[Senate Hearing 110-223]
[From the U.S. Government Printing Office]



                                                        S. Hrg. 110-223
 
            ACCESS TO VA HEALTH CARE AND BENEFITS IN HAWAII

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

           AUGUST 21, 2007, AUGUST 23, 2007, AUGUST 27, 2007

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                                 senate


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                     COMMITTEE ON VETERANS' AFFAIRS

                   Daniel K. Akaka, Hawaii, Chairman
John D. Rockefeller IV, West         Larry E. Craig, Idaho, Ranking 
    Virginia                             Member
Patty Murray, Washington             Arlen Specter, Pennsylvania
Barack Obama, Illinois               Richard M. Burr, North Carolina
Bernard Sanders, (I) Vermont         Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Lindsey O. Graham, South Carolina
Jim Webb, Virginia                   Kay Bailey Hutchison, Texas
Jon Tester, Montana                  John Ensign, Nevada
                    William E. Brew, Staff Director
                 Lupe Wissel, Republican Staff Director


                            C O N T E N T S

                              ----------                              

                            August 21, 2007
                                SENATORS

                                                                   Page
Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........     1
Inouye, Hon. Daniel K., U.S. Senator from Hawaii.................     3

                               WITNESSES

Del Negro, Ariana, Spouse of Operation Enduring Freedom Veteran..     5
    Prepared statement...........................................     7
Hoe, Allen K., Vietnam Veteran...................................    12
    Prepared statement...........................................    15
Joaquin, Thomas L., Senior Vice President of Operations, Hawaiian 
  Electric Company, Inc., and Member VA Advisory Council.........    18
    Prepared statement...........................................    19
Victor Opiopio, Vietnam Veteran..................................    19
Park, William Clayton Sam, Case Manager/Veterans Specialist, 
  Helping Hands-Hawaii...........................................    21
    Prepared statement...........................................    25
Vincent, Darryl J., Site Director, United States Veterans 
  Initiative-Hawaii..............................................    28
    Prepared statement...........................................    31
Kussman, Hon. Michael J., M.D., M.S., M.A.C.P., Under Secretary 
  for Health, Department of Veterans Affairs; accompanied by 
  Robert L. Wiebe, M.D., Director, VISN 21, Department of 
  Veterans Affairs; and James Hastings, M.D., F.A.C.P., Director, 
  VA Pacific Islands Health Care System, Veterans Health 
  Administration, Department of Veterans Affairs.................    35
    Prepared statement...........................................    37
Tuerk, Hon. William F., Under Secretary for Memorial Affairs, 
  Department of Veterans Affairs; accompanied by Gene 
  Castignetti, Director, National Memorial Cemetery of the 
  Pacific........................................................    42
    Satellite images, National Cemetery of the Pacific...........    79
    Prepared statement...........................................    43
Aument, Ronald R., Deputy Under Secretary for Benefits, 
  Department of Veterans Affairs; accompanied by Gregory Reed, 
  Director, Honolulu Regional Office, Department of Veterans 
  Affairs........................................................    46
    Prepared statement...........................................    47
Watrous, Julie, R.N., Regional Director, Office of Healthcare 
  Inspections, Office of Inspector General, Department of 
  Veterans Affairs; accompanied by Dr. Michael Shepherd, 
  Physician, Office of Healthcare Inspections, Office of 
  Inspector General, Department of Veterans Affairs..............    50
    Prepared statement...........................................    51
Wallace, Colonel Arthur P., Deputy Commander for Nursing, Tripler 
  Army Medical Center; on Behalf of Major General Carla Hawley-
  Bowland, Commanding General, Tripler Army Medical Center (TAMC) 
  and Pacific Regional Medical Command...........................    66
    Prepared statement...........................................    68
Lee, Major General Robert G.F., Adjutant General, State of Hawaii    71
    Prepared statement...........................................    74
Moses, Mark S., Director, Office of Veterans Services, Department 
  of Defense, State of Hawaii....................................    75
    Prepared statement...........................................    77
      Attachment, Hawaii Office of Veterans Services fact sheet..    79

                                APPENDIX

WW II Fil-Am Veterans and Ladies Auxiliary, Hawaii Chapter, 
  prepared statement.............................................    83
Caleda, Luz N., President, Ladies Auxiliary, WWII Fil-Am 
  Veterans, Hawaii Chapter, prepared statement...................    83
Clark, Charles L., President, Radiated Veterans of America, 
  prepared statement.............................................    84
                              ----------                              

                            August 23, 2007
                                SENATOR

Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........    87

                               WITNESSES

Evangelista, Rogelio, President, Maui Veterans Council...........    89
Kamai, Clarence, Jr., Member, VA Advisory Council................    91
Kanahele, Danny, Member, VA Advisory Council.....................    92
Skaggerberg, Mitch, President, Vietnam Veterans of Maui County...    93
Haupt, Prentiss Carl, Vietnam Veterans of Maui County............    95
    Prepared statement of Prentiss Carl Haupt and Mitch 
      Skaggerberg, on behalf of the Vietnam Veterans of Maui 
      County.....................................................    97
Karl Calleon, Vietnam Veteran....................................    98
Steward, Grant, Operation Iraqi Freedom Veteran..................    99
    Prepared statement...........................................   100
Stroud, William Fielding, Past President, Vietnam Veterans of 
  Maui County....................................................   101
    Prepared statement...........................................   103
Kussman, Hon. Michael J., M.D., M.S., M.A.C.P., Under Secretary 
  for Health, Department of Veterans Affairs; accompanied by 
  Robert L. Wiebe, M.D., Director, VISN 21, and James Hastings, 
  M.D., F.A.C.P., Director, VA Pacific Islands Health Care 
  System, Veterans Health Administration, Department of Veterans 
  Affairs........................................................   108
    Prepared statement...........................................   110
Moses, Mark S., Director, Office of Veterans Services, Department 
  of Defense, State of Hawaii....................................   113
    Prepared statement...........................................   116
      Attachment, Hawaii Office of Veterans Services fact sheet..    79
Shepherd, Michael, M.D., Physician, Office of Healthcare 
  Inspections, Office of the Inspector General, Department of 
  Veterans Affairs; accompanied by Julie Watrous, R.N., Regional 
  Director, Office of Healthcare Inspections, Office of Inspector 
  General, Department of Veterans Affairs........................   119
    Prepared statement...........................................   121

                                APPENDIX

Concerned Maui Disabled Vets, letter.............................   129
                              ----------                              

                            August 27, 2007
                                SENATOR

Akaka, Hon. Daniel K., Chairman, U.S. Senator from Hawaii........   131

                               WITNESSES

Ferreira, David T., Family Assistance Specialist, Hawaii Army 
  National Guard.................................................   132
    Prepared statement...........................................   134
Yano, First Sergeant Allison T., Operation Iraqi Freedom Veteran.   134
    Prepared statement...........................................   136
Ishikawa, Brigadier General Gary, Deputy Adjutant General, Hawaii 
  Army National Guard............................................   140
    Prepared statement...........................................   141
Gibbons, Colonel Gerald, Chief of Staff, 9th Regional Readiness 
  Command, U.S. Army Reserve.....................................   142
    Prepared statement...........................................   143
Hastings, James E., M.D., F.A.C.P., Director, VA Pacific Islands 
  Health Care System, Veterans Health Administration, Department 
  of Veterans Affairs............................................   147
    Prepared statement...........................................   149
Moses, Mark, Director, Office of Veterans Services, Department of 
  Defense, State of Hawaii.......................................   153
    Prepared statement...........................................   155
      Attachment, Hawaii Office of Veterans Services fact sheet..   157
Reed, Gregory, Director, Honolulu Regional Office, Veterans 
  Benefits Administration, Department of Veterans Affairs........   159
    Prepared statement...........................................   161

                                APPENDIX

Michael Kilpatrick, M.D., Deputy Director, Force Health 
  Protection and Readiness, Office of the Assistant Secretary of 
  Defense for Health Affairs, Department of Defense, prepared 
  statement......................................................   173
                              ----------                              


 HEARING ON HEALTH CARE AND BENEFITS FOR VETERANS IN HAWAII--HONOLULU, 
                                 HAWAII

                              ----------                              


                        TUESDAY, AUGUST 21, 2007

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10 a.m., in Oahu 
Veterans Center, Honolulu, Hawaii, Hon. Daniel K. Akaka, 
Chairman of the Committee, presiding.

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                    U.S. SENATOR FROM HAWAII

    Senator Akaka. Aloha.
    Audience. Aloha.
    Senator Akaka. I want to welcome you to today's hearing of 
the Senate Committee on Veterans' Affairs. This is the first of 
three field hearings that I'm chairing here in the state this 
week and next week.
    As you know, we held similar hearings at the start of 2006. 
Much of it has been improved since that time for which I am 
grateful.
    Audience. We cannot hear back here, sir. Turn the mic on, 
Senator Akaka.
    Senator Akaka. Can you hear now?
    Audience. (Applause.)
    Senator Akaka. Thank you. We held similar hearings before. 
And since then. I want to tell you that the Department of 
Veterans Affairs has done so much more than they were doing 
before, and we look forward to this hearing and continuing to 
improve services to our veterans. And it is important for the 
Committee to understand the remaining challenges we have now, 
which is the reason for these hearings.
    The VA Pacific Islands Health Care System's flagship is 
Hawaii. The Spark M. Matsunaga VA Medical Center is a very busy 
place and is in need of better ambulatory surgery space. We 
know, too, that the VA nursing home here is full and there are 
pockets on Oahu, especially on Leeward Oahu, that are 
underserved.
    I want to applaud the efforts of every VA employee on Oahu. 
These men and women work hard to help the veterans who seek 
their assistance and there are many things that VA does well in 
Hawaii. However, there is always room for improvement. I want 
to hear about how we can give VA the tools to make a difference 
in the lives of Hawaii's veterans.
    Back in Washington, we have worked hard to ensure that VA 
has the resources to provide the best possible care. The VA 
spending bill, which the Senate will take up early in 
September, includes $43 billion for VA, $3.6 billion more than 
was sought in the President's budget request. We are finally on 
track to adequate funding for VA mental health care and care 
for those veterans with traumatic brain injuries.
    We have also been spending time to ensure that DOD and VA 
work together to improve the transition process for 
servicemembers and veterans. Given the existing relationship 
between VA and Tripler Army Hospital, Hawaii should be at the 
forefront of national efforts to ensure that the two 
departments work closely together. We will explore that issue 
today.
    Congress has also given VA a significant increase in 
funding to hire new staff to deal with VA's claims backlog. The 
Veterans' Affairs Committee will carry out focused oversight to 
ensure that the hiring and training process proceeds in a 
timely fashion. And I've been sending my staff in Washington 
across the country to do this. VA and several veterans service 
organizations are working on innovative ways to process claims 
in a more efficient manner. I will ask VA to describe specific 
plans for using this funding to improve the claims adjudication 
process here in Hawaii.
    Another concern that the Committee will be looking into is 
the status of Punchbowl. VA erected columbaria at the cemetery 
to accommodate cremated remains but the demand has been much 
greater than we anticipated. I have worked with VA on how to 
address this problem and look forward to VA's testimony today.
    Over this week and next, I will examine health care and 
benefits in Hawaii. I want to tell you that when most of you 
were in here prior to our coming into this building and into 
this hall, we had a ceremony, an important ceremony outside in 
which Under Secretary Tuerk presented a check for $743,035, 
which will fund the next phase of the West Hawaii Veterans 
Cemetery in Kailua-Kona. This is a great plus for Hawaii and 
for its cemeteries, and I want to thank Under Secretary Tuerk 
for that. Given the state's unique features, VA must adjust its 
strategies that may be successful on the mainland but do not 
work as well here.
    It is vitally important that you share your thoughts with 
us so we know how to help VA help you and the rest of Hawaii's 
veterans. VA officials are here to listen to and respond to the 
concerns raised by the witnesses on the first two panels.
    Finally, I note that there are many veterans today who 
would like to testify. Following the more formal part of 
today's hearing, we are going to invite members of the audience 
to address the Committee. We ask that your comments be focused 
on veterans' issues only, and that you stick to the three 
minutes that you will have for your comments at that time.
    My staff is here to follow up with each of you and you will 
receive further information on that. If you do not wish to 
speak, feel free to provide a written comment to my staff. Once 
again, I want to say mahalo nui loa to all of you who are in 
attendance today. I look forward to hearing from today's 
witnesses, and we are so fortunate to have with us today, and 
to have him in the United States Senate, Senator Inouye. We are 
delighted to have him here.
    We do not have time to tell you all about him, but you know 
about him and how he has been such a leader in helping Hawaii 
over the years. We are so fortunate to have him here with us 
today, so I call on Senator Inouye for his opening comments.

              STATEMENT OF HON. DANIEL K. INOUYE, 
                    U.S. SENATOR FROM HAWAII

    Senator Inouye. Thank you very much, Mr. Chairman, and I'm 
pleased to join you and the Senate Committee on Veterans' 
Affairs on this field hearing on the topic of health care and 
benefits for veterans. And I thank you for your leadership in 
this very important area.
    Before I proceed, I'd like to join my Chairman in thanking 
the Department of Veterans Affairs through Under Secretary 
Tuerk. His presence here is a demonstration of the support of 
the Department that no veteran will be forgotten. It's very 
important. West Kona is not in the big city, but they are 
remembered. And Washington is here to tell us that and I'm most 
grateful to you, Mr. Secretary. Thank you.
    Mr. Chairman, I'm a wounded veteran of World War II, the 
very ancient war. There are many differences between that war 
and the current war in which we find ourselves embroiled. These 
differences are in one sense very simple and yet very profound 
and should be taken into consideration as we all work to ensure 
a more seamless continuum of care for our Nation's veterans. 
I'd like to make a few comments on this matter.
    First, the wounded veterans in the war in Iraq are usually 
transported on helicopters and find themselves receiving 
medical care in the field hospital within a half-hour of the 
infliction of the injury, which clearly increases their 
survivability rate.
    In World War II, there were no helicopters. The wounded 
were transported by stretchers, sometimes by ambulances and 
often times carried over rivers and mountains. My evacuation 
began at 3 o'clock in the afternoon on a stretcher, and we 
arrived at a field hospital at midnight nine hours later. As a 
result of the prolonged transport period, many of those who 
were wounded perished before they reached the hospital. I was 
lucky.
    Second, with the advancement of medical technology and the 
sophisticated capacity available in the field hospitals, 
today's veterans would survive much greater injuries. According 
to studies, double amputations are much more common in today's 
war as compared to World War II. Very seldom would you see a 
double amp World War II veteran. I think the reason is simple, 
the bleeding and trauma could not be sustained for nine hours.
    Additionally, during World War II great battles involving 
divisions, regiments were commonplace. The landing on Normandy, 
the Battle of the Bulge, and in the case of fire rescue of the 
Lost Battalion, it's no secret that medical facilities were 
inadequate to care for the thousands of wounded. We would never 
readily admit, but very difficult decisions and choices had to 
be made.
    In today's war, there are no great battles with thousands 
of injured. Fatalities are more likely caused by roadside 
bombing, terrorist suicide attacks, and loss of helicopter and 
the crew. The number of injured has not been too large to 
manage. Moreover, advancements in medical care have greatly 
increased the number of wounded veterans who survive life-
threatening injuries.
    Today's wounded veterans spend less time in hospitals than 
the veterans of my era. According to the best information 
available, if I had been wounded in Iraq with identical 
injuries, I would very likely be discharged from a military 
hospital in about six or seven months. And after that, spend a 
few months in a VA hospital.
    I spent 21 months in a military hospital. Nine months taken 
up for medical and surgical purposes and the fitting of a 
prosthetic device. There's no question that the prosthetic 
device I received was inferior to the state-of-the-art 
prosthetic device that today's veterans are receiving. Then I 
spent a year in a military rehab hospital. During that period, 
I learned how to drive. I was young when I left Hawaii. I 
didn't know how to drive. I received the license to drive in 
all states. I was taught carpentry, plumbing, taught how to do 
some electrical work.
    In fact, they taught me how to dine. After all, when I left 
Hawaii, I was accustomed to the spoon, the fork and a 
chopstick. I didn't know what an oyster fork looked like. I 
learned to play a musical instrument. It was required in my 
hospital. I couldn't play a saxophone because you needed two 
hands for that; so finally they decided to teach me how to play 
the piano, and I got approval of my peers and instructors to 
perform. And I was required to take up two sports, basketball 
and swimming. My swimming lessons were not in the hospital 
pool. It was in a public place with people all over the place.
    So my first lesson was a rather difficult one. I did what 
most humans do. I wrapped myself in a big towel to hide my 
scar. I didn't want to expose them. However, after two or three 
lessons, no big deal. That's rehab. I remember when I returned 
home to Hawaii and I told my mother I'm going to Waikiki, and 
she was very happy. She thought I was going to do some 
shopping. I said, ``No I'm going swimming.'' Her first reaction 
was, ``Are you going to swim with your clothes on?'' It's human 
nature to hide scars from your friends and your beloved ones.
    Well, when I told her I'm going to swim in a regular pair 
of shorts, she was stunned. But rehabilitation is very 
important. It's not enough just for the physical, but you must 
take care of the mental and the emotional well being of the 
person. I can honestly tell you that I left the hospital with a 
measure of confidence in myself, and I was ready to face the 
world.
    Today our advancements in technology has allowed us to 
swiftly transport our injured to high quality field hospitals 
where our advancements in medicine have resulted in a high 
survival rate such as brain injuries. There are very few 
internal injuries because you have your armored vest. The 
double amps are very common. Brain injuries are very common. 
You don't see too much of that on the front pages. That's what 
it is.
    There are many fellow veterans who lie today looking at the 
ceiling and nothing else. So may I suggest that we do not 
forget the importance of also healing the mind, healing the 
spirit which comes often times from basic human contact. And 
advancement of technology cannot replace that. Time, patience, 
counseling should also be a part of the rehab package. Our 
obligations should not end after the operating table. The 
standard for which we must strive for today's veterans is to 
leave government care completely healed both body, mind, and 
soul and be ready to face the world with a measure of 
confidence and hope.
    Mr. Chairman, I look forward to hearing the testimony of 
the witness panels which we'll touch upon the issues and the 
needs of Hawaii's veterans, veterans of my age, veterans of 
those who recently came home.
    Mr. Secretary, I'm happy to tell you that our VA in Hawaii 
is doing an absolutely great job. The service at Tripler is 
unbelievably good. In fact, we set the motto for the rest of 
the Nation to follow. But we must build upon this to continue 
and ensure access to quality health care services. May I once 
again tell you publicly you got a good man in chain. He's doing 
a good job in Washington.
    Thank you very much.
    Audience. (Applause.)
    Senator Akaka. Thank you very much, Senator Inouye. Many of 
you know that he has shared very personal information about 
what has happened to him and how much he cares for veterans. I 
want to welcome the first panel, and I want to thank them all 
for being here.
    First, I welcome Ariana Del Negro. She is the wife of an 
Operation Enduring Freedom veteran with Traumatic Brain Injury. 
Second, I welcome my good friend Allen Hoe, a veteran of the 
Vietnam War and member of the VA's Advisory Committee on the 
Readjustment of Veterans. I also welcome Tom Joaquin, a member 
of VA's advisory council.
    I welcome Victor H. Opiopio, who suffered a back injury 
while serving in the military. I welcome Clay Park, a case 
manager for Helping Hands-Hawaii and a former medic in the 
Vietnam War. Darryl J. Vincent will be our last witness on 
panel one. He is the site director of the United States 
Veterans Initiative.
    I want to thank each of you for being here today. Your full 
statements will appear in the record of the Committee.
    Ms. Del Negro, would you please begin with your statement.

                STATEMENT OF ARIANA DEL NEGRO, 
           SPOUSE OF OPERATION IRAQI FREEDOM VETERAN

    Ms. Del Negro. Good morning.
    Senators, thank for very much for the opportunity to share 
our experience regarding our medical care my husband received 
in Hawaii for his Traumatic Brain Injury also known as TBI. 
I'll do my best to keep this brief and will refer you to my 
written testimony for further detail and discussion.
    My name is Ariana Del Negro, and, sadly, I represent one of 
the many military wives or caregivers coping with the hardships 
of having a soldier return wounded from Iraq or Afghanistan. 
What my husband and I have had to endure over the course of the 
last 10 months struggling to navigate through a convoluted, 
outdated, unprepared bureaucratic military health care system 
has been absolutely untenable.
    The treatment we received here in Hawaii fell well short of 
what the standard of care should be for those who fought to 
protect democracy and freedom. It is my hope that sharing our 
story today will increase awareness regarding the gaps in care 
for TBI, will highlight the importance of supporting and 
educating families and will emphasize the benefits of early and 
appropriate referrals to Centers of Excellence.
    On September 28, 2006, my husband suffered a TBI when a 
7,000 pound VBIED (vehicular-borne improvised explosive 
device), detonated 45 yards from where he was standing. The 
primary, secondary and tertiary concussive forces from the 
blast rendered him unconscious for at least 10 minutes. He 
spent three days in the intensive care ward at Balad Military 
Hospital and was subsequently released and returned to his base 
in Iraq with the anticipation that the fog of his closed-head 
TBI would subside sufficiently enough that he could return to 
duty.
    An Army Ranger, my husband is a well-respected member of 
his battalion and held one of the most esteemed and coveted 
positions for a lieutenant, that of a Scout Platoon Leader 
responsible for collecting intelligence in an area rich with 
diverse religious and political sects. He commanded deep 
respect from his men and performed his job to the highest 
degree of excellence and professionalism. He deserved the same 
from the system that he served.
    Instead, this brain-injured soldier and Purple Heart 
recipient was returned three weeks later to his home base in 
Hawaii and told to follow up with the system for evaluation and 
treatment. My husband could barely keep his balance, let alone 
figure out where he was supposed to go and who he was supposed 
to see. From his first doctor's appointment, it became clear 
that the system was reactive, not proactive. There was no 
initiative taken to get him care. We had to do it all alone 
facing obstacle after obstacle.
    In short, referrals were not made and there was absolutely 
no communication or consensus between the providers we were 
ultimately able to see and only able to see after demanding 
that those appointments be made.
    My husband describes the struggles we've had with Tripler 
Army Medical Center as being as painful as sustaining the 
injury itself. Perhaps some of our difficulties were because 
his injury was hidden, only overtly apparent to those familiar 
with the man that he was before his injury. As we would 
eventually learn, the subtleties of TBI often lead to claims 
that soldiers are malingering, shirking out of having to 
redeploy to the battlefield. Such flagrant accusations were 
thrust upon my husband adding salt to an already open wound. 
This was a system that was supposed to heal wounds, not create 
new ones.
    My husband was fortunate enough to have remarkable support 
from his command. His commander took interest in his case, 
provided support and dedicated many hours of his time seeking 
resolution to our long list of outstanding issues. Without his 
support and the support of the 25th Infantry Division, it's 
likely I would be sharing a different story with you today.
    Our frustrations with my husband's care endured for long 
and frustrating weeks. After not being a priority in the system 
and after no coordinated plan of care meeting was organized, my 
husband's request for a referral to an experienced center was 
granted. Five months after his injury, a pivotal time during 
the acute rehabilitation stage, and with the help of the 25th 
Infantry Division, we were fortunate enough to report to the 
Defense and Veterans Brain Injury Center, the DVBIC, at Balboa 
Naval Medical Center in San Diego, which coordinated with the 
community reentry program at Sharp Rehabilitation Center, a 
civilian center for follow-up care.
    The care in San Diego represented the complete antithesis 
of what we received in Hawaii. My husband underwent intensive 
rehabilitation six hours a day, four days a week, care he 
should have received all along. The providers at Sharp 
Rehabilitation Center addressed all of my husband's needs, 
integrated our requests into their rehab program and provided 
amazing support to both of us.
    Importantly, they educated us. We learned that the adverse 
effects of the injury would have resolved faster had some of 
the frustration with his medical care been avoided.
    My husband left San Diego a changed man. He regained his 
ability to accomplish complex tasks, his speech was fluid, he 
was able to run and he passed a driving evaluation. He has 
since returned to duty in an administrative capacity working 
with his units, Rear Detachment here in Hawaii.
    Since our return to Hawaii, we learned that Tripler Army 
Medical Center has launched several initiatives to assist its 
wounded warriors.
    I am pleased to know that Tripler recognizes the need to 
make the care of wounded soldiers its top priority and has 
begun to implement programs that have the potential to improve 
tracking and coordination of care as well as support for 
families. There is still much work to be done, however. My 
husband and I hope to collaborate with Tripler to help ensure 
that no other wounded warriors and their families experience 
similar hardships.
    Senators, I urge you and your and colleagues to remain 
steadfast in your endeavors to ensure: (1) that programs are 
instituted to increase awareness of the signs, symptoms and 
appropriate treatments for TBI especially closed-head TBI; (2) 
that soldiers with TBI and their families receive education 
about the injury, are provided access to resources and receive 
unconditional support; and (3) that appropriate and early 
referrals are made to dedicated centers adequately prepared to 
treat the complexities of Traumatic Brain Injury.
    Certainly we can all agree that it's time the excellence 
that these soldiers dedicated in the battlefield be matched by 
the system for which they sacrificed. I again, thank you for 
the opportunity to participate in this vital forum.
    [The prepared statement of Ms. Del Negro follows:]

                Prepared Statement of Ariana Del Negro, 
               Spouse of Operation Iraqi Freedom Veteran

    Mr. Chairman, Members of the Committee, and panel members, thank 
you for the opportunity to participate in this vital forum on veterans' 
care and benefits in Hawaii. By sharing our story today, I hope to 
increase awareness regarding the gaps in medical care for veterans 
receiving treatment in Hawaii, as it is my opinion that the military 
healthcare system here on Oahu, as it now stands, is insufficiently 
prepared to address the needs of our wounded veterans and their 
families suffering from Traumatic Brain Injury (TBI). There is much 
work to be done that requires diligent initiatives for research, 
education, and family support. My hope is that our story demonstrates 
the importance of prompt referral to centers specifically tailored to 
the individual needs of each wounded warrior and highlights the need to 
streamline the transition from active duty to veteran status.
    My name is Ariana Del Negro and, sadly, I represent one of the many 
military wives/caregivers coping with the hardships of having a soldier 
return wounded from Iraq or Afghanistan. But I'm one of the lucky ones. 
My husband and I are well educated, I work in the healthcare industry, 
and we are financially independent. What we have had to endure over the 
course of the last 10+ months struggling to navigate through a 
convoluted, outdated, unprepared bureaucratic military healthcare 
system has been absolutely untenable. If it has been this difficult for 
us, I cannot imagine what it must be like for the other families--those 
with warriors who return far worse off than my husband; families with 
children; with mothers who have to work to supplement the family 
income; and those who don't know that the care they are receiving is 
far inferior to what they need and, importantly, deserve. The wounds 
suffered from these injuries extend beyond the soldier; the 
frustrations, gaps in care, and lack of support also wound the families 
fighting for their loved ones. There are soldiers and families out 
there that need help and the onus to get them that help falls on the 
Nation for whom these warriors fought to protect democracy and freedom.
    On September 28, 2006, my husband suffered a TBI when a 7,000 pound 
VBIED (vehicular-borne improvised explosive device) detonated 45 yards 
from where he was standing. He was exposed to 3 concussive forces: 
first the explosion; then the engine block from the vehicle which 
struck him on the back of the head as he was thrown into the air; and 
finally when he hit his head again after falling to the ground on his 
back, where he remained unconscious for at least 10 minutes. He spent 3 
days in the intensive care ward at Balad Military Hospital and was 
subsequently released and returned to his base in Iraq with the 
anticipation that the fog of his mild/moderate (closed-head) TBI would 
subside sufficiently enough that he could return to full duty.
    An Army Ranger, my husband is a well-respected member of his 
battalion and held one of the most esteemed and coveted positions for a 
lieutenant--that of a Scout Platoon Leader responsible for collecting 
intelligence in an area rich with diverse religious and political 
sects. He commanded deep respect from his men and performed his job to 
the highest degree of excellence and professionalism. He deserved the 
same from the system that he served.
    Instead, this brain-injured soldier and Purple Heart recipient was 
returned 3 weeks later to his home base in Hawaii and told to follow-up 
with the system for evaluation and treatment. My husband could barely 
keep his balance, let alone figure out where he was supposed to go and 
who he was supposed to see. Unfortunately, the system he reported to 
didn't know either. From his first doctor's appointment in Hawaii, it 
became abundantly clear that the system was ``reactive,'' not 
``proactive''. There was no initiative taken to get him care; we had to 
do it all alone, facing obstacle after obstacle along the way. In 
short, referrals were not made, diagnostic tests were not ordered, 
complaints of mental duress (anxiety) went ignored, and there was 
absolutely no communication or consensus between the providers we were 
ultimately able to see (and only able to see after demanding that those 
appointments be made). In my opinion, regardless of the medical 
setting--military or otherwise--this care or the lack thereof amounts 
to negligence and malpractice.
    My husband describes the struggles we have had with Tripler Army 
Medical Center as being as painful as sustaining the injury itself. 
Perhaps some of our difficulties were related to the fact that a 
closed-head TBI is literally a hidden injury; an injury with the 
potential for subtle (yet devastating) sequelae that go unnoticed by 
those who are unfamiliar with the individual's function before his or 
her injury. Healthcare professionals are used to having physical 
evidence of an injury, but typically, the diffuse axonal injury pattern 
that results from the blast wave of pressure from an exploding IED 
cannot be neuroimaged and proper identification and referral to 
treatment are made on the basis of neurologic examination, self-and 
family reported symptoms, and the results of neuropsychological 
testing. Oftentimes, this can lead providers to think that soldiers are 
malingering, shirking out of having to return to duty in Iraq or 
Afghanistan. Such accusations were wrongly thrust upon my husband, 
adding salt to an open wound. This was a system that was supposed to 
heal wounds, not create new ones. It failed and it has not failed us 
only; it has failed many of the returning wounded warriors.
    However, my husband was fortunate enough to have remarkable support 
from his Command. His Commander took interest in my husband's case, 
provided support, and dedicated many hours of his time seeking 
resolution to our long list of outstanding issues. Without his support 
(and the support of the 25th Infantry Division), it's likely that I 
would be sharing a different story with you.

                         EARLY DISAPPOINTMENTS

    My husband returned to Hawaii approximately 3 weeks after he was 
wounded. At that time, he complained of debilitating headaches, chronic 
vertigo, memory lapses, anxiety, and hearing loss. He always leaned to 
the left, had hand and facial tics, and could not maintain eye contact 
when speaking. Two weeks thereafter, some symptoms worsened and new 
ones emerged. He developed a significant stutter, had difficulty with 
word recall, and had a propensity to drop things. It was also at this 
time that he began to withdraw socially, avoiding public and busy 
areas. His time was mostly spent sitting, staring blankly. My husband 
is an exceptionally accomplished and strong individual and it was very 
hard for me to see him struggle with simple tasks.
    After much insistence, he was referred for speech pathology and 
received speech cognition therapy once a week. The next mountain to be 
climbed was to get his vision checked and then to obtain referral for 
vestibular and audiology testing. During this time his symptoms 
persisted, and although some subsided, they never fully resolved. After 
14 long and frustrating weeks of not being a priority in the system, 
after no coordinated plan of care meeting was organized, and after 
being denied access to additional care (i.e., occupational therapy), 
our request to be referred to the Defense and Veterans Brain Injury 
Center (DVBIC) in San Diego for thorough evaluation and intensive 
treatment was finally granted. We waited another 6 weeks for all 
paperwork to be finalized and then reported to the DVBIC at Balboa 
Naval Medical Center who coordinated with the Community Re-entry 
Program at Sharp Rehabilitation Center (civilian) for follow-up care. 
All told, it took us more than 5 months to get access to excellent 
care. This was 5 months of valuable time lost, during what should have 
been the important acute rehabilitation stage of TBI.

        FINE EXAMPLE OF EXCELLENT CARE AND INVALUABLE EDUCATION

    The care in San Diego represented the complete antithesis of what 
we received in Hawaii. The providers at Sharp addressed all of my 
husband's needs (physical, occupational, and speech therapy), 
integrated our requests into their rehab program, and provided amazing 
support to both of us. My husband underwent intensive rehabilitation 6 
hours a day, 4 days a week--care he should have received all along. We 
had biweekly coordination meetings with providers at both Sharp and 
Balboa who met with us to discuss his progress, make suggestions, and 
ask for feedback. And, importantly, they educated us. We learned that 
our situation was not unique and that many closed-head TBI patients 
face similar obstacles and frustrations that compound their symptoms. 
They explained that the adverse effects of the injury would have 
resolved faster had some of the frustration with his medical care been 
avoided. They also explained that my husband would have probably made 
greater progress during rehabilitation had he been referred earlier in 
the treatment process; likely he would have reached the same degree of 
benefit, but at a much faster rate. Importantly, they also explained to 
us that there may be some symptoms that will never resolve and that the 
success of his rehabilitative therapy requires us to recognize 
reasonable goals while maintaining practical expectations.
    Shortly after coming home from Iraq, my husband commented that 
because he wasn't missing a limb and/or didn't have scars on his head 
or body, he didn't consider himself as seriously wounded as those with 
visible injuries, a sentiment reinforced by Tripler Army Medical 
Center's lack of initiative for his care. The absence of a visible sign 
of his injury took away from its severity, as well as his perceived 
need to treat it. The education we received from Sharp Rehabilitation 
as well as from the DVBIC helped alleviate some of those concerns and 
provided affirmation to my husband that he was seriously injured and 
did deserve the best possible care. It is our hope that with greater 
awareness of the consequences of TBI, providers will appreciate the 
importance of educating and supporting the patient and his/her family.
    My husband left San Diego a changed man. He regained his ability to 
accomplish complex tasks, his speech was fluid, he was able to run, and 
he passed a driving evaluation. He has since returned to duty in an 
administrative capacity, working with his unit's Rear-Detachment here 
in Hawaii. Although he still suffers from intermittent headaches, 
vertigo, fine motor skill deficits, and some memory problems, they are 
far less intense than when he first came home and he has applied the 
lessons we learned in San Diego and is accepting and compensating for 
these limitations accordingly.
    Our success with Sharp's Community Re-entry Program was the result 
of receiving excellent individualized care and education from a 
multidisciplinary group of providers who worked well together and 
integrated the family unit into the decision-making process. This 
medical model supports the plans outlined in Section 3 of the Veterans 
Traumatic Brain Injury Rehabilitation Act of 2007 (cited as S. 1233) 
describing rehabilitation programs that provide individualized care and 
family support to veterans with TBI. Section 3 of S. 1233 also 
identifies the importance of periodic evaluation and adjusting care as 
needed, which we experienced at the Sharp Rehabilitation Center.

        COMPREHENSIVE CARE: WHEN A REFERRAL IS REALLY NECESSARY

    My husband was very high-functioning after his injury and was not 
an individual who one would typically consider eligible for intensive 
rehabilitation. However, with the increasing awareness of the 
deleterious and long-term consequences of TBI--namely through the 
adoption of the DVBICs across the country--my husband was properly 
identified as someone who could benefit from such care. We utilized all 
of the tools at our disposal to the fullest. We knew that he was one of 
the lucky ones to get treatment and it is our hope that the success he 
(and Sharp Rehabilitation, in collaboration with the DVBIC and Balboa 
Naval Medical Center) achieved sets a fine example for what the 
standard of care should be for all soldiers returning with TBI. Our 
experience at the Sharp Rehabilitation Center also represents the 
importance of extending civilian healthcare services to returning 
soldiers. Programs, such as the one at Sharp, have experience with the 
injury, have an effective and efficient program in place, and clearly 
yield excellent results. More initiatives need to be taken to institute 
similar programs partnering military and civilian healthcare services. 
In addition, consideration must be given to properly pairing the 
offerings of a rehabilitation center with the specific needs of a 
veteran with TBI. In our case, and because my husband was high-
functioning, referral to the Sharp Community Re-entry Program was more 
appropriate than referral to the Veterans' Affairs (VA) Palo Alto 
Health Care System because the latter primarily manages patients with 
more severe TBIs. Veterans with TBI will be greatly served by having 
access to non-Department facilities for rehabilitation, as outlined in 
Section 4 of S. 1233.
    Our referral to the DVBIC in San Diego was absolutely appropriate, 
but the decision should have been made much earlier. In fact, my 
husband never should have been returned to Hawaii for evaluation and 
treatment of TBI. Typically, soldiers that are wounded and returned 
home are routed to Landstuhl for referral to Walter Reed or another 
center adequately equipped to treat the specific injury. Tripler was 
not an experienced center for TBI and should have recognized the 
importance of referring my husband to a center that could provide the 
necessary comprehensive care. This also speaks to the importance of 
Section 4 of S. 1233 for referral to a non-Department facility when 
``the Secretary is unable to provide such intervention, treatment, or 
services at the frequency or for the duration prescribed in such 
plan''. Tripler's unpreparedness to adequately treat TBI was reflected 
in the fact that appointments were few and far between and no 
coordination efforts were put forth to institute a plan of care for my 
husband's treatment--a necessary course of action mandated in Section 3 
of S. 1233.
    Since our return from San Diego, awareness of TBI has increased and 
programs are now being instituted to assist wounded warriors at all 
Army facilities, including Tripler. I am pleased to know that Tripler 
recognizes the need to make the care of wounded soldiers its top 
priority and has begun to implement programs that have the potential to 
improve tracking and coordination of care, as well as support for 
families.
    Although these initial steps are very promising, I remain concerned 
that much more work needs to be done before Tripler Army Medical Center 
has the necessary tools in place to effectively coordinate and manage 
the care of soldiers or veterans with TBI. Noted in Section 3 of S. 
1233, and also listed in a Veteran's Health Initiative, \1\ optimal 
care for TBI requires a multidisciplinary approach consisting of a team 
of providers from at least 9 specialties. I do not believe that Tripler 
will be able to establish a team that could coordinate or collaborate 
effectively enough to yield the necessary outcomes owed to a TBI 
wounded warrior, at least not at the present time.
---------------------------------------------------------------------------
    \1\ Veterans Health Initiative. Traumatic Brain Injury. Independent 
Study Course Released: January 2004.
---------------------------------------------------------------------------
                          ACCESS TO RESOURCES

    We hope to work with Tripler and its faculty to help ensure that no 
other wounded warriors and their families endure the same hardships 
that we faced. Furthermore, it is our hope that we will be given the 
opportunity to meet with some of the soldiers and their families to 
provide support, whether that be as simple as lending an ear or a 
shoulder or helping them gain access to important resources.
    It is critically important that soldiers and their families are 
proactively made aware of the resources that are available to them; 
they shouldn't have to seek them out. I wouldn't have known about the 
DVBIC unless I had actively sought out information and made contact 
with both Walter Reed and San Diego. I wouldn't have known that my 
husband wasn't getting the standard of care if I didn't work in the 
healthcare industry and if I hadn't done extensive research to educate 
myself on TBI and the multiple disciplines that must work together to 
treat the condition.
    Our endeavors paid off, it would seem. But what about those 
individuals who, in addition to the needs of their wounded loved one, 
have to tend to the needs of their children, or who don't have the 
flexibility with their work, or who don't have the benefit of higher 
education, or who don't know that they can ask questions? Those are the 
families in need. These families need immediate access to resources, 
they need advocates, and they need support. It's one thing to develop 
resources--it's another to actually utilize them. If the families don't 
know these resources exist, then they are certainly not likely to ever 
reap the benefits from said programs.

            TRANSITIONING FROM ACTIVE DUTY TO VETERAN STATUS

    The above traces the trials and tribulations that my husband and I 
faced during the early phases of his injury. Our frustrations, I fear, 
will continue for months and years to come. My husband is still on 
active duty and we are no closer to definitively determining his 
potential for return to full duty status than we were when he first 
returned from Iraq in October 2006. Unfortunately, the obstacles we 
faced during active duty will likely be inevitably revisited once he is 
discharged from the service and once he enters and seeks care in a 
backlogged and overwhelmed VA system (described as such after reading 
media accounts); whether that happens in the next year or in 12 years 
when he retires, remains to be determined.
    Although my husband is still on active duty, our experience 
represents what most young veterans suffering TBI have had to face 
before being discharged from the service. We must be able to learn from 
these initial experiences to avoid similar obstacles within the VA 
system. The continuum of care begins on the battlefield, moves to the 
military healthcare system, and then to the VA system. The Dignity for 
Wounded Warriors Act of 2007 (H.R. 1268) aims to overcome many of the 
limitations associated with wounded servicemembers' access to care. 
However, the success of both S. 1233 and H.R. 1268 are contingent on 
establishing an effective transition system. As noted in Section 2 of 
S. 1233, a collaborative effort between the Department of Defense and 
the VA is absolutely necessary to facilitate care and streamline the 
transition of soldiers from active duty to veteran status. More 
research and greater awareness of blast-related TBIs will likely 
facilitate this transition process.

