would rather just not worry about being seen at the VA. For 
those who make that 4-hour drive it is not as easy at it seems.
    It is very tiring and the fuel cost, lodging, and food is very 
costly for those that depend on a family member to take them to their 
appointments. The travel pay assistance that one receives is not enough 
to cover these expenses.
    Having a hospital in the Valley would benefit the vets that have 
supported this Nation and now it is time for the Nation to step up to 
the plate and assist our south Texas veterans. I am a Navy vet and 
hearing their stories of war and their sacrifice that they face each 
and every day is something I do not wish on anyone.
    Mr. Ortiz, we in south Texas are behind you 100% and do appreciate 
everything you have done for us. We stand next to you in this battle 
and I pray that those who make this decision will hear our cries for 
help.

            God Bless,
                                                    Joseph D. Ramos
                               __________
Dear Rep. Ortiz:

    I'm a Vietnam veteran with several service-related health problems. 
I've made about 8 trips to Audie Murphy in San Antonio this past year 
and am scheduled to make several more in the next month or so. My 
health is still well enough where I can make the trips OK. As my 
conditions worsen I know it will get harder and harder to make the 5-
hour trip each way.
    I see a lot of veterans from the Valley every time I go there. 
There are a lot of veterans who cannot make the trip on their own. They 
make the trip by bus or take relatives who I'm sure have to make 
sacrifices missing work, caring for children and other parents to make 
the trip. It is a real hardship for most veterans and their families to 
have to go all the way to San Antonio for medical care.
    Americans from the Rio Grande Valley have always responded with 
great patriotism when our country had called. PLEASE HELP THE MANY, 
MANY VETERANS FROM THE VALLEY GET A VA HOSPITAL IN THE VALLEY.

                                                   Filiberto Conde,
                                                Rancho Viejo, Texas
                               __________
                                                     April 24, 2007

Dear Congressman Ortiz:

    I'm a disabled vet from WWII who used to drive 357 miles to San 
Antonio for treatment but I can't do that anymore. I now visit the 
Harlingen outpatient clinic and the McAllen outpatient clinic for 
podiatry. They do the best they can with limited space and equipment 
and time.
    This Valley is in dire need of a hospital or more inpatient clinics 
to deal with the thousands of vets from the previous war era and now 
the Iraq War.
    Congressman Ortiz, I know you will do your best to remedy this 
situation, anything you do will be appreciated.

            Sincerely,
                                                      Bernard Reyes
                                                     Staff Sergeant
                                             99th Infantry Division
                                                   1st and 3rd Army
                                                       World War II
                               __________
Mr. Ortiz:

    First of all I'm not a veteran but I do work with them. I was a 
scout leader and I teach all my kids the importance of honoring a vet 
(a warrior). Here in the Valley our warriors have given up 3% of all 
deaths compared to 1% in any community in all the Nation in all wars 
and are the most highly decorated in the Nation. Just on that alone our 
Valley warriors deserve more than what they are getting.

                                                Epifanio Valdez III
                               __________
Respectable Congressman Ortiz:

    You have our support and encouragement. Do us well. And, thank you 
in advance. Tomorrow, my husband and I will get up at 4:30 a.m. to get 
ready and be on our way to San Antonio by 6:00 a.m. My husband has an 
appointment with the cardiologist. He has a heart condition and we have 
to make that trip periodically. Our trip is not any longer than the 
veterans that come from Brownsville, McAllen and all those other small 
towns. Many of our veterans can not afford private supplemental 
insurance. If we have a medical emergency after the hours of operation 
of our local VA clinic or during the weekend that requires 
hospitalization we are encouraged to go to our local emergency room, 
but that leaves us with the total expenses. The other alternative is to 
drive to the VA hospital in San Antonio at whatever time and with a 
near-death condition. The services and attention in Audie Murphy are 
excellent, but Audie Murphy is overextended. It is a problem to find a 
parking space due to the number of patients they see daily. Every time 
we go we see the increase in patients and it will only get worse 
especially with soldiers coming from the war. Also, because south Texas 
is the temporary home for many veterans that come for the winter. Yes, 
we need a veterans' hospital in south Texas.

            Sincerely,
                                                      Miltan Martiz

                                               Rudolph Salinas, Sr.
                                                 Korean War Veteran
                               __________
Vets fight for hospital in Valley
They endure long trips, long waits, lots of red tape to get healthcare
12:37 AM CDT on Sunday, April 22, 2007

By DAVID McLEMORE / The Dallas Morning News
Brad Doherty/Special Contributor
   Veteran Steve Dunn of Harlingen must travel hundreds of miles to 
          receive treatment at the VA hospital in San Antonio


[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]


WESLACO--Every Sunday and Wednesday morning, small groups of military 
veterans, some in their faded camouflage shirts, stand patiently at 
designated locations in the Rio Grande Valley, waiting for the ``vet 
van.''
    Veteran Steve Dunn of Harlingen must travel hundreds of miles to 
receive treatment at the VA hospital in San Antonio. Eventually, two 
government-leased, 15-passenger vans will weave their way to the stops 
between McAllen and Brownsville, picking up the passengers for the 240-
mile drive to the Audie Murphy Veterans Memorial Hospital in San 
Antonio.
    They'll travel 5 hours to an appointment that took months to get. 
Sometimes, it's for a specialized X-ray that takes 15 minutes. 
Sometimes it's for a procedure that requires an overnight stay in San 
Antonio. And sometimes, veterans find, their appointment has been 
canceled.
    On most days, the vans leave behind people who reserved a place 
weeks in advance or waited in line in the hope that someone would miss 
the van, veterans say.
    ``It's a long trip. But it's the only way to get to the hospital,'' 
said Ruben Cordova, a Navy veteran with Persian Gulf service. ``The 
buses aren't handicapped accessible and you have to tell the driver if 
you need to go to the bathroom. People bring their breakfast tacos and 
pain meds and hope for the best.''
    For years, veterans in the VA system in south Texas--which at last 
count numbered more than 107,000 for the 60-county service area--have 
been asking for their own VA hospital. They're tired of traveling 
hundreds of miles, enduring long waits for care and putting up with 
bureaucratic snarls.
    And with their numbers on the rise, they want the hospital now. The 
patient load at the south Texas VA facilities has grown 31 percent 
since 2001.
    ``We've never said VA doesn't provide good medical care,'' said 
Felix Rodriguez, district director for the Veterans of Foreign Wars in 
the Valley. ``The doctors and staff do the best they can with what they 
have. The problem is getting into the system to get the care. There are 
too many barriers to eligibility.''
    There is also a sense of promises not kept, Mr. Rodriguez added.
    Their complaints come at a time when VA facilities are coming under 
attack following reports of inadequate care at Walter Reed Army Medical 
Center in Washington, D.C.
    ``We did what we were asked by this country and we don't believe 
there is any excuse, any reason for VA to refuse to build a veterans 
hospital here,'' he said. ``We believe we've earned the right to see a 
doctor where we live.''
    The Department of Veterans Affairs operates two routine healthcare 
clinics in the Valley--one in McAllen, the other in Harlingen. The 
clinics are part of the south Texas Veterans Healthcare System, which 
also includes the Audie Murphy hospital in San Antonio, a smaller 
facility at Kerrville, and outpatient clinics in Corpus Christi, San 
Antonio and the Valley.
    For the more complicated procedures, veterans have no choice but to 
drive to San Antonio.
    The VA takes the veterans' concerns seriously, said Amjed Baghdadi, 
spokesman for the San Antonio-based south Texas health system.
    It's launched a feasibility study for either a hospital or expanded 
outpatient services in the Valley. And in 2003, the VA received 
approval for an outpatient clinic at Harlingen as a temporary measure 
pending construction of a primary care clinic scheduled for completion 
later this year, Mr. Baghdadi said.
    The new clinic will provide expanded audiology, dental and pharmacy 
services, as well as physical therapy, mental health and social work 
services not now available.
    Veterans groups are glad for the new clinic. But they believe a 
fully staffed hospital would better fit their needs.
Unprecedented growth
    Nationally, VA's medical system has experienced unprecedented 
growth, ballooning 22 percent since 2001 when it had 4.1 million 
veterans registered. It now has 5.3 million, including 1.7 million in 
Texas. And while the largest single group is Vietnam-era vets, the 
number of Iraq and Afghanistan vets is growing.
    The Texas Veterans Commission reports it has received about 2,000 
discharge documents a month since 2001.
    ``Iraq and Afghanistan veterans are a rapidly growing component of 
VA care,'' said Terry Jemison, VA spokesman. ``Just a year ago, they 
made up 2 percent of our 
caseload. With the war continuing, we anticipate their numbers will cont
inue to rise.''
    In south Texas, about 3 percent of the patient load is veterans of 
Iraq and Afghanistan.
    Yet VA projections about 3 years ago showed veterans requiring VA 
services diminishing. A report by a special commission appointed to 
study Valley veteran health needs, said only 10 beds were needed for 
both the Lower Rio Grande Valley and the Coastal Bend area near Corpus 
Christi.
    Homer Gallegos, a Vietnam vet and a member of VFW Post 8788 in 
McAllen, fears returning modern vets will soon face the same inadequate 
reception at VA that veterans of his war did.
    ``When I returned home after Vietnam, there were few resources here 
for veterans and VA wasn't equipped to handle the number of veterans 
coming back,'' he said. ``Now, we're seeing some of the same things 
with the Iraqi vets. I'm really afraid these guys are going to fall 
through the cracks.''
    Young vets are dealing with a host of different problems, Mr. 
Gallegos said, from an increasing number of head and brain injuries and 
amputations to emotional problems resulting from the combat they saw 
and the strain of multiple deployments to the war zones.
    ``Right now, the younger guys don't feel comfortable with the VA 
system and they don't relate much to the concerns of the older vets,'' 
Mr. Gallegos said.
    The younger vets are more worried about ``getting jobs, getting 
married and aren't too concerned with long-term health issues,'' he 
said. ``I just don't want them to get lost.''
More sad than angry
    State Rep. Aaron Pena, D-Edinburg, who represents part of Hidalgo 
County and is also a military veteran, has joined the call for 
construction of a VA hospital in the Valley.
    ``What the veterans in my district tell me is that health services 
to vets is lacking, distant and bureaucratic,'' he said. ``There is 
more sadness than anger when they talk about this. They want to believe 
the system will respond to their needs. They gave so much and they feel 
forgotten.
    ``But what isn't spoken is the sense that they are being ignored 
despite the long history of Hispanics' service to the U.S. military,'' 
he said. ``We've fought in almost every American war and we feel we've 
suffered disproportionately in the current war. And we're still being 
ignored.''
    Approximately 10 percent of the 320 Texans killed in Iraq and 
Afghanistan are from south Texas. According to Defense Department data, 
100,000 Hispanics currently on active duty make up about 9 percent of 
the military.
    Mike Escobedo, 38, returned home to the Valley in 1982 after a 4-
year hitch in the Marines. But it wasn't until 17 years later that he 
learned he could get his hearing loss--a result of working around 
aircraft--treated at a VA clinic.
    To go to the audiologist, he must still periodically travel to San 
Antonio.
    ``It's not so bad for me, but we have a lot of older vets and 
people without arms or legs who need more care,'' he said. ``They 
shouldn't have to spend 5 hours in a van to see the doctor.''
Seeking help
    Jesus Bocanegra, 25, a veteran of Iraq, came home to Progresso 
nearly 3 years ago. After he was discharged, memories of some of the 
terrible things he saw in combat led to severe depression and thoughts 
of suicide.
    A friend talked him into going to the VA office in McAllen. He was 
subsequently referred to the VA hospital in Waco for evaluation for 
post-traumatic stress disorder and intensive treatment.
    Caseworkers there told him he needed to begin regular sessions with 
a therapist once he returned to the Valley.
    ``They told me I'd get an appointment in the mail,'' Mr. Bocanegra 
said. ``Three weeks later, I got a letter from VA that I could see the 
doctor in 8 months. I had heard about red tape, but I didn't realize 
how bad it was.''
    Currently, there are five full-time VA psychological counselors and 
two part-timers for the entire Valley, a VA spokesman said.
    Mr. Bocanegra said only three are available at any given time. The 
veteran clinics in Harlingen and McAllen are closed on the weekends. 
The PTSD hotline is available from 8 a.m. to 5 p.m., he said.
    ``There's a lot of people not getting the help they need and 
they're falling off a cliff and there's no net,'' Mr. Bocanegra said. 
``The Viet vets have been dealing with this kind of stuff for 30 years. 
But there's a lot of Iraq vets coming back, and we're not going to wait 
that long to get someone's attention.''
    In late 2005, Mr. Bocanegra and two dozen other veterans 
participated in a 5-day march from the Valley to San Antonio to promote 
the need for a VA hospital. Shortly thereafter, the VA commissioned the 
study to determine whether a VA-staffed hospital in south Texas is 
warranted.
    ``Let's face it. This is a largely Hispanic area that the feds 
routinely ignore unless they want to send more Border Patrol agents,'' 
he said. ``But Hispanics have a lot of pride and they're proud to serve 
our country. In return, we get a lot of promises, but no one does 
anything about it.''
    VA officials said the study, later expanded to include evaluation 
for specialty outpatient care, should be completed this summer.
    In the meantime, the outpatient clinic expansion in Harlingen will 
result in increased mental health services, as well as improved access 
to some of the services now available only in San Antonio, Mr. Baghdadi 
said. ``The south Texas Veterans Healthcare System is actively working 
to increase access to services throughout the system,'' he said.
    U.S. Sen. Kay Bailey-Hutchison, a Ranking Member of the Veterans 
Affairs Appropriations Subcommittee, recently pushed VA Secretary Jim 
Nicholson on the delay of the report.
    ``Secretary Nicholson assured me that the study I requested in 
February 2006 to determine the need to establish a veterans hospital in 
the Valley will be completed by July,'' Ms. Hutchison said. ``This 
study has taken an awfully long time and I am anxious to learn the 
results. Our veterans in the Valley deserve accessible, quality care.''
Twenty-five year effort
    U.S. Rep. Solomon Ortiz, whose district covers much of the Valley, 
said he's tried for 25 years to get a VA hospital in south Texas. Time 
and again, VA officials said there weren't enough veterans or enough in 
the budget.
    ``Congressman Ortiz has been at this so long, it's gotten to the 
point he's boiled the argument down to its essence out of 
frustration,'' said Cathy Travis, the congressman's spokeswoman. ``We 
want south Texas veterans to get the healthcare they need where they 
live. However it gets done, let's do it.''
    Veterans in the Valley have no shortage of stories about treatment 
delayed, appointments scheduled months in advance, long waits, and 
piles and piles of paperwork to receive medical treatment.
    Mr. Cordova received a referral for an MRI for persistent shoulder 
pain. It took the VA 3 weeks to notify him that he would have an 
appointment in San Antonio 4 months later. After a 5-hour drive, the 
procedure took 15 minutes.
    ``You can't afford not to make an appointment,'' he said. ``If you 
miss an appointment or have to reschedule, everything starts back at 
ground zero and it's many more months before you see a doctor.''
    Mr. Cordova is 90 percent disabled. Like many Valley veterans, he 
finds that the difficulties in getting appointments and traveling to 
meet them make it hard to maintain a sense of normalcy.
    ``It's hard to hold a job when you have to miss work four or five 
times a month to travel to San Antonio for medical appointments.''
    Apolonio Uresti is a Vietnam veteran still being treated for post-
traumatic stress disorder. His father is a World War II veteran. His 
two sons, both active-duty military, have served multiple tours in 
Iraq.
    Recently, a late-night phone call from one of his sons saying that 
he'd been hurt in an IED explosion dredged up memories of Mr. Uresti's 
own war experiences.
    He called the clinic in Harlingen about seeing the psychiatrist. He 
was told the soonest appointment was in 6 months.
    ``You get tired of waiting,'' he said. ``When my sons leave active 
duty, I'll have to tell them that they will have to fight to make the 
government keep its end of the bargain. I've seen it in my Dad's life 
and in mine.''

                               __________
Ortiz wants to hear from south Texas veterans ahead of key hearing
20 April 2007
Steve Taylor, Rio Grande Guardian

WASHINGTON--U.S. Rep. Solomon Ortiz wants to hear from south Texas 
veterans about the healthcare they are receiving and the efforts they 
have to make to get it. And he wants it in a hurry.