                        MORE RESEARCH IS NEEDED

    Recovery from and treatment for TBI requires patience. The 
complexity of the injury and its pathophysiology require a long-term 
multi-tiered management approach. In the acute setting, management is 
focused on stabilizing the patient and ruling out life-threatening 
complications, such as shrapnel wounds or spinal injuries. The second 
step is assessing and treating the intermediate effects of the injury, 
namely, neurocognitive difficulties, reflected in self-reports of 
symptoms such as forgetfulness, anxiety, headaches, balance 
difficulties, and other sequelae commonly associated with post-
concussive syndrome. Less defined at this time, however, is what will 
be needed in the long run. How long should care be administered? When 
is a patient considered fully recovered and what are the long-term 
consequences of closed-head TBI (i.e., epilepsy, Alzheimer's, 
Parkinson's)? Answers to these questions remain ambiguous, at best.
    Data suggest that a person with a mild TBI who does not receive 
early adequate treatment and education is more likely to endure a long 
recovery process with lingering symptoms. However, these data are 
largely based on older studies evaluating outcomes of patients who 
sustained a TBI in an automobile accident, a fall, or a sports injury. 
It does not take into consideration that a blast-related TBI may injure 
cells at a more severe microscopic, sub-cellular level.\2\, \3\ Injury 
to this fine of a degree may influence outcomes and possibly require 
longer periods for maximum recovery than TBIs suffered in a non-combat 
setting.
---------------------------------------------------------------------------
    \2\ The Washington Post National Weekly Edition, April 16-22, 2007, 
page 25.
    \3\ Taber, et al., J. Neuropsychiatry Clin Neurosci. 
2006;18(2):141-145.
---------------------------------------------------------------------------
    There is little doubt that more research on blast-related TBI is 
needed, particularly as it relates to the effects of exposure to 
multiple primary blasts and long-term outcomes. TBI in a combat 
environment is a complex injury. A thorough understanding of the 
nuances of the injury, whether physically evident or otherwise, is 
absolutely essential to identify effective therapies and maximize 
outcomes. Currently, much of the evidence on blast-related TBIs is 
derived from animal studies, which have helped researchers understand 
the pathophysiologic effects of the injury; however, the implications 
of these findings in the clinical setting have not been well studied. 
As the number of TBI wounds increase, so too does the need for 
allocated funding to support clinical research and facilitate the 
drafting of practice guidelines, as well as the need to develop 
educational tools and implement training requirements for all 
providers.
    The importance of more research in this area is recognized in 
Section 5 of S. 1233, which states that the ``Secretary shall establish 
a program on research, education, and clinical care to provide 
intensive neuro-rehabilitation to veterans with a severe Traumatic 
Brain Injury''. However, this language excludes the majority (80 
percent) of TBI injuries--those classified as mild or moderate. It is 
my opinion that without documentation from large clinical studies with 
long-term follow-up, it may be premature to assume that veterans with 
mild or moderate TBI do not need the same services offered by this 
initiative. Furthermore, persistent post-concussive syndrome (defined 
as symptoms that continue beyond 6 months post-injury) is more common 
after mild TBI than moderate or severe TBI and individuals with 
persistent post-concussive syndrome are likely to continue to suffer 
symptoms for a number of years.
    It took months for me to convince my husband that he deserved the 
same priority of care as those soldiers with visible injuries. 
Hopefully, with more research and greater awareness, soldiers in 
similar situations will be counseled appropriately by the system 
responsible for helping these individuals maximize their potential. 
These soldiers (and their families) need validation and they need 
dedicated support.
    I am aware that this continues to be an ongoing learning process, 
but I also believe that measures need to be put in place to assess the 
efficacy of these programs, that specific benchmarks need to be set to 
reduce the length of time between presentation and treatment 
initiation, and that processing of disability claims must be 
streamlined. The proposed programs set forth by S. 1233 and H.R. 1268 
are promising in theory, but without adequate resources and without 
intense coordination and organization, the therapy and these efforts 
will likely fail for most.
    I urge you and your colleagues to remain steadfast in your 
endeavors to ensure: (1) that soldiers with TBI and their families get 
the care that they need and deserve; (2) that appropriate funding be 
allocated for research; and (3) that immediate actions are put into 
place to increase the awareness of the devastating effects of TBI. It's 
time that the excellence that these soldiers dedicated and displayed in 
the war zone be matched by the system for which they sacrificed.
    I thank you for your time.

    Senator Inouye. Thank you very much.
    The Audience. (Applause.)
    Senator Akaka. Thank you very much, Ms. Del Negro, and now 
we'll receive the testimony of Allen Hoe.

            STATEMENT OF ALLEN HOE, VIETNAM VETERAN

    Mr. Hoe. Good morning, Senator Akaka and Senator Inouye. 
The Hawaii Veterans Community is honored by your presence and 
continuing dedication in fulfilling your promise to serve those 
who have served our country in uniform.
    My name is Allen Hoe and like many here this morning, I am 
a proud veteran who wore the U.S. Army jungle fatigues in 
combat in Vietnam in 1967 and 1968. However, for me a greater 
source of pride is my two sons who also wore the uniform as 
infantrymen in service of their country. I would like to 
believe that our family is not unique. Hawaii sons and 
daughters have a long and honored tradition of service and 
sacrifice to our country.
    Duty, honor, country, those three simple words have the 
power to motivate young men and women to do remarkable things 
when called upon by their country. To the veteran who has worn 
the uniform to the young warriors who wear it today, we owe 
them our gratitude for their selfless service, but more 
importantly, we must ensure that they receive the fullest 
measure of those benefits to which they are entitled to.
    I have had the privilege to wear many different hats over 
the years. As a Vietnam veteran, the one I wear as a member of 
the Advisory Committee on the Readjustment of Veterans provides 
the greatest sense of duty for me. I accepted that role several 
years ago when I realized my sons would soon be going off to 
service and I needed to focus my energies on protecting our 
veterans' benefits programs and to secure them for the current 
generation of our brave young heroes. As we, Vietnam vets, are 
so fond of saying never again will one generation abandon 
another.
    My testimony this morning is not in any official capacity 
with my service on the advisory committee. I'm here simply as a 
veteran, a member of this proud community of veterans and the 
father of a couple of young soldiers to whom our obligations 
must be fulfilled.
    Earlier this year our Committee issued its 11th Annual 
Report. I merely wish to highlight the report's recommendations 
which are presented to the secretary. If there is any ulterior 
motive on my part, it is merely to provide this honorable 
Committee and its Members the perspective of ``boots on the 
ground'' regarding the importance of the work done by my 
colleagues who serve on the Advisory Committee on the 
Readjustment of Veterans.
    Number one, Vet Centers have become as we say in Olelo 
Hawaii, ``Puuhonua'' or sanctuaries, special place of refuge. 
Veterans are utilizing its services and programs in increasing 
numbers. Two new Vet Centers and staff augmentation at existing 
Vet Centers are in progress.
    However, based on a number of findings as listed, it is 
clear that additional augmentation of the Vet Center program is 
needed. The high number of National Guard and Reserve 
combatants in OEF and OIF and our own experience especially 
with the mobilization of the 29th Infantry Brigade and the 
100th Battalion, along with the continuing separate unit 
mobilization throughout the Pacific Command, many of these 
young warriors are now coming from widely dispersed, rural 
areas. Thus, the need exists to prioritize the creation of Vet 
Centers outstations and augmenting staff in Vet Centers that 
provide access to these rural areas. The capacity to respond to 
the service needs of the increasing number of OEF/OIF veterans 
and family members will be critical for years to come and that 
expanding the Vet Center program to provide access would 
perhaps be an effective way to build and expand the veterans' 
benefits infrastructure to meet their needs over time.
    In our Hawaiian family tradition of Ohana, we are defined 
as who we are as veterans and the importance of our families in 
every aspect of our lives as we serve our country. Thus, the 
recent legislative authority allowing for treating veterans' 
families at Vet Centers is a great accomplishment. It is truly 
a no brainer that a veteran's successful readjustment also 
includes their Ohana's readjustment as well. Providing family 
treatment by Vet Centers which have qualified family therapists 
on staff needs to be expanded. The augmentation of family 
counselors at Vet Centers would enhance the program's capacity 
to clinically address the more complicated family adjustment 
problems among the increasing numbers of returning combat 
veterans.
    A very key factor in the Vet Center program's success is 
its design to function as an off-campus entity, if you will. It 
provides a safe haven for many veterans. Thus, it is important 
to validate its rule with the secure and separate system of 
client records and related policy of guaranteeing 
confidentiality for the veteran. This is perhaps the most 
essential item in serving war-traumatized veteran population 
and goes a long way toward mitigating the stigmas manifested by 
this population against accessing care.
    Nakoa Wahine or women warriors are an integral part of our 
ancient Hawaiian tradition and culture. They stood along side 
their husbands in battle. And in some instances, due to a 
greater family allegiance, they found themselves opposite their 
husband. Today American women in service uniform comprise an 
ever increasing component of who we are as veterans. With 
increasing numbers of female military personnel serving in 
combat areas, the Vet Centers will need to carefully monitor 
the demographics of this local catchment areas to ensure that 
the female veterans service providers are represented on the 
Vet Center Teams at appropriate levels.
    Increasing awareness of the impacts of multiple 
deployments, extended deployments and traumatic battlefield 
experiences have exposed a higher incidence of mental health 
needs of returning OEF/OIF veterans as documented by the Land 
Combat Study research by Colonel Charles Hogue. Veterans must 
be extended priority access to VA medical centers for mental 
health screening, assessment and treatment to avoid the barrier 
of waiting lists of several months of appointment.
    The blending of our Armed Forces of active duty, Guard and 
Reserve units are presenting some unique issues on tracking 
these individual heroes as they change out of uniform into 
civilian attire. The establishment of the aggressive Global War 
on Terrorism veteran outreach program which consists of 100 
OEF/OIF veterans whose mission is to provide early contact 
program information and educational briefings to veterans at 
military demobilization and National Guard and Reserve sites, 
is vital to the efforts to service all our veterans. There must 
be a system to closely monitor the program's outcomes to 
further access the feasibility of further extensions to this 
program.
    There is a realization that as time increases following 
demobilization and separation from active military, increasing 
numbers of veterans will experience readjustment concerns to 
include the delayed onset of PTSD. To facilitate a veteran's 
ease of access for care, the more traditional methods of 
community outreach in addition to the Global War on Terrorism 
outreach program at the demobilization sites need to be 
enhanced. Such methods would include liaison with community 
emergency responders, educational presentations at community 
mental health and social service agencies and any other form of 
community liaison that will result in facilitating veteran 
referrals for follow up readjustment counseling.
    The points above clearly represent a cross section of those 
issues of services which are of great importance to our veteran 
community not just in Hawaii but at large.
    More particular with regard to Hawaii veterans' community, 
the disability claims need more resources to decrease the 
current backlog in the disability claims. Two critical areas 
are elderly veterans who often give up or die before their 
claim is resolved, and the OIF/OEF veterans who often 
experience serious financial difficulties while awaiting a VA 
decision on their disability.
    OIF and OEF vets need greater focus on unique needs of 
soldiers and veterans from those combat areas. The need for 
more full-time personnel assigned to coordinate care to ensure 
a seamless transition. Too often VA personnel are assigned 
duties as ancillary to primary job responsibilities.
    Each VA facility should have a full-time fully staffed OIF/
OEF treatment team. As pointed out by Ariana, Traumatic Brain 
Injury treatment, there needs to be great improvement in the 
VA's ability to assess and treat TBI. Increase number of neuro-
psychologists to do the testing for TBI.
    Eligibility periods: Returning soldiers and veterans must 
apply for medical benefits within two years after returning 
from a war zone. Unfortunately, many do not seek VA care within 
this allotted time period. Eligibility for peer should be 
extended to years after return.
    In short, there are many things which the VA does that is 
absolutely wonderful and, as we know, there are many things 
that needs great improvement. And again, I wish to extend my 
heartfelt gratitude for the opportunity to offer some of my 
observations and concerns to the Committee this morning.
    For those of you who know me, you understand the importance 
of symbolisms to me. I wear my cap. This flag is a special 
flag. This flag I carried 40 years ago with me in combat in 
Vietnam. And we carry that to honor 18 of my fellow recon team 
members who were killed. And we promised their families that 
when they were recovered and brought home, that this flag would 
fly at their service.
    This past January we had the honor, after my lieutenant was 
missing for 38 years and my RTO missing for 38 years, to have 
this flag accompany us as we attended the services at Arlington 
as well as Oklahoma. And as a tribute to how important these 
symbols are to our kids and our families, this flag was carried 
by my son in Mosul in January of 2005 in honor of his dad's 
lieutenant who was killed and missing in Vietnam. And this flag 
was carried by my son the morning he was killed in Iraq. So if 
you look at it, it really says a lot of who we are as a people, 
who we are as veterans in this community and who we are as a 
Nation. Thank you.
    [The prepared statement of Mr. Hoe follows:]

          Prepared Statement of Allen K. Hoe, Vietnam Veteran

    Good morning Senator Akaka, Senator Craig and Members of the 
Committee on Veterans' Affairs. Your presence and your continuing 
dedication in fulfilling your promise to serve those who have served 
our Country in uniform is deeply appreciated.
    My name is Allen Hoe, I am a proud veteran who wore U.S. Army 
jungle fatigues in combat in Vietnam in 1967 and 1968; however, for me 
a greater source of pride is in my 2 sons who also wore the uniform as 
infantrymen in service of their country. I would like to believe that 
our family is not unique. Hawaii's sons and daughters have a very long 
and honored tradition of service and sacrifice to our country.
    Duty, Honor, Country, those three simple words have the power to 
motivate young men and women to do remarkable things when called upon 
by their country. To the Veteran who has worn the uniform, to the young 
warriors who wear it today, we owe them our gratitude for their 
selfless service but more importantly we must ensure that they receive, 
to the fullest measure those benefits to which they are entitled to.
    Of the many hats which I have had the privilege to wear over the 
years, from my veteran's perspective, the one I wear as a member of the 
``Advisory Committee on the Readjustment of Veterans'' provides the 
greatest sense of duty for me. I accepted that role several years ago, 
when I realized that my sons would soon be going off to serve and that 
I needed to focus my energies on veterans benefits programs to secure 
them for the current generation of our brave young heroes. As we 
Vietnam Vets are so fond of saying, ``never again will one generation 
of veterans abandon another.''
    The Advisory Committee on the Readjustment of Veterans, which I 
have the honor to serve as a member is mandated under Public Law 104-
262, to:

     Assemble and review information relating to the needs of 
veterans in readjusting to civilian life.
     Provide information relating to the nature and character 
of psychological problems arising from service in the Armed Forces.
     Provide an ongoing assessment of the effectiveness of the 
policies, organizational structures, and services of the Department of 
Veterans Affairs (VA) in assisting veterans in readjusting to civilian 
life.
     Provide ongoing advice on the most appropriate means of 
responding to the readjustment needs of veterans in the future.
     In carrying out these activities, the Committee shall take 
into special account the needs of veterans who have served in a combat 
theater of operations.

    My testimony this morning is not in any official capacity with my 
service on the Advisory Committee on the Readjustment of Veterans. I am 
here simply as a veteran, a member of this proud community of veterans 
and the father of young soldiers, to whom our obligations must be 
fulfilled.
    Earlier this year the Committee issued its Eleventh Annual Report. 
I would merely wish to highlight the report's recommendations which are 
presented to the Secretary. If there is any ulterior motive here it is 
merely to provide this honorable Committee and its Members, the 
perspective of ``boots on the ground'' regarding the importance of the 
work done by my colleagues who serve on the Advisory Committee on the 
Readjustment of Veterans.

    1. The Vet Centers have become, as we say in Olelo Hawaii, 
``Puuhonua'' or sanctuaries, a special place of refuge. Veterans are 
utilizing its services and programs in increasing numbers. Two new Vet 
Centers and staff augmentation at 11 existing Vet centers is in 
progress. However, based on a number of findings as listed below, it is 
clear that additional augmentation of the Vet Center program is needed:

     The growing number of separated servicemembers from OEF/
OIF to date.
     The high number of National Guard and Reserve component 
forces who disperse to all corners of the country upon separation from 
OEF/OIF.
     The Army studies conducted by Colonel Charles W. Hogue, 
that document the incidence of combat related stigma and readjustment 
problems among OEF/OIF returnees.
     The effectiveness of VA's community-based Vet Centers in 
contacting the new veterans through an aggressive GWOT outreach 
campaign and in providing timely readjustment counseling to veterans 
and veterans' family members.

    The high number of National Guard/Reserve combatants in OEF/OIF; 
our own experience with mobilizations of the 29th Infantry Brigade and 
the 100th Bn., and the continuing separate unit mobilizations 
throughout the Pacific Command, many of whom come from widely dispersed 
rural areas, the need exists to prioritize the creation of Vet Center 
outstations and augmenting staff in Vet Centers that serve rural areas. 
The capacity to respond to the service needs of the increasing number 
of OEF/OIF veterans and family members will be critical for years to 
come, and that expanding the Vet Center program is perhaps an effective 
way to build and expand the veterans benefits infrastructure to meet 
their needs over time.
    2. Our Hawaiian tradition of Ohana defines who we are as veterans 
and the importance of our families in every aspect of our lives as we 
serve our country. Thus, the legislative authority for treating 
veterans' families at Vet Centers, is a great accomplishment. It really 
is a no brainer that a veterans' successful readjustment also includes 
the Ohana's readjustment. Providing family treatment by Vet Centers 
which have qualified family therapist on staff needs to be expanded. 
The augmentation of family counselors at Vet Centers would enhance the 
program's capacity to clinically address the more complicated family 
adjustment problems among increasing numbers of returning OEF/OIF 
combat veterans.
    3. A key factor in the Vet Center program's success is due to 
structure as an ``off campus'' entity, if you will. Thus it is 
important to validate that with a secure and separate system of client 
records and related policy of guaranteeing confidentiality for the 
veteran. This is perhaps the most essential item in serving the war-
traumatized veteran population and goes a long way toward mitigating 
the stigmas manifested by this population against accessing care.
    4. Nakoa Wahine, women warriors are an ancient Hawaiian tradition, 
they fought along side their husbands, and in some instance due to a 
greater family allegiance that found themselves opposite their husband; 
in any regards women in service as another trait of who we are as 
veterans. With the higher number of female military personnel serving 
in OEF/OIF, the Vet Centers continue to carefully monitor the 
demographics of local catchment areas to ensure that female veteran 
service providers are represented on Vet Center teams at appropriate 
levels.
    5. Increasing awareness of the impacts of multiple deployments, 
extended deployments and traumatic battlefield experiences, have 
exposed a higher incidence of mental health needs of returning OEF/OIF 
veterans as documented by the ``Land Combat Study'' research of Colonel 
Charles W. Hogue, M.D., OEF/OIF veterans must be extended priority 
access to VA medical centers for mental health screening, assessment 
and treatment to avoid the barrier of waiting lists of several months 
for an appointment.
    6. The blending of our Armed Forces of active duty, Guard and 
Reserve units presents some unique issues on tracking these individual 
heroes as they change out of uniform into civilian attire. The 
establishment of the aggressive GWOT veteran outreach program which 
consisted of 100 OEF/OIF veterans whose mission is to provide early 
contact, program information and educational briefings to veterans at 
military demobilization and National Guard and Reserve sites is vital 
in the efforts to service all our veterans. Thus, there must be a 
system to closely monitor the program's outcomes to further assess the 
feasibility of further extensions to this program initiative contingent 
upon increasing workload volume among returning OEF/OIF veterans.
    7. There is the realization that as time increases following 
demobilization and separation from active military, many veterans will 
develop readjustment problems to include the delayed onset of PTSD. To 
facilitate a veterans' ease of access for care, the more traditional 
methods of community outreach in addition to the GWOT outreach at 
demobilization sites need to be enhanced. Such methods would include 
liaison with community emergency responders, educational presentations 
at community mental health and social service agencies, and any other 
form of community liaison that will result in facilitating veteran 
referrals for follow-up readjustment counseling.
    The points referenced above represent a cross section of those 
issues or services which are of great importance to our veteran 
community not just in Hawaii but at-large.
    The following issues are what I have surmised as being specific 
needs to our Hawaii veterans community as they have been shared with 
me.
    Disability Claims: More resources are needed to decrease the 
current backlog in the disability claims process. Two critical areas:

     Elderly veterans often ``give up'' or ``die'' before their 
claim is resolved.
     OIF/OEF veterans can often experience serious financial 
difficulties while awaiting a VA decision on their disability.

    OIF/OEF: Need greater focus on unique aspects/needs of OIF/OEF 
soldiers/veterans:

     Need more full-time personnel assigned/designated to 
coordinate OIF/OEF care to ensure a seamless transition. To often VA 
personnel are assigned OIF/OEF duties as ancillary to primary job 
responsibilities. Each VA facility should have a full-time and fully 
staffed OIF/OEF treatment team.
     Traumatic Brain Injury treatment. Need to improve VA's 
ability to assess and treat TBI. Increase number of neuro-psychologists 
to do testing for TBI.

    Eligibility Period: Returning soldiers/veterans must apply for 
medical benefits within 2 years after returning to the U.S. from the 
war zone. Unfortunately, many do not seek VA care within this allotted 
time period. Eligibility for care should be extended to 5 years after 
return.
    Access to Care: Need to expand resources and increase 
accessibility/availability of care:

     Sometimes difficult to get an appointment in a timely 
manner and there often is too much time between appointments.
     Increase medical staff and expand specialties 
(orthopedics, endocrinologists, OB/GYN, TBI) to improve care and 
alleviate wait time.
     Expand hours of operation for both medical and mental 
health services. Present hours of 0800 to 1600 may be sufficient for 
unemployed and elderly veterans; however, it often poses a hardship for 
the younger veteran making the transition from the military to a new 
job or school. Often, they do not have the ``sick-leave'' or 
``vacation'' time accrued.
     Develop mobile clinics that travel to communities to 
provide general health care. It is sometimes difficult for veterans to 
go to VA. This is particularly critical for elderly, disabled, or 
homeless veterans who often need increased medical care for chronic 
medical problems or for service-connected conditions. Elderly and the 
disabled often can't drive, don't want to inconvenience family and 
cannot endure long rides on the bus or handi-van. Taking health care to 
their community via a medically equipped bus/van can provide a valuable 
service to these veterans.

    Veterans Service Organizations: Veterans Service Organizations 
(DAV, VFW, American Legion, etc.) are congressionally chartered 
organizations that advocate for veterans and assist in filing 
disability claims. Unfortunately only the DAV provides a full-time 
National Service Officer in Hawaii to assist veterans with their 
claims. As a result, many veterans are not properly represented in 
filing their disability claims.
    Again I wish to extend my heartfelt gratitude for the opportunity 
to offer some of my observations and concerns to the Committee this 
morning.
    A very special aloha and mahalo to Senator Akaka and to Congressman 
Abercrombie for being there for my family and for your loving tributes 
in honor of my son.

    The Audience. (Applause.)
    Senator Akaka. Thank you very much, Allen Hoe, for your 
testimony. Now, we'll hear from Tom Joaquin.

   STATEMENT OF THOMAS L. JOAQUIN, SENIOR VICE PRESIDENT OF 
  OPERATIONS, HAWAIIAN ELECTRIC COMPANY, INC., AND MEMBER VA 
                        ADVISORY COUNCIL

    Mr. Joaquin. Good morning, everyone, Mr. Chairman and 
Members of the Committee. Mahalo for the opportunity to appear 
here today to discuss VA care in Hawaii. While I'm here today 
to praise the VA, most of my involvement over the last 43 years 
has been adversary.
    I want to thank you, Mr. Chairman, as well as Senator 
Inouye for your steadfast commitment to our veterans. 
Legislation that you and others have introduced have led to 
unprecedented care for veterans. From humble beginnings on Ward 
Avenue in the 1960s to world-class medical facilities today, 
not only on Oahu, but serving all of the neighbor islands with 
Community Based Outpatient Clinics (CBOCs).
    Recently, an accreditation audit found our facilities on 
Oahu to be one of the best in the VA. I can attest to the level 
of care and concern of my VA doctor and her staff. I can assure 
you that it rivals my civilian experience.
    Many of these accomplishments have come about under the 
capable leadership of Dr. James Hastings, the director of 
Pacific Islands Health Care System. I belong to an advisory 
board that meets with Dr. Hastings and his leadership staff 
quite often. We have a very healthy exchange of concerns and 
ideas, all designed to allow input into the local VA and 
subsequent buy in from our constituents we serve. I suggest 
that the VA consider these advisory boards elsewhere.
    I live in Kapolei, the fastest growing area on Oahu quickly 
living up to the expectations of the Second City of Oahu. I 
understand that we are looking to establish a CBOC in this area 
and are awaiting availability of facilities closed by the Navy.
    I would encourage a more aggressive approach perhaps 
working with the state or even just building or leasing a 
facility. The population of the area surrounding Kapolei 
exceeds any of the neighbor islands and there are many, many 
veterans that reside in that area.
    Mr. Chairman, I thank you again for the opportunity to 
testify at this hearing.
    [The prepared statement of Mr. Joaquin follows:]

   Prepared Statement of Thomas L. Joaquin, Senior Vice President of 
  Operations, Hawaiian Electric Company, Inc., and Member VA Advisory 
                                Council

    Mr. Chairman and Members of the Committee, mahalo for the 
opportunity to appear before you today to discuss VA care in Hawaii. 
While I am here today to praise the VA, most of my involvement over the 
last 43 years had been adversarial.
    I want to thank you, Mr. Chairman, for your steadfast commitment to 
our veterans. Legislation that you and others have introduced has led 
to unprecedented care for veterans. From humble beginnings on Ward 
Avenue in the 1960s to world class medical facilities today, not only 
on Oahu, but serving all of the neighbor islands with community based 
outpatient clients (CBOCs).
    Recently, an Accreditation audit found our facilities on Oahu to be 
one of the best in the VA. I can attest to the level of care and 
concern of my VA doctor and her staff. I can assure you that it rivals 
my civilian experience.
    Many of these accomplishments have come about under the capable 
leadership of Dr. James Hastings, the Director of the Pacific Islands 
Health Care System. I belong to an advisory board that meet with Dr. 
Hastings and his leadership staff quite often. We have a very healthy 
exchange of concerns and ideas, all designed to allow input into the 
local VA and subsequent buy in from the constituents we serve. I 
suggest that the VA consider these advisory boards elsewhere.
    I live in Kapolei, the fastest growing area of Oahu; quickly living 
up to the expectations of the Second city of Oahu. I understand that we 
are looking to establish a CBOC in this area and are awaiting 
availability of facilities closed by the Navy.
    I would encourage a more aggressive approach, perhaps working with 
the State or even just building or leasing a facility. The population 
of the area surrounding Kapolei exceeds any of the neighbor islands.
    Mr. Chairman, I thank you again for the opportunity to testify at 
this hearing. I would be happy to take any questions you might have.

    The Audience. (Applause.)
    Senator Akaka. Thank you very much Tom Joaquin. And now 
we'll hear from Victor Opiopio.
    Victor is, as you know, a kamaaina here and I know him as 
Crash.

          STATEMENT OF VICTOR OPIOPIO, VIETNAM VETERAN

     Mr. Opiopio. I want to say good morning to everyone, to 
all the ladies and gentlemen from the States that have come 
here. You heard me use the term ``the states.'' People say to 
me, ``but isn't this is a state? '' And I say to them, ``Well, 
let's look at it. I was born here, I was raised here and I live 
here. This is my mainland. And you guys are from the states. 
But welcome.
    Onakala, Kaniala, aloha to your family very talented, 
talented family. Danny, who just happens to be my mother's 
godfather. He doesn't even realize. My grandfather was Byron 
Bridges and--well, my mom has passed away, but I remember you 
when I was young. But aloha and welcome and thank you for 
listening to us.
    I don't have a prepared speech. I don't have anything in 
writing in front of me because when I speak, I speak from my 
heart. And sometimes I get messed up or I mess up along the 
way. But when it comes to the VA, it's an issue that is very 
important to me. Because, number one, I love the VA. Number 
two, I hate the VA.
    I mean, there's no ``ifs'', ands and ``buts.'' The VA has 
done a lot for me recently. But for 20 years I had to bang my 
head against the wall asking for help, and at no time did 
anyone step forward and say, ``Could I help you?'' I joined the 
organizations that said we are set up to help the veterans. I 
signed up. I sent in my money. I never heard from them.
    When I received a rating, I would get a letter from them 
inviting me to join. I was already a lifetime member. So I felt 
deserted. I felt lost. This is my story because I can't speak 
for all the veterans. I can't. But I can speak about myself. I 
want to share this with all of you because I have not shared it 
before.
    For the last 30 years here in the islands, I have been in 
radio and in television. I know a lot of you are smiling 
because I'm sure you remember me. The name Crash Kealoha was 
given to me by Lucky Luck many, many years ago. I was one of 
his students. Well, when I wanted to get into radio, I was only 
14 and you had to be 15. So, I messed around till I was 15.
    This was 1965. There was something going on on the other 
side of the world that was called a conflict or a police 
action. It wasn't called a war. Right? It was a conflict. It 
was a police action. Only now it's called a war. What happened? 
When we came home, there were no cheers. People didn't say, 
``Welcome home.'' Today I walk up to veterans and say welcome 
home. And they look at me and they know what I'm saying. So 
when I talk about the VA, I've got to talk about myself.
    I fell and hurt myself. I hurt my back. I cracked my spine. 
They put me in the hospital, put me in a body cast and told me 
that the best way for your body to heal is to heal naturally. I 
was in a body cast for about six months. By the way, it was 
done in Missile Shack. After my fall, they found blood in my 
urine. It was a total surprise because that never happened to 
me.
    I took so many physical exams before joining the military. 
There was no blood in my urine. And they said you know 
something? You have a kidney condition that you had before you 
joined the military. And I said what? You had this before you 
joined the military. So we're going to discharge you with your 
back condition, but your kidney condition is not service 
connected. And I said, now wait a minute. They said no, it's 
not service connected.
    I did some research and what I had was a UPJ obstruction 
which is something that people are born with. I didn't know 
that. It's a more common incidence among babies. It happens 
that's when it's discovered. Very rarely does it linger on. 
Well, I did not know of this condition. But something happened 
to make my kidney bleed.
    What happened? I fell down. I hurt my back. I was 
discharged for my back. And the doctors, private doctors told 
me it would cost about $30,000 to work with my kidney. I 
couldn't afford $30,000. So I went to VA, and I said I need 
help because of my kidney problem. VA said no problem, we'll 
take care of you. I was surprised. The next day I was at 
Tripler meeting with my doctor who said we're going to operate 
next Thursday. I said fantastic, how long is this going to keep 
me in the hospital? He said well, 10 days, 2 weeks at the most. 
Go home, relax. You'll be fine.
    They worked on my kidney. The morning before the operation, 
I spoke with my doctor and he took my hand and I shook his 
hand. I said to him, you know, God bless everything. I woke up. 
I was in so much pain that I could not believe it. I asked for 
my doctor and they said he was rotated out. I didn't know what 
that meant. But where is my doctor? He's rotated out. Hmm.
    What's going on? Well, my kidney did not work at all after 
that. And I was up there for 15 months in total, total pain. 
Finally, they removed my kidney because there was nothing else 
they could do. After that I went to the VA to file a claim and 
they said to me, it's not service connected. I said what? That 
kidney condition was not service connected. You lost your 
kidney. Sorry.
    I couldn't believe that. And then my back condition. I was 
given--and you guys don't know about this--painkillers and 
muscle relaxers. Painkillers and muscle relaxers and go home 
and lie down. Take it easy, painkillers and muscle relaxers. 
This one doctor I had--the very first doctor I had--I thought 
he was nuts. And I found out he was nuts because he burned his 
house down because he was treating his children to a lesson not 
to play with fire so he burned his house down. Needless to say 
he was let go from the VA and I was appointed another whacko. 
This one I won't even talk about because he's still there. And 
if it was up to me, I would get rid of him.
    But anyway, the fight with my back I was granted for my 
lower back. The pain in my back started started going up to my 
spine. And the doctors saw all of this. They saw all of this 
pain, and I went through all of the MRIs and all of that, and 
they said your condition has worsened. And it's gotten to the 
point where it hit my neck, I had to have three surgeries done 
on my neck that VA paid for, sent me to Straub. Thank you VA. 
And then when I filed for a claim they said, no. The neck and 
the back are not service connected.
    Now I'm going to wrap it up right here because, like I 
said, I have a love and hate relationship with the VA. After 
all those years of fighting, this beautiful woman walked into 
my life. Her name is Jane Watson, and she is a doctor at VA. 
She was the very first person I met who actually care about 
veterans. Without that lady's help, I probably would not be 
here today.
    There's one other person, without him I probably would have 
blown myself away a long time ago, and this man is incredible. 
He suffered from a personal problem that took him away from the 
VA. I never thought I'd ever see him again, but he came back. I 
asked him why he came back, and he said because he wants to 
help the veterans. His name is Dr. Cameron, and I know he's 
sitting in the back. Dr. Cameron, thank you. Thank you for 
saving my life. That's why I said I have this love-hate 
relationship with the VA. And you guys know what I'm talking 
about. Mahalo.
    The Audience. (Applause.)
    Senator Akaka. Thank you. Now we'll hear from Clay Park.

 STATEMENT OF WILLIAM CLAYTON SAM PARK, CASE MANAGER/VETERANS 
                SPECIALIST, HELPING HANDS-HAWAII

    Mr. Park. Senator Akaka, Senator Inouye, my name is William 
Clayton Sam Park. I am of Native Hawaiian ancestry, a disabled 
veteran who served as a combat medic during the Vietnam War, 
and a retired master sergeant with three years active duty with 
the U.S. Army and 21 years of service with the Hawaii Army 
National Guard.
    Thank you for this opportunity to address the Senate 
Veterans' Affairs Committee. I am a case manager/veterans 
specialist with the agency on whose behalf I testify today, 
Helping Handss-Hawaii.
    Helping Hands is a nonprofit agency with 33 years of 
service to the people of Hawaii, providing behavioral health 
and mental health service. It also offers other community-based 
services such as Bilingual Access Line (providing 
interpreters), the Community Clearinghouse and the Ready-to-
Learn Program, known to many because of Senator Inouye's and 
his wife's (Maggie) efforts. I will speak today primarily of 
community, linkage and advocacy on behalf of our veterans.
    Helping Hands has been an active partner in this community 
for over 30 years. As our community welcomes back our newest 
warrior, there's no doubt that we face significant challenges 
not only for these veterans and their families, but also for 
the generations of veterans who went before them who also have 
been affected by this war.
    The need for support in our veterans community became more 
and more evident over the past year or two. While no formal 
program had yet been developed, the need did not wait. 
Veterans' concerns and problems began to surface on the day-to-
day activities of Helping Hands' staff, such as myself. As a 
case manager and also as a veteran, the veterans with 
psychological problems, many of whom were homeless, were 
assigned to me.
    While some came directly to us from the State Department of 
Health, the Adult Mental Health Division, others came by word 
of mouth from social service workers. A contact would say 
something like this: There is a veteran who lives on the side 
of the Pali and we have not seen him for days. Can you help? 
Outreach often means doing what is unconventional and that is 
what was required in this case. Using my tracking skills and my 
familiarity with the mountains as a long-time pig hunter, to 
find this veteran who was using his military skills to hide 
from the populated area.
    Having found this particular veteran, it was not possible 
to convince him to seek VA benefits and services because he did 
not understand the VA system and feared that he would lose his 
existing social security benefits if he chose to go through the 
VA. While this veteran now has a different life, attending the 
State's Club House and sharing his life with a girlfriend, he 
still is not receiving services from the VA which he would be 
entitled to.
    Outreach is not simply about finding someone and providing 
services. Often times it is about support and direction for the 
veteran who is about to give up on seeking or accepting 
services. Some of the time that means the veteran has become so 
frustrated with the obstacles along the way to accessing 
benefits for services that he or she woud simply say forget it 
and struggles to survive without the VA assistance. Other 
times, more drastically, the veteran has decided it is better 
to give up his life rather than to continue to struggle.
    The desperate call then comes from many family members 
hoping to find someone who knows what to do to change his mind. 
A recent example comes from a case management situation where 
an individual was seen at the request of a family member 
concerned about how discouraged and despondent he was. He had 
been deployed with the Oregon Army National Guard unit to Iraq. 
Upon return, he applied for VA services and encouraged prior to 
leaving the unit, he waited for the VA's reply while trying to 
provide for his wife and his three children. He was not with 
his family since his wife already had filed a temporary 
restraining order on him.
    He had changed so much since his return, especially in 
terms of his inability to control his frustration and anger, a 
sign that we would consider possibly related to Post Traumatic 
Stress Disorder from his time in combat. When the VA letter 
arrived, he was informed that he was not eligible since there 
was no evidence that he was an OEF/OIF veteran who had served 
in combat.
    In helping this veteran follow up through the VA Benefits 
Administration, there had been some confusion due to the 
veteran's prior service with the U.S. Navy, at which time he 
was not deployed to combat. It is this separate DD-214 and not 
the one he submitted documenting his combat with the National 
Guard unit which was reviewed when his benefits application was 
not being considered. Rather than the depression he was 
experiencing, when he first was seen by the Helping Hands 
staff, he is now reconnected with the VA and is pursuing 
benefits and services.
    Just how critical timely outreach can be was recently 
brought home very painfully when I and Dr. Rodney Torigoe, the 
psychologist who consults with Helping Hands-Hawaii, were 
invited to address the Army National Guard unit in Hilo. This 
was the unit which had made the newspapers because a fellow 
soldier had been arrested and charged with killing his son and 
his wife's unborn child, as he reportedly attacked his wife in 
a fit of rage.
    Upon initial contact to set up a time for our visit, one of 
the members of the unit commented, ``You're a little too 
late.'' Though they had been back from their service in Iraq 
for 18 months, the majority of the members of the unit did not 
understand that they had entitlement to VA services, because 
the briefing which explained this occurred only five hours 
after they arrived on U.S. soil.
    Meanwhile, other wives were heard on news reports stating 
that they just wanted their husbands back, and the men who 
returned were not the same as those who left. By way of follow 
up and preventive measures, the unit's First Sergeant has now 
been encouraging his cunning soldiers to seek assistance from 
the VA. This unit is now in training and expects to be deployed 
again.
    Being a responsible member of this community is being 
responsive to the needs of our veterans community. I have been 
joined by four other veterans, one of whom is here today who 
just testified. Mr. Victor Opiopio. Also included are Mr. Sam 
Stone, James Kimo Opiana and Mr. Charles Kanehailua, who 
volunteered their time and mana'o, and under the auspices of 
Helping Hands, began what was called the ``Uncle's Project.''
    This project was about veterans reaching out to veterans 
bringing them in for services, encouraging them to have trust 
in the system and persist even when frustrated and undoing the 
attitude instilled through a military culture which labels 
psychological distress as a weakness.
    Helping Hands now has a dedicated program to reach out to 
veterans and their families--veterans of all wars and all 
eras--in order to provide support and, when needed, direct 
linkage with appropriate social service and government 
agencies. The linkage is about providing what is needed upfront 
and not after the fact. It is about providing guidance to 
families of our veterans who help welcome back our newest 
veterans and their spouses, fathers, mothers sons and daughters 
to be sure that the transition is as smooth as possible.
    For our earlier generations of veterans, it is also about 
continuing the transition home or, in some case, may be 
beginning that transition after 40 years or more of emotional 
pain. I want to emphasize the government agency link, 
especially the link with the Department of Veterans Affairs. As 
Senator Akaka has noted in his recent legislation S. 1233, 
``the Department of Defense and the Department of Veterans' 
Affairs have made efforts to provide smooth transition . . . 
but more can be done to assist our veterans and their families 
in the reintegration of the wounded or injured veterans into 
our community.''
    Our newest program is a community-based Native Hawaiian 
Veterans Resource Program. The cornerstone of this program is 
what started as the ``Uncle's Project,'' and is now Na Hana 
No'eau No Na Mea Pono (the Work Toward Righteous Things), which 
is supported by grants from the Castle Foundation and from Papa 
Ola Lokahi. Recently, Trustees of OHA met with some of the 
``Uncles'' and representatives of Helping Hands-Hawaii 
administration to discuss what role they may take in supporting 
this program so that no veteran will be left behind. We look 
forward to the benefit of their mana'o as well.
    The veterans we have seen have been referred to state or 
private social service agencies, at times identified by our own 
case managers or even referred through the VA benefits system 
itself. We have identified our mission quite clearly as not one 
that will duplicate services nor in any way distract from the 
VA or what the VA offers. Rather, we intend to assist the 
veteran in navigating the VA system and support the VA system 
in accomplishing its mission.
    As the report of 2007 President's Commission on Care for 
America's Returning Wounded Warriors acknowledges both the DOD 
and VA benefits and health care systems are complicated and 
complex. Both are difficult to understand and marked by 
inequities. By having Helping Hands staff available who are 
familiar with the VA system, and working closely with current 
VA staff, our goal is to help veterans become aware of and find 
it easier to access the services for which they may be eligible 
because they will have a coach, a partner, and a helping hand 
available to guide them.
    We do not doubt that there are caring and concerned 
individuals among the staff at the VA, but things do not always 
go smoothly. The VA staff must contend with complexity of the 
paperwork, the rules and the regulations and they're only 
human. This very same paperwork and those rules and regulations 
often are perceived by the veterans as obstacles and hurdles, 
confirming whatever beliefs they may already have developed 
about not trusting that their government can see them as 
anything other than a number.
    Their frustration in dealing with the system often leads to 
anger or despair and a tendency to abandon any hope for 
assistance. It is our hope that our newest program will allow 
the VA to more easily find those veterans who are eligible for 
service and facilitate their access to the most appropriate 
care in a timely manner. Helping Hands is all too aware of the 
benefit which can come from improving access to services in 
order to prevent more serious problems at a later time.
    For our veterans who do not find the VA system accessible, 
the cost in terms of economic, emotional and social hardship is 
an added burden to which they already are experiencing. Being 
successful as we carry out this newest of our missions will 
honor the sacrifice our soldiers have made as we support the 
mission of the VA in making the veteran's mental health and 
adjustment to civilian life among the highest priorities of our 
Nation.
    Having addressed the importance of community partnership 
and linkage, I come to the final area of importance to Na Hana 
No'eau No Na Mean Pono, that is, advocacy. There is research 
showing that Native Hawaiians experience significant 
disparities in health care, opting to avoid health care 
services when dealing with bureaucratic systems, cultural 
insensitivity and other similar barriers to care. Our work is 
guided by the experience of Papa Ola Lokahi with the federally 
funded comprehensive health care centers so that the 
intimidation created by the bureaucracy and the potential for 
culturally insensitive delivery of service within the large 
and, at time, impersonal VA system can be reduced.
    There is also documentation that Native Hawaiians serving 
in the Vietnam war experienced symptoms of Post Traumatic 
Stress Disorder to a greater degree than the general population 
of soldiers serving in that war. There is no reason to expect 
that there will be any significant change either in the health 
disparities or in the incidence of psychological symptoms among 
Hawaii's current military force returning from combat.
    This situation is likely to be made even worse by the fact 
that many of the members of our Guard and Reserveunits come 
from our rural areas both on Oahu and on our neighbor islands, 
where access to health care, especially mental health care and 
continuity of care are already problems. While our program will 
certainly be accepting veterans of any ethnicity, and not just 
Native Hawaiian veterans, our primary focus remains to provide 
service for our generally underserved Hawaiian population.
    Consequently, the mission of our program as we extend a 
helping hand will be to provide the advocacy necessary to each 
individual veteran, their families, their family members so 
that they have ready and easy access to care as well as having 
the most appropriate care.
    Mahalo nui loa for allowing me the time to share my mana'o 
with you today. Thank you.
    [Prepared statement of Mr. Park follows:]