    Ortiz, D-Corpus Christi, is set to testify at a hearing of the 
House Veterans' Affairs Subcommittee on Health regarding his 
legislation to establish a veterans hospital in south Texas next 
Thursday.
    Ortiz said he wants south Texas veterans to send him messages, 
stories, petitions--anything that will help the Veterans' Affairs 
Subcommittee on Health understand the context of the difficulties south 
Texas veterans face.
    ``I know the time is short, but our veterans need to `surge' now to 
help me characterize for Congress the everyday difficulties they 
encounter in terms of healthcare,'' said Ortiz, a veteran himself. ``I 
want to tell these guys the personal stories of south Texas veterans.''
    In January, Ortiz introduced the South Texas Veterans Access to 
Care Act, which requires the VA to advise Congress in 180 days how they 
will tend to the acute healthcare needs for south Texans.
    Ortiz introduced the same bill last year in an attempt to get the 
Administration to deal realistically with the massive number of wounded 
veterans in south Texas.
    Ortiz has asked in for the construction of a veterans' hospital for 
south Texas in each Congress that he has served. ``Each year, the bill 
is rebuffed, mostly for financial reasons,'' he said. ``Testifying 
before the Health Subcommittee next week will be a step forward for 
this legislation.''
    Perhaps one of the Rio Grande Valley veterans the House Veterans' 
Affairs Subcommittee on Health would like to hear from is Ruben 
Cordova, a USN retired disabled veteran.
    Cordova is waiting to have several surgeries to correct injuries he 
had sustained while in the service. That means numerous visits to the 
Audie Murphy hospital in San Antonio, the nearest VA hospital to the 
Valley.
    ``The worst case was when I had shoulder surgery and I spent the 
night in my car so that the anesthesia would wear off. I didn't take 
any pain medication so that I could make the 4-hour drive back home,'' 
Cordova said.
    ``The pain was unbearable and I had to make several stops along the 
way to vomit from the pain. But that was what I had to do because it is 
the only place for veterans to have surgery.''
    Cordova said he had also slept in his car in San Antonio to make an 
early appointment.
    ``By the time I arrived in San Antonio all the rooms available for 
veterans had been issued out,'' he said.
    Cordova said he knew of many veterans that cannot sit for very long 
periods and have to lay down while in transit to San Antonio. ``Their 
family has to make arrangements to transport their loved ones in these 
conditions to make their appointments,'' he said. ``If a veteran 
doesn't make their appointment they sometimes have to wait until there 
is an available appointment--usually another 6 months.''
    Cordova said people who don't have to live these ordeals don't know 
what veterans and their families have to endure.
    ``I wish you would live through a trip with a veteran and see what 
it takes to have medical attention,'' Cordova told the Guardian.
    ``Veterans don't want a handout they want what is rightfully 
theirs. We want service from our government without questions just like 
we served without questioning what was asked of us. We were ready to do 
or die for our country. Now it's time to receive.''
    Ortiz said his legislation gives the government three different 
options in establishing a method to better provide acute healthcare 
services for veterans in south Texas.
    ``They can either establish a public-private venture to provide 
inpatient services; or they can build a hospital there; or they can 
utilize an existing military treatment facility with a sharing 
agreement,'' Ortiz said. ``The end result is that veterans' inpatient 
healthcare are attended to, near where the veterans live, not several 
hours away.''
    Ortiz said veterans should email their stories to: 
ortizvets@mail.house.gov or hand-deliver them to his Brownsville office 
by noon Wednesday, April 25.

 Copyright of Rio Grande Guardian, www.riograndeguardian.com; 2007.

                                 
   Prepared Statement of Hon. Steven R. Rothman, a Representative in 
                 Congress from the State of New Jersey
    Let me begin by thanking the Committee on Veterans' Affairs for 
allowing me to testify. I want to especially recognize the leadership 
of Chairman Bob Filner and Ranking Member Steve Buyer. Under your 
stewardship, this Committee is continuing its important work in looking 
after our veterans.
    Mr. Chairman and Members of the Committee, I am here today to 
testify about the moral responsibility and practical obligation of the 
Federal Government to honor its commitment to all of our veterans--
namely, the commitment to provide them with quality, affordable 
healthcare.
    It is a moral responsibility because the American Government makes 
a promise to every veteran. We say that because you have volunteered to 
put your lives on the line for freedom--because you are willing to 
sacrifice yourself for the good of all Americans--because of this 
courage, we will take care of you when you leave the service.
    We don't make that promise with our fingers crossed. We don't tack 
on fine print or attach a bunch of strings to the promise. We make that 
promise freely because our veterans gave freely of themselves in the 
service.
    It is a practical obligation because how on Earth can a young 
soldier fight with all of his willpower on behalf of a government if he 
meets a 60-year-old veteran who is battling cancer without any 
healthcare because he has been banned by his own President from 
enrolling in the healthcare service for veterans?
    It's outrageous. Yet, as the representative for more than 156,000 
veterans, I have heard story after story from veterans in Bergen, 
Hudson, and Passaic Counties who tell me that their government has 
broken its promise to them.
    That's because in January 2003, the Bush Administration decided to 
cut costs by telling veterans designated as ``Priority 8'' that they 
are banned from enrolling in the VA health system and will no longer 
have access to VA hospitals, clinics and medications.
    The Administration defended its decision by saying that Priority 8 
veterans make too much money to be worth the added expense. I say 
that's hogwash.
    Hogwash because a veteran is a veteran is a veteran. Hogwash 
because we made a promise to those men and women to take care of them 
and there is absolutely no justification whatsoever for breaking that 
word. And hogwash because those veterans often live in areas where the 
cost of living eats up all of the income that the Bush Administration 
seems to think they have.
    In fact, the national income threshold for Priority 8 veterans is 
$26,902. I don't know of any town in America where that qualifies as 
Bill Gates-style wealth. And in towns where the amount is slightly 
higher, it is still much too low to account for the high cost of 
living. Bergen County--which I represent--has the second largest 
concentration of veterans in the State of New Jersey and the largest 
number of Priority 8 veterans. All in all, it is estimated that nearly 
5,000 veterans in New Jersey alone have been turned away from the VA 
healthcare system. Nationwide, the number of veterans turned away is 
over 273,000.
    Turned away--listen to those words. I don't have to tell the good 
Members of this Committee how terrible a message we send to young 
soldiers when we ``turn away'' 273,000 veterans from the VA healthcare 
system.
    We ``turned away'' hundreds of thousands of brave servicemembers 
who said they were willing to die for the freedom of all Americans when 
they are at their most vulnerable.
    The fact is that ``turned away'' is another way of saying we broke 
our promise. We broke our promise to 273,000 veterans. We broke our 
promise to people who said they were willing to die for the freedom of 
all Americans and we broke our promise when they were at their most 
vulnerable.
    Imagine: You have a loved one who is 60 years old. He served 
bravely for 10 years as a young man and afterward worked hard as a 
civilian for decades, raised a family. But suddenly, he is diagnosed 
with cancer. He doesn't have health insurance. He can't afford private 
health insurance. So he turns to the Veterans Administration to save 
his life. But our VA says to him: `Sorry, Charlie. You should've come 
to us before January 2003. We can't care for you. You're out of luck.'
    Can you imagine? Can you imagine what that does to the faith of all 
our veterans in their government? Can you imagine what that does to the 
morale and trust of our current soldiers serving in Iraq and 
Afghanistan?
    It's not right and I believe this Committee must ensure that we 
stop breaking our promise.
    That's why I have introduced the Honor Our Commitment to Veterans 
Act, which tells the Bush Administration that it can't just promise to 
care for our veterans, but has to actually care for them. I strongly 
urge the good Members of this Committee to consider and move on this 
legislation.
    Republicans and Democrats will never agree on everything, but we 
should all agree on the importance of keeping our promises to veterans.
    As I said earlier, those promises weren't made with our fingers 
crossed behind our backs. They were promises made in earnest and they 
are promises that we must keep--for the good of our veterans and of our 
country. I will submit my full remarks for the record.
    Once again, I thank the Committee, Chairman Filner, and Ranking 
Member Buyer for your time and consideration of the Honor Our 
Commitment to Veterans Act and the very important issue of providing 
healthcare to all of our veterans.

                                 
  Prepared Statement of Hon. Tom Latham, a Representative in Congress 
                         from the State of Iowa
    Mr. Chairman and Members of the Subcommittee, I am honored to have 
the opportunity to testify before you today regarding H.R. 1426, the 
Veterans' Access to Local Healthcare Options and Resources Act, known 
as the VALOR Act.
    I introduced this legislation in response to growing concern 
expressed by veterans in my district regarding access to VA healthcare. 
Veterans who live in rural parts of my district must travel long 
distances to VA medical facilities to receive the healthcare promised 
to them. Oftentimes they have to wait months for an appointment. They 
are frequently forced to give up a full day, sometimes in fragile 
condition, to travel for care. Despite the remarkable improvement in 
the quality of VA healthcare during the past decade, the fact remains 
that not all America's veterans have equal access to these services.
    One example of this inequity is the story of a Vietnam Army veteran 
from Fort Dodge, Iowa. This recipient of the Bronze Star is service-
disabled, and he estimates that he has made the 4-hour round trip from 
Fort Dodge to the VA medical center in Des Moines more than 100 times 
over the last 3 years. Because he cannot drive, he relies, like many 
veterans, on a shuttle graciously provided by one of the Veterans' 
Service Organizations, which takes up to 10 or more veterans to Des 
Moines at a time. Since they have to wait until the last appointment to 
return, the trip takes an entire day, starting at 5:00 a.m. and 
returning late in the evening.
    Countless similar cases have been reported to me by veterans in my 
district. This situation leads me to ask the question, ``Can we really 
say that we are providing `top quality' care for our veterans when so 
many have limited access to it?'' Out of nearly 8 million veterans 
enrolled in the VA healthcare system last year only 5 million veterans 
actually used VA healthcare. Recent reports show that the VA healthcare 
system continues to match or outrank private-sector healthcare in 
overall quality and consumer satisfaction. Out-of-pocket costs are 
extremely low, particularly for service-connected veterans. So why are 
less than two-thirds of the veterans enrolled in the system actually 
using it? I believe that access problems account for a great deal of 
this disparity. For millions of veterans, VA healthcare is simply not 
readily accessible, especially in rural areas.
    VA-funded research conducted by Dr. William Weeks and his 
colleagues from the VA Outcomes Group highlights the urgent need for 
action to increase healthcare access for our rural veterans. This 
research supports the conclusion that, compared with their urban 
counterparts, rural veterans have a higher prevalence of mental and 
physical health problems, but the least access to VA healthcare.
    I am concerned that this disparity will continue to grow over time 
unless we do something to stop it. First, rural residents are 
overrepresented among veterans. The VA Outcomes Group found that 22% of 
veterans are rural, compared with 14% among the general population. 
Furthermore, rural veterans are overrepresented among those serving in 
Iraq and Afghanistan, due to increased use of the National Guard and 
Reserve units. These units are often dispersed in rural areas, far from 
large urban centers or concentrations of veterans where VA facilities 
tend to be located. As I previously mentioned, rural veterans are 
already more likely to experience health problems. With large numbers 
of these veterans returning from combat, the need for VA healthcare in 
rural areas will increase dramatically in coming years.
    The VALOR Act aims at meeting this need by providing veterans with 
an option to receive care they would otherwise be eligible to receive 
in a VA facility, at a local hospital or physician's office. To provide 
this option the legislation builds on the existing VA system for 
contracting with non-VA providers known as fee-basis care. The VA 
already has specific statutory authority to contract with non-VA 
facilities for medical care, but it is subject to a number of 
restrictions that limit its use.
    The VALOR Act would require an expansion of fee-basis care to allow 
greater access to VA-funded healthcare in local communities. Under the 
bill, covered services include hospital care, medical services, 
rehabilitative services and preventative health services that a veteran 
would be eligible to receive at a VA facility. It also clarifies that 
VA drugs can be obtained with prescriptions written by contracted 
providers.
    In region 23, which includes Iowa, the VA already spends roughly 10 
percent of its regional healthcare budget on fee-basis care. The fee-
basis system is already in place, and I believe expanding this system 
would be a very practical way to address the rural access problem. I 
understand that some are concerned about ensuring quality of care for 
veterans in expanding fee-basis. I would answer that access to care is 
a key component of quality, which is currently lacking for many rural 
veterans.
    I also understand there are concerns about the integrity of VA 
medical records for veterans moving between VA and non-VA providers. 
This is one of the issues being addressed in the VA's Project HERO 
demonstration programs. It is not an insurmountable problem, and I 
applaud the Chairman for including in his draft rural health bill a 
provision specifically establishing a health information technology 
pilot program to examine ways to improve quality of care for veterans 
who use fee-basis care.
    I know that many of my colleagues representing rural districts 
share my concerns about access to care for veterans. I applaud Jerry 
Moran and Steven Pearce for also bringing legislation forward that 
would allow veterans to get care closer to home. I ask Members of the 
Subcommittee to carefully consider H.R. 1426 and I look forward to 
working with you to improve access to healthcare for our rural 
veterans.

                                 
Prepared Statement of Hon. Jason Altmire, a Representative in Congress 
                     from the State of Pennsylvania
    I would like to thank Chairman Michaud, Ranking Member Miller and 
Members of the Committee for the opportunity to testify today about 
H.R. 1944, the Veterans Traumatic Brain Injury Act of 2007, bipartisan 
legislation that I introduced to increase the screening and treatment 
of traumatic brain injuries (TBI) for our Nation's veterans.
    Mr. Chairman, we are facing an impending crisis in this country. 
Our brave men and women are returning from Iraq and Afghanistan with 
TBI at an alarming rate. Of those treated at Walter Reed Army Medical 
Center, 65 percent have been diagnosed with TBI as a primary or co-
morbid diagnosis. Many now consider TBI to be the signature injury of 
the wars in Iraq and Afghanistan.
    I am concerned that the Veterans Affairs Administration may not be 
properly identifying and treating TBI among the Nation's veterans. It 
is estimated that more than half of all combat casualties have 
associated brain injuries. Most of them include mild TBI, which is 
often missed in initial exams as physicians attend to other more 
apparent injuries.
    The Veterans Traumatic Brain Injury Act improves the coordination 
of TBI care for our Nation's veterans by requiring the Veterans Affairs 
Administration to screen veterans for symptoms, develop and operate a 
comprehensive program of long-term care for post-acute TBI 
rehabilitation, establish TBI transition offices at all polytrauma 
network sites, and create and maintain a TBI veteran health registry.
    In our first 4 months, the 110th Congress has taken enormous 
strides in meeting its commitment to veterans. We have provided more 
than $11 billion in increased funding for veterans' healthcare and 
passed the Wounded Warrior Assistance Act to improve the management of 
their medical care.
    I believe that we owe no greater debt than to our veterans and, 
while we have made some progress, we can do more to improve their 
healthcare. To this end, the bipartisan Veterans Traumatic Brain Injury 
Act will allow us to properly screen America's returning heroes for TBI 
and improve their treatment.
    Thank you for the opportunity to speak today. I would be pleased to 
answer any questions that you may have.

                                 
                 Prepared Statement of Hon. Bob Filner
                Chairman, Committee on Veterans' Affairs
    I appreciate the opportunity to speak on two bills of importance to 
veterans, especially to the veterans returning from the wars in Iraq 
and Afghanistan.
    Right now, a special opportunity presents itself!! Forty-two 
percent of the medical problems in the returning servicemembers from 
Iraq and Afghanistan are musculoskeletal, and many can undoubtedly 
benefit from chiropractic care. I am one American who has benefited 
from chiropractic care, so I can promote it in absolute good faith.
    H.R. 1470, which former Congressman Jeb Bradley introduced last 
session, is the Chiropractic Care Available to All Veterans Act. It 
requires that chiropractors are phased into the VA, with not fewer than 
75 medical centers by the end of December 2009 and all by the end of 
2011.
    H.R. 1471, re-introduced from my bill (H.R. 917) in the last 
session, is the BACK Our Veterans Health Act (The Better Access to 
Chiropractors to Keep Our Veterans Healthy Act.) It requires that 
veterans have direct access to chiropractic care at VA hospitals and 
clinics, so that veterans do not have to go through a general 
practitioner, or ``gatekeeper'' as this doctor is sometimes called.
    We must remember that since the creation of the VA healthcare 
system, the Nation's doctors of chiropractic have been kept outside and 
all but prevented from providing proven, cost-effective, and much-
needed care to veterans. So we are grateful that access is becoming 
greater.
    The support for VA chiropractic care is bipartisan in nature. You 
may recall that former Secretary Anthony Principi released a policy 
directive before his departure regarding the true and full integration 
of chiropractic care in the VA.
    Now, Secretary Nicholson and I have developed a truly working 
relationship, so chiropractic is an area that I will be working on with 
him. Both Republican and Democratic VA Committee Members have supported 
the inclusion of chiropractic care in the VA.
    I have worked closely with chiropractic patients, particularly our 
veterans, on these two bills, as well as with the American Chiropractic 
Association. Hopefully, the two bills I have introduced might not even 
be necessary, because the VA will continue on its own to do what is 
right.
    But as insurance, it is important to pass H.R. 1470 and H.R. 1471.

                                 
  Prepared 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 
view on the several pieces of legislation being considered by the 
Subcommittee today. In recent years, The American Legion conducted a 
program, ``I Am Not a Number,'' that identified many of the access 
problems identified in these bills. In addition, The American Legion's 
series, A System Worth Saving, has also validated many of the issues 
addressed. Research conducted by the Department of Veterans Affairs 
(VA) indicated that veterans residing in rural areas are in poorer 
health than their urban counterparts. 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. The American Legion commends the Subcommittee for holding a 
hearing to discuss these very important and timely issues.
Improving Timeliness of Healthcare
    H.R. 92, Veterans Timely Access to Healthcare Act, seeks to 
establish standards of access to healthcare provided by the Department 
of Veteran Affairs (VA). Although timeliness of care is not a challenge 
unique to rural areas, veterans who reside in rural areas face an 
additional challenge to accessing care. Setting standards for 
timeliness in the delivery of healthcare and requiring VA to report on 
how these standards were executed will provide a realistic illustration 
of the ongoing challenges of rural veterans in gaining timely access to 
care. It will allow VA and lawmakers to determine the best ways to 
improve timely access for rural veterans. The American Legion supports 
this endeavor.
    H.R. 315, Help Establish Access to Local Timely Healthcare for Your 
Vets (HEALTHY Vets), would require the VA to contract with community 
healthcare providers to improve access to healthcare for veterans in 
highly rural areas. The American Legion believes that, where there is 
very limited access to VA healthcare, it is in the best interest of 
veterans residing in highly rural areas that local care be made 
available to them. Some of these veterans have physical limitations or 
suffer from conditions that make extensive travel dangerous. Many 
veterans have expressed concerns to The American Legion about their 
limited financial resources prohibiting travel, citing the rising cost 
of gas, the limitations of the mileage reimbursement rate, and the need 
to pay for overnight accommodations, as huge obstacles. Providing 
contracted care in highly rural communities--when VA healthcare 
services are not possible--would alleviate the unwarranted hardships 
these veterans encounter when seeking access to VA healthcare.
    H.R. 339, Veterans Outpatient Care Access Act of 2007, would 
improve access at outpatient clinics with exceptionally long waiting 
periods by allowing veterans to utilize non-VA providers. The American 
Legion has no official position on this issue, but believes that more 
focus should be placed on remedying the causes of the long wait periods 
to ensure timeliness of care. Doing otherwise would perpetuate the 
problem.
Improving Eligibility for Healthcare
    H.R. 463, Honor Our Commitment to Veterans Act, discusses lifting 
the healthcare enrollment restriction on Priority Group 8 veterans. A 
total of 378,495 Priority Group 8 veterans have been denied enrollment 
from the time the restriction was instituted in January 2003. The 
American Legion believes that a more effective method of ensuring that 
VA can continue to provide quality care to veterans would be to ensure 
that VA is sufficiently funded to care for their needs, not limiting 
access for those who have incomes that fall above means tests 
thresholds. These veterans are required to make copayments, in addition 
to identifying their third-party health insurance that will reimburse 
VA for reasonable charges. Many of these Priority Group 8 veterans may 
very well be VA employees, Medicare beneficiaries, TRICARE or TRICARE 
for Life beneficiaries, or enrolled in the Federal Employees Health 
Benefits Program. The American Legion supports the lifting of the 
current prohibition on healthcare enrollment restriction for Priority 
Group 8 and exploring effective means to improve third-party 
reimbursement collections.
Improving Access to Healthcare
    H.R. 538, South Texas Veterans Access to Care Act of 2007, 
addresses the healthcare needs of those who reside in south Texas. 
Although The American Legion has no official position on this proposal, 
we believe that VA should do everything in its power to improve access 
to its healthcare system for those residing in rural areas.
    H.R. 542, bill to Require the Department of Veterans Affairs to 
Provide Mental Health Services in Languages other than English, seeks 
to make mental health services available in languages other than 
English for those who have limited English proficiency. The American 
Legion strongly supports English as the official language of the United 
States. However, The American Legion believes that VA needs to remove 
any hindrance that prevents veterans from obtaining the care they have 
earned through their military service. This is an extremely important 
issue for family members who may be required, by law, to make medical 
procedure decisions on behalf of a veteran.
    H.R. 1426, the Richard Helm Veterans' Access to Local Healthcare 
Options Resources Act, would provide veterans enrolled in the VA 
healthcare system the option of receiving covered health services 
through non-VA facilities. It also would allow VA to fill prescriptions 
obtained from non-VA doctors. The American Legion believes that VA is a 
Federal healthcare provider not a Federal health insurer like the 
Department of Health and Human Services (Centers for Medicare and 
Medicare Services). Clearly, there will be unique situations in which 
VA should and must reimburse other healthcare providers, but this 
should be the exception to the rule, not a standard practice. Veterans 
should not have to travel hundreds of miles for healthcare or 
rehabilitation.
    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. It is more important that VA is adequately 
funded at a level that would allow it to service the needs of veterans 
and 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.
    The American Legion also supports VA pharmacy benefits for enrolled 
veterans when prescribed by an authorized VA physician or provider in 
the course of providing medical care.
Improving Healthcare and Treatment
    H.R. 1470, the Chiropractic Care Available to All Veterans Act, 
seeks to make chiropractic care available at all VA medical centers. 
The American Legion has no official position on this issue.
    H.R. 1471, Better Access to Chiropractors to Keep Our Veterans 
Healthy Act (BACK Our Veterans Health Act), would allow eligible 
veterans direct access to chiropractic care. The American Legion has no 
official position on this issue.
    H.R. 1527, the Rural Veterans Access to Care Act, would allow 
highly rural veterans who are enrolled in the VA healthcare system to 
receive covered healthcare services through non-VA providers. It would 
also allow VA to fill non-VA prescriptions for highly rural veterans. 
As stated previously, The American Legion believes that, when there is 
no other acceptable VA healthcare option, veterans residing in highly 
rural and rural areas should be able to receive healthcare services 
through non-VA providers.
    The American Legion supports VA pharmacy benefits for enrolled 
veterans when prescribed by an authorized VA physician or provider in 
the course of providing medical care.
    Draft Discussion, Rural Veterans Healthcare Act of 2007, discusses 
a pilot program utilizing mobile vet centers in rural areas for a 
period of 5 years. The provisions in this bill are essential in 
addressing the challenges to providing quality care for rural veterans:
    Section 2 establishes mobile vet centers. The mobile vet centers 
would provide a glimpse of health issues affecting rural veterans, 
while providing care to mitigate the problem of inaccessibility.
    Section 3 establishes a health information technology program. The 
health information technology program would ensure that rural veterans 
receive continuum of care.
    Section 4 describes the establishment and duties of an Advisory 
Committee. The Advisory Committee on Rural Veterans would regularly 
assess the needs of rural veterans and identify gaps in policy and 
care.
    Section 5 addresses research and training. Rural health research, 
education and clinical care centers would afford VA the opportunity to 
build strategies to improve its system of care for rural veterans, as 
well as educate and train healthcare professionals on health issues 
prevalent in specific rural veteran populations. It also mandates the 
designation of centers for rural health research, education and 
clinical activities.
    Section 6 addresses homelessness. It identifies that homeless 
veterans in rural areas have more challenges in obtaining local 
resources.
    Section 7 discusses rotations and medical residents in rural areas, 
establishing programs to enhance education/training/recruitment and 
retention of nurses and allied health professionals in rural areas. 
Since VA has had challenges with finding providers who can furnish the 
types of services needed by veterans in rural areas, this section 
offers a remedy that would result in the ability of VA to provide 
quality care to rural veterans in their communities.
    H.R. 1944, Veterans Traumatic Brain Injury Treatment Act of 2007, 
seeks to have certain veterans screened for symptoms of traumatic brain 
injury. It also discusses the creation of a comprehensive program for 
long-term care and rehabilitation that includes residential, community 
and home-based components. The American Legion believes that the 
provisions in this bill are both necessary and timely. Symptoms of 
traumatic brain injury may not be obvious and may be dismissed or may 
occur over time. Screening those who were known to have been subjected 
to blast trauma in theater--even if they have no visible physical 
wounds--would aid in diagnosing injuries more quickly. Early diagnosis 
would also help to mitigate the effects of the trauma and improve the 
chances of a successful rehabilitation.
    Mr. Chairman, a critical element in screening veterans from 
traumatic brain injury will begin with the quality of the military 
health records. The Department of Defense (DoD) and VA must work in 
close harmony on this newest identified medical condition. DoD 
healthcare providers must work to identify and document ``blast 
injuries,'' especially non-penetrating traumatic brain injury. DoD and 
VA established the Defense and Veterans Brain Injury Center. However, 
there remains little expertise to formulate an effective definition, 
clinical guidelines, and treatment for returning Operation Enduring 
Freedom and Operation Iraqi Freedom veterans.
    In most cases, not only is the diagnoses of the less visible 
injuries of war difficult, physical wounds may ``mask'' the accurate 
diagnosis and treatment of traumatic brain injury. Blast impacts may 
not be properly documented and consequently the patient may have 
potential brain injuries that may very well go undetected until much 
later after behavioral changes become more evident.
    Currently, DoD does not measure individual cognitive ability upon 
enlistment or pre-deployment; therefore, it is much more difficult to 
measure any decrease in cognitive ability after deployment that is due 
to military service. This clearly complicates diagnosis, treatment, and 
service-connection determinations.
    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.

                                 
              Prepared Statement of Kimo S. Hollingsworth
       National Legislative Director, American Veterans (AMVETS)
    Mr. Chairman and Members of the Subcommittee:
    I am pleased to appear today to offer testimony on behalf of 
American Veterans (AMVETS) related to pending Department of Veterans 
Affairs (VA) healthcare bills before this Subcommittee.
    The VA healthcare system has evolved into one of the best 
healthcare systems in the Nation. The Veterans Health Administration 
(VHA) is uniquely qualified to care for veterans' needs because of its 
highly specialized experience in treating service-connected injuries. 
The VHA provides a wide array of specialized services to veterans and 
this type of care is extremely expensive. It is absolutely critical 
that the VA healthcare system be fully funded.
    The central problem for veterans with regards to the VA healthcare 
system is how to access the system in a timely fashion. Over the years 
VA has become increasingly efficient in providing timely care, though 
problems still remain.
    As this Committee is aware, AMVETS hosted the ``National Symposium 
for the Needs of Young Veterans'' in Chicago, Illinois last year. More 
than 500 veterans, active duty and National Guard and Reserve 
personnel, family members, and others who care for veterans examined 
the growing needs of our returning veterans. Some of the issues 
relevant to today's hearing identified at the Symposium include timely 
access to VA healthcare and funding for the Department. AMVETS believes 
these issues are inextricably linked.
    Regarding the 12 bills that this hearing is supposed to cover, 
AMVETS will discuss the nature of the overriding issue(s) of these 
proposals and some of our recommended solutions. Overall, AMVETS is 
concerned about the ``wave'' of legislative proposals to mandate the 
Secretary of the VA to contract out medical and other services. AMVETS 
recognizes that many of these bills are well intentioned and our 
organization supports veterans being able to access the benefits and 
healthcare they are legally authorized to receive.
    Mr. Chairman, veterans enrolled in the VA are already allowed to 
elect coverage in a non-VA facility. Veterans are free to choose when 
and where they receive medical care. One of the common themes for all 
of these proposals is allowing veterans to receive care at non-VA 
facilities and providers and having the Secretary of Veterans Affairs 
be responsible for the cost of coverage.
    AMVETS reaffirms its commitment that service-disabled veterans 
should have the highest priority access to VA healthcare services and 
these services should be of the highest quality. AMVETS believes that 
service-connected veterans currently have that level of access and 
quality in VA today. VA's current policy statement on this issue 
clearly affirms this priority, as follows:

          ``VA is committed to providing priority care for non-emergent 
        outpatient medical services and inpatient hospital care for any 
        veteran seeking treatment of his or her service-connected 
        disability. It is VA's policy to provide priority access to 
        outpatient medical care and elective inpatient hospital care 
        for any veteran who requires non-emergent care for a service-
        connected disability. . . . For veterans who are 50 percent 
        service-connected or higher, VA's policy is to provide priority 
        access to medical services and inpatient care, regardless if 
        treatment is needed for their service-connected disability.''

    Many of today's proposals risk some potential unintended 
consequences to include quality control and safety, and potential 
adverse impact on the statutory requirement by VA to maintain the 
capacity of specialized medical programs in Public Law 104-262. 
Overall, these proposals would seem to move VA toward higher costs. The 
escalating costs of healthcare in the private sector are well 
documented and VA has done an excellent job of holding down costs 
compared to the private healthcare industry.
    AMVETS believes the central question to all of these ``contract'' 
proposals is whether or not Members of Congress believe the VA 
healthcare system is a national asset worth preserving or a system that 
should be abandoned. AMVETS believes the problem with VA continues to 
be access to the system. This in turn is reliant on appropriate levels 
of funding to hire staff, operate facilities and clinics and provide 
unique and specialized services. Appropriate levels of funding would 
also allow VA to open outpatient clinics and provide other contractual 
arrangements to provide VA sanctioned healthcare.
    As we are all well aware, the Secretary of VA already has the 
authority to enter into contracts for medical services. Many of these 
proposals have some ``triggering'' mechanism that would mandate the 
Secretary to contract care. These ``triggering'' mechanisms appear to 
be a ``one-time'' event that authorizes veterans to ``opt out of the 
system'' and have VA pick up the costs. For lack of a better word, 
these bills appear to authorize a ``vouchering system.''
    Sections 212 and 213 of Public Law 109-461 are specifically 
targeted at advancing the healthcare needs of veterans living in rural 
areas. VA is mandated to establish an Office of Rural Health within the 
Veterans Health Administration (VHA). The office is charged with 
improving VA healthcare for veterans living in rural and remote areas. 
Among other provisions, the law 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. AMVETS would encourage 
Congress to fully fund the Office of Rural Health and allow VA to 
conduct the mandated assessment.
    Regarding the overall issue of VA providing timely access to care, 
the Government Performance and Results Act, Public Law 103-62, requires 
that agencies develop measurable performance goals and report results 
against these goals. In the President's Fiscal Year 2008 budget 
request, VA focuses on the Secretary of Veterans Affairs priority of 
providing timely and accessible healthcare that sets a national 
standard of excellence for the healthcare industry. VA generally tracks 
the timeliness of care in two broad areas--primary and specialty clinic 
appointments. Over the next year, the percent of appointments scheduled 
within 30 days of the desired date is expected to reach 96 percent for 
primary care appointments and 95 percent for specialty care 
appointments.
    In July 2005, the VA Office of Inspector General reported that 
VHA's scheduling procedures needed to be improved and issued eight 
recommendations. As of September 2006, five of the eight 
recommendations for improvement remained open and AMVETS would 
encourage the Department to implement the remaining recommendations.
    The issue of nonservice-connected veterans accessing VA healthcare 
is not new. Since colonial times, this country has pledged its 
continued support for medical care and other benefits for those who 
served in the military. During the 1920s, three Federal agencies--the 
Veterans Bureau, the Bureau of Pensions in the Interior Department, and 
the National Home for Disabled Volunteer Soldiers--administered various 
benefits for the Nation's veterans. The Congress, in 1924, gave wartime 
veterans with nonservice-connected conditions access to Veterans' 
Bureau hospitals. With the establishment of the Veterans Administration 
(VA) in 1930, previously fragmented care for veterans was consolidated 
under one agency. Over the years, Congress expanded eligibility for 
hospital care and it was gradually extended to wartime veterans with 
low incomes; then, in 1973, to peacetime veterans with low incomes; and 
finally, in 1986, to higher-income veterans.
    In 1996, Congress passed and the President signed H.R. 3118, the 
Veterans' Healthcare Eligibility Reform Act. This veterans' healthcare 
bill updated and simplified many of the outdated and existing 
eligibility rules in effect at that time. Most importantly, the bill 
established a ``medical need'' as the sole test for veterans who enroll 
for care with VA. In short, veterans have generally always had access 
to the VA healthcare system and they should not now be denied access 
because of a lack of funding; especially if they are willing to pay for 
these healthcare services.
    The Capital Asset Realignment for Enhanced Services (CARES) was 
supposed to be a systemwide process to prepare the VA for meeting the 
current and future healthcare needs of veterans. CARES addressed the 
appropriate clinical role of small facilities, vacant space, the 
potential for enhanced use leases and the consolidation of services and 
campuses. To date, it is the most comprehensive analysis of VA's 
healthcare infrastructure conducted.
    In May 2004, the VA issued a Decision Document that was supposed to 
serve as VA's guide for capital planning decisions. Annual updates with 
new forecasts of future demand were supposed to be incorporated in VA's 
strategic planning process. The May 2004 Decision Document identified 
18 sites for additional analysis and studies. Overall AMVETS supported 
the CARES Commission process.
    As a veteran and patriotic organization, AMVETS also associates 
itself for the purpose ``to help unify divergent groups in the overall 
interest of American democracy.'' Veterans earn benefits and services, 
and are granted access to the system by virtue of their qualifying 
military service. This should continue to be the overriding principle 
when discussing veterans' issues. Mandating the Secretary to provide 
services in other than the English language only serves to create 
division and separation among veterans that took an oath to uphold and 
defend the Constitution of the United States in English.
    Mr. Chairman, Public Law 107-135 mandated the VA to require 
implementation of a nationwide chiropractic care program. VA was less 
than enthusiastic about this endeavor and it took the Department until 
June 2004 to actually make these services available. Overall, 
chiropractic care is a complementary and alternative healthcare 
profession with the purpose of diagnosing and treating mechanical 
disorders of the spine and musculoskeletal system with the intention of 
affecting the nervous system and improving health. A similar program 
was mandated on the Department of Defense (DoD) around the same 
timeframe and DOD. It is AMVETS understanding that the DoD program has 
been highly successful and we would like to see similar results at the 
VA.
    VA's approach to Post-Traumatic Stress Disorder (PTSD) is to 
promote early recognition of this condition for those who meet formal 
criteria for diagnosis and those with partial symptoms. The goal is to 
make evidence-based treatments available early to prevent chronicity 
and lasting impairment. The same must be done for Traumatic Brain 
Injury (TBI). However, there is no medical diagnostic code specific to 
TBI--a patient may carry more than one diagnostic code (fracture of 
facial bones, concussions, and/or brain injury of an unspecified 
nature, etc.). AMVETS is asking Congress to increase funding for PTSD 
and TBI, with an emphasis on developing improved screening techniques 
and assigning a new medical code specifically for TBI.
    Mr. Chairman, this concludes my testimony.