            Prepared Statement of William Clayton Sam Park, 
         Case Manager/Veterans Specialist, Helping Hands-Hawaii

    Mr. Chairman and Members of the U.S. Senate Committee on Veterans' 
Affairs:
    My name is William Clayton Sam Park. I am of Native Hawaiian 
ancestry, a disabled veteran, who served as a combat medic during the 
Vietnam War, and a retired Master Sergeant with 3 years active duty 
with the U.S. Army and 21 years of service with the Hawai'i Army 
National Guard.
    Thank you for this opportunity to address the Senate Veterans' 
Affairs Committee. I am a Case Manager/Veterans Specialist with the 
agency on whose behalf I testify today--Helping Hands Hawaii (HHH). 
Helping Hands is a nonprofit agency with 33 years of service to the 
people of Hawai'i, in particular providing behavioral and mental health 
services, but also offering such other community-based services as the 
Bilingual Access Line (providing interpreters), the Community 
Clearinghouse, and the Ready-to-Learn program (known to many because of 
Senator Inouye and his wife Maggie's efforts). I will speak today 
primarily of community, linkages, and advocacy on behalf of our 
veterans.
    Helping Hands Hawaii has been an active partner in this community 
for over 30 years. As our community welcomes back our newest warriors, 
there is no doubt that we face significant challenges, not only for 
these veterans and their families, but also for the generations of 
veterans who went before them who also have been affected by this war. 
The need for support in our veteran community became more and more 
evident over the past year or two. While no formal program had yet been 
developed, the need did not wait. Veterans' concerns and problems began 
to surface in the day-to-day activities of HHH staff, such as myself. 
As a case manager but also a veteran, the veterans with psychological 
problems, many of whom were homeless, were assigned to me. While some 
came directly to us through the State Department of Health (Adult 
Mental Health Division), others came by word of mouth from other social 
service workers. A contact would say something like: ``there is a 
veteran who lives on the side of the Pali and we have not seen him for 
days . . . can you help? '' Outreach often means doing what is 
unconventional, and that is what was required in this case: using my 
tracking skills and familiarity with the mountain as a long-time pig 
hunter to find this veteran who was using his military skills to hide 
away from the populated area. Having found this particular veteran, it 
was not possible to convince him to seek VA benefits and services 
because he did not understand the VA system and feared that he would 
lose his existing Social Security benefit if he chose to go through the 
VA. While this veteran now has a different life, attending the State's 
Club House and sharing his life with a girlfriend, he still is not 
receiving services of the VA to which he would be entitled.
    Outreach is not simply about finding someone and providing 
services. Oftentimes, it is about support and direction for the veteran 
who is about to give up on seeking or accepting services. Some of the 
time that means the veteran has become so frustrated with the obstacles 
along the way to accessing benefits or services that he or she has 
simply said ``forget it'' and struggles to survive without the VA's 
assistance. Other times and more drastically, the veteran has decided 
it is better to give up his life rather than to continue the struggle. 
The desperate call then comes from the family member hoping to find 
someone who knows what to do to change his mind. A recent example comes 
from a case management situation where an individual was seen at the 
request of a family member concerned about how discouraged and 
despondent he was. He had been deployed with the Oregon Army National 
Guard Unit to Iraq and upon return applied for VA service as encouraged 
prior to leaving the Unit. He waited for the VA's reply, while trying 
to provide for his wife and three children. He was not with his family 
since his wife already had filed a Temporary Restraining Order on him. 
He had changed so much since his return, especially in terms of his 
inability to control his frustration and anger--a sign that we would 
consider possibly related to Post Traumatic Stress Disorder from his 
time in combat. When the VA letter arrived, he was informed that he was 
not eligible since there was no evidence he was an OEF/OIF veteran who 
had served in combat. In helping this veteran follow-up through the VA 
Benefits Administration (VBA), there had been some confusion due to the 
veteran's prior service with the U.S. Navy, at which time he was not 
deployed to combat. It was this separate DD-214 and not the one he 
submitted documenting his combat with the National Guard Unit which was 
reviewed when his benefits application was being considered. Rather 
than the depression he was experiencing when he first was seen by HHH, 
he now has re-connected with the VA and is pursuing benefits and 
services.
    Just how critical timely outreach can be was recently brought home 
very painfully when I and Dr. Rodney Torigoe, the psychologist who 
consults with HHH, were invited to address the Army National Guard Unit 
in Hilo. This was the Unit which had made the newspapers because a 
fellow soldier had been arrested and charged with killing his young son 
and his wife's unborn child, as he reportedly attacked his wife in a 
fit of rage. Upon initial contact to set up the time for our visit, one 
of the members of that Unit commented, ``you're a little too late.'' 
Though they had been back from their service in Iraq for 18 months, the 
majority of the Unit did not understand that they had entitlement to VA 
services, since their briefing which explained this occurred only 5 
hours after they arrived back on U.S. soil. Meanwhile, other wives were 
heard on news reports stating that they just wanted their husbands back 
and the men who returned were not the same as those who left. By way of 
follow-up and as a preventive measure, the Unit's First Sergeant has 
now been encouraging his soldiers to seek the assistance of the VA. 
This Unit is now in training and expects to be deployed again.
    Being a responsible member of this community means being responsive 
to the needs of our veteran community. I have been joined by four other 
veterans (one of whom is here today to testify before you also, Victor 
Opiopio, and also including Sam Stone, James ``Kimo'' Opiana, and 
Charles Kanehailua), who volunteered their time and mana'o, and under 
the auspices of Helping Hands began what was called ``The Uncle's 
Project.'' This project was about veterans reaching out to veterans, 
bringing them in for services, encouraging them to have trust in the 
system and persist even when frustrated, and undoing the attitude 
instilled through a military culture which labels psychological 
distress as a weakness.
    HHH now has a dedicated program to reach out to veterans and their 
families--veterans of all wars and all eras--in order to provide 
support and, when needed, direct linkage with appropriate social 
service and government agencies. The linkage is about providing what is 
needed up front, and not after the fact. It is about providing guidance 
to the families of our veterans, to help welcome back our newest 
veterans and their spouses, fathers, mothers, sons and daughters, to be 
sure that the transition is as smooth as possible. For our earlier 
generations of veterans, it also is about continuing the transition 
home, or in some case may be only beginning that transition after 40 
years or more of emotional pain.
    I want to emphasize the government agency link, and especially the 
link with the Department of Veterans Affairs. As Senator Akaka has 
noted in his recent legislation (S. 1233), ``the Department of Defense 
and Department of Veterans Affairs have made efforts to provide a 
smooth transition . . .  but more can be done to assist veterans and 
their families in the . . . reintegration of the wounded or injured 
veterans into their community.'' Our newest program is the community-
based Native Hawaiian Veterans Resource Program. The cornerstone of 
this program is what started as ``the Uncle's Project'' and is now Na 
Hana No'eau No Na Mea Pono (``The Work Toward Righteous Things''), 
which is supported by grants from the Castle Foundation and from Papa 
Ola Lokahi. Recently, Trustees of OHA met with some of the ``Uncles'' 
and representatives of Helping Hands Hawaii's administration to discuss 
what role they might take in also supporting this program so that no 
veteran will be left behind. We look forward to the benefit of their 
mana'o, as well.
    The veterans we have seen have been referred through State or 
private social service agencies, at times identified by our own case 
managers, or even referred through the VA benefits system, itself We 
have identified our mission quite clearly as not one that will 
duplicate services nor in any way detract from what the VA offers. 
Rather, we intend to assist the veteran in navigating the VA system, 
and support the VA system in accomplishing its mission. As the report 
of the 2007 President's Commission on Care for America's Returning 
Wounded Warriors acknowledges, both the DOD and VA benefits and health 
care systems are complicated and complex; both are difficult to 
understand and marked by inequities. By having HHH staff available who 
are familiar with the VA system and by working closely with the current 
VA staff, our goal is to help veterans become aware of and find it 
easier to access the services for which they may be eligible because 
they will have a coach, a partner, and a helping hand available to 
guide them. We do not doubt that there are caring and concerned 
individuals among the staff at the VA, but things do not always go 
smoothly. The VA staff must contend with the complexity of the 
paperwork, the rules, and the regulations, and they are only human. 
This very same paperwork, and those rules and regulations, often are 
perceived by the veterans as obstacles and hurdles, confirming whatever 
beliefs they may already have developed about not trusting that their 
government can see them as anything other than a number. Their 
frustration in dealing with the system often leads to anger or despair, 
and a tendency to abandon any hope for assistance. It is our hope that 
our newest program will allow the VA to more easily find those veterans 
who are eligible for services and facilitate their access to the most 
appropriate care in a timely manner. HHH is all too aware of the 
benefit which can come from improving access to services in order to 
prevent more serious problems at a later time. For our veterans who do 
not find the VA system accessible, the cost in terms of economic, 
emotional, and social hardships is an added burden to that which they 
already are experiencing. Being successful as we carry out this newest 
of our missions will honor the sacrifice our soldiers have made as we 
support the mission of the VA in making the veteran's mental health and 
adjustment to civilian life among the highest priorities of our Nation.
    Having addressed the importance of community partnership and 
linkages, I come to the final area of importance to Na Hana No'eau No 
Na Mea Pono--that is, advocacy. There is research showing that Native 
Hawaiians experience significant disparities in health care, opting to 
avoid health care services when dealing with bureaucratic systems, 
cultural insensitivity, and other similar barriers to care. Our work is 
guided by the experience of Papa Ola Lokahi with the federally funded 
comprehensive health care centers, so that the intimidation created by 
the bureaucracy and the potential for culturally insensitive delivery 
of service within the large and at time impersonal VA system can be 
reduced. There also is documentation that Native Hawaiians serving in 
the Vietnam War experienced symptoms of post traumatic stress to a 
greater degree than the general population of soldiers serving in that 
war. There is no reason to expect that there will be any significant 
change in either the health disparities or in the incidence of 
psychological symptoms among Hawaii's current military force returning 
from combat. This situation is likely to be made even worse by the fact 
that many of the members of our Guard and Reserve Units come from our 
rural areas, both on Oahu and on our neighbor islands, where access to 
health care, especially mental health care, and continuity of care are 
already problems. While our program will certainly be accepting 
veterans of any ethnicity, and not just our Native Hawaiian veterans, a 
primary focus remains to provide support services for our generally 
underserved Native Hawaiian population. Consequently, the mission of 
our program, as we extend a helping hand, will be to provide the 
advocacy necessary for each individual veteran and their family members 
so that they have ready and easy access to care, as well as having the 
most appropriate care.
    Mahalo nui loa for allowing me the time to share my mana'o with you 
today.
    Mr. Chairman, I would be pleased to answer any questions that you 
or the Committee Members have for me at this time.
    Aloha.

    Senator Akaka. Thank you very much, Clay Park. And now the 
last member of this panel is Darryl Vincent, site director of 
U.S. Veterans Initiative.

        STATEMENT OF DARRYL J. VINCENT, SITE DIRECTOR, 
            UNITED STATES VETERANS INITIATIVE-HAWAII

    Mr. Vincent. Good morning, Senator Akaka and Senator 
Inouye, and others distinguished officials, my name is Darryl 
Vincent, I'm the Hawaii Site Director of the United States 
Veterans Initiative, a nonprofit agency that helps military 
veterans experiencing homelessness. In Hawaii, our facilities 
are located at Kalaeloa, at the former Barbers Point Naval Air 
Station where we currently serve approximately 200 veterans.
    I'm here to speak to you about the realities of 
homelessness among veterans in Hawaii, what United States 
Veterans Initiative is currently doing to reduce homelessness 
among Hawaii veterans. Most importantly, I'm here to advocate 
for expansion of known solutions that can reduce homelessness 
for military veterans and to request that solutions be 
seriously considered in upcoming Federal legislation and 
appropriations.
    First the realities. For many, the face of the modern 
homeless began with the image of homeless veterans--sign in 
hand asking for food, shelter, job--on the streets, stop signs 
at nearly every town in America. Still today despite pockets of 
progress, the VA estimates that 250,000 military veterans in 
America will be sleeping in the streets tonight. And I hope we 
can only grasp that number 250,000. The number is estimated to 
be as many as a thousand veterans in Hawaii.
    One-third of the America's adult male homeless population 
is estimated to be veterans, and in Hawaii it's no different. 
Tonight many homeless veterans in Hawaii will be sleeping at 
the beach, parks, in cars, at bus stops, sidewalks and other 
places not suitable for human habitation. Others remain in 
emergency shelters without appropriate services and treatment.
    And the flow of veterans continues from the older veterans 
who served during the Vietnam era to the veterans of the Gulf 
War and most tragically even young veterans back from Iraq and 
Afghanistan. For soldiers who escape physical and mental 
injury, it remains tough for many that are returning without 
jobs, and to a rental market that has priced them out of a home 
or even an affordable apartment rental.
    For veterans returning with PTSD and other trauma related 
injuries from war, the transition back to the community will be 
a most difficult one. Research shows that veterans typically 
experience homelessness a few years after military discharge, 
after the support of the family and friends have been exhausted 
and failed attempts to successfully reintegrate back into 
community or after the full effects of their physical and 
mental injuries have taken their toll. Whenever they call for 
help, we must remain firm in our commitment to honor these 
honorable men and women.
    We also wonder how many veterans will come to our doors in 
the next year, two years and five years. We wonder, with so 
many soldiers from Hawaii being deployed, will the state be 
prepared for their unique needs in the future. The full effects 
are not often seen for years, but 30 years of modern 
homelessness guarantee us that more veterans will need 
assistance. As a veteran myself, I feel that it's a crime that 
we have allowed those who once committed themselves to die for 
our freedoms to plummet to homelessness. That's the reality, 
past, present and future.
    Now, just a little bit about what United States Veterans 
Initiative does. It offers a strong blueprint of what can be 
done to help our veterans. Since we opened up in 2002 in 
Hawaii, we provided services to over 800 homeless veterans with 
holistic, residential treatment approach, including medical, 
mental health and substance abuse treatment, employment 
reintegration and housing placement. We also provided an 
additional 1,500 veterans with outreach and referral to other 
needed programs.
    Services are provided in collaboration with the local VA 
and through key partnerships with other service providers. The 
initiative in Hawaii is one of 11 sites operated by the 
Initiative based in Inglewood, California that's been serving 
homeless veterans since 1992.
    The Initiative offers a two-stage housing and treatment 
program that incorporates time tested best practice treatments 
and recovery principles. The first stage is our Veterans-in-
Progress program which serves about 250 homeless veterans 
annually. Our outreach staff scours over 60 public areas on 
Oahu where homeless veterans congregate. They engage them, talk 
to them and encourage them to come to Barbers Point facility.
    Interested homeless veterans are enrolled in the program 
where they receive immediate housing, meals, laundry, mail, 
transportation and other essential services. There are no 
program fees if the veteran doesn't have an income. This allows 
the veterans to focus first on addressing substance abuse and 
mental health issues and medical problems, key barriers to 
employment, house retention and full social integration. For 
those in need of substance abuse treatment, the vast majority 
of those we serve, the veteran immediately enrolls in intensive 
outpatient substance abuse treatment. Those with a little more 
complex dual-diagnosis needs are typically served by the VA.
    At our site in Hawaii, eight out of every ten veterans that 
are enrolled in our program need substance abuse and/or mental 
health services. All receive a minimum of 90 days of treatment, 
more depending on their needs. To be sure, many veterans have 
lost their job, housing and too often their family because of 
substance abuse. Substance abuse is often caused by underlying 
mental illness like depression and PTSD. Substance abuse often 
grows worse during the time of service and we certainly 
advocate for better identification, prevention and treatment of 
substance abuse while in the military.
    Our program works. During 2006, 83 percent of our veterans 
maintain their sobriety while in the program. Seventy-three 
percent of veterans enrolled in workforce development found a 
job, and 76 percent transitioned to some type of permanent 
housing or appropriate transitional housing. Many of those that 
were unsuccessful become successful after reenrolling in a 
program for the second time. Much of the success of our program 
is due to a therapeutic community we foster at Barbers Point. 
Staff cannot do it alone. Veterans help veterans as buddies, 
peers, chaperones and informal counselors. We attribute our 
success to the fact that after a veteran completes our program, 
they have the opportunity to move into a sober-living, long-
term affordable housing which is co-located right there at 
Barbers Point. The long term housing is offered to veterans who 
have successfully completed the program and have at least 90 
days of being clean and sober and can support living 
independently.
    The veteran continues to receive supportive services 
through case management and workforce development, but they're 
not held to the same structure as they were in the program. 
They continue to be drug tested and this allows them to stay 
connected with the services that helped them in the first 
place. More than over 150 veterans have taken advantage of this 
sober living.
    So what do we need to handle both today's homeless veterans 
and tomorrow's homeless veterans?
    There are three things that I'd like to emphasize.
    First, funding must be increased through the VA's Grant and 
Per Diem program. Success from our VIP program funded by the 
Grant and Per Diem Program shows that, yes, money when funding 
a successful program model can reduce homelessness. Currently, 
the approximate rate is $29.00 per day per person. In Hawaii, 
it takes about $55.00 a day to serve a homeless veteran in our 
program. And while we do look for collateral funding sources, 
it becomes more competitive as the cost of services grow. A 
long-term commitment to funding the VA's Grant and Per Diem 
Program must include greater funding commitment. Programs like 
ours need to spend less time trying to find additional money 
each year and more time serving homeless veterans. Veterans 
deserve high quality treatment by skilled professionals not 
barely above minimum wage workers. We would like to open a 
program on outer islands, but it would not be possible without 
other funding.
    Second, more allocations are needed for funding alternative 
vocational training programs. We found it very effective to 
place veterans in the early stages of substance abuse into pre-
employment vocational internship positions. These positions 
such as running our veteran store, supervising the career 
center, directing meal services, apprenticing to be a resident 
manager and assisting our maintenance and landscaping manager, 
providing the veteran with a transitional period of employment-
like experience while they go through their treatment program. 
They can be given a small stipend while they learn a new skill 
and maintain participation in a treatment program.
    We feel modest funding in these areas can produce great 
benefits. As you know, getting a job is the easy part. 
Maintaining the job and getting a job that has a career is the 
difficult part. Veterans often need a stepping stone that 
vocational program, which we refer to as the Transitional Work 
Experience, can offer. A program that they can participate in 
while in treatment, that complements the success achieved in 
treatment while laying a stronger foundation for long-term 
recovery and self-sufficiency. An increase in the general per 
diem rate could help fund this type of program or through 
separate appropriations.
    Congress can also take a more active role in helping to 
provide scholarships for retraining veterans in union 
apprentice programs and business training programs which are 
quite costly.
    Finally, more funding is needed for sober housing 
supportive housing services. As I mentioned, the key component 
of our long-term success of our program and the key component 
of any substance abuse program is the ability to maintain 
individuals in a sober and supportive atmosphere.
    Our independent living apartments offer that opportunity 
and over 150 veterans have taken advantage of that opportunity. 
As we expand these units, we ask that the VA consider a funding 
stream to provide long-term supportive services to sober-living 
housing like ours. The cost is minimal. We estimate $5.00 per 
day per individual compared to the cost of relapse, recidivism 
to homelessness.
    On behalf of all the veterans we serve at the United States 
Veterans Initiative, I appreciate the time you've given me to 
share with you, how together, we can do a much better job for 
our military veterans in Hawaii and throughout the country. 
These three points I've emphasized come from day-to-day tasks 
of delivering high-quality services to your veteran heroes that 
have served our country. Thank you, sir.
    [The prepared statement of Mr. Vincent follows:]

        Prepared Statement of Darryl J. Vincent, Site Director, 
                United States Veterans Initiative-Hawaii

    Aloha Senator Akaka and other distinguished officials, my name is 
Darryl Vincent and I am the Hawaii Site Director for the United States 
Veterans Initiative, a nonprofit agency that helps military veterans 
experiencing homelessness. In Hawaii, our facilities are located at 
Kalaeloa, at the former Barbers Point Naval Air Station, where we 
currently serve approximately 200 veterans.
    I am here today to speak to you about the realities of homelessness 
among veterans in Hawaii, what United States Veterans Initiative is 
currently doing to reduce homelessness among Hawaii veterans, and, most 
importantly, I am here today to advocate for an expansion of known 
solutions that can reduce homelessness for our military veterans--and 
to request that these solutions be seriously considered in upcoming 
Federal legislation and appropriations.
    First the realities--
    For many, the face of modern homelessness began with the image of 
the homeless veteran--sign in hand, often wheelchair-bound, asking for 
food, shelter, a job--on the streets and at the stop signs of nearly 
every town in America. Still today, despite pockets of progress, the VA 
estimates that 250,000 military veterans in America will be sleeping on 
the streets tonight. In Hawaii, that number is estimated to be as many 
as one thousand (1,000) veterans. One third of America's adult male 
homeless population is estimated to be veterans and in Hawaii it is no 
different. Tonight, many homeless veterans in Hawaii will be sleeping 
at beach parks, in cars, at bus-stops, on sidewalks, and other places 
not suitable for human habitation. Others remain in emergency shelters, 
without appropriate services and treatment.
    And the flow of veterans continues--from older veterans who served 
during the Vietnam era, to veterans of the Gulf War, and most 
tragically even young veterans back from Iraq and Afghanistan.
    For soldiers who escape physical and mental injury, it remains 
tough for many that are returning without jobs, and to a rental market 
that has priced them out of a home or even an affordable apartment 
rental. For veterans returning with Post Traumatic Stress Disorder and 
other trauma-related injuries from war, the transition back into their 
community will be a most difficult one. Research shows that veterans 
typically experience homelessness a few years after military discharge, 
after the support of family and friends has been exhausted, after 
failed attempts at successfully reintegrating back into the community, 
or after the full effects of their physical and mental injuries have 
taken their toll. Whenever they call for help, we must remain firm in 
our commitment to these honorable men and women.
    We also wonder how many more veterans will come through our doors 
in the next year, 2 years, and 5 years. We wonder, with so many 
soldiers from Hawaii having been deployed, will the state be prepared 
for their unique needs in the future? The full effects are often not 
seen for a few years--but 30 years of modern homelessness guarantees 
us--that more veterans will need assistance. As a veteran myself, I 
feel that is a crime that we have allowed those who once committed 
themselves to die for our freedoms to plummet to homelessness.
    That's the reality--past, present and future. Now, a little about 
what United States Veterans Initiative does--which offers a strong 
blueprint for what can be done to help more veterans.
    Since opening in 2002, United States Veterans Initiative has 
provided over 800 homeless veterans with holistic, residential 
treatment services--including medical, mental health and substance 
abuse treatment, employment reintegration and housing placement. We 
have also provided an additional 1,500 veterans with outreach and 
referral to other needed programs. Services are provided in 
collaboration with the local VA and through key partnerships with other 
service provider agencies. United States Veterans Initiative-Hawaii is 
one of 11 sites operated by the United States Veterans Initiative, 
based in Inglewood, California that has been serving homeless veterans 
since 1992.
    United States Veterans Initiative offers a two-stage housing and 
treatment program that incorporates time-tested, best-practice 
treatment and recovery principles. The first stage is our Veterans-in-
Progress, or VIP program which serves about 250 homeless veterans 
annually. Our outreach staff scours over 60 public areas on Oahu where 
homeless veterans congregate--they engage them, talk to them, and 
encourage them to come to the Barbers Point facilities. Interested 
homeless veterans are then enrolled in the VIP program, where they 
receive immediate housing, meals, laundry, mail, transportation and all 
other essential services. Program fees are waived for veterans, until 
they begin receiving income. This allows the veterans to focus first on 
addressing substance abuse, mental illness and other medical problems--
key barriers to employment, housing retention and full social 
integration.
    For those in need of substance abuse treatment--the vast majority 
of those we serve--the veteran immediately enrolls in intensive 
outpatient substance abuse treatment--those with more complex dual-
diagnosis needs are typically served by the VA. At our site in Hawaii, 
8 of every 10 veterans we enroll will need substance abuse services. 
All receive a minimum of 90 days of treatment, more depending on their 
needs. To be sure, many veterans have lost their job, housing, and too 
often their family, because of substance abuse. Substance abuse is 
often caused by underlying mental illnesses like depression and Post 
Traumatic Stress Disorder. Substance abuse often grew worse during 
their time of service. And we certainly advocate for better 
identification, prevention and treatment of substance abuse while in 
the military.
    And our VIP program works. During 2006, over 83 percent maintain 
their sobriety while in the program and at time of discharge, 73 
percent of veterans enrolled in Workforce Development find jobs, and 76 
percent successfully transition into permanent housing or appropriate 
transitional housing. Many of those unsuccessful can often be served by 
re-enrolling them into the program--a second chance--when they are 
better ready and able to change their lives. Much of the success of the 
VIP program is due to the therapeutic community we foster at Barbers 
Point--staff cannot do it alone, veterans help fellow veterans, as 
buddies, peers, chaperones and informal counselors.
    We also attribute program success to the fact that after a veteran 
completes our VIP program they have the opportunity to move into our 
sober-living, long-term affordable housing, co-located at the Barbers 
Point facility.
    This long-term housing is offered to veterans who have successfully 
completed the requirements of the VIP program, that have at least 90 
days of being clean and sober, and that have an income to support 
living independently. The veteran continues to receive supportive 
services through case management and workforce development, but they 
are not held to the same structure as if they were in the program. And 
Veterans continue to be drug-tested on a regular basis. This allows a 
veteran to stay connected with the services that helped them in first 
place, while allowing the veteran to become more independent and self 
reliant--knowing there is still help just a few feet away. More than 
150 individuals have taken advantage of these sober-living independent 
housing, with many using it as a stepping-stone to full community 
reintegration.
    So, what do we need? To handle both today's homeless veterans and 
tomorrow's homeless veterans there are three things that I would like 
to emphasize:
    (1) Funding Must Be Increased Through the VA's Grant and Per Diem 
Program--Success with our VIP program funded by the Grant and Per Diem 
program shows that yes, money, when funding a successful program model, 
can reduce homelessness. Unfortunately, the current Per Diem rate of 
approximately $29 per day per person, pays for only half of the real 
costs of effective treatment services--which for our Hawaii site is 
about $55 per day--and that cost is delivered with a bare bones staff, 
paid much lower than VA staff salaries.
    Access to collateral funding sources through HUD and the DOL have 
slowly evaporated--while the cost of services continues to grow. A 
long-term commitment to funding the VA's Grant and Per Diem program 
must include a greater funding commitment.
    Programs like ours need to spend less time trying to find this 
additional money each year, and more time serving homeless veterans. 
Veterans deserve high-quality treatment by skilled professionals, not 
barely above minimum wage workers. We would like to open a program on 
Maui and the Big Island, but collateral funds will not be present. Try 
providing housing, treatment, transportation, food and other amenities 
on Maui for $850 a month (the monthly per diem for one veteran)--you 
can't even rent an apartment for that amount.
    At a minimum, we strongly advocate for a 20 percent increase in the 
Per Diem rate, an annual cost to the Federal Government of $15-$20 
million, a sum that will ensure the continuation of services provided 
by the other 300 per diem veteran service providers throughout America, 
and one that will ensure new programs can open to serve the remaining 
gap of homeless veterans identified by the VA.
    (2) Second, More Allocations Are Needed for Funding Alternative 
Vocational Training at Our Barbers Point Program--We have found it very 
effective to place veterans in the early stages of substance abuse into 
pre-employment vocational internship positions. These positions, such 
as running our veteran store, supervising the career center, directing 
meal services, apprenticing to be a resident manager, and assisting our 
maintenance and landscaping manager, provide the veteran with a 
transitional period of an employment-like experience while they go 
through our treatment program. Veterans are given small, but important 
stipends, $200 per month or so, and learn a new skill, while 
maintaining participation in the treatment program, contributing to the 
healthy environment at United States Veterans Initiative and preparing 
for the eventual re-entry into the marketplace.
    We feel modest funding in this area can produce great benefits. As 
you know, getting a job is often the easy part, maintaining the job and 
getting a job that has a career is the difficult job. Veterans often 
need a stepping stone that a vocational program--which we refer to as 
the Transitional Work Experience program--can offer. A program that 
they can participate in while still in treatment--that complements the 
successes achieved in treatment while laying a stronger foundation for 
long-term recovery and self-sufficiency. An increase in the general per 
diem rate could help fund this type of program, and through separate 
appropriations. Congress can also take a more active role in helping to 
provide scholarships for retraining veterans in union apprentice 
programs and business training programs which are quite costly.
    (3) Finally, More Funding is Needed For Sober Housing Supportive 
Housing Services--As I mentioned, a key component of the long-term 
success of our program, and the key component of any substance abuse 
program is the ability to maintain individuals in a sober and 
supportive atmosphere. Our independent living apartments offer that 
opportunity and over 150 veterans have taken advantage of this 
opportunity. As we expand these units, we ask that the VA consider a 
funding stream to provide long-term supportive services to sober-living 
housing like ours--the cost is so minimal--we estimate $5 per day per 
individual--compared to the cost of relapse and recidivism to 
homelessness.
    On behalf of all the veterans we serve at United States Veterans 
Initiative, I appreciate the time given to me to share with you how, 
together we can do a much better job for our military veterans--in 
Hawaii and throughout the country. These three points I have emphasized 
come from the day-to-day tasks of delivering high-quality services--to 
our veteran heroes that have served their country.
    I am available for questions or further elaboration. I would like 
to specifically thank Senator Akaka for his tireless dedication to 
serving our veterans and the people of Hawaii. As a veteran himself we 
know that he can relate and empathize with the many issues faced by our 
veterans and with his strong leadership and vision we can start to 
address and solve these issues one day at a time.

    The Audience. (Applause.)
    Senator Akaka. Thank you very much.
    I want to thank this panel very much for your personal and 
heartfelt testimony. For the Committee, we are really grateful 
for what you have shared with us. You have questions that will 
be helpful to the work that the Committee will be doing.
    Senator Inouye will not be able to stay. I would like to 
ask Senator Inouye if he has any concluding remarks. And then 
following that, we'll conclude the first panel.
    Senator Inouye. Well, Mr. Chairman, I thank you very much. 
I must say that I am impressed by your testimony and willing to 
come publicly to candidly advise us of your concerns whether 
it's good or bad. And Ms. Del Negro, we'll do our very best to 
see that it's not repeated again.
    To all of you, I feel a special bond and kinship and I can 
assure you that I will not knowingly let my fellow veteran 
down. Thank you.
    The Audience. (Applause.)
    Senator Akaka. Thank you, Senator Inouye. I want to again 
thank the first panel and mahalo nui loa, and it will be 
helpful to the Committee and we appreciate all that you're 
doing.
    Mahalo. I want to welcome the second panel of witnesses. 
Thank you everyone. I know many of you have messages to pass 
on. But we would like to continue with the second panel, and I 
want to welcome here today, Dr. Michael Kussman, who is the 
former Deputy Under Secretary for Health and is now the top man 
here across the country in VA health care. I'm so delighted 
that he had the time to join us here.
    He is accompanied by Dr. Jim Hastings, who is Director of 
the VA Pacific Islands Health Care System; and Dr. Robert 
Wiebe, Director of Network 21. He has been here before and he 
has been so helpful in our cause to improve care for Hawaii's 
veterans. Also, Under Secretary Tuerk is here, and he is 
accompanied by Gene Castignetti, the Director of the National 
Memorial Cemetery of the Pacific. Finally, I want to welcome 
Ronald Aument, who is the Deputy Under Secretary for Benefits.
    We have the top people here from VA to testify this 
morning. And let me say that Ronald Aument here is accompanied 
by Gregory Reed, who has been doing a good job as the Director 
of the Honolulu Regional Office. Finally, I welcome Julie 
Watrous, Director of the Los Angeles Regional Office, Office of 
Healthcare Inspections, Office of the Inspector General. She is 
accompanied by Dr. Michael Shepherd, also from the IG's office.
    I want to welcome this panel with much aloha and thank each 
of them for being here. I will just remind you that your full 
statements will appear in the record of the Committee. And with 
that, those of you standing if there are seats, please find a 
seat and be comfortable. And at this time I'd like to call Dr. 
Kussman to begin with his testimony.

  STATEMENT OF HON. MICHAEL J. KUSSMAN, M.D., M.S., M.A.C.P., 
  UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS; 
   ACCOMPANIED BY ROBERT L. WIEBE, M.D., DIRECTOR, VISN 21, 
   DEPARTMENT OF VETERANS AFFAIRS; AND JAMES HASTINGS, M.D., 
                           F.A.C.P., 
       DIRECTOR, VA PACIFIC ISLANDS HEALTH CARE SYSTEM, 
         VETERANS HEALTH ADMINISTRATION, DEPARTMENT OF 
                        VETERANS AFFAIRS

    Dr. Kussman. Aloha, Mr. Chairman, mahalo nui loa. Thank you 
very much for the opportunity to appear before you today to 
discuss the VA health care services in Hawaii and the Pacific 
Region. It is a privilege to be here again on Oahu, the 
Gathering Place, to speak and answer questions about health 
care issues important to veterans residing in Hawaii.
    As you know, I was fortunate enough to be stationed here in 
the past, at Tripler Army Medical Center, as a division surgeon 
for the 25th Infantry Division. I have a great passion for what 
I do and great appreciation and respect for the people of these 
wonderful islands.
    Before I get into my prepared remarks, I'd like to make a 
few quick comments about the first panel, if that's OK with 
you. I want to recognize them and appreciate and thank them for 
their comments. I appreciate the good things, but I more 
appreciate many ways the negative things that they said, so we 
can learn from that and be better. As was mentioned, we believe 
that we're not your father's VA and that we've made quantum 
leap changes in our approach to the veterans on all levels. I 
appreciate Mrs. Del Negro's comments and thank her husband for 
his service and continuing service as a Ranger in the United 
States Army.
    I did then talk to her a little bit after the testimony. 
And although her husband did not avail himself at the present 
time of the VA services, I assured her that we stand ready in 
every way to help her husband and people like that. We have a 
very robust TBI service. And as you know, Mr. Chairman, we 
screen everyone who comes to us from Hawaii for TBI along with 
other ailments. We appreciate the comments of the Vet Centers, 
and we're increasing our capacity. We've increased 32 Vet 
Centers around the country in the last year and we'll probably 
continue to expand that capacity.
    The VA has achieved some remarkable accomplishments in 
providing better and more accessible care to veterans in Hawaii 
and the Pacific Islands. I'd like to share some of this good 
news with you today, news about the superior care that we 
provide and information on new developments regarding our 
facilities. In fiscal year 2006, the VA Sierra Pacific Network, 
was the highest ranked network in overall performance based on 
quality access, satisfaction and business metrics.
    The Network is home to more Centers of Excellence than any 
other and has the highest funded research programs in the 
Veterans Health Administration. In the most recent all employee 
survey, VA staff from this Network reported the highest overall 
job satisfaction throughout the Veterans Health Administration. 
I understand that in the next few months, the State of Hawaii 
Veterans Home in Hilo will accept its first patient. In no 
small part due to the more than $18 million VA contributed to 
this project. A 95-bed facility will provide more inpatient 
long-term care and adult day-care center services for Hawaii 
veterans.
    VA recently dedicated the Community Based Outpatient Clinic 
in America Samoa on July 21, 2007. The Capital Asset 
Realignment for Enhanced Services process that we use to build 
new facilities identified some additional locations for 
consideration of future CBOCs here in Hawaii. VA learned about 
the possibility of opening--of obtaining the vacant U.S. Navy 
medical clinic at Barbers Point near Kapolei.
    Although this clinic is about 13 miles from Waianae, this 
location could open quickly to support the veterans homeless 
shelter at Barbers Point and relieve some of the space crunch 
at the VA clinic on the Tripler campus. It's not clear whether 
or not the VA will be able to obtain this property, and so we 
will continue to explore other options on the west side of Oahu 
if that turns out to be necessary.
    In fiscal year 2005, the VA approved $5.6 million for a 
minor construction project to build a 15,000 square foot 
facility on the Tripler campus that will house the relocated 
inpatient PTSD residential rehabilitation unit, and the new 
outpatient PSTD program. The contract for an environmental 
assessment and design phase of the project is expected to be 
awarded before the end of the current fiscal year and 
construction should begin in fiscal year 2008.
    VA also approved a minor construction project estimated at 
$6.9 million to build a new ambulatory surgery center on the 
Tripler campus. This will greatly enhance the ability of the 
health care system here to provide ambulatory services and 
procedures and reduce the need for referrals elsewhere. 
Construction should begin in fiscal year 2009. For our Guam 
veterans, VA determined the best option to improve care is to 
build a new clinic at the periphery of the U.S. Naval Hospital 
Guam campus.
    I'm pleased to report that on July 30 of this year 
Secretary Nicholson announced plans for the VA to build this 
clinic at an estimated cost of $5.4 million. The clinic will be 
about 6,000 square feet and will have its own parking. The Navy 
will relocate its fence around the clinic so veterans will not 
have to pass through the Navy security to enter the facility. 
The new clinic is scheduled to open in the summer of 2009.
    In summary, Mr. Chairman, the support of the Senate 
Committee on Veterans Affairs and the Hawaiian congressional 
delegation, VA is providing an unprecedented level of health 
care services to veterans residing in Hawaii and the Pacific 
Region. VA now has a state-of-the-art facilities and enhance 
services in Honolulu as well as robust staffing in the neighbor 
islands and has expanded or renovated clinics in many 
locations.
    Mr. Chairman, again, mahalo nui aloha for the opportunity 
to testify this morning. And I and all the members of the panel 
and my associates, Dr. Wiebe and Dr. Hastings, will be 
delighted to address any questions that you may have of us. 
Thank you.
    [The prepared statement of Dr. Kussman follows:]
 Prepared Statement of Hon. Michael J. Kussman, M.D., M.S., M.A.C.P., 
       Under Secretary for Health, Department of Veterans Affairs
    Mr. Chairman and Members of the Committee, mahalo nui loa for the 
opportunity to appear before you today to discuss VA care in Hawaii and 
the Pacific Region. It is a privilege to be on Oahu--The Gathering 
Place--to speak and answer questions about VA health care issues that 
are important to veterans residing in Hawaii. I was fortunate to have 
been stationed in Honolulu at Tripler Army Medical Center (AMC) and 
Schofield Barracks (as Division Surgeon for the 25th Infantry Division) 
from 1979 to 1983. It is always a pleasure to return to Hawaii.
    First, Mr. Chairman, I would like to thank you for your outstanding 
leadership and advocacy on behalf of our Nation's veterans. During your 
tenures as Ranking Member and Chairman of this Committee, you have 
consistently demonstrated your commitment to veterans by introducing 
legislation designed to meet the needs of veterans. As I will highlight 
later, your vision and support have led to an unprecedented level of 
health care services for veterans, construction of state-of-the-art 
facilities here in Honolulu and remarkable improvements in access to 
health care services for veterans residing on neighbor islands. In 
addition, I appreciate your interest in and support of the Department 
of Veterans Affairs (VA).
    Today, I will briefly review the VA Sierra Pacific Network that 
includes Hawaii and the Pacific Region; provide an overview of the VA 
Pacific Islands Health Care System (VAPIHCS) and the VA facilities here 
on Oahu; and highlight issues of particular interest to veterans 
residing in Hawaii, including long-term care (LTC) services, potential 
new VA clinics on Oahu, planned VA construction projects and our VA-
Department of Defense (DOD) joint venture at Tripler AMC. I will also 
discuss our plans to build a replacement VA clinic in Guam and address 
any questions you might have for me and my staff.