                                 
                Prepared Statement of Adrian M. Atizado
  Assistant National Legislative Director, Disabled American Veterans
    Mr. Chairman and Members of the Committee:
    On behalf of the more than 1.3 million members of the Disabled 
American Veterans (DAV) and its auxiliary, I wish to express my 
appreciation for this opportunity to present the views of our 
organization on healthcare legislation before the Subcommittee.
    The DAV is an organization devoted to advancing the interests of 
service-connected disabled veterans, their dependents and survivors. 
For the past 8 decades, the DAV has been devoted to one single purpose: 
building better lives for our Nation's disabled veterans and their 
families.
    The measures before the Subcommittee today cover a range of issues 
important to DAV, to veterans and their families. My testimony includes 
a synopsis of each of the bills you are considering, along with DAV's 
position or other commentary. We ordered our testimony numerically by 
bill in the same way you listed the bills in your letter inviting our 
testimony.
    We have previously testified that through their extraordinary 
sacrifices and contributions in military service, veterans have earned 
the right to the Department of Veterans Affairs (VA) healthcare as a 
continuing cost of national defense. Moreover, we adamantly believe 
America's free citizens, as beneficiaries of veterans' service and 
sacrifices throughout our history, desire that the government fully 
honor its moral obligation to provide quality and timely healthcare 
services to wartime service-connected disabled veterans.
    This Subcommittee is aware the DAV is opposed to any initiative 
that would turn VA into a primary insurer rather than a provider of 
healthcare to veterans. We believe VA must use its resources to 
maintain the base of its healthcare services, which is provided through 
and by VA healthcare facilities and healthcare providers. This current 
form of VA healthcare has served well to the benefit of all veterans, 
offers an uninterrupted flow of services to veterans in need, and 
ensures the quality of those services. VA is well recognized as 
America's best healthcare value, with the lowest error rates, highest 
satisfaction rate and lowest cost. Why would Congress want to contract 
out some of those services, at higher error rates, lower satisfaction, 
and higher cost?
    Notably, VA currently spends $2 billion or more each year on 
contract healthcare services, from all sources. Unfortunately, as VA's 
contract workloads have grown significantly, it has not been able to 
monitor this care, consider its relative costs, analyze patient care 
outcomes, or even establish patient satisfaction measures for most 
contract providers. VA has no systematic process for contracted care 
services to ensure that:

      care is safely delivered by certified, licensed, 
credentialed providers;
      continuity of care is sufficiently monitored, and that 
patients are properly directed back to the VA healthcare system 
following private care;
      veterans' medical records accurately reflect the care 
provided and the associated pharmaceutical, laboratory, radiology and 
other key information relevant to the episode(s) of care; and
      the care received is consistent with a continuum of VA 
care.

    The DAV is deeply concerned that any bill seeking to contract for 
care outside VA without addressing these concerns would essentially 
shift medical resources and veterans from VA to the private sector to 
the detriment of the VA healthcare system and eventually sick and 
disabled veterans themselves. Any proposal to contract for care with 
non-Department facilities and providers would encourage VA to refer 
patients, and thereby spend dollars for their care outside a system 
that is specifically created for veterans. Such a proposal sets a 
dangerous precedent that, if allowed to expand, could endanger VA 
facilities' ability to maintain a full range of specialized inpatient 
and outpatient services for all enrolled veterans. It would erode 
Veterans Health Administration's (VHA) patient resource base, undermine 
VHA's ability to maintain its specialized service programs, and 
endanger the well-being of veteran patients under care within the 
system.
    This Subcommittee is well aware of the funding crisis VA healthcare 
is experiencing and its impact on sick and disabled veterans who depend 
on VA's specialized programs. In the years since open enrollment was 
terminated, VA has been forced to do more with less. Even though over 
the past two budget cycles, Congress has provided increased 
discretionary appropriations for veterans' healthcare, the funding 
levels have not kept pace with VA's current services costs and the 
steady and significant increases in demand for services from enrolled 
veterans. If given sufficient funding on time to meet the growing need 
of all enrolled veterans' healthcare, including rural veterans, VA 
should be held accountable for meeting demand in a timely manner. Only 
as a last resort would we want care to be contracted out. Moreover, if 
VA timely receives adequate appropriations, it should be expected to 
plan for the appropriate number of staff, infrastructure, and other 
resources necessary to provide veterans medical care in a cost-
effective manner.
                                H.R. 92
    The stated goal of this bill is to provide timely access to VA 
healthcare. To accomplish this, a 30-day standard would be established 
as the maximum length of time that a veteran would have to wait to 
receive an appointment for primary care in a VA facility. It would also 
direct VA to establish a standard for the maximum length of time that a 
veteran would have to wait to actually see a provider on the day of a 
scheduled appointment. Under the bill, if the Secretary found that any 
particular VA geographic service area failed to substantially comply 
with the time standards, facilities in that area would be required to 
contract for the care of a veteran in each instance in which facilities 
would be unable to meet those standards. The contracting requirement 
would be mandatory for veterans who are classified within enrollment 
Priority Groups 1 through 7, and discretionary for those within 
Priority Group 8.
    The bill would require the Secretary to carry out a one-time 
examination of waiting time data for the entire system, stratified by 
geographic service area. The Secretary would be required to issue a 
determination regarding compliance with the standard in each geographic 
service area. If the compliance rate for any area were below 90 
percent, then facilities located in that area would be subject to the 
requirement that they contract for care whenever they are unable to 
meet those standards. The bill would also require that the Department 
of Veterans Affairs (VA) submit a variety of reports to the Committees 
on Veterans' Affairs concerning the purposes of the bill.
    In addition, the bill's language pertaining to the payment 
mechanism VA would use for outpatient services provided under the terms 
of the bill is unclear. Specifically, if VA's reimbursement rate were 
linked to current policy under Part B of the Medicare Program, VA would 
be required to pay private providers 80 percent of the scheduler fee 
amount for which Medicare is ordinarily responsible. Under Medicare, 
beneficiaries must meet an annual Part B deductible for all outpatient 
services. Participating physicians under the Part B program can only 
receive equitable reimbursement for services rendered by invoicing 
Medicare beneficiaries the remaining 20 percent of the scheduler 
amount, and collect deductibles for given services or procedures.
    DAV has a longstanding legislative resolution stating our firm 
opposition to copayments in VA healthcare. Under this measure, if a 
non-Department facility or provider were to receive the standard 80 
percent of the fee schedule amount for which Medicare pays for a 
particular service, and they are forbidden to bill the veteran for any 
difference between the billed charges and the amount paid by VA, then, 
we believe this may act as a strong disincentive for private healthcare 
providers to accept and treat veterans under this authority, 
frustrating the very purposes of the bill.
    Mr. Chairman, this Subcommittee held a thoroughgoing legislative 
hearing on September 30, 2003 (Serial No. 108-24) to consider an 
earlier version of this same bill. Among the statements made at that 
hearing was the following, by the then-Under Secretary for Health, Dr. 
Robert Roswell:

          ``My concern is that in the long run, I believe veterans are 
        better served if we build a system of care that will address 
        their needs, not leave it up to geographic location or a 
        particular clinic that they might choose to use to determine 
        what their healthcare benefit is on any particular day or any 
        particular month. Ultimately, I think we have to build the 
        system that addresses those needs. And purchasing care, because 
        we are frustrated with waiting times, may not be the best way 
        to do it. It might be, I don't know. I think we have to explore 
        that in greater detail. I do believe there are a number of 
        things that this Committee could do to enhance veterans' access 
        to care. And I appreciate the leadership of the Committee in 
        seeking those issues.''

    The Subcommittee apparently agreed with Under Secretary Roswell. 
After considering all the views of witnesses and Members, and reviewing 
a series of policy issues raised by that bill, the Subcommittee took no 
further action on that bill for the duration of that Congress. We do 
not believe circumstances have changed since that time that would 
warrant this Subcommittee to take any action on the bill now. While we 
appreciate that on its surface this bill would seem helpful in the 
short run to some veterans, its probable but unintended destructive 
consequences demand that we oppose it.
                                H.R. 315
    This bill would expand VA's existing authority to contract for 
private healthcare by redefining ``geographic inaccessibility'' through 
the use of population density markers and highway mileage distance from 
VA facilities. Under the bill, if a veteran's home of residence met a 
given inaccessibility standard, the Secretary would be required to 
permit that veteran to receive private healthcare for primary care, 
acute or chronic symptom management and for ``nontherapeutic medical 
services.'' Most likely the Congressional Budget Office would conclude 
this bill constitutes mandatory spending under the PAYGO policy of the 
House.
    As indicated in many other forums including this one, DAV supports 
passage of mandatory, guaranteed or assured VA funding to ensure sick 
and disabled veterans receive adequate VA healthcare, but we do not 
support mandatory funding for private providers to care for veterans 
via a VA insurance function. Thus, similar to H.R. 92, we do not 
support this bill.
                                H.R. 339
    This bill would require the Secretary, in the case of a VA facility 
with a waiting list of 6 months or greater, to provide for any veteran 
so informed of that waiting period, contract services by private 
providers under the same terms and conditions as those services would 
be provided in a VA facility.
    DAV opposes this bill for the same reasons we are concerned about 
the two earlier bills dealing with access. Insufficient resources is a 
primary cause of delayed access to care. This can be surmounted with 
new resources. This measure, like the others similarly aimed, would 
exacerbate VA's problems by stripping it of what limited resources it 
possesses to care for the patients now in the VA system, making its 
rationing and waiting lists even worse.
                                H.R. 463
    This bill would legislatively moot Title 38, section 1705, thereby 
rescinding the Secretary's authority to establish and operate a system 
of annual enrollments for VA healthcare, and it would make every 
American veteran entitled to enrollment for VA healthcare on request. 
Over 1,000,000 veterans have unsuccessfully attempted to enroll in VA 
healthcare since the cut-off of enrollments for Priority 8 veterans 
occurred in 2003. While we certainly support the proponent's premise 
that every veteran who wants it should be able to enroll in VA 
healthcare, without a major infusion of new funding, enactment of this 
bill would worsen VA's financial situation, not improve it, and would 
not serve veterans well. We recommend the Subcommittee defer action on 
this bill until after Congress enacts mandatory, guaranteed or assured 
funding for VA healthcare.
                                H.R. 538
    This bill would establish a requirement for a special study of the 
needs of veterans in 24 counties of ``far south Texas,'' with the goal 
of establishing either a public-private venture, a full service VA 
facility, or a shared VA-military facility to meet their healthcare 
needs.
    In accordance with our Constitution and Bylaws, the DAV's 
legislative agenda is determined by mandates formed by resolutions 
adopted by our membership. We have no resolution specific to the 
provisions of this measure. While we have some concerns about whether 
this bill would contravene the results of the recent Capital Assets 
Realignment for Enhanced Services (CARES) process in one particular 
geographic area, to the exception of all others, we take no official 
position on its passage.
                                H.R. 542
    This bill would require VA mental health counseling to be provided 
in languages other than English when veterans are not English-
proficient. The bill would also require the VA Secretary to ensure the 
purposes of Executive Order 13166, dealing with English as a second 
language among Federal beneficiaries, are carried out.
    Again, we have no resolution relevant to the provisions of this 
measure; however, its purposes appear beneficial and therefore DAV 
would not oppose passage of this measure.
                               H.R. 1426
    This bill would empower an enrolled veteran to elect to receive VA 
healthcare from private sources. Under its terms, the Secretary would 
have no discretion to deny such an election once it was made. The bill 
would also provide a medication benefit to all enrolled veterans for 
the dispensing of VA pharmaceuticals based on prescriptions written by 
private physicians. For similar reasons supporting our opposition to 
H.R. 92, H.R. 315 and H.R. 339, we oppose this bill.
                        H.R. 1470 and H.R. 1471
    H.R. 1470 would expand VA chiropractic care by requiring such 
services to be available in at least 75 VA medical centers before the 
end of 2009 and available at all medical centers by the end of 2011. VA 
was authorized to offer chiropractic care and services under the 
provisions of section 204 of Public Law 107-135, the Department of 
Veterans Affairs Healthcare Programs Enhancement Act of 2001. We 
believe chiropractic care offers a valuable healthcare service to 
veterans and DAV members support the systemwide availability of 
chiropractic services within the VA healthcare system.
    While we support broader availability of chiropractic in VA 
facilities that would be brought about by enactment of H.R. 1470, the 
purpose of H.R. 1471 raises concerns. This bill would establish 
chiropractic service practitioners on the same level as VA medical 
doctors in the direct provision of primary care services. Each veteran 
receiving care in VA is assigned a single primary care provider, a 
medical doctor. A VA primary care provider is part of a primary care 
team charged with the responsibility for addressing the healthcare 
needs of the veterans assigned to that team. Accordingly, we believe in 
the VA healthcare system, access to chiropractic services should be 
provided in consultation with VA primary care providers responsible
for maintaining the overall health of patients assigned to them. Thus, 
we oppose
H.R. 1471.
                               H.R. 1527
    Similar to H.R. 315, reviewed above in this testimony, this bill 
would grant election to veterans living at considerable distances from 
VA facilities to choose private care instead of care in VA facilities. 
The Secretary would not be able to deny this election, and VA would be 
required to pay associated costs. Furthermore, this measure would 
provide a pharmaceutical service similar to that of H.R. 1426. DAV 
opposes this bill for the same reasons as we oppose the earlier 
measures.
Draft Bill--Veterans' Rural Healthcare
    The bill would require the Secretary to establish a mobile ``vet 
center'' pilot program in rural areas, and a pilot program for health 
information exchange with rural clinics, critical access hospitals and 
community health centers in rural areas. It would create an Advisory 
Committee on Rural Veterans and specify its membership and mission. The 
bill would establish at least four VA rural health research, education 
and clinical activities centers in VA medical centers in rural areas. 
It would amend section 2061 of Chapter 20, Title 38, United States 
Code, by adding the term ``rural'' as one of several groups defined 
with special needs to be addressed through VA's homeless assistance 
programs. The bill would expand VA's graduate medical educational 
mission into rural areas and enhance the education, training, 
recruitment and retention of nurses in rural areas. Finally, the bill 
would require a series of reports from the VA Secretary dealing with 
several of the matters contained in the bill.
    As this Committee is aware, the cost of providing care in rural and 
remote areas is higher than in urban settings. In much of our 
deliberation on this issue, we struggle to find a way to fill the 
indeterminate gap between limited resources and the demand for rural 
healthcare. We are hopeful the creation of an Advisory Committee on 
Rural Veterans and the Rural Health Research, Education and Clinical 
Care Centers will strive to strike the balance we seek when providing 
better outreach and high quality VA medical care to veterans residing 
in rural and remote areas. Moreover, when striving for good stewardship 
of taxpayer dollars we ask due consideration be given to the cost 
effectiveness of the mobile vet center program, which is a concern for 
such a program serving rural areas. Much of the content of this bill is 
consistent with recommendations of the Independent Budget. Further, we 
believe this measure is a good first step in addressing the healthcare 
needs of rural veterans, thus; DAV fully supports its purposes.
                               H.R. 1944
    The Veterans Traumatic Brain Injury Act of 2007 would require the 
VA to establish a screening program for all veterans of Operations 
Iraqi and Enduring Freedom, of the Persian Gulf War and earlier 
conflicts dating from 1998. The bill would require the Secretary to 
report the results of such screening to Congress on an annual basis. 
The bill would require the Secretary to establish comprehensive 
traumatic brain injury (TBI) rehabilitation programs in four 
geographically dispersed polytrauma network sites (presently centered 
in Richmond, Minneapolis, Tampa and Palo Alto VA medical centers), and 
to report that establishment within 1 year of enactment, with 
additional information about the veterans so served. The bill would 
establish a TBI transition office within each polytrauma network to 
coordinate healthcare delivery and other services. The bill would 
require VA to establish cooperative agreements with other entities 
capable of providing appropriate services to veterans with TBI. 
Finally, the bill would establish a TBI registry to identify, track and 
communicate with, veterans suffering from TBI.
    Mr. Chairman, much of the content of this bill is consistent with 
our review of TBI and our recommendations in the Independent Budget for 
fiscal year 2008. Clearly, TBI is going to remain a major focus of VA 
healthcare for the next several decades. Press reports indicate that 
over 12,000 improvised explosive devices (IEDs) have been detonated in 
the current OIF/OEF campaigns. This means the average soldier or marine 
has been exposed to concussion, possibly multiple times. VA needs to 
prepare for this coming healthcare challenge, particularly for those 
veterans whose exposure may be classified as ``mild,'' or ``moderate'' 
in nature and when no head wound resulted from that exposure. We 
believe this is going to be one of VA's greatest healthcare challenges 
in the near term. This bill will aid VA in making those preparations; 
thus, we fully support its enactment.
    In previous testimony, the DAV has raised concerns regarding the 
lack of effective screening and clinical assessment tools for mild to 
moderate TBI. While we applaud the Committee for considering this bill, 
and we support it, we note that VA issued a directive in the past 2 
weeks (VHA Directive 2007-013), implementing a TBI initiative that 
features a screening ``pop up'' within the VistA clinical software 
system. The directive also makes reference to a screening protocol and 
the mandatory continuing education requirement for specialized training 
in TBI. The directive makes no mention of the clinical assessment tool, 
which was the subject of a vigorous discussion at the Committee's 
hearing on September 28, 2006. We understand that earlier this year, VA 
established a clinical task group to develop that clinical assessment 
tool, and we urge the Subcommittee to closely monitor this development 
to ensure that tool is put into the hands of VA practitioners at the 
earliest possible time.
    Furthermore, we recommend greater flexibility be afforded to the 
Secretary regarding the number of locations for which the comprehensive 
program for long-term traumatic brain injury rehabilitation shall be 
carried out, such that if the need arises to expand the program, the 
current language limits VA's ability to meet that need. Also, the 
legislative language for eligibility of a veteran to receive care under 
this program may preclude veterans suffering from service-connected 
TBI. Finally, a provision of this measure encourages the Secretary to 
provide the comprehensive program for long-term traumatic brain injury 
rehabilitation through cooperative agreements with appropriate public 
or private entities. We are cognizant of the opportunities a 
cooperative agreement may offer but left undefined as currently 
written, we are concerned that this provision may overtime erode VA's 
special emphasis program of TBI care.
    Mr. Chairman, this concludes my testimony. I and other members of 
the DAV Legislative Staff will be pleased to make ourselves available 
to you and your staffs for further discussion of our positions on any 
of these issues, in hopes of working toward compromise on measures that 
we can eventually support. Thank you for asking DAV to testify today. I 
will be pleased to respond to any of your or other Committee Members' 
questions.

                                 
                    Prepared Statement of Carl Blake
      National Legislative Director, Paralyzed Veterans of America
    Mr. Chairman and Members of the Subcommittee, on behalf of 
Paralyzed Veterans of America (PVA), I would like to thank you for the 
opportunity to testify today regarding the proposed legislation. We 
recognize that the Department of Veterans Affairs (VA) faces serious 
challenges as it continues to face rapidly growing demand on its 
healthcare system. It seems ironic that in the face of some criticism 
about the care being provided in VA facilities that the demand on the 
system has never been higher.
       H.R. 92, THE ``VETERANS TIMELY ACCESS TO HEALTHCARE ACT''
    H.R. 92, the ``Veterans Timely Access to Healthcare Act,'' would 
establish standards of access to care within the VA healthcare system. 
Under the provisions of this legislation, the VA will be required to 
provide a primary care appointment to veterans seeking healthcare 
within 30 days of a request for an appointment. If a VA facility is 
unable to meet the 30-day standard for a veteran, then the VA must make 
an appointment for that veteran with a non-VA provider, thereby 
contracting out the healthcare service. The legislation also requires 
the Secretary of the VA to report to Congress each quarter of a fiscal 
year on the efforts of the VA healthcare system to meet this 30-day 
access standard.
    Access is indeed a critical concern of PVA. The number of veterans 
enrolled in the VA is approaching 8 million and the number of unique 
users is nearly 6 million. Despite the ongoing policy to deny 
enrollment to Category 8 veterans, the numbers of enrolled veterans 
will continue to increase, particularly as more and more veterans of 
the Global War on Terror take advantage of the services in VA.
    Unfortunately, funding for VA healthcare has not kept pace with the 
growing demand. Furthermore, Congress has failed to live up to its 
responsibility to provide adequate funding in a timely manner. Despite 
a positive funding outlook for this year, we remain skeptical. As long 
as VA continues to receive funding months into its fiscal year, it will 
never be able to properly plan to meet demand. To that end, access 
standards without sufficient funding provided by the start of the 
fiscal year are standards in name only.
    PVA is concerned that contracting healthcare services to private 
facilities when access standards are not met is not an appropriate 
enforcement mechanism for ensuring access to care. In fact, it may 
actually serve as a disincentive to achieve timely access for veterans 
seeking care. Contracting out to private providers will leave the VA 
with the difficult task of ensuring that veterans seeking treatment at 
non-VA facilities are receiving quality healthcare. We do think that 
access standards are important, but we believe that the answer to 
providing timely care is in providing sufficient funding in the first 
place in order to negate the impetus driving healthcare rationing. For 
these reasons, PVA cannot support H.R. 92.
  H.R. 315, THE ``HELP ESTABLISH ACCESS TO TIMELY HEALTHCARE FOR YOUR 
                       VETS (HEALTHY VETS) ACT''
          H.R. 1527, THE ``RURAL VETERANS ACCESS TO CARE ACT''
    Because these two bills principally address the same issue, I will 
outline our concerns with the proposed bills in one statement. PVA is 
fully aware of the challenges the VA faces every day to provide timely 
access to quality healthcare for veterans who live in rural areas of 
the country. However, we are concerned that in addressing the problem 
of access for these veterans, the long-term viability of the VA 
healthcare system may be threatened. PVA members rely on the direct 
services provided by VA healthcare facilities recognizing the fact that 
they do not always live close to the facility. The services provided by 
VA, particularly specialized services like spinal cord injury care, are 
unmatched in the private sector. If a larger pool of veterans is sent 
into the private sector for healthcare, the diversity of services and 
expertise in different fields is placed in jeopardy.
    Ultimately, PVA has serious concerns about the provisions of this 
legislation that would give VA additional leverage to broaden 
contracting out of healthcare services to veterans in geographically 
remote or rural areas. If you review the early stages of VA's Project 
HERO, it is apparent that this is a direction that some VA senior 
leadership would like to go. We believe that this pilot program would 
set a dangerous precedent, encouraging those who would like to see the 
VA privatized. Privatization is ultimately a means for the Federal 
Government to shift its responsibility of caring for the men and women 
who served.
    Current law limits VA in contracting for private healthcare 
services to instances in which VA facilities are incapable of providing 
necessary care to a veteran; when VA facilities are geographically 
inaccessible to a veteran for necessary care; when medical emergency 
prevents a veteran from receiving care in a VA facility; to complete an 
episode of VA care; and, for certain specialty examinations to assist 
VA in adjudicating disability claims. The VA could better meet the 
demands of rural veterans through more judicious application of its 
fee-for-service program.
    In the end, we believe that in order for the VA to best meet this 
demand, adequate funding needs to be provided for VA healthcare in a 
timely manner. As we previously stated, placing the VA in the position 
it has dealt with for many years because Congress continues to wrangle 
over Federal budgets, does not prepare the VA to properly meet demand, 
including demand in rural areas.
    Finally, we realize that it is an extremely difficult task to 
establish a standard for when a veteran's home is considered to be 
rural. This legislation attempts to do so by stating defining 
``geographically inaccessible'' in terms of a population density as it 
relates to a distance from a VA facility. However, this is very much a 
subjective idea. Access to VA healthcare is subject not only to 
population density or distance, but time as well. The difficulty in 
addressing this subject is apparent just by comparing the methods that 
the proposed bills take to define rural accessibility. However, due to 
the concerns that we have outlined, PVA cannot support H.R. 315 or H.R. 
1527.
         H.R. 339, THE ``VETERANS OUTPATIENT CARE ACCESS ACT''
    PVA opposes H.R. 339, the ``Veterans Outpatient Care Access Act.'' 
As with the previous bills discussed, this bill would simply encourage 
broader contracting out of healthcare services without attempting to 
fix the problems that exist as a result of insufficient funding. With 
adequate resources and staffing, the challenges faced by outpatient 
clinics could be minimized. However, with the passage of this 
legislation, the VA would be discouraged from doing the right thing. 
For example, if a local clinic loses a particular specialty doctor, 
that clinic would likely turn to a contract provider without trying to 
refill that position.
    Legislation such as this, once again, allows the Federal Government 
to absolve itself from the responsibility to care for the men and women 
who have served and sacrificed for this country. It is time for 
Congress to stop trying to pass the buck and provide the resources it 
will take the VA to provide this critical care. It makes no sense to 
continue to consider legislation that would lead veterans away from the 
best healthcare system in America.
         H.R. 463, THE ``HONOR OUR COMMITMENT TO VETERANS ACT''
    PVA fully supports H.R. 463, the ``Honor Our Commitment to Veterans 
Act.'' The provisions of this legislation are in accordance with the 
recommendations of The Independent Budget. We have continued to 
advocate for this policy to be overturned since it was put into place. 
It is unacceptable that these veterans are being denied access to 
healthcare simply because the Administration and Congress have been 
unwilling to provide the necessary funding to reopen the VA healthcare 
system to them. We believe this policy should be overturned and that 
adequate resources should be provided to overturn this policy decision.
    VA estimates that more than 1.5 million Category 8 veterans will 
have been denied enrollment in the VA healthcare system by FY 2008. 
Assuming a utilization rate of 20 percent, in order to reopen the 
system to these deserving veterans, The Independent Budget estimates 
that VA will require approximately $366 million in discretionary 
dollars.
       H.R. 538, THE ``SOUTH TEXAS VETERANS ACCESS TO CARE ACT''
    PVA has no official position on this legislation. We believe that 
this is a local access issue. If a demonstrated need is there, then the 
VA must develop a solution to meet the needs of the men and women in 
this region.
                                H.R. 542
    PVA has no opposition to the provisions of H.R. 542. Overall, we 
are pleased with the direction that VA has taken and the progress it 
has made with respect to its mental health programs. A great deal of 
time and resources have been invested in the VA's mental health 
programs in recent years to meet the growing demand of new veterans 
from Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). 
The War Supplemental currently being debated even includes significant 
additional resources to meet the mental health needs of OEF/OIF 
veterans. Many of the servicemembers who have served in OEF/OIF have 
experienced mild to severe mental health problems. Our only concern is 
that the VA does not invest considerable resources into the 
requirements of this legislation if the demand for such services is not 
really there. However, given that we do not have specifics about this 
type of demand, we would simply urge the VA to proceed with caution.
  H.R. 1426, THE ``RICHARD HELM VETERANS' ACCESS TO LOCAL HEALTHCARE 
                      OPTIONS AND RESOURCES ACT''
    PVA finds it difficult to comprehend the rationale for establishing 
a precedent for veterans in the VA healthcare system to leave that 
system and seek services elsewhere, as this proposed legislation would 
do. Over the past year we have read, as I am sure every Member of 
Congress has, all of the accolades given to VA healthcare by 
independent observers, newsweeklies and other publications. While we 
believe VA represents the best available care, oversight is needed to 
provide an additional guarantee that VA-provided services are of the 
highest quality for all veterans who use VA, especially for those with 
service-connected disabilities.
    While this legislation may be well intentioned, the potential 
unintended consequences far outweigh any benefit that this bill might 
provide. There would almost certainly be a diminution of established 
quality, safety and continuity of VA care if veterans were to leave the 
system. It is important to note that VA's specialized healthcare 
programs, authorized by Congress and designed expressly to meet the 
needs of combat-wounded and ill veterans, such as the blind 
rehabilitation centers, prosthetic and sensory aid programs, 
readjustment counseling, polytrauma and spinal cord injury centers, the 
centers for war-related illnesses, and the national center for post-
traumatic stress disorder, as well as several others, would be 
irreparably affected by the loss of service-connected veterans from 
those programs. The VA's medical and prosthetic research program, 
designed to study and hopefully cure the ills of disease and injury 
consequent to military service, would lose focus and purpose were 
service-connected veterans no longer present in VA healthcare. 
Additionally, Title 38, United States Code, section 1706(b)1 requires 
VA to maintain the capacity of these specialized medical programs, and 
not let their capacity fall below that which existed at the time when 
Public Law 104-262 was enacted.
    While as a consequence of enactment of this bill some service-
connected veterans might seek care in the private sector as a matter of 
personal convenience, they would lose the many safeguards built into 
the VA system through its patient safety program, evidence-based 
medicine, electronic medical records and medication verification 
program. These unique VA features culminate in the highest quality care 
available, public or private. Loss of these safeguards, that are 
generally not available in private sector systems, would equate to 
diminished oversight and coordination of care, and ultimately may 
result in lower quality of care for those who deserve it most.
    With regards to the prescription drug provisions included in the 
legislation, P.L. 108-199, the ``Consolidated Appropriations Act of 
2004'' provided the Secretary of VA the authority to dispense 
prescription drugs from Veterans Health Administration (VHA) facilities 
to enrolled veterans with prescriptions written by private physicians. 
Included in the public law, and further explained in the Conference 
Report H. Rpt. 108-401, was the requirement that the VA would incur no 
additional cost in providing such a benefit.
    VA physicians, by being the sole source of care, have been fully 
able to monitor patients for potentially contra-indicative 
prescriptions. PVA is concerned that if VA is to accept non-VA 
physician written prescriptions, veteran patients may be put at risk 
with this loss of monitoring should the patient seek treatment both 
inside and outside the VA healthcare system.
   H.R. 1470, THE ``CHIROPRACTIC CARE AVAILABLE TO ALL VETERANS ACT''
    PVA has no opposition to H.R. 1470, the ``Chiropractic Care 
Available to All Veterans Act.'' Chiropractic care is another medical 
service that could benefit many veterans and disabled veterans who face 
spinal and musculoskeletal difficulties. Currently, the VA provides 
chiropractic care in selected sites in accordance with P.L. 107-135, 
the ``Department of Veterans Affairs Healthcare Programs Enhancement 
Act of 2001.'' We see no problem with expanding this specialty care to 
the broader VA healthcare system; however, we must emphasize that 
adequate resources must be appropriated to allow VA to provide this 
care.
 H.R. 1471, THE ``BETTER ACCESS TO CHIROPRACTORS TO KEEP OUR VETERANS 
                             HEALTHY ACT''
    As we previously stated, PVA has no objection to the provision of 
chiropractic care within the VA healthcare system. However, we do not 
support section 3 of this legislation which would elevate chiropractors 
to the status of a primary care physician in the VA. The primary care 
provider is responsible for assessment of illness and injury and triage 
to the appropriate specialty care. The primary care provider also 
provides basic care far beyond the scope of musculoskeletal conditions 
and the interaction with the nervous system--the principal focus of 
chiropractors. We believe that chiropractic care should be provided in 
consultation with the primary care provider responsible for the total 
healthcare needs of the veteran.
    H.R. 1944, THE ``VETERANS TRAUMATIC BRAIN INJURY TREATMENT ACT''
    PVA supports H.R. 1944, the ``Veterans Traumatic Brain Injury 
Treatment Act.'' It is fair to say that traumatic brain injury (TBI) is 
considered the signature health crisis for Operation Enduring Freedom 
(OEF) and Operation Iraqi Freedom (OIF) veterans. We believe that the 
provisions of this legislation will enhance the ability of the VA to 
provide comprehensive care for veterans with TBI; however, we also have 
a couple of concerns with the legislation.
    Proper screening for this newest generation of veterans is critical 
to their immediate and long-term care. Unofficial statistics suggest 
that many OEF/OIF veterans have suffered mild brain injuries that have 
gone undiagnosed. In many cases, symptoms have manifested themselves 
after the veterans have returned home. The Department of Defense (DoD) 
admits that it lacks a systemwide approach for proper identification, 
management, and surveillance for individuals who sustain mild to 
moderate TBI. It is only appropriate that the VA be able to fill the 
gap left by DoD.
    Furthermore, it will allow the VA to identify veterans who have 
experienced a TBI but whose symptoms have been masked by other 
conditions. We have heard anecdotally that this is a particular problem 
for veterans who have incurred a spinal cord injury in the upper 
cervical spine. Veterans who have incurred this level of injury as a 
result of a blast incident often have experienced a traumatic brain 
injury as well. However, their symptoms may be diagnosed as the result 
of their significant impairment at the cervical spinal level.
    PVA certainly supports the need for a comprehensive long-term care 
program for veterans who have experienced TBI. The VA is the only real 
healthcare system in America capable of providing complex sustaining 
care over the life of the seriously disabled veteran. Private treatment 
options often give no consideration whatsoever to the long-term care 
needs of the veteran. Meanwhile, the VA has developed its long-term 
care program across the broad spectrum of services for many years.
    However, we have some concern about the provision of this 
legislation that defines an eligible veteran as one who has served on 
active duty in a combat theater of operations. Recognizing that the 
vast majority of newly injured TBI veterans have experienced their 
injury as a result of combat service, this should not preclude the VA 
from providing long-term care services to any TBI veteran whose 
condition is service-connected.
    PVA also is concerned about the provision within the section 
establishing TBI transition offices that further encourages cooperation 
with public and private entities. We understand that outside facilities 
and programs can bring some level of expertise to this population of 
veterans. However, we would hope that the VA would see fit to invest 
the majority of its resources in improving its own TBI programs, even 
as it taps into outside expertise. We urge the Congress, and VA, to 
proceed with caution as it looks to services provided outside of the VA 
healthcare system.
                 THE ``VETERANS RURAL HEALTHCARE ACT''
    PVA recognizes that there is no easy solution to meeting the needs 
of veterans who live in rural areas. These veterans were not originally 
the target population of men and women that the VA expected to treat. 
However, the VA decision to expand to an outpatient network through the 
Community-Based Outpatient Clinics reflected the growing demand on the 
VA system from veterans outside of typical urban or suburban settings.
    PVA has no objection to the proposal to create two mobile vet 
centers. However, the one caution we would offer is that services 
provided in this manner tend to be more expensive and less cost-
effective. I would suggest that mobile services tend to be much more 
cost-effective in areas where a large segment of the target population 
can be served because it drives down the overall cost-per-patient. This 
implies that mobile centers would be best served in urban areas. 
However, we are willing to allow this pilot program to test the waters. 
We would suggest that the length of the program be shortened to 3 years 
or less so as to allow a sooner cost-benefit analysis of that program.
    We fully support the creation of an Advisory Committee on Rural 
Veterans. We are particularly pleased that the legislation includes a 
provision for Veterans Service Organization representation; however, we 
believe that more than one voice should be included. While the proposal 
includes the Secretary of Health and Human Services and the Director of 
the Indian Health Service as ex officio Members of the Committee, we 
believe that the Department of Defense Under Secretary for Personnel 
and Readiness or the Assistant Secretary of Defense for Health Affairs 
should also be included. This committee could provide well-researched 
and reasonably considered alternatives for rural healthcare.
    We also support the creation of rural health research, education, 
and clinical care centers. These centers would essentially serve as 
centers-of-excellence for rural healthcare. This could allow the VA to 
address the needs of rural veterans through broad application of the 
``hub-and-spoke'' principle. This is the same structure utilized in the 
spinal cord injury service. A veteran can get his or her basic care at 
a Community-Based Outpatient Clinic (spoke). However, if the veteran 
requires more intensive care or a special procedure, he or she can then 
be referred to the larger rural research, education, and clinical care 
center (hub). This would ensure that the veteran continues to get the 
best quality care provided directly by the VA, thereby maintaining the 
viability of the system. It will also allow the VA to develop 
excellence within the actual VA healthcare system, instead of farming 
out these services to the private sector.
    Mr. Chairman and Members of the Subcommittee, we recognize that the 
challenges the VA faces in the healthcare arena are difficult. However, 
we must reiterate that the VA will struggle to meet the ever-growing 
demand of veterans, particularly rural veterans, as long as it does not 
receive adequate resources in a timely manner. It is unreasonable, and 
frankly unacceptable, to place expectations on VA to meet certain types 
of demand, if it is not given the resources and tools necessary. 
Furthermore, allowing the VA to send veterans out into the private 
sector for care will absolutely not be the most cost-effective 
approach, nor will it allow veterans to get the best quality of care.
    We look forward to working with the Subcommittee to develop 
workable solutions that will allow veterans to get the best quality 
care available. I would like to thank you again for allowing us to 
testify on these important measures. I would be happy to answer any 
questions that you might have.