                  VA SIERRA PACIFIC NETWORK (VISN 21)

    The VA Sierra Pacific Network (Veterans Integrated Service Network 
[VISN] 21) is one of 21 integrated health care networks in the Veterans 
Health Administration (VHA). The VA Sierra Pacific Network provides 
services to veterans residing in Hawaii and the Pacific Region 
(including the Philippines, Guam, American Samoa and Commonwealth of 
the Northern Marianas Islands), northern Nevada and central/northern 
California. There were an estimated 1.1 million veterans living within 
the boundaries of the VA Sierra Pacific Network in Fiscal Year (FY) 
2006.
    The VA Sierra Pacific Network includes six major health care 
systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA; 
Sacramento, CA; Fresno, CA; and Reno, NV. Dr. Robert Wiebe serves as 
director and oversees clinical and administrative operations throughout 
the Network. In FY 2006, the Network provided services to 235,000 
veterans. There were about 2.9 million clinic stops and 24,500 
inpatient discharges. The cumulative full-time employment equivalents 
(FTEE) level was 8,400 and the operating budget was about $1.5 billion.
    The VA Sierra Pacific Network is remarkable in several ways. In FY 
2006, VISN 21 was the highest-ranked Network in overall performance 
(based on an aggregation of quality, access, patient satisfaction and 
business metrics). The Network hosts the most Centers of Excellence and 
also has the highest funded research programs in VHA. In the most 
recent all-employee survey, staffs in VISN 21 reported the highest 
overall job satisfaction in VHA. Finally, VISN 21 operates one of four 
Polytrauma units in VHA that are dedicated to addressing the clinical 
needs of the most severely wounded Operation Enduring Freedom/Operation 
Iraqi Freedom (OEF/OIF) veterans.

            VA PACIFIC ISLANDS HEALTH CARE SYSTEM (VAPIHCS)

    As noted above, VAPIHCS is one of six major health care systems in 
VISN 21. Dr. James Hastings is the director at VAPIHCS. VAPIHCS is 
unique in several important aspects: its vast catchment area covering 
2.6 million square-miles (including Hawaii, Guam, American Samoa and 
Commonwealth of the Northern Marianas); island topography and the 
challenges to access it creates; richness of the culture of Pacific 
Islanders; and the ethnic diversity of patients and staff. In FY 2006, 
there were an estimated 102,000 veterans living in Hawaii (representing 
8 percent of the total population in Hawaii and 9 percent of total 
veteran population in VISN 21).
    VAPIHCS currently provides care in seven locations: Ambulatory Care 
Center (ACC) and Center for Aging (CFA) on the campus of the Tripler 
AMC in Honolulu; and Community Based Outpatient Clinics (CBOCs) in 
Lihue (Kauai), Kahului (Maui), Kailua-Kona (Hawaii), Hilo (Hawaii), 
Hagatna (Guam) and Pago Pago (American Samoa). VAPIHCS also has 
outreach clinics in Molokai and Lanai. The inpatient Post Traumatic 
Stress Disorder (PTSD) unit is now also on the campus of Tripler AMC 
(the unit was formerly in Hilo). In addition to VAPIHCS, VHA operates 
five Readjustment Counseling Centers (Vet Centers) in Honolulu, Lihue, 
Wailuku, Kailua-Kona and Hilo that provide counseling, psychosocial 
support and outreach.
    In FY 2006, VAPIHCS provided services to nearly 22,500 veterans, 
19,000 of whom reside in Hawaii. There were 198,000 clinic stops in 
Hawaii during FY 2006 (7 percent of Network total). The cumulative FTEE 
in FY 2006 for the health care system was 502 employees. The operating 
budget for VAPIHCS (i.e., General Purpose allocation from appropriated 
funds) increased from $68.0 million in FY 2002 to $110 million in FY 
2007--an increase of 62 percent. For comparison, during this same time 
period, the operating budgets for VISN 21 increased 48 percent and VHA 
increased 43 percent. (Please note these amounts do not include 
Specific Purpose funds and Medical Care Cost Funds [MCCF].)
    VAPIHCS provides or contracts for a comprehensive array of health 
care services. VAPIHCS directly provides primary care, including 
preventive services and health screenings, and mental health services 
at all locations. VAPIHCS does not operate its own acute medical-
surgical hospital and consequently, faces challenges in providing 
specialty services. VAPIHCS recently hired specialists in orthopedics, 
ophthalmology, nephrology and inpatient medicine (``hospitalist'') and 
is providing selected specialty care in Honolulu and to a lesser 
extent, CBOCs. VAPIHCS is actively recruiting additional specialists 
(e.g., urology) and will continue to refer patients to DOD and 
community facilities.
    Inpatient long-term and acute rehabilitation care is available at 
the CFA. Inpatient mental health services are provided by VA staff on a 
20-bed ward within Tripler AMC and at the 16-bed PTSD Residential 
Rehabilitation Program (PRRP). VAPIHCS contracts for care with DOD (at 
Tripler AMC and Guam Naval Hospital) and community facilities for 
inpatient medical-surgical care.
    The current constellation of VA facilities and services represents 
a remarkable transformation over the past several years. Previously, 
the VAPIHCS (formerly known as the VA Medical and Regional Office 
Center [VAMROC] Honolulu) operated primary care and mental health 
clinics based in the Prince Kuhio Federal Building in downtown Honolulu 
and CBOCs on the neighbor islands that were staffed primarily with 
nurse practitioners. Congress approved $83 million in Major 
Construction funds to build a state-of-the-art ambulatory care facility 
(i.e., ACC) and long-term care/rehabilitation unit (i.e., CFA) on the 
Tripler AMC campus and these facilities were activated in 2000 and 
1997, respectively. VISN 21 allocated nearly $17 million from FY 1998-
FY 2000 to activate these projects. VISN 21 also provided dedicated 
funds to enhance care on the neighbor islands by expanding/renovating 
clinic space and adding additional staff to ensure there are primary 
care physicians and mental health providers at all CBOCs.

                            OAHU FACILITIES

    VA operates the Spark M. Matsunaga VA Medical Center in Oahu, 
located on the campus of Tripler AMC at 459 Patterson Road, Honolulu, 
HI 96815. The medical center consists of the ACC, CFA and 
administrative space (located on the E wing of Tripler AMC). Congress 
appropriated $25.1 million Major Construction funds during FY 1993/1994 
to build the CFA; $14.9 million in FY 1995 to construct the parking 
garage; and $43.0 million in FY 1994/1995/1997 to build the ACC and 
renovate the E Wing of Tripler AMC for VA administrative use. Veterans 
Benefits Administration (VBA) is co-located with VHA on this campus. 
The Honolulu Vet Center is located nearby at 1680 Kapiolani Boulevard.
    The VA facilities in Oahu serve an estimated island veteran 
population in FY 2006 of 73,000. In FY 2006, 25,800 veterans on Oahu 
were enrolled for care and 13,400 of these veterans received VA care 
(``users''). The market penetrations for enrollees and ``users'' are 35 
percent and 18 percent, respectively and compare favorably with rates 
within VISN 21 and VHA.
    The average FTEE level on Oahu in FY 2007 is 440. With this staff, 
VAPIHCS provides a wide range of outpatient services, including primary 
care, several medical subspecialties (e.g., cardiology, 
gastroenterology, nephrology, orthopedics, pulmonary and women's 
health), mental health and dental care. In addition, VAPIHCS provides 
diagnostic services such as laboratory, echocardiography and radiology. 
As noted earlier, VA staffs a 20-bed inpatient mental health unit 
within Tripler AMC, 60-bed nursing home care unit (i.e., CFA) and 16-
bed PRRP. If veterans need services not available at the ACC or CFA, 
VAPIHCS arranges and pays for care at Tripler AMC, local community or 
VA facilities in California.
    In FY 2006, VA facilities in Oahu recorded about 161,000 clinic 
stops, representing a 39 percent increase from FY 2000 (i.e., 116,000 
stops). Although some veterans waited more than 30 days in FY 2007 for 
their first primary care appointment, at this time, there are very few 
patients on a waiting list for an initial primary care appointment. In 
FY 2006, the combined average daily census (ADC) was 11 in the mental 
health ward and 54 at the CFA. VAPIHCS spent about $15.5 million for 
clinical services for veterans at Tripler AMC and another $20 million 
for non-VA care in the community.

                             SPECIAL ISSUES

Long-term care (LTC)
    Older veterans have special needs and LTC services are a critical 
issue for many of them. In FY 2006, about 40 percent of all veterans 
seen at VAPIHCS were 65 years or older. VAPIHCS meets their special 
needs with a full spectrum of inpatient, ambulatory and home services.
    VAPIHCS provides inpatient LTC and transitional rehabilitative care 
at the CFA. Over the past several years, the average daily census in 
the CFA has been around 90 percent of capacity. In addition, VA manages 
a community nursing home (CNH) care program and pays for care of 
eligible veterans in private nursing homes. Currently, VAPIHCS has 
contracts with four community LTC facilities in Oahu. VA is motivated 
to expand CNH in Oahu and neighbor islands, but other facilities appear 
to be unwilling or unable to meet VA standards (e.g., life-safety 
codes) and contractual requirements.
    In addition to the LTC services directly provided by VAPIHCS, VA 
has contributed over $18 million to construct the State of Hawaii 
Veterans Home in Hilo. This 95-bed facility will provide both inpatient 
LTC and adult day care services for Hawaii veterans. I understand the 
facility will accept its first admission this month (i.e., August 
2007). I commend the State Advisory Board on Veterans Services for the 
recommendation to name the facility in honor of Mr. Yukio Okutsu. As 
you know, Mr. Chairman, Mr. Okutsu was a resident of Hilo and a 
recipient of our Nation's highest award for valor, the Medal of Honor, 
for his heroism during World War II.
    VA understands that most veterans prefer to remain at home for as 
long as possible. Consequently, VA emphasizes non-institutional care 
(NIC) services. NIC includes Adult Day Health Care (ADHC), Contract 
Adult Day Health Care (CADHC), Home-based Primary Care (HBPC), Contract 
Home Health Care (CHHC), Homemaker/Home Health Aid (H/HHA), Home 
Hospice, Home Respite and Spinal Cord Injury (SCI) Home Program.
    VA has substantially increased these programs over the past several 
years and has ambitious plans to expand further. This trend is also 
present in Hawaii. Since this Committee held hearings here in January 
2006, the ADC for all NIC services at VAPIHCS increased nearly 40 
percent (i.e., from 109.9 in FY 2006 to 153.2 in FY 2007 through June 
2007). In addition, since FY 2005, VAPIHCS has aggressively implemented 
Care Coordination Home Telehealth (CCHT) technologies. Through CCHT, 
veterans have daily contact with VA clinicians by using telehealth 
devices in their homes. Currently, VAPIHCS has about 60 patients 
utilizing CCHT.
    CCHT is especially important for veterans who receive care on Oahu 
and live on a neighbor island. As an example, Mr. Delbert Watson is a 
61 year-old disabled veteran who lives on Kauai and had major heart 
surgeries at Tripler AMC. In a recent letter he wrote, ``The VA saved 
my life. I'd be dead without them. They identified my heart condition 
and got me where I needed to be. I had two heart operations at Tripler, 
but the VA was always there for me. I have a VA health buddy [Health 
Buddy' is a type of CCHT equipment] so the VA nurse still 
keeps an eye on my blood pressure regularly.'' This coordinated system 
of VA, DOD and telehealth care ensures veterans in Hawaii receive 
leading-edge medicine.
Additional Community Based Outpatient Clinics (CBOCs)
    In 2000, VA formally began its long-range capital and strategic 
planning process known as Capital Asset Realignment for Enhanced 
Services (CARES). One of the major goals of the CARES initiative is to 
improve access to health care services and the CARES Commission 
specifically assessed the need for new CBOCs. The CARES Decision 
announced in May 2004 identified one high-priority CBOC for VAPIHCS--
namely, a new outpatient facility in American Samoa. The CBOC in 
American Samoa was dedicated on July 21, 2007. The CARES Decision also 
identified two additional locations for consideration of future CBOCs. 
These locations are Waianae (west side of Oahu) and Kaneohe (east side 
of Oahu).
Waianae
    Originally, VA planned to activate a CBOC on the west side of Oahu. 
However, recently VAPIHCS became aware of the possibility of obtaining 
the vacant U.S. Navy medical clinic at Barber's Point near Kapolei 
(just west of Ewa Beach). Although this clinic is about 13 miles from 
Waianae, it offers the potential advantages of earlier activation, 
support for the veterans' homeless shelter at Barber's Point and 
partial decompression of the ``space crunch'' at the VA clinic building 
on the Tripler AMC campus. It is not clear whether or not VA will be 
able to obtain this property (i.e., Navy has until September 2008 to 
convey its assets at Barber's Point), so we will continue to explore 
other options on the west side of Oahu.
Kaneohe
    VA is also interested in the possibility of having a CBOC on the 
east side of Oahu since the distance and travel times (especially 
during ``rush hour'') to and from Honolulu are significant. We are 
currently reviewing demographic information and potential locations. We 
plan to open a CBOC on the west side of Oahu first (particularly if the 
opportunity at Barber's point comes to fruition).
Construction Projects
    VA has several important construction projects planned for VAPIHCS 
that will enhance services for veterans in Hawaii. In FY 2005, VA 
approved a Minor Construction project to build a facility on the 
Tripler AMC campus that will house the relocated inpatient PRRP and new 
outpatient PTSD program. The facility will be about 15,000 square-feet 
and have an estimated total project cost of $5.6 million. The specific 
location on the Tripler AMC campus has not been determined and will, in 
part, depend on an upcoming environmental study. The contract for the 
environmental assessment and design phase of the project is expected to 
be awarded before the end of the current fiscal year. Construction 
should begin in FY 2008.
    Earlier this fiscal year, VA approved a Minor Construction project 
to build a new ambulatory surgery center on the Tripler AMC campus. The 
facility will be used for ``same day'' surgery and other outpatient 
procedures. This will greatly enhance the ability of VAPIHCS to provide 
ambulatory procedures and reduce the need for referrals elsewhere. We 
are also exploring the opportunities to share the facility with Tripler 
AMC and/or provide services to its beneficiaries through a sharing 
agreement. The total project cost is estimated to be about $6.9 
million. The contract for the design of the facility should be awarded 
in FY 2008, with construction in FY 2009 and activation in FY 2010.
    In addition to these Minor Construction projects, VA spends more 
than $1 million of Non Recurring Maintenance (NRM) funds annually at 
VAPIHCS to renovate and maintain existing structures (e.g., $1.2 
million in FY 2007). As I will discuss at the hearing in Maui on August 
23, 2007, VA has and will continue to expand and improve clinic 
buildings and parking at CBOCs on neighbor islands. I would like to 
thank you, Mr. Chairman, and your colleagues in Congress for your 
generous support of the capital asset programs in VHA (i.e., VHA 
Medical Facilities Appropriation). Without this support, these 
improvements would not be possible.
VA-DOD Joint Ventures
    VAPIHCS participates in one of the largest and most complex VA-DOD 
partnerships. As I noted earlier, I had the privilege of serving at 
Tripler AMC in the early 1980s as chief of Internal Medicine. Both my 
military and VA experiences have helped me understand the systemic 
barriers that VA-DOD joint ventures face: conflicting mission 
priorities, lack of computer interoperability, ambiguities regarding 
dual-eligible beneficiaries and differences in financial systems. 
Further, deployments and increased obligations to TRICARE beneficiaries 
have constrained the ability of Tripler AMC to provide services to VA 
beneficiaries.
    The VA-DOD joint venture in Honolulu has addressed these challenges 
and made great strides in both clinical and administrative areas. The 
partnership with Tripler AMC accelerated when VA began to move clinical 
and administrative functions from the Prince Kuhio Federal Building to 
the Tripler AMC campus in 1997. The co-location of VAPIHCS and Tripler 
AMC allows functional integration and opportunities to provide high 
quality care to Federal beneficiaries residing in Hawaii and the 
Pacific Region. VAPIHCS relies on Tripler AMC for emergency room care, 
acute medical-surgical inpatient care (including intensive care unit), 
outpatient specialty care and ancillary services. Tripler AMC admits 
about 1,400 VA beneficiaries and provides about 12,000 specialty clinic 
visits to VA beneficiaries each year. VAPIHCS also partners with 
Tripler AMC for nutritional services (e.g., inpatient meals at Tripler 
AMC and CFA), housekeeping, security, instrument sterilization and 
medical maintenance. In FY 2006, VAPIHCS purchased a total of about $20 
million of clinical and support services from Tripler AMC.
    VAPIHCS and Tripler AMC also collaborate in several other important 
endeavors. The joint venture in Honolulu has successfully competed for 
several Joint Incentive Fund (JIF) projects. JIF was established by 
Congress in the National Defense Authorization Act (NDAA) in FY 2003 to 
encourage ongoing collaboration. The VA-DOD joint venture in Honolulu 
has secured about $4 million in JIF funding since FY 2004 for projects 
related to computer-aided design and manufacturing of prosthetic 
devices; chronic dialysis center; and chronic pain management program. 
The venture was also selected as one of eight formal VA-DOD Joint 
Venture Demonstration Sites and will specifically assess budget and 
financial management systems.
    VA appreciates the leadership of Major General (MG) Carla Hawley-
Bowland and the responsiveness her staff to VA concerns. She has 
continued the tradition of a productive working relationship between 
senior VA and DOD leaders. I am confident that Dr. Hastings (a former 
Commanding General at Tripler AMC) and MG Hawley-Bowland will continue 
the growth and accomplishments of this very important joint venture.
Guam
    VA has operated a clinic in Guam since 1989 and potentially serves 
an island population of about 9,000 veterans. The VA clinic is 
currently located in leased space within the U.S. Naval Hospital Guam. 
The clinic has nine staff members, including an internal medicine 
physician, psychiatrist and nurse practitioner. The clinic provides 
primary care, mental health care, limited specialty services (through 
telehealth technologies and visiting clinicians) and compensation and 
pension (C&P) examinations. In FY 2006, the clinic evaluated and 
treated 1,235 veterans with 5,824 clinic stops.
    The current clinic site is problematic in many respects, including 
its small size (i.e., 2,700 square feet), related concerns regarding 
patient privacy and lack of parking. Moreover, due to security measures 
imposed by Navy, it is often difficult for veterans to traverse the 
security gate and access the clinic. These challenges will be 
exacerbated in the upcoming years when Navy relocates an estimated 
8,000 U.S. Marines (and 9,000 dependents) from Okinawa to Guam.
    VA Sierra Pacific Network and VAPIHCS collaborated with U.S. Naval 
Hospital Guam to address these concerns. Based on a combination of 
cost, access, timelines and VA-DOD sharing considerations, we 
determined the best option is for VA to build a new clinic at the 
periphery of the U.S. Naval Hospital Guam campus. I am pleased to 
report to the Committee that on July 30, 2007, Secretary Nicholson 
announced plans for VA to build this clinic at an estimated cost of 
about $5.4 million. The clinic will be about 6,000 square-feet and will 
have its own parking. Navy will relocate its fence around the clinic so 
veterans will not have to pass through Navy security to enter the 
facility. The new clinic is scheduled to open in the summer of 2009.

                               CONCLUSION

    In summary, with the support of the Senate Committee on Veterans' 
Affairs and the Hawaiian congressional delegation, VA is providing an 
unprecedented level of health care services to veterans residing in 
Hawaii and the Pacific Region. VA has state-of-the-art facilities and 
enhanced services in Honolulu, as well as robust staffing on the 
neighbor islands and has expanded or renovated clinics in many 
locations. VA is bringing more mental health providers and specialists 
on board to meet the needs of veterans.
    VAPIHCS still faces several challenges including timely access to 
health care services (in part due to the topography of its catchment 
area and lack of an acute medical-surgical hospital), aging veteran 
population and special needs of our newest veterans who bravely served 
in southwest Asia. VAPIHCS will meet these challenges by working with 
DOD and community partners, activating an ambulatory surgery center, 
utilizing telehealth technologies and opening new clinics as 
demographics suggest and resources allow. I am proud of what VA has 
accomplished in Hawaii and the Pacific Region, but I understand that 
our job is not done.
    Again, Mr. Chairman, mahalo nui loa for the opportunity to testify 
at this hearing. I and the staff who accompany me would be delighted to 
address any questions you may have for us.

    Senator Akaka. Thank you. Thank you very much, Dr. Kussman.
    The Audience. (Applaud.)
    Senator Akaka. Your testimony has really revealed many 
things that will be happening here in Hawaii and across the 
country, and we are delighted to hear all of that. And now I 
would like to welcome the testimony of William Tuerk, Under 
Secretary for Memorial Affairs, Department Veterans Affairs. 
Under Secretary Tuerk.

    STATEMENT OF HON. WILLIAM F. TUERK, UNDER SECRETARY FOR 
           MEMORIAL AFFAIRS, DEPARTMENT OF VETERANS 
 AFFAIRS; ACCOMPANIED BY GENE CASTIGNETTI, DIRECTOR, NATIONAL 
                MEMORIAL CEMETERY OF THE PACIFIC

    Mr. Tuerk. Thank you, Mr. Chairman.
    Mr. Chairman, I appreciate the opportunity to testify today 
on issues of great interest to Hawaii veterans. With the 
Committee's permission, I will offer a brief summary statement 
and request that my written testimony be accepted by the 
Committee for placement in its hearing record.
    Senator Akaka. Without objection, it will be accepted and 
it will be included in the record.
    Mr. Tuerk. Mr. Chairman, for my oral presentation, I will 
focus on three items, each of which, I think, represents good 
news for the veterans of Hawaii. The first item concerns VA 
initiatives to ensure that the National Memorial Cemetery of 
the Pacific remains open to provide uninterrupted service in 
meeting the burial needs of Hawaii veterans and their families. 
These initiatives will also ensure that the Punchbowl is 
preserved as an active national treasure in the spirit of the 
ancient Hawaiians who know this site as puuvana.
    NCA is proceeding now to design a columbarium expansion 
project which we anticipate will add over 30,000 niches for the 
inurnment of cremated remains at NMCP. Subject to the 
availability of fiscal year 2008 funding, we intend to advance 
a project that would extend the life of the cemetery to 
approximately 2016. We are, in addition, studying the 
feasibility of other columbarium projects into the future.
    Mr. Chairman, we will seek every opportunity, every 
opportunity, to maximize the space available for columbarium 
inurnments at the Punchbowl and to extend the time frame within 
which that national treasure will remain an active cemetery. We 
understand what the Punchbowl means to the citizens of Hawaii. 
We understand what it means to the citizens of the Nation.
    The second item I will discuss this morning relates to the 
strong partnership between the Federal Government and the State 
of Hawaii in providing options for burial through the State 
Cemetery Grants Program. This morning's presentation of 
$743,000 in grant funds for the phased expansion of West Hawaii 
State Veterans Cemetery marks the newest era in that long-
standing partnership.
    The state veterans cemetery expansion project at Kailua-
Kona will allow for continued access to a full casket burial 
option on both the east and west sides of the Big Island of 
Hawaii. Hawaii leads all states in the development and 
operation of state veterans cemeteries. This grant will assist 
Hawaii in maintaining that national leadership position into 
the future. We hope, Mr. Chairman, that other states will 
follow Hawaii's lead in building successful partnerships with 
the VA.
    The third item I'd like to discuss this morning relates to 
further future improvements planned for West Hawaii State 
Veterans Cemetery. Last December, staff members of both Hawaii 
senators expressed concerns to me about the appearance of some 
sections of that cemetery, and they asked me to give this 
matter my personal attention. As you know, Mr. Chairman, I have 
visited the West Hawaii State Veterans Cemetery along with four 
other Hawaii State Cemeteries, and today I'm prepared to report 
our response to those concerns.
    To meet the unique challenges of this site, the state 
cemetery grant, which was announced this morning, will fund the 
purchase of grave liners to assist cemetery staff in 
maintaining the grounds to the highest standards of appearance. 
This was an issue that I know that both you and Senator Inouye 
were particularly concerned about. We will attend to it.
    In the future, we anticipate additional funding of 
approximately $3.5 million to construct a permanent committal 
shelter, restrooms, roadway infrastructure and other 
improvements at West Hawaii State Veterans Cemetery. Be 
assured, Mr. Chairman, that VA will continue in its strong 
support of the veterans cemeteries here in Hawaii today and 
into the future. We are grateful, Mr. Chairman, for your 
steadfast support of NCA, the VA, and the Nation's veterans.
    Thank you again for this opportunity to testify. I'd be 
happy to entertain any questions that you may have for me. 
Thank you.
    [The prepared statement of Under Secretary Tuerk follows:]
     Prepared Statement of Hon. William F. Tuerk, Under Secretary 
          for Memorial Affairs, Department of Veterans Affairs
    Mr. Chairman, Mr. Ranking Member and Members of the Committee, 
thank you for the opportunity to testify today on issues of great 
interest to Hawaii veterans.
    The National Cemetery Administration (NCA) and the Veterans 
Benefits Administration (VBA), which is responsible for burial flags 
and monetary burial benefits, jointly administer the Department of 
Veterans Affair's burial and funeral benefits for veterans. We, in NCA, 
have four statutory missions under title 38, United States Code:

     To provide burial for eligible veterans and their eligible 
dependents and to maintain those places of burial as national shrines;
     To provide Government-furnished headstones and markers for 
the graves of eligible veterans worldwide;
     To administer the State Cemetery Grants Program (SCGP), 
which provides Federal funds up to 100 percent of the development cost 
for establishing, expanding and improving veterans cemeteries owned and 
operated by the States; and
     To administer the Presidential Memorial Certificate (PMC) 
program, which provides the families of honorably discharged, deceased 
veterans Certificates bearing the signature of the President, to 
commemorate the veterans' service.

    NCA currently maintains more than 2.8 million gravesites at 125 
national cemeteries in 39 States and Puerto Rico, as well as 33 
soldiers' lots and monument sites. Since 1973, when Congress created a 
National Cemetery System under the jurisdiction of VA, annual 
interments in VA national cemeteries have almost tripled from 36,400 to 
about 97,000 in fiscal year 2006. We expect to perform nearly 105,000 
interments in 2008, an 8.3 percent increase over the number performed 
in 2006. NCA processed more than 336,000 applications for Government-
furnished headstones and markers for the graves of veterans worldwide 
and issued nearly 406,000 Presidential Memorial Certificates to the 
families of eligible veterans in fiscal year 2006. Sixty-seven State 
veterans cemeteries funded under the SCGP are operated in 34 States, 
Guam and Saipan--of which 8 are located in Hawaii.

                  MEETING THE BURIAL NEEDS OF VETERANS

    One of VA's primary missions is to ensure that the burial needs of 
veterans are met. In support of this mission, VA's goal is to provide 
veterans with reasonable access to a burial option (whether for 
casketed or cremated remains) in a national or State veterans cemetery 
within 75 miles of their residence.
    Our ability to provide reasonable access to a burial option is a 
critical measure of the effectiveness of our service delivery to 
veterans and their families. Currently, 83.5 percent of all veterans in 
the Nation are served by a burial option in a national or State 
veterans cemetery within 75 miles of their homes. NCA intends to 
increase the percentage of veterans served to 90 percent by fiscal year 
2010. Strategic initiatives are in place to meet this goal. They are:

     Establishment of additional national cemeteries in 
unserved areas;
     Expansion of existing national cemeteries to provide 
continued service; and
     Establishment or expansion of State veterans cemeteries 
through the SCGP.

    NCA will continue to expand, and make improvements to, existing 
national cemeteries by acquiring additional land, where possible, and 
completing development projects that make additional gravesites or 
columbaria available for interments. We have major and minor 
construction projects underway to expand the life cycles of several 
national cemeteries so that they can continue to meet the burial needs 
of veterans in their geographic regions. One such project was here at 
the National Memorial Cemetery of the Pacific (NMCP) where a 
columbarium expansion project was undertaken to add 4,160 niches to 
allow the cemetery to remain open for cremated remains until 2011.
    Dedicated on September 2, 1949, on the fourth anniversary of the 
end of World War II, the National Memorial Cemetery of the Pacific (the 
Punchbowl) originally provided a final resting place for approximately 
13,000 World War II casualties from Guadalcanal, Burma, Saipan, Guam, 
Iwo Jima, the prison camps of Japan and other battlegrounds of the 
Pacific as well as Hawaii's own sons from other theaters of war. Among 
the nearly 30,000 graves tended today, 57 Medal of Honor recipients are 
interred or memorialized.
    In 2006, over 950 burials were performed at NMCP; 105 were full-
casket burials of eligible family members of those already buried at 
the cemetery. NCA also furnished 477 headstones or markers for eligible 
Hawaii veterans interred at private cemeteries and provided over 500 
Presidential Memorial Certificates to honor the service of Hawaii 
veterans.
    NMCP has undergone numerous improvements over the years to ensure 
that it remains a national shrine to honor all those who served their 
country. Several projects currently in design illustrate NCA's 
commitment to retaining this unique national treasure as an active 
national cemetery and as a special ceremonial venue for commemorating 
the dedicated men and women who have made the ultimate sacrifice.
    NCA is designing an additional columbarium expansion project at 
NMCP which we anticipate will add over 3,000 niches for the inurnment 
of cremated remains. This project would extend the life of the cemetery 
to approximately 2016. We are committed to constructing this project to 
ensure there could be no lapse in future gravesite availability until 
that date. We are also studying the feasibility of potential 
columbarium projects further into the future. Among the options to be 
considered will be the relocation of administrative functions, where 
possible, to provide for grave site expansion in suitable areas. Toward 
this end, options for the design of a new administration building and 
visitors information center are under development. I assure you that we 
will take every opportunity to employ innovative methods to maximize 
the space available to continue to serve the needs of our veterans at 
NMCP. We are determined to preserve NMCP as the cherished icon that it 
is, one that is known throughout the world.

                     STATE CEMETERY GRANTS PROGRAM

    Established by Public Law 95-476 in 1978 to complement VA's network 
of national cemeteries, the NCA State Cemetery Grants Program (SCGP) 
provides funding up to 100 percent for the development and startup 
equipment costs for State veterans cemetery projects. At of the end of 
July 2007, VA had awarded 156 grants totaling more than $286 million to 
establish, expand or improve 71 veterans cemeteries nationwide. 
Utilizing VA grant funding, sixty-seven State cemeteries are currently 
operational and four new State cemeteries are under construction. In 
fiscal year 2006, State veterans cemeteries provided for 22,434 
burials, 19 percent of all burials in either a national or State 
veterans cemetery.
    As a complement to our national cemeteries, the State Cemetery 
Grants Program is vital to achieving NCA's burial access goal and 
permitting NCA to meet the needs of veterans in less populated areas 
where the concentration of veterans cannot meet NCA's criterion for the 
establishment of a national cemetery. Nowhere is access to veterans 
cemeteries more extensive than in Hawaii, where 100 percent of veterans 
are served within 75 miles of their homes by the presence of a State 
veterans cemetery.
    Hawaii leads all States in the development and operation of State 
veterans cemeteries, and ranks as the ninth busiest State in providing 
burial services to veterans and their families in State veterans 
cemeteries. Of its eight State veterans cemeteries, only East Hawaii 
Veterans Cemetery No. 1 is closed to new interments. The seven 
operating Hawaii veterans cemeteries are:
    Hawaii State Veterans Cemetery (Island of Oahu); East Hawaii 
Veterans Cemetery No. 2 (in Hilo on the Island of Hawaii); West Hawaii 
Veterans Cemetery (on the Kona Coast of the Island of Hawaii); Kauai 
Veterans Cemetery (Island of Kauai); Maui Veterans Cemetery (Island of 
Maui); Molokai Hawaii Veterans Cemetery (Island of Molokai); and Lanai 
Veterans Cemetery (Island of Lanai).
    I am privileged to have had an opportunity visit five of these 
sites. In 2006, 1,171 veterans were interred in a Hawaii veterans 
cemetery, either at NMCP or in one of the 7 open Hawaii State veterans 
cemeteries.
    NCA has provided over $11 million in grants for Hawaii State 
veterans cemeteries. Recently, the Hawaii Congressional delegation 
requested assistance from NCA to work with the West Hawaii State 
Veterans Cemetery to ensure national shrine standards were being met. 
To do so, we are currently processing an award for more than $700,000 
for the phased expansion at West Hawaii State Veterans Cemetery that 
will provide local veterans with access to a full-casket burial option 
on both the east and west side of the island of Hawaii. This project 
includes the purchase of grave liners to assist cemetery staff in 
maintaining the grounds to meet the highest standards of appearance. 
Project plans also address infrastructure needs at the facility, to 
include construction of a permanent committal shelter, rest rooms, 
improved equipment storage facilities, and roadways. NCA will continue 
to serve as a partner with the State in the expansion and improvement 
of Hawaii State cemeteries to serve Hawaii veterans on every island.
    In addition to grants, NCA also provides technical assistance and 
support to State cemetery field and administrative staff through site 
visits and invitations to participate in NCA's annual and regional 
conferences where innovative operational techniques, best management 
practices and ideas are exchanged. Hawaii has also cultivated 
successful working partnerships with the counties in operating and 
maintaining the State cemeteries, a technique now being considered by 
other States.
    Hawaii has met the challenge of operating multiple State cemeteries 
through the use of innovative cooperative agreements between public and 
private entities. The recent water and planting improvement project the 
State undertook at West Hawaii State Cemetery addressed the difficult 
and unique site conditions at the cemetery. Successful projects such as 
this demonstrate Hawaii's ingenuity in maintaining all veterans 
cemeteries as national shrines that honor the service of our country's 
servicemembers. We hope that other States will follow Hawaii's lead. We 
hope that they will build successful partnerships with VA as pioneered 
by the State of Hawaii. Be assured that NCA will continue in its strong 
support of the cemeteries here in Hawaii today and in the future. We 
are grateful for your vital cooperation in commemorating our Nation's 
veterans. We are also grateful, Mr. Chairman, for your steadfast 
support for NCA, and for our Nation's veterans.
    That concludes my statement, Mr. Chairman. I would be happy to 
entertain any questions you or the other Members of the Committee may 
have.

    Senator Akaka. Thank you very much.
    The Audience. (Applause.)
    Senator Akaka. Thank you very much for your work in our 
state, and we are really grateful for that.
    Now, we will hear from Deputy Under Secretary Aument.

          STATEMENT OF RONALD R. AUMENT, DEPUTY UNDER 
    SECRETARY FOR BENEFITS, DEPARTMENT OF VETERANS AFFAIRS; 
   ACCOMPANIED BY GREGORY REED, DIRECTOR, HONOLULU REGIONAL 
             OFFICE, DEPARTMENT OF VETERANS AFFAIRS

    Mr. Aument. Thank you, Mr. Chairman.
    Chairman Akaka, thank you for the privilege of being here 
today to discuss our efforts to meet the needs of veterans 
residing in Hawaii and the Pacific Region. I am pleased to be 
accompanied by Gregory Reed, Director of the Honolulu VA 
Regional Office.
    Like Dr. Kussman, I listened to the first panel with great 
interest today. We have much to learn from the veterans that we 
serve, the Honolulu Regional Office is responsible for 
delivering VA benefits and services to veterans residing in the 
Pacific Region including Hawaii, Guam, American Samoa and the 
Commonwealth of the Marianas.
    Today I will discuss the important services provided by the 
Honolulu Regional Office. My comments will also focus on the 
actions we are taking to expedite the processing of claims from 
Operations Iraqi and Enduring Freedom veterans, VBA's national 
hiring initiatives that will improve our ability to provide 
more timely, accurate and consistent determinations on 
veterans' claims.
    More than 107,000 veterans are served by the dedicated 
employees of the Honolulu Regional Office. Of these veterans, 
approximately 16,700 are receiving disability compensation. 
This fiscal year through June, the Honolulu Regional Office 
processed approximately 3,500 veterans disability claims. 
Through their aggressive outreach and public contact 
activities, the Regional Office employees have this year alone 
conducted nearly 1,350 personal interviews and 2,250 telephone 
interviews, and briefed approximately 800 separating 
servicemembers.
    The Honolulu office recently extended telephone service, 
benefits counseling and other inter-island itinerant services 
to the South Pacific encompassing the Federated States of 
Micronesia. Expediting the claims process is critical to 
assisting OIF and OEF veterans in their transition from combat 
operations back to civilian life.
    Since the onset of combat operations in Iraq and 
Afghanistan, VA has provided expedited and case-managed 
services for all seriously injured OIF/OEF veterans and their 
families.
    These individualized service begins at the military 
treatment facilities where the injured servicemembers return 
for treatment, and continue as these servicemembers are 
medically separated and enter the VA medical care and benefits 
systems. VA assigns benefits counselors, social workers and 
case managers to work with these servicemembers and their 
families to assist in the transition to VA care and benefits 
systems and to ensure the expedited delivery of all benefits.
    Since February of this year, VA has provided priority 
processing of all OIF/OEF veterans' disability claims. This 
issue covers all active duty, National Guard and Reserve 
veterans who are deployed, in the OIF/OEF or in support of 
these combat operations as identified by the Department of 
Defense. This allows all the brave men and women returning from 
the OIF/OEF theaters who are not seriously injured in combat, 
but who nevertheless have a disability incurred or aggravated 
during their military service, to enter the VA system and begin 
receiving disability compensation as soon as possible after 
separation.
    We are also continuing to focus on reducing pending 
workload and providing more timely claims decisions to veterans 
of all periods of service. I'm especially pleased today to be 
able to discuss with you our national hiring initiative. We've 
already added more than 800 new employees since April of this 
year and our plans call for adding a total of 3,100 new 
employees by the end of next fiscal year.
    These employees will be placed in critically needed 
positions in our regional offices throughout the Nation. The 
Honolulu Regional Office has been authorized to increase its 
staffing level by over 10 percent as a result of this hiring 
initiative. A number of the new employees are already onboard, 
and the Regional Office is in the process of filling another 
five vacancies. These additional resources will enable the 
Regional Office employees to make great strides to improve the 
delivery of benefits and conduct more outreach in the Pacific 
Region.
    Since 1993, VA has made almost 600 loans to Native American 
veterans for the purchase, construction or improvement of homes 
on Federal Trust land under the Native American Direct Loan 
program. Over 75 percent of all loans made under this program 
will be Native American veterans living in the Pacific Region. 
As an aside, I just noted today that during fiscal 2006, almost 
$4 billion worth of loans are guaranteed for veterans here in 
Hawaii. We believe that much of the credit for these successes 
must go to the ongoing partnerships of the Department of 
Hawaiian Homelands, the Community Development Bank of American 
Samoa, the Territorial Government of Guam, the Commonwealth of 
the Northern Marianas and the Department of Community and 
Cultural Affairs' Veterans Affairs Office, and the Mariana 
Islands Housing Authority.
    Further, veterans are eligible through VA-guaranteed and 
direct loans equal to the Freddie Mac conforming loan limit. As 
of January 2006, that rate increase is $625,500 for high cost 
areas such as Hawaii and Guam. VA anticipates that this will 
make VA guaranteed home loans much more attractive to veterans.
    Mr. Chairman, this concludes my testimony. I greatly 
appreciate being here today, and look forward to answering any 
questions you may have.
    [The prepared statement of Deputy Under Secretary Aument 
follows:]

    Prepared Statement of Ronald R. Aument, Deputy Under Secretary 
              for Benefits, Department of Veterans Affairs

    Chairman Akaka, it is my pleasure to be here today to discuss our 
efforts to meet the needs of veterans residing in the Pacific Region. I 
am pleased to be accompanied by Gregory Reed, Director of the Honolulu 
VA Regional Office.
    The Veterans Benefits Administration (VBA) is responsible for 
administering a wide range of benefits and services for veterans, their 
families, and their survivors. Today I will discuss the important 
services provided by the Honolulu Regional Office. My comments will 
also focus on the actions we are taking to expedite the processing of 
claims from Operations Iraqi and Enduring Freedom (OIF/OEF) veterans 
and VBA's national hiring initiative that will improve our ability to 
provide more timely, accurate, and consistent determinations on 
veterans' claims.

                        HONOLULU REGIONAL OFFICE

    The Honolulu Regional Office is responsible for delivering VA 
benefits and services to veterans residing in the Pacific Region, 
including Hawaii, Guam, American Samoa, and the Commonwealth of the 
Northern Marianas.
    The Honolulu Regional Office administers the following benefits and 
services:

     Disability Compensation
     Dependency and Indemnity Compensation
     Disability and Death Pensions
     Vocational Rehabilitation and Employment Assistance
     Home Loan Guaranties and Native American Direct Home Loans
     Outreach
     Burial Benefits

    More than 107,000 veterans are served by the dedicated employees of 
the Honolulu Regional Office. Of these veterans, approximately 16,700 
are receiving disability compensation. This fiscal year through June, 
the Honolulu Regional Office provided approximately 3,500 veterans with 
decisions on their disability claims. Through their aggressive outreach 
and public contact activities, the regional office employees have this 
year alone conducted nearly 1,350 personal interviews and 2,250 
telephone interviews, and briefed approximately 850 separating 
servicemembers.
    The Honolulu office recently extended telephone service, benefits 
counseling, and other inter-island itinerant services to the South 
Pacific area encompassing the Federated States of Micronesia. Telephone 
service is also provided to veterans residing in the Republic of Palau 
and the Marshall Islands by the Honolulu Regional Office.

                PRIORITY PROCESSING FOR OIF/OEF VETERANS

    Since the onset of the combat operations in Iraq and Afghanistan, 
VA has provided expedited and case-managed services for all seriously 
injured OIF/OEF veterans and their families. This individualized 
service begins at the military medical facilities where the injured 
servicemembers return for treatment, and continues as these 
servicemembers are medically separated and enter the VA medical care 
and benefits systems. VA assigns special benefits counselors, social 
workers, and case-managers to work with these servicemembers and their 
families throughout the transition to VA care and benefits systems, and 
to ensure expedited delivery of all benefits.
    Since February 2007, VA has provided priority processing of all 
OIF/OEF veterans' disability claims. This initiative covers all active 
duty, National Guard, and Reserve veterans who were deployed in the 
OIF/OEF theaters or in support of these combat operations, as 
identified by the Department of Defense (DOD). This allows all the 
brave men and women returning from the OIF/OEF theaters who were not 
seriously injured in combat, but who nevertheless have a disability 
incurred or aggravated during their military service, to enter the VA 
system and begin receiving disability benefits as soon as possible 
after separation.
    We designated our two Development Centers in Roanoke, Virginia, and 
Phoenix, Arizona, as well as three of our Resource Centers, as a 
special ``Tiger Team'' for processing OIF/OEF claims. The two 
Development Centers assist regional offices in obtaining the evidence 
needed to properly develop the OIF/OEF claims. Medical examinations 
needed to support OIF/OEF veterans' claims are also expedited.
    We expanded our outreach programs for National Guard and Reserve 
components and our participation in OIF/OEF community events and other 
information dissemination activities. An OIF/OEF team at VBA 
Headquarters addresses OIF/OEF operational and outreach issues at the 
national level and provides support to the newly designated OIF/OEF 
managers at each regional office. The OIF/OEF team is also coordinating 
the development of national memoranda of understanding (MOUs) with each 
of the Reserve Components to formalize relationships with them, 
mirroring the agreement between VA and the National Guard Bureau signed 
in 2005. Having an MOU with each Reserve Component will help ensure 
that VA is provided service medical records and notified of ``when and 
where'' Reserve members are available to be briefed during the 
demobilization process and at later times.
    In order to ensure that VA benefits information is provided to all 
separating servicemembers, including Reserve and Guard members, we are 
working with DOD to expand our role in DOD's military pre-separation 
process. Specifically, we are now providing ``Claims Workshops'' in 
conjunction with many of our VA benefits briefings for separating 
servicemembers. At such workshops, groups of servicemembers are 
instructed on how to complete the VA application forms. Personal 
interviews are also conducted with those applying for VA disability 
benefits.
    Expediting the claims process is critical to assisting OIF/OEF 
veterans in their transition from combat operations back to civilian 
life. We are also continuing to focus on reducing the pending workload 
and providing more timely claims decisions to veterans of all periods 
of service.

                       NATIONAL HIRING INITIATIVE

    I am especially pleased today to be able to discuss with you our 
national hiring initiative. We are extremely grateful for the funding 
support we have received from Congress that has allowed us to undertake 
this unprecedented hiring program. We have already added more than 800 
new employees since April, and our plans call for adding a total of 
3,100 new employees by the end of next year. These employees will be 
placed in critically needed positions in our regional offices 
throughout the nation.
    Along with the multitude of activities involved in a recruitment 
program of this magnitude, we have begun the critical tasks of 
training, equipping, and acquiring space to house our new employees. We 
are accelerating the training of these employees and focusing in 
specialized areas of claims processing in order to have them ``on-
line'' and productive within a few months. This will be followed by 
ongoing, carefully structured, and progressively complex training until 
full journey expertise is achieved.
    The Honolulu Regional Office has been authorized to increase its 
staffing level by over 10 percent as a result of this hiring 
initiative. A number of the new employees are already on board, and the 
Regional Office is in the process of filling another five vacancies. 
These additional resources will enable the Regional Office employees to 
make great strides in improving the delivery of benefits and conducting 
more outreach in the Pacific Region.

                      HOME LOAN GUARANTY SERVICES

    Since 1993 VA has made almost 600 loans to Native American veterans 
for the purchase, construction, or improvement of homes on Federal 
Trust land under the Native American Veteran Direct Loan Program. Far 
and away our greatest successes under this program have been in the 
South Pacific. Over 75 percent of all loans made under this program 
have been to Native American veterans living on the homeland 
territories of American Samoa, Guam, Hawaii, and the Commonwealth of 
the Northern Marianas.
    We believe that much of the credit for these successes must go to 
our ongoing partnerships with the Department of Hawaiian Homelands, the 
Community Development Bank of American Samoa, the Territorial 
Government of Guam, the Commonwealth of the Northern Marianas (CNMI), 
the CNMI Department of Community and Cultural Affairs Veterans Affairs 
Office and the Mariana Islands Housing Authority. These offices have 
played crucial roles in assisting with outreach and delivery of the VA 
home loan benefit to veterans located throughout the South Pacific. 
They have acted as our partners in assisting with loan packaging, 
appraisals, and construction-related inspections, as well as providing 
crucial communication links between our staff and the veterans we 
serve.
    With the ongoing activation of Reserve and National Guard members 
in support of the military operations in Iraq and Afghanistan, 
servicemembers are becoming eligible for VA home loan benefits faster 
and in greater numbers. Instead of the time-in-service requirement of 6 
years for members of the Reserves or National Guard, eligibility is 
established under the Loan Guaranty and Native American Veteran Direct 
Loan Programs after 90 days or more of active wartime service. Further, 
as a result of P.L. 108-454, veterans are eligible for VA-guaranteed 
and direct loans equal to the Freddie Mac conforming loan limit. As of 
January 2006, that rate increased to $625,500 for high cost areas such 
as Hawaii and Guam. VA anticipates that this will make VA guaranteed 
home loans much more attractive to veterans. As a result, we anticipate 
continued growth in the Loan Guaranty Program and Native American 
Direct Loan Program in the Pacific Region.
    Mr. Chairman, this concludes my testimony. I greatly appreciate 
being here today and look forward to answering your questions.

    Senator Akaka. Thank you very much.
    The Audience. (Applause.)
    Senator Akaka. Thank you very, very much, Deputy Under 
Secretary Aument. And now we will hear from Julie Watrous, 
Director of the Inspector General's Regional Office.

STATEMENT OF JULIE WATROUS, R.N., REGIONAL DIRECTOR, OFFICE OF 
HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL, DEPARTMENT 
                     OF VETERANS AFFAIRS; 
        ACCOMPANIED BY DR. MICHAEL SHEPHERD, PHYSICIAN, 
OFFICE OF HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL, 
                 DEPARTMENT OF VETERANS AFFAIRS

    Ms. Watrous. Mr. Chairman, mahalo for the opportunity to 
testify today on VA health care in Hawaii. Thanks also for your 
strong commitment to veterans and your interest in the 
oversight work that we do.
    I've been the Director of the Office of Healthcare 
Inspections Regional Office in Los Angeles for the past eight 
years. Prior to that, I served as a staff nurse and also a 
quality manager in various VA facilities. My current territory 
is the western United States and includes the VA Pacific 
Islands Health Care System. I'm accompanied today by my 
colleague Dr. Michael Shepherd, a physician in the Office of 
Healthcare Inspections.
    As you requested, I will discuss the relationship between 
the Tripler Army Medical Center and the Pacific Islands Health 
Care System from our perspective as well as highlight some of 
the findings from two reports we issued in 2006. In preparation 
for this hearing, I visited Honolulu last month to interview 
staff at both the VA and Tripler. There are at least three 
issues in the sharing agreement relationship that would benefit 
from further attention. I believe you're familiar with all 
three.
    The first concerns differences between the two electronic 
patient health record systems which cause difficulties in 
clinician communication and patient care coordination. I 
understand that efforts are underway to connect the two 
systems, and the sooner the better. The second issue concerns 
the two financial systems with problems such as late billings 
and delayed payments. The third issue concerns access to care 
for veterans at Tripler. Because of deployments and active duty 
military members needing care, care for veterans at Tripler is 
not always available or timely.
    As part of our oversight mandate, we conduct periodic 
reviews of VA health care facilities which we call CAPs. We 
conducted a CAP review of the Honolulu facility in June 2006. 
We made recommendations to improve patient information 
security, community nursing home oversights and oversight of 
veterans' care in Tripler. The details are published in our CAP 
report as well as in my written testimony. We accepted the 
actions taken by Dr. Hastings and closed this report on March 
30, 2007.
    In early fiscal year 2006, at your request, we conducted a 
review that included access to non-institutional care and 
timely elective procedures. We visited five medical facilities 
in this national review including the Honolulu facility. 
Regarding non-institutional care, we made a number of 
recommendations to increase access. VHA agreed and submitted an 
action plan that included monitoring the demand and supply of 
non-institutional services, increasing capacity and expanding 
coverage to geographic areas that did not offer these services.
    The Pacific Islands Health Care System's 2006 workload 
numbers show that the number of veterans using these services 
has increased. Regarding access to timely electives specialty 
procedures, we reviewed procedures that had been performed in 
fiscal year 2005 in cardiology, gastroenterology and orthopedic 
surgery.
    Many veterans waited a very long time for the procedures 
from the date they were ordered until the date they were 
performed. Reasons for these delays included difficulty 
recruiting specialists, lack of support staff and insufficient 
space including inpatient beds and operating rooms. These 
barriers to timely care existed across the country but were 
especially applicable to Hawaii.
    This past February, the Pacific Islands Health Care System 
hired a part-time orthopedic surgeon to operate at Tripler. 
Both facilities agree that this move has helped stabilize the 
planning for orthopedic surgery, but stated that more staffing 
is needed. As Dr. Kussman mentioned, additional operating rooms 
will be constructed as part of the VA's same-day surgery 
project and will provide more capacity, but only when fully 
staffed.
    We were told repeatedly about the difficulty in recruiting 
specialists to work in Hawaii. In our access to care report, we 
recommend that VHA establish appropriate performance metrics to 
evaluate and improve the timeliness of elective procedures. VHA 
agreed and plans to develop performance metrics to evaluate 
timeliness of elective procedures. This recommendation remains 
open and we are tracking progress to complete it.
    In summary, with respect to VA care in Hawaii, Dr. Kussman 
for VHA, Dr. Wiebe for VISN 21 and Dr. Hastings for the VA 
Pacific Islands Health Care System, have responded 
appropriately to specific recommendations made by the OIG in 
these two reports. However, the three issues relating to the 
sharing agreement, the electronic medical record systems, 
billing and payment systems and consistent and timely access to 
care would benefit from additional attention at the highest 
level of VA and DOD.
    Mr. Chairman, thank you again for this opportunity. Dr. 
Shepherd and I would be happy to answer any questions that you 
may have.
    [The prepared statement of Ms. Watrous follows:]

Prepared Statement of Julie Watrous, R.N., Regional Director, Office of 
  Healthcare Inspections, Office of Inspector General, Department of 
                            Veterans Affairs

                              INTRODUCTION

    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to testify today on VA health care in Hawaii. I will 
discuss the relationship between the Tripler Army Medical Center (TAMC) 
and the Spark M. Matsunaga Medical Center (part of the VA Pacific 
Islands Health Care System), as well as the status of findings from two 
reports the Office of Inspector General (OIG) issued in 2006. I am 
accompanied by Michael Shepherd, M.D., Physician, Office of Healthcare 
Inspections, OIG.
    In preparation for this hearing, I traveled to Honolulu July 23-24, 
2007, to interview managers and staff at the VA Pacific Islands Health 
Care System and at TAMC. Based on these interviews, as well as previous 
reviews conducted here, I would like to highlight three issues in the 
sharing agreement relationship that would benefit from further 
attention. The first concerns differences between the two facilities' 
electronic patient health record systems, which make it difficult for 
clinicians to document veterans' care, as well as to review other 
clinicians' documentation. The second issue concerns the billing and 
payment systems, which both facilities' managers complained result in 
problems such as late billings and delayed payments. The third issue 
concerns equal access to care for veterans at the TAMC. Because of TAMC 
staff deployments and the influx of active duty military members 
needing care, access to care for veteran patients at TAMC is not always 
consistently available or timely. I will discuss this issue in more 
detail later in my testimony.

                 COMBINED ASSESSMENT PROGRAM REVIEW \1\

---------------------------------------------------------------------------
    \1\ Combined Assessment Program Review of the VA Pacific Islands 
Health Care System, Honolulu, Hawaii, Report No. 06-02003-225, 
September 26, 2006.
---------------------------------------------------------------------------
    The OIG conducts periodic reviews of VA health care facilities. 
These Combined Assessment Program (CAP) reviews are part of the OIG's 
efforts to ensure that high quality care is provided to our Nation's 
veterans. We reviewed documents and medical records and visited the 
Honolulu facility June 19 through 23, 2006, and in September 2006, we 
published the CAP review report of the VA Pacific Islands Health Care 
System.
    In the CAP report, we noted four areas that were in compliance: 
quality management, breast cancer management, patient satisfaction 
survey results action plans, and monitoring patients on atypical 
antipsychotic medications. We made recommendations concerning security 
of patient information, follow-up care for patients in community 
nursing homes, and communication and oversight of veteran patients 
treated at TAMC.
    With regards to security of patient information, we found unsecured 
patient information in hard copy paper and on unattended computer 
terminals and recommended that the facility's managers ensure that all 
patient information is protected. In response to our recommendation, 
managers provided privacy training and increased their oversight of 
patient information management throughout their facilities.
    With regards to follow-up care for patients in community nursing 
homes, we recommended that the facility's managers improve care plans 
for veterans residing in community nursing homes and increase facility 
oversight of these homes. In response, managers standardized care plan 
notes and increased the membership on the oversight committee.
    The issue of communication about and oversight of veteran patients 
treated at TAMC was not a new finding. We had a similar finding during 
our 2001 CAP review and closed the recommendation based on the 
corrective action plan submitted. However, the corrective actions were 
only partially implemented. We again recommended that senior managers 
at the two facilities formalize their communication mechanisms and 
ensure that key staff attend the meetings. Several committees were 
formed as a result of this recommendation, including a Joint Venture 
Committee, to address clinical care and quality improvement issues 
between the two organizations.
    We reviewed the actions taken by the facility's managers in 
response to our CAP recommendations and concluded that the 
recommendations were appropriately addressed. We closed the report on 
March 30, 2007.

                    REVIEW OF ACCESS TO CARE IN THE 
                   VETERANS HEALTH ADMINISTRATION \2\

---------------------------------------------------------------------------
    \2\ Review of Access to Care in the Veterans Health Administration, 
Report, No. 05-03028-145, May 17, 2006.
---------------------------------------------------------------------------
     In early fiscal year (FY) 2006, at the request of Senator Akaka, 
we reviewed access to non-institutional care, appropriateness of 
enrollment practices, and timeliness of clinically indicated elective 
procedures. We visited five medical facilities in this national review, 
including the Spark M. Matsunaga VA Medical Center. We interviewed 
facility personnel, reviewed medical records, and analyzed workload 
data through fiscal year 2005 provided to us by the facilities.
Non-Institutional Care
    The Millennium Act, passed in 1999, directed VA to provide veterans 
eligible for medical services with certain non-institutional care 
services--services that are provided to veterans in their own homes or 
in community settings. In response, VHA implemented policies requiring 
medical facilities to provide non-institutional care services to all 
eligible veterans, when appropriate. These services include:

     Home based primary care.
     Purchased skilled home health care.
     Homemaker and home health aides.
     Adult day health care.
     Geriatric evaluation and management.
     Respite care.
     Hospice and palliative care.
     Care coordination and telehealth.

    We noted that veteran access to non-institutional care services had 
increased from fiscal year 2003 to fiscal year 2005 in several of the 
non-institutional care services. However, we found that improvement was 
still needed and made a number of recommendations aimed at further 
increasing access. VHA agreed with the recommendations and submitted an 
action plan that included monitoring the demand and supply of non-
institutional services, increasing capacity, and expanding coverage to 
geographic areas that did not offer non-institutional care services. 
The VA Pacific Islands Health Care System's fiscal year 2006 workload 
numbers show that all the non-institutional care services are 
available, and the number of veterans using these services increased in 
fiscal year 2006 in almost all services.
Enrollment Process
    The enrollment process at the five facilities we visited complied 
with national enrollment policies. We made several recommendations 
aimed at improving the tracking of new veterans who desire VA care. VHA 
agreed with the recommendations and planned to issue revised directives 
establishing policies for use of electronic wait lists and scheduling 
processes. VHA issued the directive ``Process for Ensuring Timely 
Access to Outpatient Clinical Care'' on May 8, 2006.
Timeliness of Elective Specialty Procedures
    Eligible veterans did not always receive clinically indicated 
specialty procedures within reasonable time frames. VHA has not 
established a method to measure the length of time veterans wait for 
elective procedures; in some cases, veterans experienced excessive 
waiting times. While a VHA performance measure requires facility 
directors to track the length of time veterans wait for their specialty 
care appointments, facilities are not required to track the length of 
time veterans must wait from the requests or authorizations for 
elective procedures until the procedures are actually performed. To 
better assess and manage their workload and ensure that veterans 
receive timely care, facility managers need to track veterans' entire 
waiting time--not just the waiting time to the appointment.
    We reviewed elective procedures that had been performed in fiscal 
year 2005 in three specialty areas: (1) cardiology, (2) 
gastroenterology, and (3) orthopedic surgery. We found lengthy average 
waiting times. For example, at the VA Pacific Islands Health Care 
System, the average wait for elective orthopedic procedures was 182 
days, and the range was 14-379 days.
    We could not locate any timeliness standards within VHA or United 
States medical organizations for the procedures we reviewed. However, 
several countries with national health systems have set timeliness 
goals of 6 months for orthopedic surgery. Evidence indicates that 
deterioration in functional health status occurs in patients waiting 
more than 6 months for joint replacement surgery.
    We interviewed the chiefs of cardiology, gastroenterology, and 
orthopedic surgery services, as well as a number of primary care 
providers, to gain their perspectives on the timeliness of elective 
procedures. Although the five facilities varied greatly in size and 
capacity, the reasons for delays given by these providers were 
consistent and fell into four themes:

     Physician vacancies and difficulty recruiting specialty 
physicians.
     Lack of support staff, such as nurses, physician 
assistants, and anesthesiologists.
     Insufficient space, including inpatient beds and operating 
rooms.
     Lack of equipment, such as scopes and data processors for 
colonoscopies.

    Some barriers to timely care were unique to one or two facilities. 
For example, some orthopedic surgery for Hawaii veterans occurs in 
operating rooms at TAMC. Delays occurred when procedures scheduled to 
be performed at TAMC were canceled due to military deployments. Some of 
these veterans had to be re-prioritized and worked into the referral 
lists to the VA Palo Alto Health Care System. In other cases, veterans 
were referred to community providers at VA expense, depending on 
veteran condition and availability of fee basis funds.
    Within the past year, the VA Pacific Islands Health Care System 
hired a part-time orthopedic surgeon to operate at TAMC. Both 
facilities' managers agreed that this move has helped stabilize the 
planning for orthopedic surgery but stated that more staffing is needed 
to manage the workload. Additional operating rooms that will be 
constructed as part of the VA Pacific Islands Health Care System's 
same-day surgery project will provide more capacity, but only when 
fully staffed. We were told repeatedly about the difficulty in 
recruiting specialists to work in Hawaii. In preparation for this 
hearing, we reviewed the VA Pacific Islands Health Care System's fiscal 
year 2006 elective procedures data and found that the average wait 
times from authorization until the procedures had been performed had 
improved in cardiology and gastroenterology, but had actually gotten 
worse in orthopedic surgery.
    In our report, we recommended that VHA establish appropriate 
performance metrics to evaluate and improve the timeliness of elective 
procedures and implement prioritization processes to ensure that 
veterans receive clinically indicated elective procedures according to 
their clinical needs. VHA agreed with the recommendation and plans to 
develop performance metrics to evaluate timeliness of elective 
procedures. This recommendation remains open.

                                SUMMARY

    With respect to VA care in Hawaii, we believe that VHA, Veterans 
Integrated Service Network 21, and the VA Pacific Islands Health Care 
System have responded appropriately to specific recommendations made by 
the OIG in these two reports. However, the three issues related to 
TAMC--electronic medical record systems, billing and payment systems, 
and consistent and timely access to care--would benefit from additional 
attention.
    Mr. Chairman, thank you again for this opportunity. I would be 
pleased to answer any questions that you or other Members of the 
Committee may have.

    The Audience. (Applause.)
    Senator Akaka. Thank you. Thank you very much, Julie 
Watrous, for your testimony. I have some questions for the 
panel. Dr. Hastings and Dr. Wiebe, these questions have to do 
with the new Oahu clinic.
    I want you to know that I'm very concerned about the need 
for additional ambulatory care capacity here on Oahu. I know VA 
has been looking at the possibility of clinics at both Barbers 
Point and at Kaneohe at the east side of the island. I 
understand that because of the need to coordinate with the 
Navy, that there have been some challenges in getting the 
clinic at Barbers Point up and running. My question to you, Dr. 
Hastings and Dr. Wiebe, is whether it's possible to move 
forward with a clinic at Kaneohe?
    Dr. Hastings. Mr. Chairman, thank you for the opportunity 
to address this very important issue for us. We are in 
negotiations with the Navy and with the state. They are moving 
forward. They're under a mandate to make progress and dispense 
with this land by September 2008. So they are under pressure to 
get the problem solved. And we think that when we look at the 
distribution of our patients, that the best decision would be 
if we could build and take over that property at Barbers Point. 
So we're in negotiations with them, and we think that we're 
going to get some decisions about that from the Navy within the 
next couple of months.
    As I talk to the engineers, they tell me that we're much 
better off if we take an old existing building, we have looked 
at it, and it will be less costly for the government to do this 
than to try to go out and start from the beginning in building 
another facility. So we think this is the best decision to keep 
pushing ahead on the Barbers Point issue.
    Senator Akaka. Well, thank you very much, Dr. Hastings.
    Mr. Aument, I appreciate your willingness to travel to 
Hawaii to participate in this hearing, and I want to thank you 
for your service to our Nation's veterans. Around 33 percent of 
rating claims at the Honolulu Regional Office have been pending 
for more than 180 days. This is the highest in the Western 
Area, as I understand.
    Please explain the factors that have contributed to the 
already overburdened RO's problems with timeliness and 
adjudicating claims for compensation and what VA can do to 
reverse this.
    Mr. Aument. We share your concern with that particular 
issue, Mr. Chairman, the timeliness of the pending claims for 
the regional office. I think there are three factors that we 
can point to that are largely responsible for this, and I 
believe we're trying to do something about each and every one 
of them.
    First of all, number one, is making sure that we have an 
adequate workforce in place at the regional office to make sure 
that we're prepared to provide timely service to the veterans 
ourselves from the Veterans Benefits Administration 
perspective. As I mentioned earlier in my testimony, we've 
increased the staff already this year by 10 percent. We've 
really actually reached the limits of the physical capacity to 
add staff to the office, but we stand ready to add the 
additional staff if we find that the increase so far is 
insufficient.
    Number two, we've been particularly challenged in obtaining 
transitioning servicemembers' military records. In particular, 
their service medical records. I am told by Dr. Wiebe, the 
Director of VISN 21s, that this had been a particular challenge 
for the servicemembers filing claims from Guam which have added 
to the overall timeliness of the office.
    We're working very diligently to try to improve that 
relationship. We've recently entered into a Memorandum of 
Agreement with the National Guard units where we've been 
particularly challenged with the Guard and Reserve units 
obtaining those records. I believe that we're moving forward to 
try and improve that relationship.
    Third, the final item is with the timeliness of our medical 
exams. We've heard before the difficulties in some cases of 
recruiting and maintaining medical support here in the Pacific 
Islands region. We've been working very closely with Dr. Wiebe 
and others to address this issue. And Dr. Wiebe even this 
morning assured me that, by the end of this year, he expects to 
be able to have the timeliness of the exams provided in this 
area up to the national standard.
    Senator Akaka. Thank you for your comment.
    Dr. Kussman. Mr. Chairman, I had a chance to talk to Dr. 
Hastings yesterday about this and he's working very 
aggressively making adjustments getting more space to do it and 
more people. And as Ron mentioned, I believe, Jim's got this 
under control and next time we talk, it won't be a problem.
    Senator Akaka. Thank you. I also want to say that I've 
heard from the Representative from Samoa and, apparently, he 
tells me that Samoan veterans are having problems as well. I'm 
sure you know about that, but I just want you to know that he 
did speak to me about that. I just want to say Dr. Wiebe also 
has been helpful in these areas.
    Under Secretary Tuerk, I'm very pleased that VA recognizes 
the importance of Punchbowl to Hawaii's veterans. And of 
course, your comments and remarks today about what you are 
doing, please us greatly.
    Can you please elaborate on the plan to provide additional 
niches at Punchbowl?
    Mr. Tuerk. I'd be delighted to elaborate on the plan, Mr. 
Chairman. I think the old adage that a picture is worth a 
thousand words might apply here. If you'll bear with me for a 
second, I'll show you what we intend to do.
    Senator Akaka. Thank you.
    Mr. Tuerk. Thank you, Mr. Chairman for your forbearance. 
This, as you can see, is a satellite image of the National 
Memorial Cemetery of the Pacific. The entrance is down here, 
the memorial is right here.
    The existing columbarium at the cemetery is shown right 
here. You asked me this morning--and you asked me last 
December--whether we would study the feasibility of how we 
might expand columbarium space in the National Memorial 
Cemetery of the Pacific. This is what we've come up with.
    We have four distinct possibilities for expansion, each of 
which I'll show you on a separate chart. Chart number one shows 
the existing columbarium. You'll notice it stops here. Our 
first plan--and the plan that I've already commissioned a 
design for--is to extend the existing columbarium space up 
further into the cemetery. That project, which we are committed 
to doing in fiscal year 2008 so long as we receive funding, 
will add another 1,265 niches to the cemetery's inventory and 
will buy us another couple of years. We currently have an 
inventory, as of the close of business yesterday of 1,845 
niches. So this new capacity added to the 1,800 that currently 
exist will get us about an additional 5 years worth of 
inurnments at the National Memorial Cemetery of the Pacific.
    An additional proposed project will be to take the existing 
columbarium that extends up the perimeter of the cemetery just 
below the Punchbowl's rim and to add further niches on the 
backside and on the outside of the walls that currently house 
the niches. So, for example, whereas here we have columbarium 
niches only within these courtyards, we can add niches to the 
exterior walls on both the back and, I believe, the frontside 
of those walls. The addition of niches to the front side is not 
shown in this diagram but my inspection of the site yesterday 
revealed to me that might be a possibility. Just adding niches 
on the backside we can gain another 2,000-plus niches and an 
additional four to five years time to extend the time frame of 
available niches at cemetery.
    Option C. If you recall, Mr. Chairman, as you approach the 
memorial to the left here below the rim, there's a very, very 
steep slope. We propose here to terrace into the slope below 
the road and have stairs coming down to a terraced columbarium 
down from the road. There would be, first, a corridor here with 
niches on both sides. Additionally, there would be a second 
corridor on the cemetery side of the rim with an additional row 
of niches along here. This concept would add almost 5,000 
additional niches and at current burial rates, that would buy 
us approximately eight additional years of life in the 
cemetery.
    And finally, Mr. Chairman, we have a fourth concept and 
that is marked on this map as option D. I might add 
parenthetically these are labeled A, B, C and D. We might not 
progress in that precise order, though project A will be the 
first one that we will do. These are four alternatives. This 
one is rather straightforward. Our administration building is 
located right inside the gate to the right as you enter the 
cemetery. It's an aging facility. It's an inadequate facility. 
It's an inappropriate facility. We have had under consideration 
for time the idea of demolishing it and building a new one.
    The new thought that we have is to demolish the current 
administration building and use the land inside the cemetery 
grounds to build additional columbaria inside the cemetery 
gate. Now the question might arise what then happens to the 
administration building? We're now studying the feasibility of 
building a new administration building outside the gate so that 
we can preserve the precious land within the crater itself for 
burial spaces.
    [The satellite images of the National Memorial Cemetery of 
the Pacific follow:]

[GRAPHIC] [TIFF OMITTED] T8961.001

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[GRAPHIC] [TIFF OMITTED] T8961.003

[GRAPHIC] [TIFF OMITTED] T8961.004

[GRAPHIC] [TIFF OMITTED] T8961.005

[GRAPHIC] [TIFF OMITTED] T8961.006

    So in summary, Mr. Chairman, with these four concepts--with 
at least these four concepts and we're receptive to other 
ideas--we anticipate that we can add 12,000 additional niches 
or more which would allow the cemetery to conduct inurnments 
into the future for another 20 years.
    Senator Akaka. Thank you very much, Under Secretary Tuerk. 
Thank you for that presentation.
    The Audience. (Applause.)
    Senator Akaka. Ms. Watrous, have you conducted oversight 
visits in other VA facilities that use DOD sharing agreements 
to provide a significant share of veterans care, as is the case 
in Hawaii? Do you see the same issues at those facilities?
    Ms. Watrous. Yes, Mr. Chairman. In my territory, I have two 
other large sharing agreements. One is in Anchorage and the 
other is in Las Vegas, and I have seen very similar situations 
in terms of the electronic medical record and also with access 
to care issue.
    In the best of times, the consistency issues are not 
optimal because of the regular deployments on the military 
side. In this time of war, there are certain higher degrees of 
difficulties that both sides experience. So yes, I have seen 
the same issues. Those are the only two I can speak of.
    Senator Akaka. Thank you very much.
    Dr. Hastings and Dr. Wiebe, I'm concerned about the 
overcrowding at the Center for Aging in Honolulu. I understand 
that this facility is at full capacity. Compounding this 
problem, few options exist for aging Hawaiian veterans outside 
of VA. What is VA doing to meet the high demand for nursing 
home services?
    Dr. Hasting. Thank you, Mr. Chairman. As you know, Hawaii 
has a very extreme problem with long-term care perhaps the most 
challenging in the country. And we, of course, are no 
different. We are working very diligently at trying to develop 
our noninstitutional care. And as you heard the testimony 
today, we have significantly increased our ability to increase 
this noninstitutional care. And we're going to continue to try 
to do that. The VA is very interested in this, and we're 
getting a lot of support and we're putting resources into it 
and so I think that's going to help us out a great deal.
    We are also working with Tripler to look at trying to get 
some more beds that we can use for an intermediate care ward 
which would give us a little more flexibility and give Tripler 
a little more flexibility. Many of our hospitals in Hawaii 
cannot place patients and Tripler is one of them.
    As a result, beds are held for patients that can be placed. 
So we are in the process of studying with Tripler the 
possibility of getting a ward there that we can operate which 
would also give us more flexibility and allow us to use more of 
the resources at Tripler for acute care patients.
    The other issue, of course, is that we are trying to 
contract with nursing homes. Since the last hearings, we have 
had two more nursing homes that we were able to work with and 
develop agreements with so that we can place veterans. And of 
course, the big issue is the new veterans homes in Hilo that we 
have been very much involved with. It's a state home, but we 
are looking at it. And hopefully, this process of looking at 
some other homes in the state will be able to take place in the 
future. Thank you, sir.
    Senator Akaka. Thank you, Dr. Hastings. Dr. Wiebe has been 
a part of this effort.
    Dr. Wiebe, do you have any comments to make at this time?
    Dr. Wiebe. Mr. Chairman, just to add one other option we're 
looking at to extend long-term care services and that's to use 
telehealth. As you know with the island geography, telehealth 
is especially applicable here in the islands. And so we're 
looking at telehealth technologies not only for long-term care, 
but also for our specialty services.
    As you know, VA has a very aggressive telehealth program 
where we can put devices in the homes of the veterans and have 
daily contact with the veterans and their caretakers to help 
them stay at home where otherwise they would have to be in 
institutions. So we appreciate the leadership that you and your 
colleagues here in Hawaii have provided in the telehealth arena 
and these applications are being extended across the United 
States. Again, thank you, Mr. Chairman.
    Senator Akaka. Thank you very much, Dr. Wiebe.
    May I ask Dr. Kussman for any final comments?
    Dr. Kussman. Well, sir, again thank you very much for 
inviting us. We very much appreciate your leadership on the 
Senate Veterans' Affair Committee, and we very much appreciate 
the partnering that we do together. And again, Mahalo.
    Senator Akaka. Thank you very much, Dr. Kussman. I want to 
thank this panel very much.
    As you know, this is a high-ranking panel that we have 
before us today. And I want to thank them for coming out to 
Hawaii to testify as they have. As you have heard, they are 
really making a difference in helping our veterans in Hawaii 
and across the country, as well. Without question, all of us, 
as was mentioned, are partners in trying to bring this about. 
The Senate, the Congress, the Administration and VA have been 
working at this and will continue to do that, so it is great to 
hear from you all.
    I want you to know that I have more questions, but we do 
not have the time, so we will include them in the record for 
this panel. So I want to thank you again very much for your 
appearance today and for coming to Hawaii to testify.
    The Audience. (Applause.)
    Senator Akaka. Now, I would like to invite the third panel 
to come forward. The hearing will be in order.
    I want to welcome our third and final panel of witnesses. 
First I welcome Colonel Arthur Wallace, Deputy Commander for 
Nursing of the U.S. Army Pacific Regional Command at Tripler 
Medical Center. I also want to welcome General Robert Lee, 
Adjutant General for the State of Hawaii Department of Defense. 
And finally, I welcome Mark Moses, Director of Office of 
Veterans Services for the State of Hawaii. I want to thank the 
panel for being here. Your full statements will appear in the 
record of the Committee.
    Colonel Wallace, will you please begin with your testimony.