                                 
                Prepared Statement of Dennis M. Cullinan
                 Director, National Legislative Service
             Veterans of Foreign Wars of the United States
    MR. CHAIRMAN AND MEMBERS OF THIS COMMITTEE:
    On behalf of the 2.4 million members of the Veterans of Foreign 
Wars of the U.S. (VFW) and our auxiliaries, I would like to thank you 
for your invitation to testify at today's important hearing on 
healthcare legislation.
    The bills under consideration today mostly revolve around what has 
been the most critical issue confronting the Department of Veterans 
Affairs (VA) healthcare system: access. We have long argued that the 
primary reason for most of the access problems veterans have is because 
of the lack of adequate and timely funding given to VA. We appreciate 
the increases of the last few years, and this year's historic budget 
resolution, but we need to ensure that VA receives the money on time, 
and that subsequent increases in future years keep pace with the needs 
of the veterans' population.
H.R. 92, the Veterans Timely Access to Healthcare Act
    This legislation would establish access standards within VA for 
veterans seeking care. For primary healthcare appointments, it would 
require veterans to be seen within 30 days. In certain circumstances, 
it would require VA to contract for care when VA is unable to live up 
to that access standard.
    The VFW strongly supports the intent of this legislation, but we do 
have some concerns about the contracting aspect. There is no doubt that 
veterans should not have to wait to access healthcare, especially for 
primary appointments. A few years ago, there were over 300,000 veterans 
throughout the country who were waiting 6 months or more for primary 
healthcare appointments, but VA has made great strides to reduce this 
and most initial appointments are being made within that 30-day 
standard. We do understand that there are certain geographical areas 
where this is not the case, however.
    We are concerned about the cost of contract care, especially when 
VA is acknowledged to provide healthcare at a lower cost than other 
providers. While it would greatly benefit veterans in areas with long 
waiting times, we must be mindful of it not eating into the healthcare 
budget for other locations. If other areas have fewer funds to work 
with they, too, will ration healthcare, increasing waiting times 
systemwide. We must be mindful of these unintended effects, and ensure 
that the entire healthcare system has the funding and resources it 
needs to adequately care for all veterans.
H.R. 315, the HEALTHY Vets Act
    This legislation aims to improve healthcare access for rural 
veterans by increasing contracting opportunities for veterans in 
geographically remote areas. This issue is of particular concern to our 
members, as a great number of them live far from VA medical centers, 
and often have difficulty accessing their earned healthcare.
    We strongly support the intent of this legislation, which creates a 
sliding scale for contracting eligibility depending on distance and 
county density to determine whether a veteran lives in a rural area.
    We do have concerns, however, with the potential for overuse of 
contracting care, as we did with H.R. 92, but there are certainly areas 
where its use is proper. We must be mindful of a demonstration project 
VA is currently undergoing, Project HERO. We have been supportive of 
Project HERO's aims, and think it might be wise to see how effective 
the demonstration project is, and what lessons can be learned from it 
before making a sweeping legislative change.
    Despite this, there are areas, particularly with respect to the 
challenges faced by today's returning servicemembers suffering from 
traumatic brain injuries and other blast injuries that could be 
supplemented with fee-basis care, but this is an area that is going to 
require strong Congressional oversight to ensure that these wounded 
warriors are receiving optimal care.
H.R. 33
    The VFW supports the intent of this legislation, which is similar 
to H.R. 92, in that it establishes standards of care for veterans 
waiting to receive care from VA. In the case of H.R. 339, it 
establishes a 6-month access standard for any care a veteran is to 
receive, and if that standard is not met, VA must provide fee-basis 
care.
    In the wide majority of cases, this standard would not come into 
play for primary care, but there are a great many places, especially in 
more rural areas, where specialty care presents unique access problems. 
In these areas, VA might not have the full number of specialists it 
needs, or they have overwhelming patient loads. Regardless, a 6-month 
wait is inexcusably long, and we cannot expect our sick and disabled 
veterans to wait that long, especially when none of us in the room 
today would wait that long for our care.
H.R. 463
    The VFW strongly supports the goal of this legislation, which would 
end the 4-year freeze on the enrollment of new Category 8 veterans. 
Category 8 veterans are those mostly nonservice-connected veterans 
making above a geographically adjusted amount, and it includes veterans 
making as little as $26,902. These veterans, since January 2003, are no 
longer allowed to enroll in the healthcare system, and are turned away 
from their earned healthcare. VA estimates that 1.5 million veterans 
will have been denied enrollment by the end of fiscal year 2008.
    If this legislation is enacted, Congress must also ensure a 
corresponding funding increase to pay for the care of these veterans. 
It is not enough to have VA make do; that will just result in the 
return of healthcare rationing and growing lines for care. Further, 
this cannot be a 1-year fix. Congress must continuously and fully fund 
VA healthcare in a timely manner in future years.
    The VFW believes that all veterans have earned access to high-
quality healthcare in a timely manner through their service to this 
Nation. When the freeze was put into place, it was a time of severe 
budget shortages and extreme waiting times. We believe that the policy 
was a short-term fix to allow VA to manage the crisis and feel that it 
is time to end this unfair policy.
H.R. 542
    The VFW supports this bill, which would make mental health services 
available for veterans with limited English proficiency.
    An increasing number of service men and women are coming from 
foreign countries. There are approximately 30,000 non-citizens serving 
in the military today, coming from around the globe. The vast majority 
of these heroes plan to use their military service as a springboard for 
citizenship, and their dedication to this country's ideals and their 
patriotic spirit, as manifested through their willingness to serve, 
cannot be questioned. These men and women put their lives on the line 
the same way any American-born servicemember does as they fight side-
by-side. And they often suffer the same disabilities and illnesses.
    Although we understand the difficulty some would have with 
providing options for treatment in other than English, we must be 
mindful that this legislation only covers mental health services, where 
clear and direct communication is integral to treatment and recovery. 
It is often difficult enough for English-speaking natives to 
communicate the emotions and problems they are facing; we cannot throw 
another barrier up for the treatment of those who have given much for 
this country. Their service is just as valuable as that of an English 
speaker, and the care and treatment--to make them whole--is just as 
essential.
H.R. 1426
    The VFW strongly opposes this legislation, which would allow any 
veteran to elect to receive contracted care whenever they choose. As we 
have acknowledged in our comments to previous legislation, there are 
certainly cases where contract care is appropriate. A blanket and 
widespread use of it to anyone and everyone, however, is shortsighted 
and misguided.
    First, we reiterate our concerns with the costs of such care. Fee-
basis care is more expensive than that of VA, and we believe that it 
would do great harm to those veterans who elect to stay in the high-
quality VA healthcare system by taking away funding for the system as a 
whole.
    Second, we have strong concerns about the viability of the 
healthcare system should this bill be enacted. VA has four essential 
missions, all of which depend on one another, and which greatly improve 
the quality of care for all Americans, not just our veterans. (1) It 
serves as the healthcare system for this Nation's sick and disabled 
veterans; (2) It acts as the primary education and training grounds for 
America's healthcare professionals (48,000 medical residents and 
students receive training at VA each year); (3) It provides world-class 
research opportunities and the development of new medical technologies; 
and (4) It is the backup to the Department of Defense healthcare system 
in national emergencies.
    We cannot lessen one of these missions without sacrificing the 
others. Reducing the number of veterans seeking care from VA would do 
irreparable damage to the others, affecting all Americans.
    Further, contract care would present problems, especially with the 
continuum of care and VA's ability to monitor and track the healthcare 
needs of veterans over their entire lives. It would also potentially 
erode the quality of care VA provides, especially with respect to the 
illnesses and disabilities veterans suffer from, such as gunshot wounds 
or prosthetics, and for which VA is uniquely qualified to treat.
    Although this legislation aims to expand the coverage available to 
veterans, it would only dilute the quality and quantity of the services 
provided to new and existing veterans today and into the future. That 
is unacceptable.
H.R. 1470, the Chiropractic Care Available to All Veterans Act
    The VFW supports this legislation which would require VA medical 
centers to begin hiring chiropractors at each facility. Currently, VA 
averages around one chiropractor per VISN.
    A great number of veterans suffer from musculoskeletal injuries, 
and although chiropractors are not for every veteran, they should be 
available as an option. As part of a team that includes pain management 
and orthopedic specialists as well as physical therapists, a great 
number of injuries can be managed and symptoms improved.
H.R. 1471
    The VFW opposes this legislation, which would allow veterans to 
receive direct access to chiropractic services. Although we support 
these services, we believe that they should be part of the specialty 
care process, requiring a referral from a primary care physician. This 
is important for case management and to ensure that a veteran's primary 
physician is fully aware of the treatments a veteran is undergoing, 
especially if that chiropractor service is a part of the team-based 
approach we discussed in our comments on H.R. 1470.
    Further, it is important to remember that no other VA healthcare 
specialty allows for direct access by patients.
H.R. 1527
    We also support the intent of this legislation that would, like 
H.R. 315 discussed above, allow for the contracting of care for certain 
veterans in rural areas.
    Despite our support, our concerns about this legislation are 
similar to those of that bill as well.
    Namely, we are concerned with the continuity of care, as records 
would need to be transferred back and forth, which could create 
difficulties with VA's state-of-the-art electronic medical records 
system. We are also concerned with the costs that such a program could 
incur as fee-basis care is more expensive than that provided by VA.
    We would urge the Committee to consider the results of Project HERO 
before passage of this bill, though. The lessons we can learn from 
this--which would answer some of these questions we have laid out--
would be beneficial to the entire system, and determine whether a 
large-scale proposal such as this is truly feasible.
H.R. 1944
    The VFW offers our strong support for this legislation which would 
require VA to implement a screening program for traumatic brain 
injuries (TBI).
    TBI is the signature wound of this war, as thousands of our men and 
women in uniform are being exposed to blasts and other traumas which 
are doing great damage to their brains. This is an area where this 
Nation clearly must do more to care for our sick and disabled, the 
wounded warriors of this war.
    TBI manifests itself in a number of ways. While some are able to 
live with its effects, it makes life extremely difficult for others. We 
know much about its causes and immediate symptoms, but we must know 
more about it. We have repeatedly called for more studies to fully 
understand the injuries, their causes, their effects, and especially 
their long-term impacts.
    This legislation considers the long-term impact, and for those who 
need it, it would establish programs to provide long-term care and 
rehabilitation. This is sorely needed.
    Further, it fosters the development of partnerships with other 
healthcare institutions through the creation of a TBI transition 
office, which is charged with coordinating services that are not 
readily available through VA. Given the difficulties we have sadly seen 
with some of these wounded warriors receiving the care they need, 
especially for those who live far from the polytrauma centers, this is 
an excellent step. Many of these clinics and specialty care facilities 
have great experience with brain injuries and can provide these 
patients the care they desperately need, and VA with the expertise and 
training it needs to fulfill its most sacred of missions.
Draft Bill, the Rural Veterans Healthcare Act
    The VFW supports this bill which would make changes and 
improvements to the availability of healthcare for rural veterans.
    This legislation includes important provisions that would expand 
vet centers, and create an Advisory Committee on rural veterans. In 
concert with last year's passage of a law that creates an Office of 
Rural Health within VA, there is much potential to reach those veterans 
who have difficulty accessing their earned VA healthcare.
    It also would create four VA healthcare centers on rural health 
research, education and clinical care. These centers would allow for 
research into the delivery of healthcare to rural veterans, education 
and training for healthcare professionals, and for the innovation of 
clinical activities to benefit rural veterans.
    With over 44% of returning servicemembers living in rural areas, 
the access problems they and all veterans face is of increasing 
importance. This legislation acknowledges that, and we are happy to 
support it.
    Mr. Chairman, I thank you for the opportunity to present the VFW's 
views on these important bills today, and I look forward to any 
questions that you or the Members of this Subcommittee may have.

                                 
                Prepared Statement of Richard F. Weidman
          Executive Director for Policy and Government Affairs
                      Vietnam Veterans of America
    Chairman Michaud, Ranking Member Miller, and Members of the 
Subcommittee on Health, Vietnam Veterans of America (VVA) thanks you 
for the opportunity to testify here today. And on behalf of our 
officers, our Board of Directors, our members and their families, we 
thank you, too, for the important work you are doing, and the 
initiatives you are taking, on behalf of our Nation's veterans.
    We would like to focus our comments this morning on three of the 
bills up for your consideration. They are H.R. 463, H.R. 1944, and the 
discussion draft of the ``Rural Veterans Healthcare Act of 2007.''
    Priority 8 Veterans/H.R. 463, the ``Honor Our Commitment to 
Veterans Act,'' would re-open the VA healthcare system to Priority 8 
veterans. These are veterans with an income of less than $28,000 a year 
who are not afflicted with a service-connected disability and who agree 
to make a co-payment for their healthcare and prescription drugs.
    Back in 1996, when Congress passed the Veterans Healthcare 
Eligibility Reform Act, the VA was able to implement major cornerstones 
of its plan to reform how it provided healthcare. The rationale behind 
this initiative was to ensure a patient base that would support the 
infrastructure needed to develop a modern, integrated healthcare 
system. This the VA has done, and in the process it has transformed a 
mediocre, inefficient system into a national model.
    However, the law--that's Public Law 104-262--gave the Secretary of 
Veterans Affairs the authority and responsibility to determine 
eligibility for enrollment based on available resources in any given 
fiscal year. Although the law did not mandate a level of funding or a 
standard of care, it did establish an annual enrollment process and 
categorized veterans into ``priority groups'' to manage enrollment.
    On January 17, 2003, the Secretary made the decision to 
``temporarily'' suspend Priority 8 veterans from enrolling. While this 
decision may be reconsidered on an annual basis, every budget proposal 
from the Administration since has omitted funding for unenrolled 
Priority 8 veterans and attempts to discourage use and enrollment of 
those ``higher income'' veterans.
    Priority 8 veterans are, for the most part, working- and middle-
class Americans without compensable disabilities incurred during their 
military service. In its budget proposal for fiscal year 2007, the VA 
estimated that some 1.1 million of these ``higher income'' veterans 
would be discouraged from using their healthcare system because of a 
$250 enrollment fee and increased co-pays for prescription drugs. 
Thankfully, you in Congress have not let this scheme get much beyond 
the proposal phase.
    H.R. 463 would amend Section 1705 of Title 38, United States Code, 
by adding this new subsection: The Secretary shall administer the 
healthcare enrollment system under this section so as to enroll any 
veteran who is eligible under this section for such enrollment and who 
applies for such enrollment.
    Enacting this bill into the law of the land would keep the promise, 
keep the covenant with those veterans who, for whatever reasons, would 
choose to use the VA for their healthcare needs. We believe that their 
addition to the rolls would ease some of the fiscal pressures 
experienced by the VA insofar as it is Priority 7 and 8 veterans whose 
private health insurance accounts for some 40 percent of the VA's 
third-party collections.
    Of course, the bottom line is funding--the funding Congress 
provides--to enable the VA to accommodate those Priority 8 veterans who 
want to avail themselves of the VA's medical services. VVA will be 
releasing shortly a White Paper on veterans' healthcare funding, which 
will place this issue in context.
    TBI/Traumatic brain injury suffered by our troops in Afghanistan 
and Iraq has become so relatively common that it is referred to by its 
acronym, TBI. This affliction is not new; it has only been so codified 
because of the carnage caused by IEDs, improvised explosive devices, 
another acronym that has been incorporated into the dialect of war.
    We understand that the Administration is going to order the 
military to screen all returning troops for mild to moderate cases of 
TBI; those whose brain injuries are more serious are quite obvious to 
clinicians. H.R. 1944, the ``Veterans Traumatic Brain Injury Treatment 
Act of 2007,'' would go a long way toward assuring troops afflicted 
with this debilitating condition that help will be there for them. 
Focusing TBI care at four VA polytrauma centers, establishing and 
maintaining a registry of veterans diagnosed with TBI, and developing 
and inaugurating a comprehensive program for long-term TBI 
rehabilitation will go a long way toward healing the wounded from these 
latest military ventures.
    Rural Veterans Access to Care/How to provide more convenient access 
to quality healthcare for veterans residing in rural areas has been the 
subject of more than a few hearings over the past two sessions of 
Congress. The language in this proposed bill is as sensible as it is 
needed. It would establish pilot projects to see what is most effective 
in providing care. One of these pilots would expand access to vet 
centers via mobile centers in rural areas. Another would establish a 
health information technology program.
    Perhaps more importantly, this legislation would direct the 
Secretary of Veterans Affairs to establish an Advisory Committee on 
Rural Veterans, which would identify specific problems and areas of 
concern and suggest cost-effective solutions. It would require the 
Under Secretary for Health to designate a minimum of four VA healthcare 
facilities as the locations for centers of rural health research, 
education, and clinical activities. And it would establish programs to 
enhance the education, training, recruitment, and retention of nurses 
and other health professionals in rural areas.
    In seeking ways to better serve our rural veterans, this bill would 
not impose bureaucratic ``solutions'' that could and, we believe, would 
only serve to undermine the VA healthcare system. H.R. 92, the 
``Veterans Timely Access to Healthcare Act,'' would give the VA a scant 
30 days to set up an appointment with a primary-care provider; if a VA 
medical center is unable to meet this standard for access to care, the 
option would be to send a veteran to a non-VA facility. H.R. 1426, the 
``Richard Helm Veterans' Access to Local Healthcare Options and 
Resources Act,'' would offer an eligible veteran the option of 
obtaining healthcare from a non-VA facility or provider. H.R. 1527, the 
``Rural Veterans Access to Care Act,'' would expand the use of fee-
basis care through which private hospitals, healthcare facilities, and 
other third-party healthcare providers are reimbursed. It would impose 
a series of conditions, or distances, to help define ``rural.'' Like 
H.R. 1527, H.R. 315, the inelegantly named ``Help Establish Access to 
Local Timely Healthcare for Your Vets (HEALTHY Vets) Act of 2007'' 
would add bureaucratic clutter to those whose responsibility it is to 
provide healthcare for veterans in ``geographically inaccessible'' 
areas.
    Rather than improve healthcare for veterans, this quartet of bills, 
along with H.R. 339, the ``Veterans Outpatient Care Access Act of 
2007,'' would, if enacted, usurp the VA healthcare system. Today, one 
out of every ten VA healthcare dollars goes to clinicians and 
facilities outside the VA system. Through a scheme called Project 
HERO--the acronym for Healthcare Effectiveness through Resource 
Optimization--the VA is attempting to get a better handle on the 
dollars spent by VA medical centers on care provided outside of the 
system. We believe that HERO--and this quartet of bills--would only 
serve to hurt what has developed into one of the best-managed care 
systems in the Nation. HERO is a pilot in four VISNs, one that we 
believe will eventuate in half care for twice the cost.
    One bill we do applaud is H.R. 538, the ``South Texas Veterans 
Access to Care Act of 2007.'' ``They've been looking at this for a long 
time,'' one VVA leader in Texas told us. ``We did get an outpatient 
clinic in Conroe, in east Texas, but there are a lot of veterans in 
south Texas who are poorly served.'' If one in five of the 114,000 
veterans there uses the VA as their healthcare provider, that's 11,400 
who have to trek up to San Antonio for any real care.
    H.R. 538 basically says, let's find out the facts, whether the 
needs of veterans in far south Texas for acute inpatient care would 
best be met through a project for a public-private venture to provide 
inpatient services and long-term care in an ex-
isting facility, through construction of a new full-service, 50-bed 
hospital with a
125-bed nursing home, or through a sharing agreement with a military 
treatment facility.
    This is a very worthy bill, one that deserves serious consideration 
by this Subcommittee and by the HVAC at large.
    VVA also endorses H.R. 542, which would require the VA to provide 
mental health services in languages other than English, as needed, for 
veterans with limited English proficiency. While it can be argued that, 
to make it in today's military a troop needs proficiency in English, it 
is quite possible that (s)he is more conversant, and more comfortable, 
speaking in his/her native language. And many families of our diverse 
population of servicemembers are hardly fluent in English. When troops 
return from places like Iraq, which have seared their soul and messed 
up their mind, and need counseling, it is highly beneficial to have a 
trained and competent counselor or therapist who can ``relate'' better 
because (s)he speaks Spanish, or French, or Vietnamese.
    Finally, two bills that would effectively expand chiropractic care 
in VA medical centers, H.R. 1470 and H.R. 1471, are also worthy of 
passage--if proper standards of care are spelled out and enforced. We 
also would encourage, as part of these bills, a mandate for the VA to 
examine other ``alternative'' forms of medicine, so long as they 
conform to VA's evidence-based medical study. To this end, VVA suggests 
that part of this legislation should direct the Secretary of Veterans 
Affairs to appoint a committee to look at the efficacy of these 
alternative medical techniques with an eye toward integrating the most 
worthy of them into the VA healthcare system.
    This concludes our testimony. Again, VVA is appreciative of having 
been afforded the opportunity to testify on the merits of these bills. 
We would be pleased to respond to any of your questions.

                                 
           Prepared 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 morning, Mr. Chairman and Members of the Subcommittee:
    Thank you for inviting me here today to present the 
Administration's views on several bills that would affect Department of 
Veterans Affairs (VA) programs that provide veteran healthcare benefits 
and services. With me today is Walter Hall, Assistant General Counsel. 
We are able to present views for most of the bills on the 
Subcommittee's agenda. However, because of the limited time we have had 
to evaluate these bills, we stand ready to work with you to provide 
further information, including costs, at a later time for those pieces 
of legislation we are not able to fully address today.
H.R. 92--Standards of Access to Care
    Mr. Chairman, I will begin by addressing H.R. 92. This bill would 
establish 30 days as the standard within which VA must provide a 
veteran with primary care (measured from the day the veteran contacts 
VA seeking primary care to the day on which the primary-care visit is 
completed). The bill would also require VA to establish a standard for 
how promptly patients must be seen in relation to their scheduled 
appointments in VA facilities (measured from the time of day of the 
veteran's scheduled appointment to the time of day the veteran actually 
sees the provider). There would be consequences for those facilities 
that do not meet these standards 90 percent of the time. In such 
facilities, if VA is unable to meet either of these standards with 
respect to a veteran, VA would be required to contract for that 
veteran's care in non-VA facilities if the veteran is enrolled in 
Priority Groups 1-7. VA would be authorized (but not required) to 
contract for such care if the veteran is enrolled in Priority Group 8.
    The bill provides that payments under these contracts could not 
exceed the reimbursement rate under Medicare, and the non-VA facility 
or provider would be prohibited from billing the veteran for the 
difference between the billed amount and the amount of VA's payment.
    We have no significant objection to H.R. 92 with respect to the 30-
day standard for the scheduling of patients but ask the Committee to 
change the bill language to clarify that it would in fact apply only to 
new patients. It is these patients who need to be tracked to understand 
if there are difficulties accessing the VA system of care. In most 
areas, VA already complies with and exceeds these standards. Almost all 
VA facilities currently comply with the 30-day standard 90 percent or 
more of the time. We note, however, that in those situations where this 
bill would require VA to contract for care, restricting VA to paying 
the Medicare rate could make it difficult for VA to obtain the care in 
the private sector. There is no requirement in the bill that 
contractors, even if they are Medicare providers, agree to accept the 
Medicare rate from VA. This would limit the services that the VA could 
provide to veterans if the services cannot be purchased in the 
community at that rate.
    VA already has in place a standard requiring that a patient see his 
or her provider within 20 minutes of the scheduled appointment. We 
monitor facilities' compliance with this standard periodically through 
the use of quarterly patient satisfaction surveys. These surveys are 
based on a sampling of patients who report retrospectively on their 
perception of their last outpatient VA experience. I'll emphasize here 
that these ``waiting room times'' are important to VA as a matter of 
customer service. Results from the Fiscal Year 06 Customer Satisfaction 
Survey indicate that 77.8% of our patients waiting for primary care 
services are seen within 20 minutes of their appointment, and 70.5% of 
veterans obtaining specialty care services are seen within 20 minutes 
of their appointments. We are unaware of any other metric that could be 
used to implement the bill's requirements.
    We also believe the bill's approach is overly prescriptive and, as 
a result, would not provide latitude that is in the patient's best 
interest. Quality of care would be interrupted and fragmented with an 
increased requirement to send veterans outside the system. Moreover, 
the requirement that VA contract for care for patients waiting more 
than 20 minutes would not remedy the wait-experience of the patient for 
that visit. The bill is also flawed in that it assumes that all private 
care in the community meets the proposed standards. There are no 
measures available to support this assumption.
    Please be assured that VA, from top to bottom, considers within-
room-time an important aspect of customer service.
    We are still in the process of developing costs for H.R. 92 and 
will provide them for the record.
H.R. 463--Termination of the Administrative Freeze on Enrollment of 
        Veterans in Category 8
    Mr. Chairman, as you and the Subcommittee are well aware, VA 
suspended the enrollment of new veterans in the lowest statutory 
enrollment category (Priority Category 8--veterans with higher incomes 
and no compensable service-connected disabilities) in January of 2003. 
This action was taken to protect the quality and improve the timeliness 
of care provided to veterans in higher enrollment-priority categories. 
H.R. 463 would require VA to enroll all eligible veterans. VA strongly 
opposes enactment of H.R. 463.
    In 1996, Congress passed an Eligibility Reform law that allowed VA 
to treat veterans in the most appropriate treatment setting. 
Additionally, in order to protect the traditional mission of VA (to 
cover the healthcare needs of service-disabled and lower-income 
veterans), that law originally defined seven priority levels (PL) of 
veterans--PL 7 veterans (higher-income and not service-disabled) were 
the lowest priority. The law mandated that beginning in FY 1999, VA use 
its enrollment decision to ensure that care to higher-priority veterans 
was not jeopardized by the infusion of lower-priority veterans into the 
system for the first time. In FYs 1999 through 2002, the VA Secretary 
determined in each year that all veterans were able to enroll. Prior to 
1999, PL 7 veterans' care was not funded in budgets, but they could use 
the system on a space available basis. Consequently, they were only 
about 2% of the annual users. In FY 2001, 25% of enrollees and 21% of 
users were PL 7 veterans (using 9% of the resources). In 2001 PL 7 
veterans were split into two parts--those making above the geographic-
specific HUD threshold for means tested benefits were moved to a new PL 
8 category. More than half of the 830,000 new enrollees in FY 2002 were 
in Priority Group 8 and VA was not able to provide service-connected 
and lower-income enrolled veterans with timely access to healthcare 
services because of the unprecedented growth in the numbers of the 
newly eligible category of users. When the appropriation was finally 
enacted for FY 2003, VA's Secretary made the decision that the 
Department would not enroll any new PL 8 veterans--but those currently 
in the system would retain their right to care. Every appropriation 
since 2003 has supported this enrollment decision.
    H.R. 463 would essentially render meaningless the prioritized 
enrollment system, leaving VA unable to manage enrollment in a manner 
that ensures quality and access to veterans in higher priorities. VA 
would have to add capacity and funding to absorb the additional 
workload that this bill would entail, and so the quality and timeliness 
of VA healthcare to all veterans, including service-disabled and lower-
income veterans, would unavoidably suffer until this capacity is added.
    We note VA has authority to enroll combat-theater veterans 
returning from Operation Enduring Freedom and Operation Iraqi Freedom 
in VA's healthcare system and so they are eligible to receive any 
needed medical care or services.
H.R. 1426--Option for Enrolled Veterans to Receive Covered Health 
        Services through Non-VA Facilities
    Mr. Chairman, H.R. 1426 would permit enrolled veterans to elect to 
receive any and all hospital and outpatient care in non-VA facilities. 
Veterans would make their election by simply submitting an application 
to VA. VA would be required to authorize payment for such care pursuant 
to a contract entered into with the facility. In addition, the bill 
would require VA to fill veterans' prescriptions written by non-VA 
physicians.
    VA strongly opposes enactment of H.R. 1426. We fully concur in the 
views of several of the major Veterans Service Organizations, who 
recently wrote to the Chairman of the Senate Committee on Veterans' 
Affairs in opposition to a more modest proposal, S. 815, which would 
permit veterans with service-connected disabilities to obtain their 
healthcare at any private medical facility. (We will provide this 
letter to the Committee for the record.) Legislation to similarly cover 
all enrolled veterans, as proposed by H.R. 1426, would be all the more 
problematic. At bottom, H.R. 1426 could lead to the undoing of the VA 
healthcare system--a world-class healthcare system--as we know it 
today. For this fundamental reason, we must oppose H.R. 1426.
    We also have other concerns. The proposal would fragment the care 
of our veterans. VA would no longer have a complete record of all the 
care a veteran has received. This could lead to VA duplicating care 
already provided in the private sector or providing care that conflicts 
with what the veteran is receiving in the private sector. As you are 
aware, some in the private sector rely on paper records while the VA 
uses a comprehensive electronic health record. Electronic records 
promote patient safety. We are concerned that the bill, if enacted, 
could jeopardize continuity of care for our patients.
    These patient safety concerns also extend to the requirement that 
VA fill veterans' prescriptions written by non-VA physicians. We are a 
provider of care, including pharmacological services. VA should not 
serve as a mere pharmacy; rather VA facilities should continue to be a 
point of care where a veteran can receive all needed care in a safe, 
coordinated, and fully integrated fashion. We provide comprehensive 
care and continuity of care.
    We also point out that VA has neither the capacity to meet this 
demand nor the resources to carry out H.R. 1426. In fact, VA's mail 
order pharmacy service is already at full capacity. Increasing this 
workload would require adding additional capacity, in addition to the 
cost of the additional drugs.
    Although we have not completed our cost projections for this bill, 
we underscore that the bill could have significant cost implications. 
As soon as the cost estimates become available, we will supply them for 
the record.
    Mr. Chairman, I now turn to the two bills currently under 
consideration by the Subcommittee that would address access to 
healthcare for rural veterans.
H.R. 315--Fee Basis Authority for Veterans for Whom VA Facilities are 
        Geographically Inaccessible
H.R. 1527--Rural Veterans Access to Care Act
    H.R. 315 would require the Secretary to contract with non-VA 
facilities to furnish primary care services, acute or chronic symptom 
management, non-therapeutic medical services, and other medical 
services as deemed appropriate to veterans for whom VA facilities are 
geographically inaccessible. Veterans covered by this bill would 
include those who live in a county with a population density of less 
than 7 people per square mile and who live more than 75 miles away from 
the nearest VA healthcare facility; those who live in a county with a 
population density of more than 7 and less than 8 people per square 
mile and who live more than 100 miles from the nearest VA healthcare 
facility; and those who live in a county with a population density of 
more than 8 and less than 9 people per square mile and who live more 
than 125 miles from the nearest VA medical facility. This bill would 
take effect at the end of a 120-day period beginning on date of the 
enactment.
    H.R.1527 also relates to healthcare for enrolled veterans who 
reside in highly rural areas.
    Section 2 of H.R. 1527 would permit an enrolled eligible veteran to 
elect to receive healthcare through a non-VA healthcare provider. 
Veterans covered by this bill would include: veterans seeking primary 
care services who reside more than 60 miles driving distance from the 
nearest VA facility that provides primary care services; veterans 
seeking acute hospital care who reside more than 120 miles driving 
distance from the nearest VA hospital providing acute care; and, 
veterans seeking tertiary care who reside more than 240 miles driving 
distance from the nearest VA facility providing tertiary care.
    Also covered by section 2 of H.R. 1527 would be veterans whose 
distance from the nearest appropriate VA healthcare facility does not 
exceed the above-stated parameters but who experience hardship or other 
difficulties in traveling to a VA facility such that the Secretary 
deems travel to a VA facility not to be in the veteran's best interest, 
as determined under VA regulations.
    In carrying out section 2, the Secretary would be required to 
consult with the Secretary of Health and Human Services to establish a 
partnership to coordinate care for rural veterans at critical access 
hospitals, community health centers, and rural health clinics.
    Section 3 of H.R. 1527 would require the Secretary to furnish 
covered veterans with prescription drugs that are ordered by licensed, 
non-VA physicians. Under this section, VA would be required to furnish 
these medications in the same manner, and subject to the same 
conditions, as apply to medications that are prescribed by VA 
physicians.
    Both bills would give rise to obstacles to successful 
implementation and further expansion of our strategic plans, which 
focus on delivering healthcare services through sources that are 
nearest to a rural veteran's home. Both bills would create 
administrative issues, and implementation may simply be unworkable. We 
are also concerned that the requirements of section 3 of H.R. 1527 
would result in fragmentation of a veteran's medical care and the 
undermining of the VA formulary process, both of which put the patient 
at increased risk.
    Mr. Chairman, while we share the Subcommittee's concern for 
ensuring that rural veterans have adequate access to needed healthcare 
and services, we ask that the Subcommittee forbear in its consideration 
of either H.R. 315 or H.R. 1527. In accordance with Congress' mandate 
in the ``Veterans Benefits, Healthcare, and Information Technology Act 
of 2006,'' VA just recently established the Office of Rural Health 
(ORH) within the Veterans Health Administration. Part of that office's 
charge is to see how we can continue to expand access to care for rural 
veterans. We therefore recommend that no legislative action be taken in 
this area until VA has had sufficient time to complete and review the 
internal assessments currently underway by ORH and other Department 
components. We will of course share those findings with the 
Subcommittee along with our recommendations.
    VA has already done much to remove barriers to access to care for 
enrolled veterans residing in rural areas. Currently, over 92 percent 
of enrolled veterans reside within 1 hour of a VA facility, and 98.5 
percent of all enrollees are within 90 minutes. Still, we continue our 
efforts to try to ensure that all enrolled veterans living in rural 
areas have adequate and timely access to VA care. We expect the data 
for this year to be even better.
    Community-Based Outpatient Clinics (CBOCs) have been the anchor for 
VA's efforts to expand access to veterans in rural areas. 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. 
In addition, there are a number of rural outreach clinics that are 
operated by a parent CBOC to meet the needs of rural veterans, and 
several additional outpatient clinics are positioned to provide care 
for veterans in surrounding rural communities. VA's authority to 
contract for care under 38 U.S.C. 1703 provides a local VA medical 
center director with another avenue through which to meet the needs of 
many rural veterans.
    These efforts have borne fruit. Rural veterans tell us that they 
are satisfied with the services and high-quality care we are providing 
to them. This is substantiated by their reporting higher satisfaction 
with VA services in comparison to their urban counterparts. Moreover, 
performance measure data indicate that as a result of our intensive 
efforts to expand services for rural veterans, veterans have access to 
services 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. Quality of care in the rural 
environment matches that of urban care on 40 standard measures.
    Finally, we note that among the services that VA would be required 
to provide under H.R. 315 are ``non-therapeutic medical services.'' The 
meaning of this term is unclear. If the Subcommittee is to act on H.R. 
315, we ask it specify what services this provision is intended to 
cover.
    We are still in the process of developing cost estimates for both 
H.R. 315 and H.R. 1527. We will supply them for the record as soon as 
they become available.
H.R. 1470--Enhancement of Chiropractic Care Program
    Mr. Chairman, H.R. 1470 is one of two bills relating to the 
provision of chiropractic care. It would require VA to increase to not 
fewer than 75 the number of VA facilities directly providing 
chiropractic care through VA medical centers and clinics. H.R. 1470 
would require this to be implemented by not later than Decem-
ber 31, 2009. In addition, H.R. 1470 would require that chiropractic 
care be pro-
vided at all VA medical centers by no later than December 31, 2011.
    VA does not support H.R. 1470. VA does not oppose eventually 
increasing the number of VA sites providing chiropractic care. 
Currently, there is a facility with an in-house chiropractic care 
program in each of our geographic service areas. However, we do not 
believe, based on current usage rates, that sufficient demand for 
chiropractic care will exist to justify the mandate to provide 
chiropractic care at all VA medical centers by the end of 2011. 
Currently, 98% of VA patients are able to get chiropractic care within 
30 days of their desired date.
    Mr. Chairman, costs for H.R. 1470 are not yet available. We will 
supply them for the record.
H.R. 1471--Chiropractic Care Practice Expansion
    The second bill on chiropractic care is H.R. 1471. This bill would 
appear to permit eligible veterans to elect to receive needed medical 
services, rehabilitative services, and preventive health services from 
a licensed chiropractor on a direct access basis, as long as the 
chiropractor acts within the scope of practice authorized under his or 
her State license.
    VA uses chiropractic care to address certain muscular-skeletal 
conditions. However, we strongly object to extending, through 
legislation, the field of chiropractic care to the treatment of other 
medical conditions. In our view, because VA's healthcare system is 
national in scope, it should limit the scope of practice of the 
chiropractors to those procedures that are generally recognized to be 
within the scope of their practice, notwithstanding that some States 
may authorize them to provide other procedures.
    We have built our success on the primary care model using 
physicians who are trained and educated in primary care medicine. 
Primary care providers not only coordinate the delivery of healthcare 
services but also make referrals for specialty care, as needed and 
appropriate. We believe it is in our patients' best interest to 
continue having their individual primary care providers remain in 
charge of managing their care.
    H.R. 1471 could also place our patients at serious risk. Our aging 
patient population is characterized by a high degree of co-morbidities 
and complex medical conditions that require intensive and highly 
integrated clinical management skills. Their care should remain under 
the care of individual primary care providers and/or teams.
    Finally, this bill would prohibit the Secretary from discriminating 
among licensed healthcare providers in the determination of needed 
services. However, the meaning and intent of this provision is not 
clear to us.
H.R. 339--Provision of Care from Non-VA Sources When There is an 
        Extended Waiting Period for VA Care
    Mr. Chairman, H.R. 339 would require VA to furnish needed medical 
services from sources outside the Department to veterans who seek 
medical services at a VA outpatient clinic but are informed by the 
clinic that the waiting period for treatment of patients is 6 months or 
longer. This bill would also require such services to be provided under 
the same terms and conditions with respect to eligibility and 
copayments as would apply if such services were provided directly by 
the VA clinic. H.R. 339 would require the Secretary to issue 
regulations to implement this provision, which would take effect 90 
days after enactment of the Act.
    Mr. Chairman, we have not had sufficient time to evaluate H.R. 339 
and its costs. We will provide written comments on this bill for the 
record.
H.R. 538--Access to Care for Veterans Residing in Far South Texas
    H.R. 538 sets out a series of findings regarding the healthcare 
needs of veterans residing in far south Texas, a geographical area 
defined in the bill. Within 180 days following enactment, the Secretary 
would be required to determine whether the needs of veterans in far 
south Texas would best be met--(1) through a public-private venture to 
provide inpatient services and long-term care to veterans in an 
existing facility in far south Texas; (2) through a project for 
construction of a new full-service, 50-bed hospital with a 125-bed 
nursing home in far south Texas; or (3) through a sharing agreement 
with a military treatment facility in far south Texas. H.R. 538 would 
require the Secretary to notify Congress as to the Secretary's findings 
and to submit a report to Congress identifying which of these options 
has been selected, along with a prospectus that includes projected 
timelines and additional specified data.
    We do not support H.R. 538. At the request of Senator Kay Bailey-
Hutchison, VA has contracted with Booz Allen Hamilton to evaluate and 
report on current needs in this region of the country. This report is 
due to be delivered to VA in July 2007. VA recommends that Congress 
await the results of this ongoing evaluation before it considers 
whether to mandate a particular means for addressing the healthcare 
needs of these veterans.
H.R. 542--Provision of VA Services in Languages Other Than English for 
        Veterans With Limited English Proficiency
    Mr. Chairman, section 1 of H.R. 542 would require the Secretary to 
ensure that counseling and other authorized mental health services are 
available in both English and a language other than English, if 
requested by a veteran who has limited proficiency in the English 
language. H.R. 542 would further mandate that the Secretary develop 
procedures to identify veterans with limited English proficiency and 
inform them of this provision.
    Section 2 of H.R. 542 would require the Secretary to implement a 
system by which persons with limited English proficiency can 
meaningfully access VA services consistent with, and without unduly 
burdening, the fundamental mission of the Department. This section 
would require the Secretary to work to ensure that recipients of 
financial assistance under VA programs, in turn, provide meaningful 
access to applicants and beneficiaries with limited English 
proficiency.
    Under section 2, the Secretary would also be required to implement 
a plan to improve access to VA programs and activities by eligible 
persons with limited English proficiency, and to ensure that the plan 
is consistent with a guidance document issued by the Attorney General 
in conjunction with Executive Order 13166. The plan would have to 
include specific steps that the Secretary would take to ensure that 
these persons can meaningfully access VA programs and activities.
    Section 3 of H.R. 542 would require the Secretary to carry out a 
number of specified tasks, in developing and implementing the plan 
required by section 2. These tasks would include: (1) conducting a 
thorough assessment of the language needs of the population served by 
VA and identifying the non-English languages that are likely to be 
encountered; (2) developing a comprehensive language assistance program 
to include hiring bilingual staff and interpreters for patient and 
client con-
tact positions; (3) translating written materials into languages other 
than English; (4) training staff on this VA access policy and its 
implementation; (5) establishing vigilant monitoring and oversight to 
ensure that persons with limited English proficiency have meaningful 
access to healthcare and services; (6) establishing a task force to 
evaluate the implementation and prioritize needed actions to implement 
the access plan; (7) developing a specific plan to ensure seamless 
transition of veterans and their families from Department of Defense 
services and benefits to VA services and benefits, including bilingual 
readjustment and bereavement counseling; (8) establishing a process to 
translate vital documents and other materials, including materials 
available on the World Wide Web, outreach brochures provided to 
servicemembers transitioning into civilian life, and the post-
deployment health reassessment program; and (9) conducting outreach to 
veterans and their families in communities which may have higher 
proportions of populations with limited English proficiency.
    Finally, section 4 of H.R. 542 would require the Secretary to 
report to Congress on VA's implementation of VHA Directive 2002-006 
(prohibiting discrimination on the basis of national origin for persons 
with limited English proficiency in federally-conducted programs and 
activities and in Federal financial assisted programs). This report 
would also have to include an analysis of VA's capacity to provide 
services to members of the Armed Forces with limited English 
proficiency.
    Because we received a copy of H.R. 542 only very recently, we are 
still in the process of developing views and cost estimates for this 
bill. Once completed, we will provide them for the record. But we would 
like the Subcommittee to know that VA has taken significant steps to 
ensure that Executive Order 13166 is fully implemented throughout the 
Department. On February 12, 2007, VHA issued Directive 2007-009, 
Limited English Proficiency (LEP) Title VI Prohibition Against National 
Origin Discrimination in Federally-Conducted and Federally-Assisted 
Programs and Activities. This new policy updates the guidance 
previously set forth in VHA Directive 2002-006 and sets forth VHA's 
guidance on services to individuals with LEP. Similar guidance 
documents have also been issued by the National Cemetery System and the 
Veterans Benefits Administration. These LEP actions plans ensure that 
VA facilities and programs fully implement all LEP requirements.
    Mr. Chairman, in anticipation of this hearing, we also received a 
draft bill entitled the ``Rural Veterans Healthcare Act of 2007'' and a 
copy of H.R. 1944, the ``Veterans Traumatic Brain Injury Treatment Act 
of 2007.'' Because we received these two bills only very recently, we 
do not have cleared positions or costs to provide on the measures. We 
will provide written comments on the draft bill and H.R. 1944 for the 
record.
    This concludes my prepared statement. I would be pleased to answer 
any questions you or any of the Members of the Subcommittee may have.