   COLONEL ARTHUR P. WALLACE, DEPUTY COMMANDER FOR NURSING, 
 TRIPLER ARMY MEDICAL CENTER; ON BEHALF OF MAJOR GENERAL CARLA 
HAWLEY-BOWLAND, COMMANDING GENERAL, TRIPLER ARMY MEDICAL CENTER 
          (TAMC) AND PACIFIC REGIONAL MEDICAL COMMAND

    Colonel Wallace. Aloha, Mr. Chairman.
    Aloha on behalf of Major General Hawley-Bowland who's 
currently off island. Thank you for the opportunity to share 
information about the collaborative relationship between 
Tripler Army Medical Center and the VA Pacific Islands Health 
Care System. At this time, I would like to submit my written 
testimony for the record.
    Senator Akaka. It will be included in the record.
    Colonel Wallace. Thank you. Mr. Chairman, Tripler 
represents the largest military medical treatment facility in 
the entire Pacific Region providing medical support to nearly 
450,000 beneficiaries. Our partnership with the Veterans' 
Administration here is the largest integrated joint venture in 
the Nation.
    What was initially conceived as a small veterans hospital 
adjunct to the military medical center is now a vast $20 
million sharing agreement spanning inpatient medical, surgical 
and psychiatric services, as well as outpatient specialty 
services and non-medical support such as security, meals, and 
housekeeping.
    Within the past year, the VA relocated the Post Traumatic 
Stress Disorder (PTSD) Residential Rehabilitation Program or 
PRRP from Hilo to Tripler. The current PRRP program admits both 
veteran and active duty patients as a cohort group and provides 
a 7-week program of integrated treatment. In the past year, 
we've also signed several new sharing agreements including 
provision of central sterilization support for the ambulatory 
care clinic at Matsunaga, provision of meals to the VA Center 
for Aging, and several agreements supporting joint clinical 
research projects.
    Our dedicated staff continues to identify and develop new 
initiatives to provide a seamless transition between our 
organizations. As mentioned earlier by Dr. Hastings, we are 
planning to create the shared same day surgery center in 2009. 
On a daily basis, VA patients represent a noteworthy part of 
Tripler's workload. Last month, approximately 22 percent of our 
hospital average daily census and 29 percent of our average 
daily admissions from the emergency room were veterans. Also 
the VA operated psychiatric inpatient ward averaged nine 
psychiatric veterans as patients daily.
    Over the years, additional clinical staff have been hired 
to accommodate the growing VA workload. This year, we also 
started to imbed VA providers into Tripler specialty clinics to 
add stability and support of VA requirements and Graduate 
Health Education programs. These providers are now evident in 
our hospitalist program, ophthalmology and orthopedic surgery 
with plans to continue to evaluate other areas for expansion. 
For the military, caring for veterans represents a commitment 
to sustain the services provided when they were on active duty. 
We must remain competent and caring for acutely ill patients 
through our Graduate Health Education programs.
    Recently several new initiatives have occurred under the 
Joint Incentive Fund Program including state-of-the-art 
computer aided system for orthotics and prosthetics with tele 
medicine capability, a chronic dialysis center for veterans, 
and a joint pain management improvement project. These 
initiatives will improve access to care to our joint 
beneficiaries and decrease wait times. Last week, two new Joint 
Incentive Fund Programs were approved. These include a sleep 
study laboratory and an integrated pain management program. Our 
ongoing joint demonstration project establishes technical 
improvements in how we exchange information for referrals and 
clinical documentation.
    This year, the Army Medical action plan has placed emphasis 
on care of our warriors in transition and the seamless 
transition to care under the Veterans Benefits Administration 
and Veterans Health Administration. Our programs in support of 
returning warriors and our ties between Tripler and the VA have 
been longstanding and well established. We assigned case 
managers to all returning wounded and had specialized treatment 
programs such as our Soldier and Family Assistance Center at 
Schofield Barracks providing a whole range of behavioral health 
and advocacy programs.
    We have had representation from the Veterans Benefits 
Administration on our Patient and Family Assistance Team since 
inception. Our case managers work daily with the Veterans 
Benefits Administration and Veterans Health Administration to 
foster a smooth transition to VA benefits, including health 
care. The Oahu Joint Executive Council's Behavioral Health 
working group, which includes the VA, is taking a greater role 
in determining needs for PTSD and mild Traumatic Brain Injury 
or TBI. Tripler recently launched training for all military 
personnel on recognizing PTSD and mild TBI to encourage self-
reporting and referrals of OIF/OEF soldiers and reduce the 
stigma associated with reporting. This field is an excellent 
opportunity for DOD and VA collaboration, and we are already 
moving forward with such joint planning.
    As with most larger type activities, there continue to be 
challenges. We need interoperability of health care computer 
systems between DOD and the VA to coordinate patient care and 
conduct financial business. Lack of integrated computerized 
patient record will continue to cause inefficiency and impact 
patient care until resolved. In terms of DOD-VA joint venture 
development, our future is now. This functional integration is 
just the beginning. The additional opportunities for improved 
coordination and cooperation are numerous. Achieving these 
goals will be dependent upon obtaining needed policy, program 
and resource support.
    There is local VA and DOD top management support to make 
Tripler a model joint venture site. We must address and resolve 
the challenges to achieve our ultimate goal: High quality care 
for our beneficiaries in a seamless health care system.
    Thank you, Mr. Chairman, for this opportunity to share our 
thoughts and this important topic. Mr. Chairman, I'm now ready 
to take any questions.
    [The prepared statement of Colonel Wallace follows:]

 Prepared Statement of Colonel Arthur P. Wallace, Deputy Commander for 
Nursing, Tripler Army Medical Center; on Behalf of Major General Carla 
Hawley-Bowland, Commanding General, Tripler Army Medical Center (TAMC) 
                  and Pacific Regional Medical Command

    Mr. Chairman and distinguished Members of the Committee, on behalf 
of Major General Hawley-Bowland, Commanding General of Tripler Army 
Medical Center (TAMC) and Pacific Regional Medical Command who is 
visiting medical facilities in the Pacific Region, thank you for the 
opportunity to share information about the collaborative relationship 
and initiatives under the auspices of the Department of Defense (DOD)-
Department of Veterans Affairs (VA) Joint Venture in Hawaii. I 
represent the largest military medical treatment facility in the entire 
Pacific Basin. TAMC's area of responsibility spans more than 52 percent 
of the entire Earth's surface and provides medical support to nearly 
450,000 beneficiaries, including Active Duty Service Members of all 
branches of service; their eligible Family Members; military Retirees 
and their Family Members; Veterans; and many Pacific Islands Nation 
Residents.
    In 1991, Under Secretary of the Army and the Deputy Secretary of 
Veterans Affairs approved the basic concept of a Joint Venture for 
Hawaii. What was initially conceived as a small veteran's hospital 
adjunct to the military medical center, is now a vast $20 million 
sharing agreement spanning inpatient medical, surgical and psychiatric 
services, as well as outpatient specialty services and non-medical 
support, such as security, meals and housekeeping. Beginning in 1997, 
the VA began to relocate administrative and health care services to the 
TAMC campus. Construction and renovation to portions of the medical 
center infrastructure have resulted in both new and relocated veteran 
services on the Tripler campus, including an inpatient psychiatric 
unit, a new parking structure, the Center for Aging, the Ambulatory 
Care Clinic and renovation of the E-Wing of TAMC for both the Veterans 
Health Administration and Veterans Benefits Administration (VBA) 
administrative functions. The relocation of the Post Traumatic Stress 
Disorders (PTSD) Residential Rehabilitation Program (PRRP) from Hilo to 
TAMC has been a very successful initiative. The current PRRP program 
admits both Veteran and Active Duty patients as a cohort group, and 
provides a 7-week program of integrated treatment, including but not 
limited to PTSD symptom management, communication skills, anger 
management, relaxation training, behavior therapy, trauma focus 
therapy, adjustment counseling, substance abuse and relapse prevention 
treatment, and general health education. The relocation of the VA to 
the TAMC campus has resulted in increased workload for both TAMC and 
the VA Pacific Islands Healthcare System (VAPIHCS). We continue to move 
forward, using joint strategic planning sessions. New initiatives 
currently underway today include planned additions for a new facility 
for the Post Traumatic Stress Disorder (PTSD) Residential 
Rehabilitation Program in 2008, a shared Same Day Surgery Center in 
2009, and a proposed inpatient tower at TAMC to consolidate nursing 
units.
    A collaborative effort of this magnitude requires diligent planning 
and oversight. Both the VA and TAMC have dedicated staff to ensure the 
exploration and development of joint efforts. On a daily basis, VA 
patients represent a large part of our workload. For example, last 
month my hospital's average daily census was 151 patients. 
Approximately 33 of those patients, or 22 percent, were veterans. 
Additionally, 29 percent of our admissions from the emergency room were 
veterans. The VA-operated psychiatric ward averaged nine psychiatric 
veterans as patients per day.
    Over the years, additional clinical staff have been hired to 
accommodate the growing VA workload, forming a reliance on the 
reimbursement from the VA. We have also begun a new program of 
embedding VA providers into specialty clinics to add stability and 
increased workload to support the Graduate Health Education programs. 
These additions are now evident in our hospitalist program, in 
ophthalmology and in orthopedic surgery. There are plans to continue to 
evaluate other areas for expansion.
    While reimbursement is essential to a successful DOD/VA 
partnership, it is not the primary motivation. For the military, caring 
for veterans represents a continuation of the services we provided when 
they were Active Duty. Our ultimate status will be as veterans. Another 
dimension of caring for the veteran is that the illnesses and surgeries 
associated with aging are very relevant to keeping Active Duty medical 
personnel trained and ready for our battlefield mission. We must remain 
competent caring for acutely ill patients. At Tripler we have a robust 
Graduate Health Education program spanning 10 different medical 
specialties and training 220 individuals per year. Our graduate medical 
education occurs in Orthopedics, Radiology, Urology, Medicine, 
Obstetrics and Gynecology, Psychiatry, ENT, Pediatrics, Family Practice 
and General Surgery. We have found that these programs benefit from 
caring for the veterans population.
    Recently several new initiatives have been undertaken under the 
Joint Incentive Program and the Joint Demonstration Project. 
Development of several Joint Incentive Fund proposals totaling $4 
million have been completed and funded including a state-of-the-art 
computer-aided design/computer-aided manufacturing system for orthotics 
and prosthetics with telemedicine capability, a chronic dialysis center 
for veterans and a joint pain management improvement project. All three 
of these initiatives will improve access to care to our joint 
beneficiaries and decrease wait times. We have submitted two additional 
Joint Incentive Fund projects--one for a joint sleep study lab and a 
second for an integrative medicine approach to pain management. These 
two projects are pending approval and funding at this time. The Hawaii 
Collaborative was also selected as one of eight sites to serve as a 
demonstration project. Our Joint Demonstration Collaborative proposes 
to meet the need of establishing a structure and process to jointly 
assess, execute, and evaluate improvements in Referral Management, Fee 
Authorization, and Document Management. The collaborative expects to 
garner benefits from these demonstration studies including transparent 
tracking of consultations and authorizations, as well as improved 
access to documents for information exchange between our organizations 
for improved continuity of patient care.
    We continue to explore opportunities and initiatives that allow 
Tripler and VA to share staffing. In the past year, we've signed 
several new sharing agreements, including provision of Central 
Sterilization support for the Ambulatory Care Clinic, additions of VA 
specialists in ophthalmology and orthopedic surgery, provision of meals 
to the VA Center for Aging and several agreements supporting joint 
clinical research projects. We have also undertaken a joint approach in 
planning for pandemic flu response. Our dedicated staff continues to 
identify and develop new initiatives including joint decontamination 
support, joint purchase of medical supplies, evaluation of a VA 
transitional/subacute care unit and increased attention to the seamless 
transition between our organizations for our Warriors in Transition.
    This year, the Department of the Army, through the Army Medical 
Action Plan (AMAP), has placed a lot of emphasis on care of our Wounded 
Warriors and a seamless transition from Active Duty military service 
and the Military Health System to care under the Veterans Benefits 
Administration and Veterans Health Administration. Our programs in 
support of returning Wounded Warriors and our ties between TAMC and VBA 
and VAPIHCS were well established even before the advent of the AMAP. 
We assigned Case Managers to all returning wounded and had specialized 
treatment programs such as our Soldier and Family Assistance Center at 
Schofield Barracks which provides a whole range of behavioral health 
and advocacy programs. We have had representation from VBA on our 
Patient and Family Assistance Team since inception and our Case 
Managers work daily with the VBA and VAPIHCS to foster a smooth 
transition to VA benefits including health care. We have also had 
VAPIHCS as a partner in our Multi-Service Market Management Office-
sponsored Joint Executive Council and subordinate working groups. At 
these forums, we explore healthcare options for Veterans, past and 
future. One key group is the Behavioral Health Working Group which is 
taking a greater role in determining needs for PTSD and mild Traumatic 
Brain Injury (TBI) to serve the greater Hawaii market of eligible 
beneficiaries. Under the AMAP directive, Tripler has launched training 
of all military personnel on recognizing PTSD and mild TBI and to 
encourage self reporting and referrals of others returning from 
Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF). 
Additionally, our Social Workers, Case Managers, Psychiatric Nurses and 
Psychiatric Nurse Practitioners are taking more focused clinical 
training courses. We are also adding Neuropsychologists and other 
clinical staff to assist with diagnosis and treatment. This area of 
urgent need is an excellent opportunity for DOD and VA collaboration 
and we are already leaning forward in our planning.
    As with most merger type activities, there are barriers that impede 
unfettered, efficient coordination. I believe, however, most of our 
Joint Venture barriers are systemic in nature. These barriers include:

    (1) The separate VA and DOD healthcare information systems which 
make data sharing difficult. We need interoperability of healthcare 
computer systems between DOD and the VA to coordinate patient care and 
conduct financial business. Our demonstration project addresses a 
portion of the identification and business processes that will support 
the joint revenue process. However, we cannot continue to conduct 
business without commercial-type claim processing software and support. 
Currently, development and release of the Charge Master Based Billing 
module has been put on hold indefinitely. As patients move between 
Tripler and the VA, the lack of an integrated, computerized patient 
record causes inefficiency and staff dissatisfaction.
    (2) Lack of venture capital to invest in joint initiatives. We 
cannot pool our resources to spend for a common need. While the Joint 
Incentive Fund is one-step in this direction--and we have taken 
advantage of funding available through this program since its inception 
in 2004--the application and reporting processes are time consuming and 
complex. Again, without truly dedicated staff, many good proposals do 
not come to fruition due to our inability to jointly address the 
requirements.
    (3) Business processes associated with Joint Ventures are not well 
defined at the VA and DOD enterprise level and impair efficient 
coordination locally. National guidance must be developed based on the 
needs of sharing sites which considers cost analyses and feedback 
whenever possible. Some of these processes have financial implications 
that cause delays in billing and payment. When there are billing and 
payment issues, ultimately there are cash-flow problems.
    (4) Other valid business process questions and issues related to 
the management of the TRICARE program. For example, do VA patients 
compete with TRICARE patients in DOD? For TRICARE Prime, this is not an 
issue because by law Prime patients have precedence. Should the medical 
treatment facility commander dedicate capacity to TRICARE eligible 
beneficiaries or commit resources to caring for VA patients? This has 
long been a point of contention with VAPIHCS, as they desire dedicated 
support from military MTFs. Lack of this dedication at Joint Venture 
sites undermines the premise of sharing and generates additional costs 
when access levels cannot be maintained resulting in sporadic need for 
high cost contracted support. The eligibility rules and associated 
entitlements for the VA's categories of veterans and dual eligible 
beneficiaries are complex and constantly changing. This complexity is 
compounded when such patients seek care at a joint venture site. We 
need to establish joint service units at these sites to not only help 
these patients understand and make informed choices but also to more 
efficiently evaluate the need for available resources and track their 
use.
    (5) Lack of policy guidance for dual eligibility. We don't need to 
require patients to choose between an entitlement to a military medical 
retirement benefit and a VA benefit but we do need to have the 
authority to coordinate access to the respective benefit. If we do not, 
we have patients duplicating services by seeking care from both 
systems. This increases the costs of providing care to both DOD and VA, 
and also results in patient safety concerns.
    (6) Neither DOD or VA has established accountability and 
responsibility for the success of joint ventures. Jointly we need to 
develop metrics and a business strategy that reflect good stewardship 
of the resources invested in both systems.
    (7) Competition between the convenience of healthcare that is 
available locally and the Veterans Integrated Service Networks' (VISNs) 
regional investment in healthcare delivery services produces a barrier 
to local coordination. For the VISNs it is an out-of-pocket cost when 
they pay DOD rather than use their own facilities. VISNs are structured 
and funded using a concept whereby satellite medical centers are 
supported by one or two flagship medical centers. In our case, Honolulu 
is a satellite center and their flagship facilities are in California 
at Palo Alto and San Francisco. Emergent care is provided at Tripler 
and, if necessary, within the local community. Non-emergent care is 
referred to the California facilities. The current VA resource 
allocation system does not provide additional dollars for VISNs to 
allow satellite centers to seek a significant amount of care from non-
VA providers.

    Despite the systemic barriers we confront, we continue to work 
together diligently to devise local solutions. Wherever possible, we 
have leveraged advances in technology to provide seamless flow of 
information. We have incorporated Pharmacy Bi-Directional Data 
Interchange, Common Data View through a program called ``Janus'' and 
Laboratory Interoperability. The Pharmacy Bi-Directional Data 
Interchange allows both DOD and VA providers to order and receive 
prescriptions from either information system. The common data view 
presents patient data (demographics, lab, pharmacy, etc.) on a common 
computer screen. Finally, the current laboratory interoperability 
allows lab orders and results to be communicated between both systems. 
We look forward to expanding this program in the near future. The 
common goal of these initiatives is to improve patient care by 
developing interfaces to allow the electronic sharing of pertinent 
patient information between the VA, DOD and other clinical data 
providers.
    In terms of DOD/VA joint venture development, our future is now. We 
are ahead of most localities in that we are already one of the most 
functionally integrated joint ventures. Instead of two freestanding 
medical centers, we have only one emergency room; one inpatient 
medical, surgical, and psychiatric service; and essentially one major 
specialty outpatient service. We have integrated clinical services for 
psychiatric on-call support, hospitalist support, ophthalmology, 
orthopedic surgery, nephrology support and psychology services. 
However, this functional integration is just the beginning.
    While we are ahead of most of the other joint venture sites in the 
Nation in developing our sharing agreements and establishing policies 
and procedures, there are still opportunities for continued development 
of our joint venture. The two key determinants when developing 
opportunities for improved coordination are expansion of our patient 
care services to care for more patients and elimination of redundant 
overhead. We have worked diligently to develop initiatives for VA 
chronic dialysis, shared pain management resources and expanded 
orthotic/prosthetic support to veteran patients through the Joint 
Incentive Fund. However, additional opportunities for improved 
coordination and cooperation are numerous. Achieving these 
opportunities will be dependent upon obtaining needed policy, program, 
and resource support.
    There is local VA and DOD top management support to make Tripler 
Army Medical Center a model joint venture site. In this respect, 
countless hours have been invested by both activities to improve our 
joint venture. In order to perpetuate sharing between VA and DOD 
entities, national initiatives applicable to all types of sharing 
should be developed, providing guidance and policy on dual-eligibility, 
authorization, and reimbursement. Venture capital monies should be 
allocated for developing proposals and procuring dedicated joint 
venture staff. Information systems must be evaluated for applicability 
to sharing, and solutions to systemic issues should be identified and 
resolved expeditiously. We must address and resolve the barriers 
described if we are to achieve our ultimate goal--high quality care for 
our respective beneficiaries in a seamless healthcare system.

    Senator Akaka. Thank you very much, Colonel Wallace.
    The Audience. (Applause.)
    Senator Akaka. Now, we will receive testimony from Major 
General Robert Lee.

                MAJOR GENERAL ROBERT G.F. LEE, 
               ADJUTANT GENERAL, STATE OF HAWAII

    General Lee. Good afternoon, Chairman Akaka, I want to 
personally thank you on behalf of all the veterans in the State 
of Hawaii and the members of the Armed Forces for your superb 
work not only as Chairman of the Veterans' Affairs Committee, 
but your hard work on the Senate Armed Services Committee that 
we all appreciate especially during these difficult times. I 
know men and women in uniform always count on you and Senator 
Inouye for the top level support for all of us. Mahalo again.
    We have five divisions in the State Department of Defense, 
and you help all of us out. From the big ones like the Army and 
the Air National Guard to our smallest Youth ChalleNGe Academy 
where we turn around at-risk kids, we thank you very much for 
it. Today, Mark Moses, the Director of Office of Veterans 
Services will talk a lot more on that. On behalf of Governor 
Lingle, thank you very much, the Office of Veterans Services of 
the State of Hawaii can interface with VA at the Federal level 
to make transition as seamless as possible and to make sure our 
veterans that reside in the State of Hawaii get their full 
benefits.
    Let me talk about the veterans in the State of Hawaii. 
Currently, the numbers run about 10 percent of our population, 
our veterans who have served in the Armed Forces of the United 
States and other recognized agencies. But over the past decade 
we saw a decline in the number of veterans in the State of 
Hawaii. Primarily from the great World War II veterans such as 
yourself, Senator, I'm kind of losing my friends in Club 100 
and the 442nd Veterans Club and all my friends in the other 
veterans organizations throughout the state.
    But after September 11, the downturn stopped. Primarily 
with our National Guard and Reserve troops being called up at 
unprecedent levels and even active duty folks from the State of 
Hawaii serving on active duty in Iraq and Afghanistan and 
returning home, the trend now goes up and we need all the 
veterans services that the previous two panels talked about.
    In the Hawaii National Guard, both Army and Air on the Army 
side of the house, nine out of our ten soldiers wear a combat 
patch. They have already served in Iraq and Afghanistan. We got 
a smaller group right now. We have 75 soldiers from the Hawaii 
Army Guard with their brothers from 1st Battalion, 158 
infantry, 29th Brigade Combat Team currently hunting down the 
Taliban on the Afghan/Pakistan border. At the same time, we 
have our Black Hawk Unit, Charlie Company 207 aviation that 
provided the medical airlift this past year. They're now in 
Bilad in the center of the Sunni Triangle providing the airlift 
that Senator Inouye talked about for our troops should they run 
into trouble. We also have two dozen airmen from the Hawaii Air 
National Guard from the Civil Engineering Squadron recently 
deployed to Iraq. Although smaller numbers than before in 2005, 
absolutely critical in the War on Terror, the Hawaii National 
Guard is doing their part just like all the other Reserve 
forces in the State of Hawaii.
    So we must ensure that these veterans from the Guard and 
Reserve when they return home to their civilian lives, they 
also can transition back from military duty to civilian life in 
good health. And our Office of Veterans Services enjoys a great 
partnership with Hawaii VA Administration, and they're with us 
every step of the way especially during the demobilization of 
our soldiers when they come off active duty.
    Right now we're pretty sure that none of our soldiers or 
airmen will have their benefits fall through the crack because 
our government has an obligation to our military members from 
when they first enlisted through the service years to veterans 
benefits and finally their death benefits--they're entitled to 
all that they are due today and in the years to come.
    I want to point out that the National Guard Bureau headed 
by General Blum recently authorized both the Army and the Air 
National Guard to release medical records to the Department of 
Veterans Affairs without the veteran's signature.
    So Mr. Aument, I'd like some feedback whether that's 
working or not, and I noted your concern about lack of medical 
records from Guam. I'm going to see my colleague General 
Goldberg this weekend, and I'll mention it to him. I just 
wanted you to know that the medical records may be kind of 
lacking because all of the Guam National Guard soldiers serve 
all of the current rotations in Africa. As you know, the 
medical facilities are not as robust in Africa like in Iraq or 
Afghanistan. But I will surely bring this up to General 
Goldberg. So I'd like really some feedback whether this is 
working better to make sure that the records from the National 
Guard are reaching the Department of Veterans Affairs, and I 
can help to make sure the transition is a lot smoother.
    This afternoon, Senator, I want to share a few concerns 
with your Committee. My most important concern is access to the 
Veterans' Administration services for all of our veterans. And 
I want to talk about Hawaii National Guard's 29th Brigade 
Combat because it's the Brigade from Polynesia. Although I'm 
the Adjutant General from the State of Hawaii, it was a 
Polynesian Brigade from the State of Hawaii, American Samoa, 
Guam, Saipan, Rota and Tinian that formed the bulk of the force 
in Iraq.
    I'm especially gratified to see finally the opening of a VA 
clinic in American Samoa, and I know you have facilities in 
Guam and that they should be beefed up to handle our soldiers 
from Saipan, Tinian and Rota. Telehealth is real good, but at 
least just a lot of cases where they need to come to Honolulu, 
Hawaii and Tripler to see the very expert and great physicians 
and caregivers in that capacity. And we just need to kind of 
figure out a better way to bring the injured soldiers and their 
family members when they need special treatment because it's 
quite a beauracracy to go through that right now. That's the 
feedback that I'm getting from my troops all across the board. 
Senator, I'm sure Congress and Governor Lingle have shared that 
with you. I've directed our C-17 squadron that flies down to 
Pago Pago to bring up veterans whenever they can on a space-A 
(available) basis.
    My next concern deals with certification of disability by 
Department of Veterans Affairs. Rather than, I guess, pick on a 
wound or, you know, along we discuss the lengthy period of the 
caseworker taking for a certification of disability, I'd like 
to make a recommendation, Senator, that we kind of cut through 
the red tape a little bit. And my recommendation is that, if 
any soldier earns Combat Infantryman's Badge, shot at, gets a 
bomb go off close to them and earns a Combat Action Badge and 
is a combat medic that goes out with the troops, or it's a 
Marine ground pounded and earns a Combat Action Badge, that we 
just cut to the chase and recognize the service and the problem 
that servicemember has. I listened intently to Senator Inouye's 
World War II recollections about how things were. I can provide 
the records of all the attacks or the rocket attacks on Bilad 
with the 29th Division Headquarters and also Camp Victory and 
the Green Zone and the 29th Brigade Combat Team lost 16 of its 
17 brave soldiers to improvise explosive devices.
    I want to shed some doubt on the caseworker's ability to 
say hey, we give you the disability because the bomb went off 
50 meters away from you, 500 meters, 1,000 meters, every 
soldier behaves differently. So my recommnedation is to have a 
combat records on file, not necessarily on the medical side, 
because, I'll share this with you, in 2005, Brigade Commander 
General Chavez called me up with the time zone difference, 
around midnight, to report that a member of the 29th Brigade 
was killed in action. But at that time, I also was elated 
because many of the reports that I received say that patrol so 
and so encountered an improvised explosive device, treated for 
headache and returned to duty.
    You know, no one got killed and I was happy then. But I 
know a lot more now because it came to my final concern to have 
adequate staffing at the VA hospitals and clinics, especially 
in the mental health area, to provide service to veterans who 
suffer from the delayed effects of PTSD.
    It was earlier brought up that when our Guard troops came 
home, no doubt they wanted to go home to their families. 
Eighteen months on active duty, 12 months in Iraq. That's why 
we have a program to periodically revisit these soldiers, and 
they're called the Post Deployment Health Reassessment program. 
But when the 29th Brigade came back and when we did this in 
early 2006, Traumatic Brain Injury was not part of the 
checklist. That's why we need to go back out and reconnect with 
all the soldiers and we have records of this, and you know the 
proud Polynesian warrior tradition. We're tough. We can take 
it. I'm OK. Let me go home. We need to make sure we have the 
opportunity to revisit this.
    I'll be meeting with General Blum and my colleagues from 
the Adjutants General across the 50 states and we're going to 
recommend that this Post Deployment Health Reassessment not end 
at the 2-year period beyond active duty because everyone 
behaves differently. We'd like that extended. I really can't 
give a recommendation right now extended another year, two, 
three. I'd like to see how the track history goes. And this is 
what we're finding out. As I talk to other Guard units, I think 
the Hawaii National Guard is, as far as the percentage of PTSD, 
is no different from our active folks that have come back. But 
yet I've heard other stories like infantry battalions out of 
New Hampshire 75 percent PTSD after 2 years. So I'd like to 
keep that option open.
    In closing, I want to make a note that all the services 
received by our soldiers from VA clinics and caregivers have 
been exceptional, and we thank you for that. We just need to 
close the gap of getting our soldiers there to you. Thank you 
very much.
    [The prepared statement of General Lee follows:]

         Prepared Statement of Major General Robert G.F. Lee, 
                   Adjutant General, State of Hawaii,

    Chairman Akaka, Senator Craig and Members of the Senate Committee 
on Veterans' Affairs, I am Major General Robert G.F. Lee, the Adjutant 
General for the State of Hawaii.
    Within the State Department of Defense, there are five major 
divisions: the Hawaii Army and Air National Guard, State Civil Defense, 
Youth Challenge Academy, and the Office of Veterans Services (OVS). The 
Director of Office of Veterans Service is Mr. Mark Moses, a retired 
Marine major and a former state legislator.
    The Office of Veterans Services is the single office in the State 
government responsible for the welfare of our veterans and their 
families. OVS serves as the liaison between Governor Linda Lingle and 
the veterans groups and organizations. They also act as an intermediary 
between the Department of Veterans Affairs and Hawaii's veterans.
    Veterans make up more that 10 percent of Hawaii's total population. 
The majority of them--about 72 percent--live on the island of Oahu. 
About 13 percent reside on the island of Hawaii, 10 percent live on one 
of the three islands that comprise Maui County, and about 5 percent 
live on the island of Kauai.
    Within this large veteran population are many World War II 
veterans, many members of the famed 100th Battalion and the 442nd 
Regimental Combat Team. Hawaii's overall numbers were declining because 
many veterans of this era, most in their 80's, are passing on in large 
numbers.
    But since September 11, 2001, mobilizations have involved nine of 
every ten Army National Guard and Reserve soldiers. They served 
honorably in Iraq, Afghanistan and other locations; and have returned 
to Hawaii after their 12-15 month activations. Air National Guard 
members have also deployed in support of Operations Iraqi Freedom and 
Enduring Freedom. Therefore, Hawaii's overall veteran population has 
increased.
    We must insure these new veterans return to their civilian lives in 
good health. The Office of Veterans Services partners with the 
Veterans' Administration here during the soldiers demobilization 
process. This partnership works to insure no one or no benefit falls 
through the crack.
    The United States Government has an obligation to our military 
members from enlistment, through their service years, to veterans' 
benefits and finally, death benefits. We must insure that all veterans 
receive all entitled benefits now and in the years to come.
    The National Guard Bureau recently issued a memorandum authorizing 
both the Army and Air National Guard to release medical records to the 
Department Veterans Affairs without the veteran's signature. This new 
procedure speeds the Department of Veterans Affairs adjudication of 
veterans' claims and provides medical care to Guard members.
    I come to you with a few concerns.
    My most important concern is the access to Veterans' Administration 
services to all our veterans, especially, on our neighbor islands and 
our Pacific Islander veterans from Tinian, Rota and Saipan. In July 
2007, a VA clinic opened in American Samoa that supports our veterans 
there. However, veterans from other Pacific islands must pay the high 
cost of airline and hotel accommodations to receive follow-on VA 
medical treatment. In Hawaii, a similar situation occurs when neighbor 
island veterans must come in to Tripler Army Medical Center or the 
Matsunaga VA Hospital in Honolulu for treatment. We must work to find a 
solution to this situation.
    My next concern deals with the certification of a disability by the 
Department of Veterans Affairs. Often a servicemember is awarded a 
decoration recognizing the specific incident that is associated with an 
injury or disability. However, when filing for a disability, the VA 
requires a complete recertification of the incident causing the injury 
or disability. Approval and certification of this letter of 
determination is required prior to providing any services.
    My final concern is the recruitment and staffing of VA hospitals to 
the levels that they are authorized. For example, the Post-Deployment 
Health Reassessment Program (PDHRA) requires an initial appointment 
within 30 days of VA registration. On average, the VA hospital 
schedules initial appointments as much as 90-120 days from the 
registration date. Our local VA hospital staff has been doing their 
best to provide services, but needs a full staff to serve all our 
veterans. They have stretched their limited health care provider 
resources to support veterans in the Pacific Basin.
    In closing, I want to thank the Committee for their continuing 
support of our veterans. Thank you for coming to Hawaii to conduct 
these hearings.
    Are there any questions?

    The Audience. (Applause.)
    Senator Akaka. Thank you. And now we will hear from Mark 
Moses. Your testimony?

         STATEMENT OF MARK MOSES, DIRECTOR, OFFICE OF 
      VETERANS SERVICES, DEPARTMENT OF DEFENSE, STATE OF 
                             HAWAII

    Mr. Moses. Thank you, Mr. Chairman.
    I'm Mark Moses, Director of the Office of Veterans 
Services. OVS is the state lead agency responsible for the 
welfare of veterans and family members. As the Governor's 
liaison to veterans and veteran groups, we serve as an 
intermediary between them and the Department of Veterans 
Affairs and provide access to state services and benefits.
    We have provided services and information to nearly 33,000 
veterans and survivors this past fiscal year. I've attached a 
summary sheet describing some of the services and activities 
made available for your review. The final service we can 
provide a veteran is interment in a veteran's cemetery with 
appropriate honors. The VA has consistently supported our 
efforts to expand Hawaii cemetery plots and columbarium space 
to keep pace with need, and they are deserving of our 
gratitude. And as you saw today, we got the new grant which we 
desperately need.
    It is important for us to take this opportunity to thank 
you, Senator Akaka, for your unwavering support for our 
Veterans Cemetery Program, and our veterans in general. We are 
particularly grateful for your assistance in obtaining the new 
grant we just discussed.
    The April 2000 data from the VA Office of Actuary, Office 
of Policy Planning Preparedness, estimated 120,000 veterans in 
Hawaii. As you heard, those numbers may have changed. I don't 
know if they're necessarily decreasing. About 72 percent of 
those lived on Oahu, 13 percent on the Big Island, 10 percent 
on one of the Maui County islands and approximately 5 percent 
on Kauai. For that very reason, we have offices on neighbor 
islands to support our veterans.
    Our Island State presents unique challenges for Department 
of Veterans Affairs. Despite these challenges, though, I want 
to share with you comments that we hear from veterans. They 
speak to the excellence of VA medical care, how VA staff treats 
veterans with dignity and respect and that the services 
rendered by the dedicated health care professional are superior 
to what they received on the mainland. In the past, you heard 
stories to the contrary, Senator, I share reports from veterans 
we have met. I think now there has been a change for the 
better.
    These comments are from local veterans and those visiting 
Hawaii, and those who need to seek services from the Spark M. 
Matsunaga medical staff. Similar comments are shared about the 
VA benefit staff. As you know, though, we still have a backlog 
and that is being addressed. I'm not going to go into it again.
    Hawaii's VA supports Guard and Reserves prior to deployment 
and upon their return, as well as those members in the military 
service from the active forces. As a disabled veteran, I can 
attest to the fact that the services provided by the VA locally 
are top in the Nation. Nevertheless, given the proper 
resources, they are capable of doing better. You recall that 
nearly 30 percent of our veterans live on the neighbor islands. 
Many of them are referred for surgical services to mainland VA 
medical centers, civilian medical facilities on Oahu or at 
Tripler Army Medical Center. For neighbor island veterans sent 
to mainland VA hospitals, this can be very traumatic. They're 
booked on flights, sent to a big city to find a VA facility, 
operated on and sent back to their homes in Hawaii.
    We ask that sufficient funding be provided for direct 
mainland flights from, and whenever possible, return flights to 
the veteran's islands of residence. Now, they are, of course, 
placed on flights that come through Honolulu.
    Changes to 38 U.S.C. 1151, Benefits for persons disabled 
due to treatment provided at a VA facility means that the only 
facilities covered under the law are those over which the VA 
Secretary has direct jurisdiction, or a government facility 
contracted by him. Tripler, Straub, Kuakini, Queen's and St. 
Francis do not qualify.
    Veterans suffering any additional disability, or worse, are 
on their own and must sue the medical facility for damages. 
That's an overwhelming task for most veterans. We suggest the 
definitions that are listed in 38 U.S.C. 170 and 38 U.S.C. 1151 
be changed allowing Hawaii veterans the same protection as 
veterans receiving care in VA facilities on the mainland.
    At a minimum, veterans must be given the opportunity to 
make an informed consent about the benefits and shortfalls 
between having medical procedures performed at a mainland VA 
facility or locally in non-VA facilities. Hawaii's neighbor 
islands must be offered the same level of medical care and 
services as veterans located on Oahu.
    Neighbor island Community Based Outpatient Clinics place 
veterans on a wait list where they are scheduled for specialty 
medical care. With the use of telemedicine and more frequent 
visits to CBOC, this backlog is being addressed. Nevertheless 
not fast enough, sir. Some veterans must wait several months to 
see a specialist.
    VA has a difficult time recruiting and maintaining 
competent medical staff in these rural areas. VA should be 
allowed to offer a premium to rural medical service providers 
and be allowed to contract for additional medical care in rural 
areas such as the neighbor islands. Thousands of National 
Guardsmen and Reservists have returned. My desire is that they 
and those already here receive medical and benefit services in 
a timely manner.
    We ask that VA Health and Benefits Administrations be 
adequately funded and staffed to provide medical care and 
benefit services to all Hawaii's veterans. Hawaii received a VA 
grant to build the Yukio Okutsu Veterans Home opening hopefully 
this year. We envision that eventually we will have several 
veterans' long-term care facilities, preferably one per county 
with your aid, sir.
    Presently, the per day veteran reimbursement rate is 
$67.71. That amount is insufficient to maintain a veteran 
without additional payments from the veteran and other 
resources that are available. We request that the reimbursement 
rate be raised to adequately cover long-term care services 
provided to assist the state in meeting the medical care of 
this frail group of older warriors. The cost is approximately 
$300 a day.
    As these veterans pass, many will utilize our state veteran 
cemetery system. Presently, the state and county are reimbursed 
$300 for each veteran burial. This is less than the cost to 
open and close a gravesite and to provide for perpetual care. 
The cost to bury and provide perpetual care is approximately 
$1,000. The burial reimbursement rate has not changed in many 
years, and we ask your Committee to look into increasing it to 
more closely reflect the true cost of these interments.
    We must continue to take care of those who have served. 
They are our sons and our daughters, our Hawaii citizens, our 
veterans. I thank the Committee and you for this opportunity, 
and I will respond to any questions you may have.
    [The prepared statement of Mr. Moses follows:]

   Prepared Statement of Mark S. Moses, Director, Office of Veterans 
            Services, Department of Defense, State of Hawaii

    Chairman Akaka and Members of the Senate Committee on Veterans' 
Affairs, I am Mark Moses, Director of the Office of Veterans Services 
(OVS). The office is the single State lead agency responsible for the 
welfare of Veterans and their family members. We act as the Governor's 
liaison to veterans, veterans groups and organizations, and serve as an 
intermediary between the Department of Veterans Affairs and Hawaii's 
veterans. The office serves in partnership with the VA to provide state 
services and benefits. We provided services and information to nearly 
33,000 veterans and eligible survivors this past fiscal year. I have 
attached a summary sheet describing some services and activities made 
available through the office for your review.
    The final service we can provide a veteran is interment in a 
veteran's cemetery with appropriate honors. The Veterans Administration 
has consistently supported our efforts to expand Hawaii's cemetery 
plots and columbarium space to keep pace with need. They are deserving 
of our gratitude.
    Additionally, it is important and proper to take this opportunity 
to thank you, Senator Akaka for your unwavering support for our 
veteran's cemetery program. We are particularly grateful for your 
assistance in obtaining the new grant for the West Hawaii Veterans 
Cemetery located in Kona. State veterans cemeteries are the only 
cemeteries accepting full body burials on a consistent basis in Hawaii. 
This VA grant will assure that West Hawaii will be the cemetery we all 
have envisioned it to be.
    Based on April 2000 data from the Office of the Actuary, Office of 
Policy, Planning and Preparedness, Department of Veterans Affairs, 
there are an estimated 120,000 veterans in Hawaii. The majority, about 
72 percent live on Oahu, 13 percent reside on the island of Hawaii, 10 
percent live on one of the three islands which comprise Maui County, 
and approximately 5 percent live on Kauai. Hawaii, an island state 
located in the middle of the Pacific Ocean, presents unique challenges 
for the Department of Veterans Affairs.
    Before I discuss some of these challenges, I want to share with you 
comments that my staff and I hear from veterans about VA health care 
and benefit services. These individuals speak to the excellence of VA 
medical care; that VA's staff treats veterans with dignity and respect, 
and that the services rendered by the dedicated health care 
professionals are superior to the care they received on the mainland 
United States. These comments are expressed by local veterans as well 
as by veterans who visit Hawaii and have a need to seek services from 
Spark M. Matsunaga medical staff. Similar types of comments are shared 
about the VA Benefit staff.
    This ``new'' VA exemplifies the well known phrase of ``supporting 
our troops.'' Hawaii's VA supports our National Guard members and 
Reservists prior to deployment and upon their return. They also offer 
services to military members who are ending their military service. As 
a disabled veteran, I can attest to the fact that the services provided 
by the VA locally are top in the Nation. Nevertheless, given the proper 
resource they are capable of doing better.
    As mentioned earlier, Hawaii presents unique challenges to the VA. 
We are an island state with one large population center on Oahu. Nearly 
30 percent of Hawaii's veterans live on the neighbor islands. Presently 
many of our veterans are referred for surgical services to mainland VA 
medical centers, civilian medical centers on Oahu, or to Tripler Army 
Medical Center. This can be very traumatic for neighbor island veterans 
who are sent to other VA hospitals. They are booked on flights, sent to 
a big city to find the VA facility, operated on and sent back to their 
home in Hawaii. We ask that funding be provided so that those who 
reside on neighbor islands be provided direct flights to the mainland. 
We also propose that whenever possible, return flights fly directly to 
the veteran's island of residence.
    Another issue that affects Hawaii and Alaska involves changes that 
were made to 38 U.S.C. 1151, Benefits for persons disabled by treatment 
of vocational rehabilitation. With this change the only facilities 
covered by the law are those over which the Secretary of Veterans 
Affairs has direct jurisdiction, or Government Facilities contracted by 
the Secretary. Tripler Army Medical Center and other medical facilities 
in Hawaii, such as Straub, Kuakini, Queens, and St. Francis do not 
qualify under the present law. Veterans suffering an unlikely event 
causing any additional disability or worse are on their own and must 
sue the medical facility for damages. For most, obtaining an attorney 
to pursue this option is overwhelming.
    We suggest that the definitions as listed in 38 U.S.C. 1701(3) and 
38 U.S.C. 1151, be changed so that veterans in Hawaii treated outside 
VA facilities are afforded the same protection as veterans who receive 
VA medical care in VA facilities on the mainland. Hawaii's veterans 
must have the same right to redress as veterans treated at mainland VA 
facilities. At a minimum, veterans must be given the opportunity to 
make informed consent about the benefits and shortfalls of choosing 
between having surgeries or other medical procedures performed at a VA 
facility on the mainland or in non-VA facilities locally.
    Hawaii's neighbor islands must be offered the same level of medical 
care and services as veterans located on Oahu. Presently neighbor 
island Community Based Outreach Clinics place veterans on a wait list 
where they are scheduled for specialty medical care. With the use of 
Telemedicine and more frequent visits, this problem is being addressed; 
however, backlogs still exist. Veterans have been known to wait several 
months before they see a specialist. Additionally, VA has a difficult 
time recruiting and maintaining competent medical staff in these rural 
areas. To address these needs, the VA should be allowed to offer a 
premium to rural medical service providers and consider contracting for 
additional medical care in rural areas such as the neighbor islands.
    As you are aware, Hawaii has received thousands of its returning 
National Guardsmen and Reservists. As Director of the Office of 
Veterans Services, my desire is that these returning military members 
and those already here be able to access medical and benefit services 
in a timely manner. We ask that VA Health and Benefits Administrations 
be adequately funded and staffed to provide medical care and benefit 
services to all veterans who make Hawaii their home.
    Hawaii has received a grant from the VA to build its first 
Veteran's Home. The Yukio Okutsu Veterans Home is scheduled to open 
within a few months. Our concern is with the reimbursement rate that 
the VA pays for veterans who will be residing at the home. The present 
reimbursement is insufficient to maintain a veteran without payment of 
additional funds. We in Hawaii are not alone in requesting that the per 
day reimbursement rate be raised so that it adequately covers long-term 
care services supplied by the facility. We envision that the Yukio 
Okutsu Veterans Home will be the first of several veterans' long-term 
care facilities, preferably at least on per county due to inherent 
island produced isolation. Adequate per resident reimbursement will 
assist the state in meeting the medical care needs of this frail group 
of older warriors.
    As these veterans pass, many will utilize our State Veteran's 
Cemetery system. Presently the state and county are reimbursed $300 for 
each veteran burial, but the cost to open and close the grave site and 
provide perpetual care greatly exceeds this amount. This reimbursement 
rate has not changed in many years. We ask that your Committee look 
into increasing the present amount so that it more closely reflects the 
true cost associated with full body and urn burials.
    We must continue to take care of our veterans. We must support our 
Soldiers, Sailors, Airmen, Marines, and Coast Guard members at home and 
abroad. They are our veterans, our sons and daughters, our citizens of 
Hawaii.
    I thank the Committee for this opportunity to speak on this matter 
and I will respond to any questions that you may have.
                                 ______
                                 
    [Note: the following is a summary of services and activities being 
offered by the Hawaii Office of Veterans Services.]
                   Hawaii Office of Veterans Services

                                MISSION

    The Office of Veterans Services (OVS) is the principal state office 
responsible for the development and management of policies and programs 
related to veterans, their dependents, and/or survivors. The OVS acts 
as a liaison between the Governor and veterans' organizations and also 
between the Department of Veterans Affairs and individual veterans. Our 
objectives are to assist veterans in obtaining State and Federal 
entitlements, to supply the latest information on veterans' issues and 
to provide advice and support to veterans making the transition back 
into civilian life.
    OVS is the State's primary advocate of veterans applying for and 
receiving benefits and services. The OVS may take action on behalf of 
veterans, their families and survivors to secure appropriate rights, 
benefits and services. This process includes the reception, 
investigation and resolution of disputes and complaints.
    The OVS serves all eligible veterans, Reservists, National Guard 
members, active-duty military personnel and their dependents (including 
stepchildren). (See List of Services at end.)

                        STATE PROVIDED BENEFITS

Special Housing for Disabled Veterans
    Payment by the State of up to $5,000 to each qualified, totally 
disabled veteran for the purpose of purchasing or remodelling a home to 
improve handicapped accessibility.
Burials
    Burials for qualified veterans (including U.S. war allies) and 
their dependents in Veterans Cemeteries on Oahu, Hawaii, Kauai, Maui, 
Molokai, or Lanai.
Vital Statistics
     Free certified copies of vital statistics forms when needed for 
veterans' claims.
License Plates
    For the same cost as regular license plates, qualified veterans can 
acquire distinctive veterans' license plates for their car or 
motorcycle. Currently available are: ``Veteran,'' ``Combat,'' ``Combat 
Wounded,'' ``Pearl Harbor Survivor,'' ``Former POW,'' 'World War II 
Veteran,'' ``Korean War Veteran,'' and Vietnam Veteran.''
Tax Exemptions
    Applies to real property that is owned and occupied as a home by a 
totally disabled veteran or their widow(er). Also applies to passenger 
cars when they are owned by totally disabled veterans and subsidized by 
the Department of Veterans Affairs.

Employment and Re-employment
    Preference is given to veterans, Vietnam-era veterans, service-
connected, disabled veterans and their widow(er)s for civil service 
positions, training programs, job counseling and referrals to civilian 
jobs by the Workforce Development Division, Department of Labor and 
Industrial Relations. Re-employment rights for veterans, Reservists or 
National Guard members who leave a position within State or County 
government for training or active military service.

We encourage you contact the Office of Veterans Services to have your 
questions answered. The sooner we begin the process together, the 
sooner you will see results. Please contact the OVS office nearest you. 
Walk-ins are welcome, and appointments are recommended. Home, worksite 
and hospital visits are available if necessary, as are Group 
presentations.
Office of Veterans Services--Oahu
    Office: Tripler Army Medical Center E-Wing
    Address: Office of Veterans Services, 459 Patterson Road,
      E-Wing, Room 1-A103, Honolulu HI 96819-1522.
    Telephone: (808) 433-0420; Fax: (808) 433-0385.
    E-mail: OVS@ovs.hawaii.gov.
    Hours: Monday-Friday, 7:45 a.m.-4:00 p.m.
Office of Veterans Services--Kauai
    Address: 3215 Kapule Hwy., #2, Lihue, HI 96766.
    Telephone: (808) 241-3346; Fax: (808) 241-3818.
    E-mail: KOVS@ovs.hawaii.gov.
    Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
Office of Veterans Services--Hawaii
    Address: 101 Aupuni Street, Room 212, Hilo, HI 96720.
    Telephone: (808) 933-0315; Fax: (808) 933-0317.
    E-mail: HOVS@ovs.hawaii.gov.
    Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
Office of Veterans Services--Maui
    Address: 333 Dairy Road, Suite 201-A, Kahului, HI 96732.
    Telephone: (808) 873-3145; Fax: (808) 243-5820.
    E-mail: MOVS@ovs.hawaii.gov.
    Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
            list of services for veterans, active military, 
                         spouses and dependents
    Assist in preparation of VA claims.
    Help individuals file VA Appeals.
    Represent veterans at VA hearings.
    Obtain veteran birth, marriage, divorce and death certificates
      nationwide.
    Assist with burial
    Provide notary.
    Assist indigents.
    Maintain DD214s.
    Refer individuals not qualified for VA benefits to other agencies.
    Legal name change.
    Review active service record.
    Assist active medical boards.
    Hawaii Veterans Newsletter.
    Hawaii Veterans Roster.
    Hawaii Veterans Website.
    Governor's Liaison to veterans.
    Legislative Advocate for veterans--State and Federal.
    Yukio Okutsu Hilo Veterans Home--development and oversight.
    State Veterans cemeteries statewide--grants and expansion.
    Grant-in-Aid for all veteran related items--veterans' cemeteries,
      Arizona Memorial, Aviation Museum, Veterans Centers
      statewide, etc.
    Tri-annual report for State Monuments.
    Coordinate veterans organizations to clean the Korean and
      Vietnam Memorials on Capitol grounds.
    Coordinate Memorial and Veterans Day ceremonies annually
      at Hawaii State Veterans Cemetery.
    Assist with Memorial and Veterans Day ceremonies at National
      Cemetery of the Pacific (Punchbowl).
    Coordinate leis for veterans cemeteries on Memorial Day.
    Staff the Advisory Board on Veterans Services.
    Hawaii Veterans Memorial Fund.
    Maintain presence on neighbor islands.
    Validate Military Service for Employee Retirement System.

    The Audience. (Applause.)
    Senator Akaka. Thank you, Mark Moses.
    I want to thank this panel. I want this panel to know that 
I do have questions for you. But, in the interests of time, I 
am going to submit the questions for the record. But I want to 
express my appreciation for your testimonies.
    To conclude, I thank all of our witnesses for their 
participation today. We heard about what VA is doing well and 
about what needs improvement. The Committee will continue its 
oversight of VA to ensure that all veterans have access to 
health care and benefits.
    Following the end of this hearing, we will take a 5-minute 
break, and then commence what we are calling the public comment 
session. John Yoshimura, one of my staff, will provide further 
information and instructions for participation in this session. 
So those of you who are interested in this session, please 
remain here.
    And again, this has been a great hearing. It has taken 
time, but we have heard from all these witnesses, which will 
really help this Committee to work on improving care and 
benefits for veterans throughout the country and in Hawaii. And 
with that, I want to say aloha and this hearing is now 
adjourned.
    [Whereupon at 12:05 p.m., the Committee was adjourned.]
                            A P P E N D I X

                                ------                                

              Prepared Statement of WW II Fil-Am Veterans

    Good morning to everyone, to our Comrades and fellow veterans, and 
to our very own Senator Daniel K. Akaka. Aloha.
    On this great opportunity, the Officers, Board of Directors and 
Members of the WWII Fil-Am Veterans and Ladies Auxiliary, Hawaii 
Chapter, extend our esteemed gratitude and sincere thank you to Senator 
Daniel K. Akaka, as Chairman of the U.S. Senate Veterans' Affairs 
Committee and to all Members of the same committee for approving on 
June 27, 2007, legislation of the Filipino Veterans Equity Bill S. 
1315.
    Likewise, we extend our thanks to U.S. Senator Daniel K. Inouye for 
consistently introduced the Filipino Veterans Equity bill since 1992 
that will restore full veterans status and benefits to the WW II 
Filipino veterans who were drafted into the U.S. Armed Forces and 
bravely fought alongside the American troops under the American flag in 
defense of freedom and democracy.
    We understand that the bill S. 1315 passed by the U.S. Senate VA 
Committee will soon, sometime in September 2007, be moved to the full 
Senate floor, which we consider a major step toward realizing 
legislation of the Filipino Veterans Equity bill S. 1315 after 15 years 
since 1992.
    While the Family Reunification bill is on hold, we propose an 
alternative amendment to the bill H.R. 2642, the Military Construction 
Veterans Affairs Budget bill approved to full Senate to incorporate as 
RIDER for the Family Reunification Act of 2007 or an alternative RIDER 
to the Filipino Veterans Equity bill S. 1315 without prejudice to pass 
legislation of the mother bills.
    We strongly APPEAL in the intent of HUMANITARIAN reason next to our 
Constitutional rights the immediate need to pass legislation of S. 1315 
so that the remaining elderly veterans now in their 80's of age and 
over can enjoy at least their equity benefits and pension during the 
rest of their twilight years.
    Mahalo. God Bless Us All.
                                 ______
                                 
Prepared Statement of Luz N. Caleda, President, Ladies Auxiliary of the 
                  WWII Fil-Am Veterans Hawaii Chapter

    Good morning everyone, to our very own Senator Daniel K. Akaka. 
Aloha.
    My name is Luz N. Caleda. I am the President of the Ladies 
Auxiliary of the WWII Fil-Am Veterans Hawaii Chapter with fifty six 
members--all wives of the veterans residing in Hawaii. We were 
organized to support and assist the veterans in carrying out their 
plans and programs including other related activities and functions.
    On behalf of the Officers and Members of the Ladies Auxiliary, I 
extend our deepest gratitude and sincere thanks to U.S. Senator Daniel 
K. Akaka and to all the Senate VA Committee Members for approving on 
June 27, 2007 the legislation of the Filipino Veterans Equity Bill. On 
April 11, 2007, I joined my husband, Art Caleda, who gave his testimony 
during the Senate VA Committee hearing chaired by our beloved Senator 
Daniel K. Akaka in Washington, DC.
    We, the Ladies Auxiliary, all shared the 65 long years of injustice 
suffering of our husband veterans in their fight for their equity 
pension and other benefits rightfully deserved by them. We suffered 
long enough. Many veterans already passed away and a number of wives 
also passed away out of their frustrations. Believe it or not, we live 
below the American living standard depending only on the SSI and Food 
Stamps from the government. Think about it, some veterans frequent to 
Food Banks to pick up free food stuffs and clothing. Some resort to 
picking up empty soda cans and empty bottles and sell them to any 
recycling outlets just to augment their meager SSI money.
    We have been separated from our children and family when we came to 
Hawaii with our husband-veterans. We cannot afford to go home to the 
Philippines to visit our family and children once in a while because of 
financial problem. We are now quite old, weak, and sickly and a number 
are bedridden at home or in the hospitals. In many instances, when a 
veteran dies, none of the children from the Philippines can come to see 
or witness the burial or funeral. The bereaved family, on several 
occasions, appeals for voluntary contributions from friends and mostly 
from the veterans and Ladies Auxiliary members to help defray the 
funeral and burial expenses of the deceased veteran.
    We appeal and I urge all U.S. Senators to support legislation of 
our very own U.S. Senator Daniel K. Akaka's bill, S. 1315, the Filipino 
Veterans Equity Act of 2007, the much awaited Equity pension and 
benefit for the Filipino veterans, who sacrificed their lives fighting 
alongside with the American troops in defense of freedom and democracy; 
and to include the family Reunification Act of 2007 which we urgently 
need at this point in time.
    Mahalo and God Bless.
                                 ______
                                 
                Prepared Statement of Charles L. Clark, 
                President, Radiated Veterans of America

    Chairman Akaka and Distinguished Panel Members:
    My name is Charles L. Clark. I am a resident of Kailua.
    I am a U.S. Navy Veteran of World War II and the Korean conflict. I 
served in the Pacific and was one of the first Americans, not counting 
on-site Prisoners of War, to enter Nagasaki after the August 9, 1945 
atomic bombing.
    I am currently the President of Radiated Veterans of America, the 
only Internal Revenue Service recognized 501(c)(19) Veterans Service 
Organization representing statutory war veterans exposed to ionizing 
radiation during service to this Nation.
    The United States, by and large, has treated Radiated Veterans 
poorly. While laws have been passed, regulations created, and huge sums 
of money have been spent addressing ionizing radiation, precious few 
Veterans have been recognized, medically cared for, or compensated for 
their losses.
    This is, I believe, because there has been little continuity in 
addressing the issues faced by Radiated Veterans. For example, Congress 
has passed laws defining and addressing ``Atomic Veterans'' being those 
potentially exposed to radiation during atmospheric, and a limited 
number of underground ``tests'', and POWs and occupying troops at 
Hiroshima and Nagasaki. Yet, the Veterans' Administration's Advisory 
Committee on Environmental Hazards, in 1993, noted 11 categories of 
Veterans, in addition to those statutorily listed as ``Atomic 
Veterans'' who could have been exposed to ionizing radiation as a 
result of their service.
    Radiation is radiation, and the system, rather than treating all 
Radiated Veterans equally demonstrably discriminates between Veterans 
who have been exposed to ionizing radiation.
    This is true even within the statutory ``Atomic Veteran'' 
classification where there is discrimination between those with so-
called ``presumptive'' cancers and ``non-presumptive'' diseases 
recognized in the medical community as radiogenic in origin, for 
purposes of compensation.
    The non-presumptive diseases require the Veteran, or his/her 
survivor to be subject to a Dose Reconstruction, admitted by government 
as ``uncertain'', and expensive, before any compensation is awarded. . 
. and much more often than not, the claim is denied.
    Dose Reconstruction is flawed, yet it is kept alive by an unholy 
alliance between the Veterans' Administration, the Defense Threat 
Reduction Agency of the Department of Defense and its private 
contractor, SAIC.
    Even some members of the congressionally mandated Veterans Advisory 
Board on Dose Reconstruction advocate that all ``Atomic Veterans'' be 
treated as a Special Cohort.
    I strongly suggest this Special Cohort classification be adopted to 
law and expanded to include all Veterans whose military duties put them 
at risk from ionizing radiation, including the 11 classification 
recognized by the VA study group in 1993.
    Further, I strongly urge that the Dose Reconstruction program, 
which is fatally flawed, because the history of dose readings is itself 
flawed, be scrapped. Too much time, and too much precious capital, has 
been spent on this program.
    The shortcomings of Dose Reconstruction, primarily based on 
theoretical statistics, and in too few instances actual recorded 
radiation readings, were recognized by the 2003 report issued by the 
National Research Council. The report was titled ``A Review of the Dose 
Reconstruction Program of the Defense Threat Reduction Agency''.
    Further, I urge Congress to give more deference to the medical 
community and less to the physical scientists, in recognizing the human 
damage caused by ionizing radiation, which impacts not only those 
subject to radiation, but even unto progeny affected by genetic changes 
that occurred when a Veteran was exposed.
    Also, I urge Congress to merge the various programs directed at 
Veterans and Civilians such as ``Downwinders'', Uranium Miners, and 
Defense Workers, so that the Nation can properly address the scourge 
brought about by the uncontrolled introduction of atomic energy, and 
the human experiments conducted to satisfy curiosities.
    As an Atomic Veteran, who was damaged by residual radiation 
following the bombing of Nagasaki (I have, for example, had 160 skin 
cancers removed from my face and neck, and have other maladies the 
medical community attributes to ionizing radiation) I can ask no less 
of Congress, our elected representatives, for fellow Veterans and all 
Humankind.
    I understand your time to listen today is short, and that you have 
many issues before you. I will, however be glad to respond, either 
verbally, or to any questions you may have, either now, or as follow-
up, in writing if necessary .
    The Internet Web Site for Radiated Veterans of America is 
www.radvets.org. That site, which is continually updated, brings 
together, in much more detail, much of what I have brought forth today.
    Thank you for your time and attention.


           FIELD HEARING ON HEALTH CARE FOR VETERANS ON MAUI

                              ----------                              


                       THURSDAY, AUGUST 23, 2007

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:30 a.m., in 
Maui County Council Chambers, Wailuku, Maui, Hawaii, Hon. 
Daniel K. Akaka, Chairman of the Committee, presiding.

   OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, U.S. 
                      SENATOR FROM HAWAII

    Senator Akaka. Aloha.
    The Audience Members. Aloha.
    Senator Akaka. I'll just start by making some preliminary 
statements. And I want to say mahalo nui loa to all of you for 
coming. I wanted to thank the Maui Counsel for giving us access 
to this room. As you know, this is the counsel chambers. And 
they've offered it to us for this hearing today. And I'm 
extremely grateful to the counsel for that and to the people of 
Maui for this as well. And to see all of you here is very 
heartening for me. Because we want to hear from you and to see 
what we can do to improve what the Department of Veterans 
Affairs has been doing for our veterans.
    And to begin with, I would like to ask Danny Kanahele to 
lead us in the pledge and Rogelio Evangelista to lead us in 
prayer. So at this moment, I ask all of you to please rise.
    [Pledge of Allegiance and Prayer.]
    Thank you very much. Danny Kanahele.
    Mr. Kanahele. Sir.
    [Pledge to Allegiance and Prayer.]
    Senator Akaka. Aloha. I want to welcome all of you to 
today's hearing. And this hearing will come to order.
    This is the second hearing held by the Senate Committee on 
Veterans' Affairs. The second of three hearings that I am 
chairing here in the State of Hawaii this week and next week. 
We held similar hearings at the start of 2006. Much has 
improved since that time, for which I'm very, very grateful. It 
took lots of work, teamwork with the Administration as well, 
with the VSOs as well, and with Congress. But it is important 
for the Committee to understand the remaining challenges.
    Both the clinic and Vet Center on Maui are tremendously 
busy and must be available to all of Maui's veterans and to 
veterans living on Lanai and Molokai as well. It is my view 
that both the clinic and the Vet Center are understaffed, and 
we need some staff enhancements. This is something that I will 
be exploring today.
    I want to applaud the efforts of every VA employee on Maui. 
These men and women work hard to help veterans who seek their 
assistance. There are many things that VA does well in Hawaii. 
However, there is always room for improvement. I want to hear 
about how we can give VA the tools to make a difference in the 
lives of Hawaii's veterans.
    Back in Washington, we have worked hard to ensure that VA 
has the resources to provide the best possible care.
    The VA spending bill, which the Senate will take up early 
in September, includes $43 billion for VA, $3.6 billion more 
than was offered by the Administration. But we are looking 
forward to taking it up when we reconvene in Washington in 
September. We are finally on track for adequate funding for VA 
mental health care and for those veterans with Traumatic Brain 
Injuries.
    Today and over this week and next, I will examine health 
care and benefits in Hawaii. Given the State's unique features, 
VA must specifically tailor its strategies that are successful 
on the mainland, as they may not work as well here. And many of 
you know what I mean.
    It is vitally important that you share your thoughts with 
us so that we know how to help VA help you and the rest of 
Hawaii's veterans. VA officials are here to listen and to 
respond to the concerns raised by the witnesses on the first 
panel.
    Finally, I note that there are many veterans here today, 
and I'm happy to see all of you. And many veterans who would 
like to testify as well. While we cannot possibly accommodate 
everyone's request to speak, we do want to hear your views.
    The Committee is accepting testimony which will be reviewed 
and made part of the record of today's hearing. If you have 
brought written testimony with you, please give it to the 
Committee staff who are located in the back of the room. If you 
do not have written testimony but would like to submit 
something, Committee staff will also assist you in that.
    In addition, the Committee staff is joined by VA staff who 
can respond to questions, concerns and comments that you raise. 
And when I say VA staff, I mean those who are on the Federal 
level, as well as those who are on the State level here in 
Hawaii.
    Once again, mahalo nui loa to all of you who are in 
attendance today. And I look forward to hearing from today's 
witnesses.
    Because of the last minute changes in witness availability, 
we made a slight change in the hearing agenda. The first two 
panels of individual witnesses have been combined into a single 
panel. So we have them now in front of us. I want to welcome 
this first panel to today's hearing. And I want to thank you 
again, mahalo nui loa for your presence here and for your 
testimony.
    First, I welcome Rogelio Evangelista, President of the Maui 
Veterans Counsel. I also welcome Clarence Kamai, Jr., a member 
of the VA Advisory Counsel. I want to welcome Danny Kanahele, 
another member of the VA Advisory Counsel.
    I welcome Mitch Skaggerberg, President of Vietnam Veterans 
of Maui County.
    I welcome Karl Calleon. I understand that it is your la 
hanau; that is, your birthday. So I want to say hauoli la hanau 
to you at this time. I also welcome Carl Haupt, a Vietnam 
Veteran. Next, I welcome Grant Steward, a Veteran of Operation 
Iraqi Freedom. And finally, welcome William Stroud, a Vietnam 
Veteran.
    Again, I want to thank all of you for being here. Your full 
statements will be included in the record of the Committee. We 
would like to move this along as best we can. And because it is 
important to do that and to keep things moving, please keep 
your statement to no more than five minutes.
    Here in front of me is a time clock. And you will see a 
green light come on for 4 minutes. Then a yellow light to sum 
up the last minute. And then a read light to stop.
    So again, let me begin by asking Mr. Evangelista to begin 
with your testimony.

               STATEMENT OF ROGELIO EVANGELISTA, 
                PRESIDENT, MAUI VETERANS COUNCIL

    Mr. Evangelista. Mr. Chairman, Senator Daniel Akaka, and 
distinguished Members of the Senate Veterans' Affairs 
Committee, greetings to you and your staff. And to the veterans 
here today, thank you for giving me the opportunity to come 
before you and discuss VA health care here on Maui, home to 
about 100,000 veterans.
    To the excellent efforts the staff of the Maui CBOC and 
with the support of the (inaudible) and the Tripler Army 
Medical Center have been extraordinary, especially due to the 
unique nature of health care within the islands all divided by 
the Pacific Ocean.
    First of all, I would like to commend you and the Committee 
for all your personal sacrifices and helping us veterans deal 
with our everyday disabilities in our daily lives. All of you, 
along with the medical staff in Hawaii that made great strives 
in our support to overcome our hardship and disabilities.
    I was even given the opportunity to address the panel on 
January 10, 2006. And since then, there have been a lot of new 
changes. We have lost our primary care doctor to CBOC in the 
summer of 2006, and the position just got filled the beginning 
of summer of 2007 by Dr. Chin.
    As you know, the State of Hawaii is very unique in that 
each county is divided by the Pacific Ocean, not like the 
mainland where the veterans can drive to the clinics or 
hospitals with his or her family support. And with less than 30 
percent of service connected disability and the attending 
physician at the clinic set you up for an appointment for a 
condition that could be a plausible cause due to your 
disability, but part of you must provide your own 
transportation.
    And this happened ever since the millennium, regarding 
veteran's health care. To travel within the neighbor islands is 
so costly for veterans because most of us are living with 
limited income. And when we are referred to a VA doctor to see 
a private practitioner here on Maui, after two months, we 
receive a letter saying the visit was not authorized.
    This has happened to me a few times. And since it takes so 
long for VA to eventually get approval and pay the provider, it 
ends up to collection agency, which gives you an appropriated 
report. How many other veterans also have this problem?
    Second, there are a lot of veterans here on Maui with 
chronic health problems. And they just live with it from day-
to-day, hoping some day the problem will go away, which will be 
when they die.
    We have a primary care doctor and nurse practitioner that 
you can get an appointment with. But when you try to call to 
get an appointment that day, the appointments are usually full. 
We need to have another doctor here at the CBOC. I think we 
also need to access VA health care after-hours when the clinic 
is closed, especially on weekends, so that we don't have to 
deal the probability of our emergency bill not being paid, 
especially here on neighbor islands.
    On Oahu, they have Tripler Army Medical Center to go to for 
emergency. They can drive there on weekends. We can't. There's 
still so much red tape using VA as primary medical care, 
especially after the clinic closed. And there would be a nurse 
on-call or doctor on-call 24/7, to authorize emergency care 
after clinic hours and during clinic hours if the clinic can 
see you.
    Third, our aging veterans are now more in need of acute 
medical care. We need to provide them with 24/7 access to 
health care. World War II, Korean and Vietnam Veterans are in 
their 60's to past 80 years old, with some of them homebound. 
With a staff of homecare nurses that can visit them at home to 
provide some sort of respite care. Hopefully, there will be a 
care home for veterans in the very near future.
    There is also no contact with other veterans. Some of them 
can no longer drive and some of them are without family 
support. Some veterans are now only realizing their 
disabilities that might have been caused by military service. 
And when they apply, they are being asked for collaborating 
evidence on something that happened over 30 years ago.
    Why can't the Veterans' Administration get these records 
for them? There are a lot of veterans here on Maui and 
throughout the state and throughout our Nation that don't even 
know certain benefits that they may be qualified to apply for 
due to their physical and mental disabilities.
    Four, let me share with you my personal experiences with 
vocational rehab. At age 34, I was very fortunate to be 
accepted in the VA Chapter 31 rehab program to secure various 
computer certifications to pursue work as an electronic 
technician. Somehow, however, I ended up with a shoulder injury 
that ultimately led to me not being able to complete my 
employment plan and resulting in my total disability from being 
able to work.
    As a result over time, I found myself to be increasingly 
stuck at home dependent on others, depressed, frustrated, and 
feeling useless. When Dr. Richard McDonald, my rehab counselor, 
noticed my physical, psychological and social functioning was 
dangerously spiraling downward, he referred me for an 
independent living evaluation at my home.
    Since I was aware that the independent living program has 
already helped out so many other veterans through my long-
standing veteran advocacy, I agreed to undergo the evaluation. 
Through Mr. McDonald's counseling and the helped of plan 
development guideline, I began to see how I could use the 
computer knowledge and skills that I gained through my rehab 
training to help other veterans.
    He completed it and we have since initiated my independent 
living plan. Through this plan, I have received a riding lawn 
mower so I can once again take care of my lawn. I also received 
a laptop computer system so I can assist other veterans with 
updating and operating their computers. It will also enable me 
to help set up a Veterans Helping Veterans in our communities. 
Veterans Helping Veterans is comprised of a growing number of 
veterans who have also been empowered, and their independent 
living plans are now helping others too disabled, too old, or 
too poor to help themselves.
    These veterans, like myself, are using their independent 
living equipment skills, interest and time to help these people 
by fixing their vehicles, repairing their homes, cleaning up 
their yards, or whatever needs doing.
    They're also fixing up their communities: school parks, 
benches, and so forth. In the process of being empowered to 
others, these veterans' lives are transforming from depression 
and isolation to lives of renewed purpose, family, social and 
community connection.
    One of the main reasons this program is so effective with 
these veterans on Maui, Molokai and Lanai, is because Dr. 
McDonald works closely with the Maui Community Based Outpatient 
Clinic staff: Dr. Kathleen McNamara, psychologist; Morey 
Springer, psychiatrist; Sue Yin Chin, primary physician; and 
our CBOC and veterans and support professionals throughout our 
community.
    It's disheartening to note, however, that this independent 
living program is not being utilized in this critically 
effective manner in many other regions in the Veterans' 
Administration. This is why I asked Dr. McDonald to provide 
more information on the independent living program.
    The veterans now can be more independent through this 
program to include full lives within their family and 
communities.
    Members of the Senate Veterans' Committee, we applaud you, 
all that you do to help us veterans live better and fruitful 
lives. Through this goal, we all ask that you do what you can 
to improve both increased support for the use of this 
independent living program, along with the increased medical 
services for our most severely disabled veterans in Hawaii and 
throughout our United Nation.
    May God bless America's people and you, the Members of the 
Senate Veterans' Affairs Committee, the Armed Forces, the 
Veterans and their families. Thank you and aloha. I think I 
went over the red light.
    Senator Akaka. Thank you very much, Rogelio. And now we'll 
hear from Clarence Kamai.

               STATEMENT OF CLARENCE KAMAI, JR., 
                  MEMBER, VA ADVISORY COUNCIL

    Mr. Kamai. Good morning, Mr. Senator, staff of Veterans' 
Affairs, staff of Veterans' Administration, Maui CBOC staff. 
Hello veterans, male and female.
    I concur with what Mr. Roger Evangelista had to say 
regarding our health care. It is important. It is needed.
    We all know that. We all know that some of us have been 
getting these bills from the collection agencies because of 
nonpayment from times we've been in the hospital. So I do 
concur with Mr. Evangelista.
    I would also like to point out that maybe we could get back 
into the system of fee basis. Get back into the fee basis 
system where I think it would be easier for the staff and the 
VA. Because what's happening now, as an example, I use myself. 
Should my wheelchair break down, I have to call Maui CBOC, get 
permission from the doctor. Now, there's a problem because it's 
hard to get in touch with the doctor and sometimes it's hard to 
get through the lines.
    So what you have to do is follow the prompts and then just 
leave your message and hope they'll call back. They do. Whether 
it's the same day, the next day, it does not matter. But as 
long as they call back. Now, I need my wheelchair fixed. This 
is my mode of transportation. Now I'm down stuck in the water 
until someone calls me back from Maui CBOC to let them now what 
my situation is. Then there are three to four steps that will 
follow after that.
    First step would be for them to call a service provider. 
The next step would be for Maui CBOC to get hold of a doctor to 
get permission. And sometimes I have to get involved to call 
Honolulu to see if prosthetics--and who knows what's happening 
and what can happen before me.
    The next step is about a week later, everything comes to a 
head to say, yes, we're going to do this, yes, we're going to 
do that. The last step is with the service provider. They will 
give you an appointment. I need a wheelchair, you know, as soon 
as possible, please. However, I won't get the service until a 
week or maybe two weeks later.
    So I'm saying that if we go with this simple fee basis and 
we'll get the allocation of funds from our senators, then it 
can be done. And this would solve a problem of too many 
veterans going to the VA. This would really lessen the load, I 
believe. It would take a lot of pressure off the Maui clinic 
staff and doctors, and would enable them more time to serve 
other veterans.
    This is only one of many, Senator, that I would like to 
speak about. And I shall let my constituents go ahead. Thank 
you very much.
    Senator Akaka. Mahalo. Thank you very much. I notice there 
are some folks standing in the back and on the sides. I see 
some seats that are empty. So feel free to please move and sit 
down. Find a seat there and be comfortable.
    At this time, I'd like to call on Danny Kanahele for his 
testimony. Danny.

                 STATEMENT OF DANNY KANAHELE, 
                  MEMBER, VA ADVISORY COUNCIL

    Mr. Kanahele. Good morning. Thank you Mr. Chairman, staff 
of Maui CBOC, Tripler Hospital, Dr. Hastings. Thanks for being 
here. Mine is real simple.
    Well, actually, what I do is public relation. Go out on the 
street talk to people, see what's going on. The most important 
thing I run across is the disability and the percentage that 
people have. The 100 percenters, not bad.
    Sometimes they get hard time, but not bad. But when you're 
under 50 percent, you've got a real problem. You're either 
going to be dead or you are mot going to make it. People call. 
All they get is wait, I'll get to you. And they call back.
    I see this done many times. I talk to friends. I run across 
people. They say they are going to call me back.
    Why did you not call me back? What is your percent? 30. 
What's your percent? 50. It seems like anybody under 50 
percent, they aren't going any place. I'd like to know who 
checks on these guys that have been there for like 20 years; I 
know two guys 20 years ago. Today, they are 50 percent. Who 
checks on these guys to find out if they're getting any better?
    They should get a note about they are not getting better. 
There's a problem over there. And for myself, well, lucky for 
me, I can take pain. But as long as you don't take too long, I 
can be all right. So I hope somebody check on these guys way 
behind in our percentage and check on why they are not moving 
their percentage up to the par that they should have. I believe 
something should be done about it. I think today would be a 
good time.
    Well, that's all I have for today.
    Thank you very much, Committee, I appreciate it. Thank you.
    Senator Akaka. Thank you very much Danny Kanahele.
    And now we'll hear from Mitch Skaggerberg. Mitch.

                STATEMENT OF MITCH SKAGGERBERG, 
           PRESIDENT, VIETNAM VETERANS OF MAUI COUNTY

    Mr. Skaggerberg. Senator Akaka, good to have you here.
    I am proud of the service you and your fellow Senator 
Daniel Inouye have done for the veterans over the last 20 years 
here. Twenty years ago, we didn't have any health care clinic 
in Maui. And now we have a good health care clinic. And thank 
you for this meeting so that we can even handle some of the big 
problems that you're going to hear today.
    I'd like to thank you for coming to our aid when we called 
you in March with the problem that we all faced here, our 
staff, our veterans, we lost both of our doctors and there were 
no doctors in site. And I can't tell you how much it means to 
us in what you did personally to make sure that we wouldn't sit 
another year without doctors. Bless you. Thank you.
    With that said, my main focus today is on long-term health 
care. The veterans that formed a committee--Roger, how long has 
it been now--to look into a long-term care facility here on 
Maui. The need for this long-term care is evident in that 70 
percent--we figure 70 percent of all the veterans that go into 
the VA clinic are 60 years or older. 60 years or older, 70 
percent. That's a staggering figure.
    Now, what does that mean for long-term care? Well, the 
urgent need for long-term care is already here. Kathy Haas is 
one of the committee members, as well as Michael Covich, Bill 
Staton, Roger Evangelista, and me.
    Did I miss anybody?
    We're proposing, Senator, like we did on the Big Island and 
like we did on Oahu, that we start planning and generating the 
funds necessary to build a 60-bed, long-term care facility 
here. I've talked to Kathy Haas and some of the other medical 
providers here in the VA Clinic.
    They said that currently, they are handling anywhere from 
20 to 35 VA disabled veterans who need long-term care in one 
form or another. Either hospice care, respite care, where the 
families are handling the job, but it's so overwhelming, that 
they need rest. And they need a place to put our fellow 
veterans for maybe a month or whatever it takes.
    We have quite a few veterans with dementia now. And then, 
of course, we have ambulatory care.
    The way we handle that now is, I've seen it personally with 
two of our close veterans, we put them in the hospital for two 
months at Maui Memorial. They induce a coma for five or six 
weeks to see if they can heal because there's no room on this 
island right now for any long-term care facilities.
    The one, Hale Makua, has a problem getting staff, Senator, 
that their beds are empty right now. They can't even take the 
veterans over there if we wanted to because there are no 
qualified nurses right now to handle patients.
    So I'm suggesting that on behalf of all the veterans and on 
behalf of the VA medical staff, we begin to plan and implement 
and construct a long-term care facility here. Not only for 
Maui, but for Lanai and Molokai, knowing eventually there may 
be new technology that allows those veterans from those two 
islands to have home care at some point, long-term care.
    But until that happens, at least they have an alternative 
there on Oahu. The center for aging in Oahu, as you know, is 
overbooked. Hilo's a long way to travel for those two veterans 
and their families from those two islands. So we have started 
studying possibilities of site locations. We have joined with 
another group called a ``Maui Long-Term Partnership.''
    We're looking at innovative ways of creating this, such as 
integrating this long-term care facility for the veterans into 
an overall community. A new community that is on the drawing 
board where we would have transitional housing, i.e., a veteran 
could move into one type of housing where he has, let's say, 50 
percent disability, and needs adult care and some long-term 
nursing care. And if he's not cured, then he can move into the 
long-term care facility.
    There could also be a branch of Kaunoa Senior Center. We'd 
put a center in there so that they can try to keep many of us 
more active and engaged. That would help us with our health and 
perhaps delay the time where we had to go into the long-term 
care facility.
    So these are some of the things that our committee is 
looking at. And we would be glad to work with you, Senator, and 
the Veterans' Affairs Committee or anybody on your staff in 
Honolulu to pursue this. We think the time is now.
    So that concludes that.
    The other thing I want to say is about the fee basis. You 
were instrumental in arranging a meeting with Dr. Hastings and 
Dr. Wiebe in Maui. I think that was in April. And one of the 
things they had as a proposal was the same thing that Danny and 
Clarence Kamai, Jr., said that we want to strengthen the fee 
basis program here. Those were their words (Dr. Wiebe and Dr. 
Hastings). So we have their support. At least, that's what they 
told us.
    I agree that anybody with 100 percent or 80 percent 
disability rating, we usually get what we need in a timely 
manner. But the veterans with 50 percent or lower, have a very 
tough time. I think one of the bottlenecks for that is VA has a 
department in Honolulu called the ``utilization board.'' I 
think that all fee basis requests come from our doctor now, Dr. 
Chin.
    I believe request go through the ``utilization board.'' 
Then, staff in Honolulu takes sometime to process them because 
they're overwhelmed with requests from the other islands; then 
they've got to get back to us. Then they have budgetary 
requirements. It seems to be a big bottleneck right now.
    I know our new doctor is not familiar with this process. I 
think she was in private practice. So I'm sure she's going to 
say, well, gee, I'm the doctor, I know what's best. If we have 
to wait three, four, five weeks for somebody in Honolulu--do 
you understand what I'm saying, Senator?
    Senator Akaka. Yes.
    Mr. Skaggerberg. So that might be a key ,fee basis 24/7, to 
have Dr. Wiebe and Dr. Hastings and all our needs met, in 
looking where the bottlenecks are and expediting the process.
    The third item I wanted to bring up is your Internet chat. 
I'd never done an Internet chat. I said I'd never do an 
Internet chat until you had one, Senator. I remember I asked 
you for some help because we really need some help for Dr. 
Springer and Dr. McNamara. You said, ``Mitch, I have good news 
for you. We're getting a psychologist at the Vet Center.'' 
Well, thank you, Daniel. We've been interviewing for quite a 
while. I understand our team leader has just found somebody 
that he really likes. But again, we're concerned about the 
length of time that it might take.
    So, Senator, if you can just let same VA management people 
know, it's not business as usual here. We have critical needs 
and, you know, things can take forever sometimes. If Tom wants 
to come here, he's been highly sought after by other people. I 
think we need to expedite that process so he can be onboard 
here in the next month or two.
    Senator Akaka. I want to thank you very much, Mitch, for 
all of this and for the gratitude you expressed.
    I want to tell you, it's not only me. I mean, this is 
teamwork. The VA people have been helpful in bringing this 
about as well. But I really appreciate hearing from you.
    Mr. Skaggerberg. Thank you.
    Senator Akaka. Thank you.
    Mr. Skaggerberg. Mahalo nui loa.
    Senator Akaka. Thank you, Mitch.
    Now we'll here from Carl Haupt for your testimony.