                                 
             Statement of the American Academy of Neurology
    The American Academy of Neurology (AAN), representing over 20,000 
neurologists and neuroscience professionals, believes that our veterans 
deserve the best possible care and treatment for neurological injuries 
sustained in their service to our country. The conflicts in Iraq and 
Afghanistan have created an emerging epidemic of traumatic brain injury 
(TBI) among combat veterans. TBI is associated with cognitive 
dysfunction, post-traumatic epilepsy, headaches and other motor and 
sensory neurological complications.
    It is essential that the Federal Government allocate the resources 
to ensure all veterans have access to the necessary neurological 
interventions and long-term treatments that their injuries require. The 
AAN believes that Congress should fund and the Department of Defense 
(DoD) should fully implement pre- and post-deployment cognitive and 
memory screening of all active duty and reserve personnel. Recognizing 
that this is not yet a reality, the AAN supports the goal of H.R. 1944 
to establish a program within the Department of Veterans Affairs (VA) 
to screen veterans who are eligible for hospital care, medical 
services, and nursing home care.
    The AAN also supports the effort to create a comprehensive program 
for long-term traumatic brain injury rehabilitation, but would 
recommend the inclusion of a specific program to address the impacts of 
TBI including seizure disorder. TBI is a major cause of epilepsy. We 
estimate that up to 40 percent of returning service personnel who 
experience TBI will develop epilepsy making this a significant service-
connected disorder for many veterans.
    Given the likely high rate of service-connected post-traumatic 
epilepsy that veterans with TBI will experience, Congress should 
authorize and the VA should fully implement a national epilepsy 
program. This program should include a statutory mandate and the 
necessary appropriations for Epilepsy Centers of Excellence (CoEs), 
available to all veterans with epilepsy and related seizure disorders. 
Congress should authorize no less than six Epilepsy CoEs to ensure 
adequate geographic distribution and access by veterans to these 
centers. The VA should also implement epilepsy referral clinics in all 
Veterans Integrated Service Networks (VISNs).
    Congress should also appropriate adequate funds to improve the 
integration and coordination of neurology, mental health and 
rehabilitative services in the VA's polytrauma program. Every TBI 
veteran should have a neurologist as part of the rehabilitation team. 
The Neurology and Mental Health Services should become equal partners 
with the Rehabilitation Services with respect to TBI in the polytrauma 
centers and subsequent initiatives involving TBI.
    We support the Committee's efforts to improve VA's delivery of care 
to rural veterans. We recommend that the draft Rural Veterans 
Healthcare Act of 2007 include a provision to improve care to those in 
rural areas with an expansion in telehealth and telemental health 
services offered by the VA to improve the surveillance and treatment of 
veterans with TBI and related seizure disorders. Specifically, VA needs 
to develop its telemedicine capacity to transmit and review 
Electroencephalograms (EEGs), a diagnostic test which measures and 
records brain electrical activity, to VA specialists in epilepsy for 
interpretation as needed. The recommended Epilepsy Centers of 
Excellence would play a vital role in expanding VA's capacity to 
provide rural veterans with state-of-the-art diagnosis and clinical 
care through improvements in telemedicine.
    The American Academy of Neurology appreciates the opportunity to 
comment on H.R. 1944 and the draft Rural Veterans Healthcare Act of 
2007. We stand ready to assist the Health Subcommittee and the full 
Committee in any efforts to help veterans who experience TBI.
                                 
Statement of Hon. Corrine Brown, a Representative in Congress from the 
                            State of Florida
    Thank you, Mr. Chairman.
    I appreciate your calling this hearing today to listen to the many 
important bills introduced this Congress relating to veterans.
    As I have known since I was first sworn into Congress in 1993, when 
I first began my service on this Committee, veterans are very important 
to the security and defense of this country.
    Under the leadership of you, Chairman Michaud, and Chairman Filner, 
we are taking back the leadership of veterans issues to this Committee. 
It is important for the Veterans Committee to be the conduit for the 
veterans of this country to the Department of Veterans Affairs.
    Thank you again for holding this hearing and I look forward to 
hearing the testimony of the witnesses.
                                 
Statement of Hon. Ruben Hinojosa, a Representative in Congress from the 
                             State of Texas
    I want to thank Chairman Michaud and Ranking Member Miller for 
holding this important hearing today on legislation that will help 
improve the quality of healthcare for our veterans. I am here to 
express my strong support for H.R. 538, offered by my colleague from 
south Texas, Congressman Solomon Ortiz, of which I am a cosponsor.
    South Texas has a proud history of patriotism and thousands of 
south Texans have fought in all of this country's major wars. They have 
returned to south Texas with a variety of injuries and illnesses as a 
result of their military service. Unfortunately, the closest veterans' 
hospital is more than 300 miles away in San Antonio. Many south Texas 
veterans do not have the financial means to travel to San Antonio and 
stay overnight in hotels waiting for appointments and procedures. The 
VA provides some transportation in cramped vans, but the journey is 
long and many veterans are unable to make the trip.
    In addition to the veterans who make their permanent residence in 
south Texas, my region also sees hundreds of so-called ``Winter 
Texans'' who travel to south Texas to avoid the cold winters. These 
veterans use the limited clinic services currently available and in the 
past the local Veterans Service Region has not even been reimbursed for 
their care. Although the VA has worked to resolve this problem, it 
still has not resolved the problem of how to provide adequate health 
services to this additional population.
    Since coming to Congress, I have been working to get a full-service 
veterans hospital in south Texas. I have brought several Secretaries of 
Veterans' Affairs to the 
region and they all agree that the service is inadequate. Still, nothing
 has been done.
    The veterans in my community are tired of waiting and have taken 
action. Last year, they organized a march to San Antonio to show their 
commitment to getting their own hospital. Hundreds of veterans made the 
300 mile trek to San Antonio in the heat to show the Veterans 
Administration that they were serious.
    I hope the Committee will approve a new veterans' hospital in south 
Texas so that these veterans will finally receive the healthcare they 
deserve.
    Attached to my testimony is a petition signed by over 10,000 
veterans in south Texas in support of a veterans hospital. I ask that 
it be made a part of the hearing record.
    Thank you for your consideration and for holding this important 
hearing.

[THE PETITION IS BEING RETAINED IN THE PERMANENT COMMITTEE HEARING 
FILES AND IS NOT BEING PRINTED.]