       STATEMENT OF PRENTISS CARL HAUPT, VIETNAM VETERAN

    Mr. Haupt. Thank you, Senator Akaka, for convening this 
session. We are proud of our VA facility and staff here on 
Maui, and grateful for your swift action when our clinic had no 
doctors, and for the arrangements made for the veterans health 
care on Lanai. We appreciate this opportunity to testify about 
health care for veterans here on Maui.
    I'd like to talk a little bit about Hawaii State Office of 
Veterans Services. The State Office of Veterans Services, as 
our testimony in front of you shows, now has a staff of ten 
statewide allowed. We now have eight people.
    We feel we need 12. Oahu has three counselors and one 
clerical staff, with 2,275 people visiting last year. We have 
2,288 people visiting--over 13 more than Oahu--with one 
clerical staff and one counselor position, which is not filled 
yet.
    What we're saying now is, the state has 10 people allowed. 
We now have 8. We feel we need 12. The Maui Office of Veterans 
Services is a vital part of the infrastructure supporting Maui 
that is in danger of being overwhelmed. The demand for their 
services, like the Veterans' Administration, will only increase 
after our soldiers come home from fighting in conflicts for far 
too long.
    We have two people now that are available for this position 
that we feel are being--well, we don't know what to say--not 
hired. Terry Garcia has been with the office for more than 10 
years. She has an associate's degree.
    The education requirement for the position is graduation 
from an accredited college or university. Well, she has that. 
She has 10 years experience. (Inaudible) machine gun in 
Vietnam. Do I really want to go out with a gunnery sergeant who 
has 10 years experience, or the new guy who has no experience? 
Why don't we hire Terry for this position. It needs to get paid 
right now, and get someone in there. Instead of Cass Russell 
coming over one day a week. We really need Cass's support and 
we appreciate all that he does and the time he spent traveling 
to come to Maui. But we need someone in the office right now, 
somebody hired in the very near future to take over the 
position which is now not being filled.
    We have someone in there right now who can fill the 
position, who has the experience, who actually has 15 years 
experience, not 10 years experience. We really feel that 
Terry's health is also being affected because of stress at 
work. Her office handles more patients than the Oahu office 
which has four staff. We handle it with just one staff right 
now. Totally unfair. Totally underpaid position. Totally 
stressed out position.
    This Office we feel, as a veterans community, we feel very 
disenchanted and unable to get just about anything done 
regarding the health measures that this Office puts out for our 
veterans. We feel with an old hippie, antiwar protester, 
antiveteran, by her political agenda and climate against 
veterans, our Governor makes a bureaucratic nightmare for the 
veterans to get their earned rights. So basically, that's what 
I have to say about that issue.
    One other issue I'd like to talk about is the DAV Van. The 
DAV Van is not equipped for handicaps. We do not have the 
support staff needed to drive patients either to Hana or to the 
other side. With the traffic and everything, we actually need 
someone in that van from 6 in the morning to 6 at night.
    We wondered if there are any grants or scholarships 
available, anything to help maybe fund this situation via MEO, 
or whatever, to get what's needed 12 hours a day, to get the 
people back and forth in all the tremendous traffic jams we 
have on Maui so they can have their health care needs taken 
care of.
    [The prepared statement of Mr. Haupt and Mr. Skaggerberg 
follows:]
  Prepared Statement of Prentiss Carl Haupt and Mitch Skaggerberg, on 
             Behalf of the Vietnam Veterans of Maui County

    Dear Chairman and Members of the Committee:
    Thank you, Senator Akaka, for convening this session. We are proud 
of our VA facilities and staff on Maui, and grateful for your swift 
action when our clinic had no doctors, and arrangements were made for 
the veterans' health care on Lanai. We appreciate this opportunity to 
testify today about health care for veterans on Maui.

                  VA COMMUNITY BASED OUTPATIENT CLINIC

    When Senator Inouye dedicated the Maui CBOC, he said this clinic 
will be our model clinic for the Nation. Is our clinic still fulfilling 
Senator Inouye's and Senator Akaka's vision? I don't think so. Two 
issues, about quality of care have come to our attention. The first is 
equipment and the second is staffing.
    We are now losing our ophthalmologist because he is not provided 
with even the most basic equipment to do his job. Where is the retina 
machine Dr. Hastings said was in the warehouse back in March?
    A VA cardiologist comes to Maui for examinations. He doesn't have 
proper equipment at the clinic. Why are we wasting his time and our 
money?
    Why does our clinical staff continue to have to work evenings and 
Saturdays, with no extra pay, just to get caught up on their paperwork? 
The Washington Post brought attention to the problems with records 
transfer between the Department of Defense and the Veterans' 
Administration but VA staff in Hawaii have been coping with it ever 
since the cooperative agreement with Tripler was signed, even before 9/
11. It is contributing heavily to staff burnout and turnover.
    There are approximately 600 people on the CBOC waiting list who are 
not yet able to get VA care. These people are paying as much as $600-
$800 per month for their maintenance prescriptions; their VA copayment 
would be about $35. Many of these veterans are our oldest and most 
distinguished World War II and Korean veterans.
    According to a 2004 study sponsored by the VA Health Services 
Research and Development Service, ``. . . about one in seven VA 
pharmacy outpatients fit a definition of having only a small number of 
outpatient visits annually with a relatively large pharmacy cost. This 
number was 10 percent of VA patients. The budget impact of this 10 
percent was only about 1 percent of medical care appropriations.'' \1\
---------------------------------------------------------------------------
    \1\ Zhu, Gardner and Hendricks, ``Just How Many Enrollees Come to 
VA Just for Pharmacy? '' HCFE Data Brief #2004-10, p. 2, VA Boston 
Health Care System Research and Development, Health Care Financing and 
Economics, funded by HSR&D SDR 97-001-01.
---------------------------------------------------------------------------
    Many people seem to forget that because of these great men who 
fought in World War II, Korea and many other conflicts, we have the 
greatest democracy right now. What can be done right now to alleviate 
this terrible financial burden on our oldest, most distinguished 
heroes?
    When will we get the necessary staff and equipment to properly 
fulfill the Maui clinic's promise?
    We have heard enough off-the-record comments about the quality of 
care in Hawaii to believe that outside Congressional-level 
investigators should interview past and present VA clinicians to get an 
accurate picture of our veterans' care.

                               VET CENTER

    We need the psychologist we've been promised. So far, no luck on 
filling this gravely needed position. What can be done about incentives 
to get the proper staff? We hear the same concerns about money from all 
the applicants. Even with the 25 percent COLA, our housing, food and 
gasoline are among the highest priced in the Nation, discouraging many 
applicants who see themselves going financially backward if they come 
to Maui.

                HAWAII STATE OFFICE OF VETERANS SERVICES

    The Office of Veterans Services, although it belongs to the State 
of Hawaii and not the Federal Government, has long been instrumental in 
helping our veterans receive the benefits and care to which they are 
entitled. The Maui office no longer has a councilor and is being 
covered one day a week by someone from Oahu.
    As of June 30, 2007 the State councilors' offices had the following 
number of office visits with the following level of staff:


------------------------------------------------------------------------
                                      Visits               Staff
------------------------------------------------------------------------
Oahu..........................  2,275............  3 councilors, 1
                                                    clerical.
Hawaii........................  2,202............  1 councilor, 1
                                                    clerical.
Kauai.........................  1,458............  1 councilor, 1
                                                    (unfilled) clerical.
Maui..........................  2,288............  1 councilor
                                                    (unfilled), 1
                                                    clerical.
------------------------------------------------------------------------


    Oahu has more telephone and outreach presentation contacts, which 
of course is due to the large active duty population on the island. The 
other islands have fewer active duty residents--in the case of Maui, 
almost none. Their councilors work intensively with their clients on a 
one-on-one basis, almost always on specific issues involving veteran's 
benefits or health care.
    With the departure of the Maui councilor, Mr. William Staton, and 
the beginning of the new fiscal year, the office needs a permanent 
full-time hire right away. We know 2 fine candidates now working full 
time at other jobs. One of them would probably fill the position but 
who would quit a permanent job for a temporary position?
    The Maui Office of Veterans Services is a vital part of the 
infrastructure supporting Maui veterans and is in danger of being 
overwhelmed. The demand for their services, like the Veterans' 
Administration's, will only increase as our soldiers come home after 
fighting in conflicts for far too long.
    We believe that Maui and the Big island each need 2 councilors and 
2 clerical staff-instead of a multi-year supply of grave liners for the 
state cemeteries. How do we get this changed and these very important 
community positions filled as soon as possible?

                                DAV VAN

    The VA needs to supplement volunteer staff to drive the van. Lack 
of staff has led to clinic transportation difficulties for handicapped 
and infirm veterans.
    Mr. Chairman, we believe the problems we've recently encountered on 
Maui are largely logistical and administrative, but magnified by cost 
and distance. As such, they are a barometer of VA health care 
efficiency in far flung, rural areas. Our clinicians are very 
dedicated, but the weather is stormy.
    Thank you for this opportunity to testify about veterans' health 
care in Maui on behalf of the Vietnam Veterans of Maui County. We also 
thank the Committee for its continuing support of the Nation's 
veterans.

    Senator Akaka. Is that your statement?
    Mr. Haupt. Yes, sir.
    Senator Akaka. Thank you. Thank you, Carl Haupt.
    Now, we'll here from Karl Calleon.

           STATEMENT OF KARL CALLEON, VIETNAM VETERAN

    Mr. Calleon. Good morning, Mr. Chairman and Members of the 
Committee. I'd like to thank you for the opportunity to testify 
today.
    I'll be talking about allowing private practice mental 
health doctors to assist the veterans.
    The VA office has become so thick that many vets are 
discouraged from getting the mental and physical health care 
they need. As a result, we have vets killing their families and 
themselves.
    It is a well-known fact that the VA does not have the 
sufficient mental health resource throughout the system. 
However, there are many qualified mental health providers who 
would love to do their patriotic duty and help injured vets. I 
don't understand why the VA would willingly outsource to 
medical doctors and dentists, but not to mental health 
specialists, who we need the most.
    The VA does outsource the C&P evaluations to assist the VA 
to process claims, but they do not outsource to private 
practice mental health specialist to assist the vets. They only 
outsource to assist the VA. It would be cost effective to 
outsource to private practice mental health specialist because 
they will only be paid on an as-needed basis. No extra money is 
needed to be spent on facilities or employee benefits, making 
this approach much more effective than maintaining the high 
cost of clinics with their administration and maintenance 
costs.
    Now we can only get help during regular office hours. 
However, most of our problems happen after office hours.
    The expensive clinic is useless two-thirds of the time, but 
the Government pays for it 24/7. I think most suicides occur on 
nonoffice hours when the mental help is not available. Lack of 
immediate attention has directly caused veterans suicides, like 
it did recently at Tripler.
    Maui has maintained a high-cost clinic. And much of the 
time, there isn't even a doctor there to treat the vets. Please 
remember, only the doctors provide life-saving treatment, not 
the facilities which cost the most.
    On Maui, after office hours and on weekends, we are told to 
call 911 and go to the hospital emergency room. This is very 
expensive and over triples the cost of our health care. And 
there is no continuity of care. Why can't we just go directly 
to a private doctor and not wait for clinic hours and face a 
long waiting period, or go to the ER at extra expense to the 
Government?
    Lastly, we'd like to thank you for your kind consideration 
and help you have provided us over the years. We are especially 
impressed at how you jumped in and worked and help us when we 
asked for help. You have a major role in resolving the problems 
we were having in the C&P process. We offer our heartfelt 
gratitude and appreciation.
    Senator Akaka. Well, thank you. Thank you very much. We 
really appreciate that. And now we'll here from Grant Steward. 
Grant.

                  STATEMENT OF GRANT STEWARD, 
                OPERATION IRAQI FREEDOM VETERAN

    Mr. Steward. Good morning. It is an honor to be allowed to 
speak here today. After returning from the Middle East, I've 
been to five different VAs. Although I generally feel 
completely lost when I go there, the staff is always 
professional and courteous.
    Having spent two and a half years going to VA, here are a 
few suggestions that may help veterans in the future. When VA 
realizes that a vet will require counseling, it may benefit the 
veteran if his or her family could get counselling as well, to 
let them know what their veteran is going through.
    An example would be, after a counseling appointment, the 
counselor could call the veteran's spouse or family and offer 
them some help. I find it difficult for myself to open up to 
what's going on in my head. And, unfortunately, my family is 
left in the dark.
    My wife is very understanding. I do feel guilty for not 
being able to communicate with her as much as I know I should. 
Having a counselor that could explain things to her would 
probably help bring some light to the situation.
    There's nothing like being woken up in the middle of the 
night with an elbow being jabbed into your side. According to 
my wife, my teeth grinding is keeping her awake. Her elbow is 
going to keep me awake. I don't have dental coverage because 
it's only allowed for veterans who have 100 percent disability. 
What I am having a difficult time understanding is, if I'm 
going to have two service-connected problems with my head, why 
can't VA take care of the whole head? So that is the whole 
thing right there.
    The following paragraph comes from a published study 
released March 2001, where 40 veterans with PTSD and 40 
veterans without PTSD had an oral examination to evaluate 
toothwear.

        Results showed significantly increased wear of tooth 
        services in the three dimensions near the gumline--
        vertical, horizontal and depth--in those with PTSD 
        compared to controls. Erosion vertically was more than 
        three times greater, horizontally more than four times 
        greater, and more than ten times greater in depth than 
        controls.

    The only reason I mentioned this is because, while I was in 
Iraq and even when I came back, I wake up constantly with pain 
in my jaw. And my dentist thinks it's from all this constant 
teeth grinding. And I've already lost several teeth since I've 
been back because of this. And VA can't do anything because of 
all the red tape. So that's why I mentioned that today.
    Lastly, I really hate missing appointments. This is a 
result of several calls to the VA to make sure of my 
appointment time, as I have a tendency to lose the paper I 
write the appointment on. If the VA had a way of e-mailing 
appointments or appointment cancellations, my memory loss 
wouldn't cause a lot of overworked VA staff.
    Thank you for your time. And I hope these suggestions 
benefit everyone who has served and sacrificed for our country. 
Thank you.
    [The prepared statement of Mr. Steward follows:]

  Prepared Statement of Grant Steward, Operation Iraqi Freedom Veteran

    Good Morning. My name is Grant Steward and I am a U.S. Army 
veteran. I feel honored to stand here before such prestigious 
individuals.
    Since returning from the Middle East, I've been to five different 
VA's. Although I generally feel completely lost when I go there, the 
staff is always professional and courteous. Of the five different 
centers, the Maui clinic, in my opinion, is the best. The doctors and 
staff all deserve a pat on the back for how attentive they are to their 
patients' well being.
    Having spent two and a half years going to the VA, here are a few 
suggestions that may help veterans in the future.
    When the VA realizes that a veteran will require counseling, it may 
benefit the veteran if their family could get counseling as well; if 
only to let them know what their veteran is going through.
    I find it difficult to open up with what's going on in my head, so 
unfortunately, my family can get left in the dark. My wife has been 
very understanding, and I do feel guilty for not being able to 
communicate with her as much as I know I should.
    Recently, I had to deal with a rather messy landlord/tenant issue. 
If the local VA had a list of lawyers who work with veterans, it would 
have helped with the stress by pointing me in the right direction. 
While in the Army, whenever a legal issue happened, JAG was full of 
wonderful answers. These days, I call my counselor and have him tell me 
to try not to stress out. Unfortunately, with a wife and 3 little 
children, not having electricity in your house can bring on lots of 
stress.
    There's nothing like being woken up with an elbow jabbing into your 
side. According to my loving wife, if my bruxism, teeth grinding, is 
going to keep her awake, her elbow will keep me awake. I even find 
myself clinching my teeth throughout the day. I don't have dental 
coverage, so my teeth get worse every month. I understand the VA 
wanting to cut costs, but when you have a service connection for two 
problems with your head, the VA should include care for the whole head.
    The following paragraph comes from a published study, released 
March, 2001, (University at Buffalo, Buffalo VA Medical Center) where 
40 veterans with PTSD and 40 patients without PTSD had an oral 
examination and evaluation of tooth wear.

        ``Results showed significantly increased wear of tooth surfaces 
        in three dimensions near the gum line--vertical, horizontal and 
        depth--in those with PTSD compared to controls. Erosion 
        vertically was more than three times greater, horizontally more 
        than four times greater and more than 10 times greater in depth 
        than controls.'' \1\

    \1\ http://www.buffalo.edu/news/fast-execute.cgi/article-
page.html?article=50630009.

    I hate the idea of missing an appointment. This usually results in 
several calls to the VA to make sure of my appointment times, as I have 
the tendency to lose the paper I write my appointments on. If the VA 
had a way of e-mailing appointments and appointment cancellations, my 
memory loss won't continue to result in an overworked VA staff.
    Thank you for your time and I hope these few suggestions benefit 
all those who have served and sacrificed for our country.

    Senator Akaka. Thank you very much, Grant. And now we'll 
hear from William Stroud.
    Mr. Stroud. Aloha.
    Senator Akaka. Thank you.

             STATEMENT OF WILLIAM FIELDING STROUD, 
        PAST PRESIDENT, VIETNAM VETERANS OF MAUI COUNTY

    Mr. Stroud. Thank you for inviting me here to speak on 
behalf of our veterans about health care system. Thanks mainly 
to a 10-year effort of the Vietnam Veterans of Maui County to 
obtain a clinic here on Maui for the veterans. There is now a 
small facility here which has guaranteed a certain level of 
stamp.
    Because this clinic handles the 11,000 veterans here in 
Maui County, it's crucial that minimum staffing level remain in 
place. Earlier this year, all of our doctors had quit from 
overwork and we were left without a staff. When I found this 
out, I immediately e-mailed you, Senator Akaka, and you took 
action by going to the VA director and presented him with this 
information, received a promise of getting one doctor fast, 
with another one coming up in a few months.
    Sir, I applaud you, not only for your words concerning the 
veterans, but of your willingness to take action. You are a 
warrior of the highest caliber for taking such good care of 
your men. In this case, the soldiers of our Nation.
    We now have a critical situation of immense proportion. Not 
only on Maui, but across our whole land.
    We have hundreds of thousands of citizen soldier veterans 
returning from combat and entering immediately back into what 
can be called their normal lives. But their lives are not 
longer normal. The reality of war can leave a person an 
internal wreck.
    One may look normal on the outside and try to fit in and do 
what is right. But believe me, if you've been in combat, you 
must agree with me that your internal world is forever changed 
from the experience. Some deal with it. And others fall apart.
    Now we hear statistics that 30 percent of the returning 
combat veterans are seeking PTSD treatment and care. We're 
talking hundreds of thousands of our men and women whom we sent 
over there, coupled with the hundreds of thousands of 
backlogged PTSD cases which we already had from Vietnam and 
earlier conflicts. We have to admit that the VA is overwhelmed, 
and very directly speaking, not up to the task. If it was, we 
wouldn't be in the situation we're in.
    VA medical care is among the best. This is not what 
concerns me personally. I am more concerned that these 
returning combat veterans get the PTSD care they need 
immediately so we do not leave these kids and their families 
hanging in the wind. But if the VA can't give them the care 
that they need, what can be done, one might ask.
    Well, I know from my personal experience that it really 
takes a combat vet to relate to another combat vet.
    For an intellectual person to address the subject of combat 
without the empathetic or analogical experience themselves is 
to make a mockery of the word treatment. Our veterans don't 
need simple therapy. They need lasting positive change, 
achieved through their experience not just words.
    I propose that such a program be funded to be run on Maui 
for these returning combat vets run by combat vets and 
professionals who have been in combat situations. And having 
returned, we're able to shed the negativity of their combat 
experience and learn from it.
    There is such a group here on Maui who can come together, 
administer and implement an effective two-month program to run 
combats through on a continual basis. There are such facilities 
right now which can be rented or purchased if we acted in a 
timely manner. These men and women returning from war need our 
help.
    Not dealing with PTSD issues is not an issue. With the Army 
having the highest suicide rate in 26 years, we definitely have 
a problem. If we fail to act now, we're looking at hundreds of 
billions of dollars in lifetime care in benefits. And more 
importantly, the utter failure of taking care of our sons and 
daughters, whom we voted to put in harm's way.
    Now, they say we are we going to pull out. Well, if the war 
ended tomorrow, we'd have a rush of people who needed treatment 
and care. Are we ready for this right now? I would say no. We 
must be ready and get ready for the realities of PTSD in a 
large way. And who better to deal with these imbalances other 
than combat vets who know the way out of this internal hell.
    Please give our returning combat vets the support they need 
and do not be afraid to try something new. We don't want to 
give these returning vets pills. We don't want to treat them on 
the cheap. We want to give them the experience and the tools 
they need to fight their internal war, coming out alive, 
healthy and being a force of good in our lives.
    The Maui Vietnam Veterans have proven their worth many 
times over, both in combat and in peace. We have supported both 
our country and our community. Our country once again needs 
help and we're here, willing and able to continue our service. 
Thank you.
    [The prepared statement of Mr. Stroud follows:]

    Prepared Statement of William Fielding Stroud, Past President, 
                    Vietnam Veterans of Maui County

    It has become public knowledge through the National News outlets 
what Vietnam Veterans and Veterans from other previous wars know from 
experience: The VA system for dealing with Veterans with PTSD issues is 
pretty much broken. Our VA professionals really do not know how to deal 
with these PTSD issues as 99 percent of them have never tasted combat 
themselves; they can provide pills but are pretty ineffectual/slow/
inexperienced in combating active PTSD issues. With a backlog of over 
250,000 cases even before the current mid-east crises' arose, and 100's 
of thousands more current Veterans seeking relief from their PTSD 
issues, our country is in a crises of unimaginable proportions.
    Older Veterans know, from experience, that if PTSD issues are not 
addressed early upon returning from a combat situation, these internal 
conflicts will continue to solidify into patterns of behavior which are 
destructive and can, and do, lead to a downward spiral of damaging 
personal behavior, many types of family conflicts, large numbers of 
homelessness and large numbers incarcerated in jails and prisons. And 
now that there are many women veterans, we are looking at new areas of 
concern for our society.
    This situation is unacceptable to us who have fought in combat in 
earlier theaters of operation. We cannot sit back and watch as our 
younger brothers and sisters go through the years of physical, 
emotional, mental and spiritual anguish which can be reduced and/or 
eliminated if approached by people of like experience who have gone 
through the process of re-integration themselves.
    This correspondence is to inform you that there is a credible team 
of peers, professionals and laymen living here on Maui consisting of 
many combat veterans who have gone through the process of ``discharging 
the negativity of the past'' and have the knowledge and expertise to 
take on these veterans with PTSD issues and teach them how no part of 
their life is so traumatic that they can't learn from it and become a 
more mature person; using their experience to become a more balanced 
person and not a conflicted one.
    There is a first-rate facility here on Maui which can easily handle 
a minimum of 75 PTSD claimants every 3-month cycle which can be 
obtained (if we act in a timely manner) to provide a place to run this 
professional operation; and the cost of putting one veteran through 
this 3-month program is infinitely small compared to a lifetime of 100 
percent disability payments. By running traumatized veterans through 
this program on a continual basis we can pretty much guarantee that our 
government (and thus our citizens) will save many Billions of Dollars 
in actual out-of-pocket expenses in taking care of these brave soldiers 
for the rest of their lives as well as the additional social costs of 
their resulting behavior. More importantly though is the fact that we 
will be helping these veterans turn their lives around after having 
undergone such traumatic experiences in such hostile environments; all 
at the request of our Country.
    We stand ready to act--Now! The PTSD issues being experienced are 
not so hard to deal with for people who have had similar experience and 
have made it out through to the other side. Please do not hesitate to 
act! Our only interest is in helping out our fellow combat veterans and 
their families; their wars continue on internally.

    Senator Akaka. Thank you, William. Thank you for your kind 
expressions as well, and for your testimony. I have a few 
questions here. Let me ask Rogelio Evangelista and Danny 
Kanahele.
    You both testified before this Committee in January of last 
year, when we held the first series of field hearings across 
the State. What has changed since then in terms of VA care? Has 
progress been made on improving access to care on Maui? 
Rogelio.
    Mr. Evangelista. Well, I notice there have been some 
progress being made. We ended up with more staff at the CBOC to 
take care of us. One thing that I'd also like to question is, 
at the last hearing, I think I mentioned that some of the staff 
there are not full-time VA staff, they're only contract 
workers. Is it possible to get them also to be on staff and not 
just contract workers?
    Senator Akaka. I will look into that. Danny?
    Mr. Kanahele. You had some pretty good improvements with 
health care. I really appreciate that because that was really 
needed. But I still think that the disability rating of the 
veterans has to be addressed. I'd like to know how they really 
go about it and how they rate these people to find out and make 
sure they get what they need. Because it's been a while. I know 
a lot--it's been a while and they have never moved yet. They're 
still there.
    Senator Akaka. Well, thank you for that. And, of course, 
what I'm reaching for is to find out what else is needed on 
Maui. Plenty of you have testified to that. So let me call on 
Carl Haupt.
    Mr. Haupt. When Senator Inouye dedicated the Maui CBOC, he 
said this clinic will be our model clinic for the Nation. Is 
our clinic still fulfilling Senator Inouye's and Senator 
Akaka's vision? I don't think so.
    Two issues about quality care have come to our attention. 
The first is equipment. The second is staffing. We are now 
losing our ophthalmologist because he is not provided with even 
the most basic equipment to do his job.
    The Audience Members. We can't hear you.
    Mr. Haupt. We are now losing our ophthalmologist because he 
is not provided with even the most basic equipment to do his 
job. I just went to see him the other day.
    His hand was out here and my eyes were over here. And I 
thought where is the retina machine Dr. Hastings said was in 
the warehouse back in March?
    A VA cardiologist comes for examinations on Maui. He 
doesn't have the proper equipment at the clinic. Why are we 
wasting his time and our money? Why does our clinical staff 
continue to have to work evenings and Saturdays with no extra 
pay just to get caught up with the paperwork?
    The Washington Post brought attention to the problems with 
records transfer between the Department of Defense and the 
Veterans' Administration, but the VA staff in Hawaii has been 
coping with it ever since the cooperative agreement with 
Tripler was signed, even before 9/11. It is contributing 
heavily to staff burnout and turnover.
    As of two months ago, there were approximately 600 people 
on the CBOC waiting list who were not able to get VA care. 
Kathy Haas told us the other day that this is not so anymore, 
that this list has been totally eliminated. We'd like to hear 
her testimony today to straighten this out.
    We can't believe that we have one doctor and one other 
doctor come onboard on the first of this month, and now all of 
a sudden, the 600 patients on waiting list are gone. That's 
unbelievable. But if they said they'd done it, I don't want to 
say anyone's a liar. I'd just like to hear the testimony on the 
record to say it was done and how it was done.
    These people are paying $600 to $800 a month for their 
maintenance prescriptions. Their VA copayment will be about 
$35. Many of these veterans are our oldest and most 
distinguished World War II and Korean Veterans.
    According to a 2004 study sponsored by the VA Health 
Services Research and Development Service, only about one in 
seven VA pharmacies fits the definition of having a small 
number of outpatient visits annually with a relatively large 
pharmaceutical cost. This number was 10 percent of the VA 
patients, only 10 percent. The budget impact of this 10 percent 
was only about 1 percent of the medical care appropriations.
    Many of these people seem to forget that because of these 
great men who fought in World War I and II and Korea, and many 
other conflicts, we have the greatest democracy in the world 
right now. What can be done right now to alleviate the terrible 
financial burden on our oldest most distinguished heroes? When 
will we get the necessary staff and equipment to properly 
fulfill the Maui clinic's promise?
    We have heard enough off-the-record comments about the 
quality of care in Hawaii to believe that outside 
Congressional-level investigators should interview past and 
present VA clinicians in order to get an accurate and better 
picture of our veterans' health care.
    We felt these people will tell us off-the-record this, 
that, and the other thing. But they will not say it to their 
bosses because they're afraid to lose their job.
    If you have an investigation, like we did before, and 
deposition from people to get the right answers to the right 
problems, I think a lot of these problems will be alleviated.
    Senator Akaka. Thank you. Let me ask a final question. And 
this is to all of you. What improvements do you believe could 
be made to VA health care on Maui and in the State of Hawaii 
overall?
    As you've said, you have had all these experiences as 
veterans and in dealing with the VA. And as I pointed out, 
we're looking for what I call challenges that we need to deal 
with to improve the services here on Maui. So let me give each 
one of you a chance to respond to what improvements do you 
believe could be made to VA health care on Maui and in the 
State of Hawaii overall.
    So let me begin with Rogelio.
    Mr. Evangelista. Well, Senator, like all other health plans 
in the State, I'm looking at 7/24 health care center to help 
the veterans. Because they suffer 7 days, 24 hours. I think 
that would, hopefully, be something that we could look forward 
to in the near future.
    Senator Akaka. Thank you. Clarence.
    Mr. Kamai. Again, Senator, I would have to agree with 
Roger. And I believe again that what Mr. Skaggerberg mentioned 
about the fee basis as being a problem solver for this island, 
and possibly for Kauai and the other outside islands. It would 
solve, I believe, a lot of the problems that is happening now.
    Senator Akaka. Mahalo. Danny.
    Mr. Kanahele. I agree with these two guys, I think we're 
all going to agree on the same subject. But I think--you've got 
that equipment in Tripler. I think if we have one here, we'd 
save a lot of money for our people traveling back and forth. If 
we can get some equipment here for us--we have Maui, Lanai, 
Molokai--that would save a lot of money from everybody flying 
that far. I think that would do it also, sir. Thank you.
    Senator Akaka. Mahalo. Mitch.
    Mr. Skaggerberg. The mental health professionals we have 
are some of the best in the country. But they're overwhelmed. 
And we (those of us with 100 percent PTSD, and have had 
numerous family problems) have to wait four or five weeks to 
have follow-up appointments. Much too long!
    As Roger and Danny said, a lot of our crisis comes during 
off-hours, weekends. All of a sudden, our family are exposed to 
us for three days and we're flashing back or we're about to do 
harmful things to our families. A lot of it is verbal abuse. 
But I think we need to look at how we are going to get a 24/7 
mental health care.
    We have hundreds and hundreds of disabled veterans with 
PTSD here on Maui and on Kauai and on the Big Island. I don't 
have answers. I mean, maybe we ``fee basis'' that too, to start 
with. I know we need at least four or five full-time mental 
health professionals right now. And I think we only have two. 
But we understand that another one at the Vet Center is 
thinking of accepting the job. But we need more than that, and 
we need it 24/7.
    Most of my episodes happen outside of clinic hours. And 
it's amazing how a lot of them happen on the weekends, for 
whatever reason. And we're sitting there for three days just to 
be able to call the clinic and say we need help.
    And then, of course, they want to help us, but they have 
other critical things going on at the same time. So I would say 
let's look at some ``fee basis.'' There are some outstanding 
psychiatrists on the island in private practice that I think we 
should look at as being able to handle that as well.
    Senator Akaka. Thank you. Thank you very much, Mitch. Carl.
    Mr. Haupt. I agree with Mitch about we need more mental 
health professionals.
    I'd also like to add that we need to offer them higher pay. 
Money paid to employees on Maui is the number one reason for 
lack of applicants. Even with 25 percent COLA, housing, food, 
gasoline, we run the highest price in the Nation, discouraging 
many applicants who see themselves going financially backward 
if they come to Maui. Thank you.
    Senator Akaka. Thank you. Karl Calleon.
    Mr. Calleon. Same with me. I agree with everybody with what 
they're stating. My testimony was about mental health problems. 
If you cannot get the doctors here at our facilities to help us 
out, why not attract the private practitioner and have them be, 
you know--like these guys said, on a fee basis. That was my 
main concern, too.
    Senator Akaka. Mahalo, Karl.
    Grant Steward.
    Mr. Steward. I think they all hit it right on the head. The 
24/7 care would be absolutely wonderful. Because life doesn't 
exist between 8 to 5 only, Monday through Friday.
    Mr. Skaggerberg. Can I interject something, Grant.
    My understanding of the dental health care policy here is 
that if you have a common injury or war injury, that even 
indirectly affects your teeth, there is some time that you 
should be able to get complete dental health care from the VA 
system.
    I can tell you a lot of our VA providers don't know this. 
So I would ask you and the Senator to really look into that. 
Because we have tremendous number of young soldiers coming back 
and being denied. And yet, I believe-- if the last time I read 
the regulations was if they can prove, you know. So to me, 
that's a no-brainer, that his teeth should be getting fixed.
    I'm sorry about that, Grant. I go crazy too sometimes. I 
want to help you, and you deserve that. I would ask that 
whoever is telling you that, ask them to look up the 
regulations and go to Dr. Hastings, if necessary.
    Mr. Kanahele. That's right.
    Senator Akaka. Grant.
    Mr. Steward. Every VA I've been to, I believe you have 6 
months of care or 3 months of care, after which--until you're 
100 percent. And I do believe it's one of the cost-saving 
measures they have. And I've asked them here again because I 
needed a dental guard. And they couldn't do it. So maybe if I 
got a certain ache, they might fix it.
    Senator Akaka. Thank you, Grant.
    William. Bill.
    Mr. Stroud. I've been using the clinic ever since it was 
established here. But one thing I realized early on is that it 
is small with only a few staff dealing with a lot of people. So 
every time I needed an appointment, whether it's dental or 
vision or dermatology or arthritis or whatever, I call the 
specific department over at Oahu, because I know they have a 
larger staff. I get appointments and I get airplane tickets I 
need to get over there. And I get referred to a local dentist.
    Like last year, I was running for Mayor and I didn't have 
my false teeth, I lost them. So I needed like partials in a 
hurry, and I explained this to them. They sent me over to a 
dentist in Kihei, and I have it taken care of before my first 
debate. So it was both necessary and very gratifying to get 
that level of service.
    So I would like to recommend that people here don't need to 
swamp the clinic with their 800 phone calls. As past president 
of Vietnam Veterans of Maui County, I used to mail out a list 
of everybody over at Oahu, all the VA staff, the doctors and 
the offices. And if you contact them directly, they're fast. 
They get back to you fast. Thus, saving this clinic a little 
bit of grief and angst for being overloaded with all of this 
stuff.
    I don't know if this defeats the purpose of not having 
everything here. But I found a way in which I can get treated 
much faster than try to go in and jam the line in the clinic, 
which nobody wants to do.
    Thank you, sir.
    Senator Akaka. Mahalo nui loa, Bill. William.
    Mr. Stroud. Bill is good.
    Senator Akaka. I want to thank all of our witnesses for 
your testimony, for your response, and for your comments. 
Without question, it's going to be helpful to all of us, and 
especially in our work on a different level of Government to 
continue to help those on the State level, and as well as on 
the Federal level.
    The Committee will keep all of these as records, and we'll 
be working on it. So I want to say mahalo nui loa to this 
panel.
    (Recess.)
    Senator Akaka. Aloha. I wanted to say aloha to all of you 
on the second panel. We'll go on with our second panel here. I 
want to welcome our second panel. I want to welcome Dr. Michael 
Kussman, who is the VA Under Secretary for Health. We're 
grateful for you coming and attending our hearings here in 
Hawaii. He is our top man for health at the VA. And so we are 
grateful to have him here. He is accompanied by Dr. Jim 
Hastings, who's the Director of the VA Pacific Islands Health 
Care System here in Hawaii; and Dr. Robert Wiebe, who's the 
Director of VISN 21.
    I also want to welcome Mark Moses. He is the Director of 
Office of Veterans Services for the entire State of Hawaii. 
He's doing a tremendous job and we're delighted to have him 
here today.
    Finally, I want to welcome Dr. Michael Shepherd, Senior 
Physician in the Office of Health Care Inspections of the 
Office of the Inspector General. And we have here Julie Watrous 
from the VA Inspector General's Office accompanying him. I want 
to thank each of you for being here today and your full 
statements will appear in the record of the Committee.
    Now I'd like to call on Dr. Kussman. As I said earlier, I 
can't say enough to welcome him and thank him for being 
present, and also the others of you on this panel.
    Dr. Kussman.

STATEMENT OF HON. MICHAEL J. KUSSMAN, M.D., MS., M.A.C.P, UNDER 
     SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS; 
   ACCOMPANIED BY ROBERT L. WIEBE, M.D., DIRECTOR, VISN 21, 
DEPARTMENT OF VETERANS AFFAIRS; JAMES HASTINGS, M.D., F.A.C.P., 
                     DIRECTOR, VA PACIFIC 
          ISLANDS HEALTH CARE SYSTEM, VETERANS HEALTH 
         ADMINISTRATION, DEPARTMENT OF VETERANS AFFAIRS

    Dr. Kussman. Mr. Chairman, mahalo nui loa for the 
opportunity to be here today to testify before you to discuss 
the state of the VA care here on Maui.
    Before I get to my prepared remarks, I'd like to express 
from the VA in total, from the Secretary to the Deputy 
Secretary, myself, and all our 230,000 people for the sorrow 
and sadness of what happened in Iraq for the deaths in the 
recent helicopter crash of the members of the 25th Infantry 
Division, to all the members of the 25th Infantry Division, 
particularly the family members of the deceased. This is 
particularly poignant for me personally, having been a member 
the 25th Infantry Division as a division surgeon. We send our 
condolences and sorrow to all the people involved.
    It's a privilege to be here in Maui, the Valley Isle, to 
speak and answer questions about issues important to the 
veterans residing in Maui County. Today I will describe our 
current services and highlight issues of particular interest to 
veterans residing in Maui, Molokai and Lanai. I would like, as 
you mentioned already, to have the written testimony submitted 
for the record. Thank you.
    Senator Akaka. In the record.
    Dr. Kussman. The Maui Community Based Outpatient Clinic 
serves an estimated veteran population of almost 10,000 
veterans. In FY 2006, 2,328 Maui veterans were enrolled for 
care and 1,436 received VA care. The Maui CBOC recorded 9,217 
clinic stops, a 46 percent increase from FY 2002. But market 
penetration rates for enrollees and users suggest additional 
demand is needed for the veterans' health care services here.
    The past year has been difficult for the staff and patients 
served by the Maui CBOC. That was mentioned already by the 
previous panel. But the health care system provided coverage 
with a combination of contract and VA staff traveling from 
Honolulu. It wasn't what we would have liked, but we did the 
best we could given the circumstances.
    I am pleased to announce we have hired additional staff and 
shortened waiting times for new patients for first primary care 
appointments. By next month, the clinic should have two full-
time VA primary care physicians and one full-time primary care 
and nurse practitioner. When the new staff is hired and 
onboard, we will have sufficient capacity for over 2,000 
primary care patients.
    There is also significant demand for mental health care 
services at the Maui Community Based Outpatient Clinic. About 
32 percent of all patients currently seen at the clinic have a 
documented mental health illness. The authorized mental health 
providers include a psychiatrist, a psychologist, a social 
worker, a clinical nurse specialist, and a substance abuse 
counselor. We will soon have a telehealth psychologist and a 
telehealth technician available as well. The Maui Vet Center is 
also recruiting for another mental health care clinician.
    Specialty care services are also available during scheduled 
visits from physicians and clinicians from the Honolulu VA 
Medical Center and other VA facilities in California. If a 
veterans' needs service is not available at the clinic, the 
health-care system arranges and pays for care in the local 
community.
    The islands of Molokai and Lanai are part of Maui County. 
VA provides limited services on these islands, but is accessing 
options to enhance care and access at both locations. VA 
estimates that the veteran population on Molokai is 649, and 
the VA provided care to 148 of them in FY 2006. The VA clinic 
in Molokai is located in shared space near Molokai General 
Hospital and operates two half-day primary care clinics per 
week.
    The clinic is staffed with a part-time VA physician and 
contract support staff. The health care system plans to acquire 
dedicated space on Molokai, telehealth care equipment, and to 
add telemental health services when the staff at Maui CBOC is 
available.
    In FY 2006, the VA provided care to more than half of the 
58 enrolled veterans on Lanai. We estimated there are 
approximately 229 veterans on the island. For the past two 
months, the VA has sent a primary care physician from Honolulu 
to Lanai once a month to provide needed primary care services. 
We will reassess the suitability of this monthly visit in about 
6 months. The health care system is exploring options with a 
nearby Straub Clinic, and we hope to relocate our services to 
this location in the coming months.
    In summary, with your support, Mr. Chairman, the VA is 
providing an unprecedented level of health care service to 
veterans residing in Hawaii and here on Maui. I am proud of the 
improvements in VA services in Hawaii, but we recognize our job 
is not done and there's more to do.
    Again, Mr. Chairman and other members, mahalo nui loa for 
opportunity to testify at this hearing. And my staff and I 
would be delighted to answer any questions you might have. 
Mahalo.
    Senator Akaka. Thank you. Thank you, Dr. Kussman.
    [The prepared statement of Dr. Kussman follows:]

 Prepared Statement of Hon. Michael J. Kussman, M.D., M.S., M.A.C.P., 
       Under Secretary for Health, Department of Veterans Affairs

    Mr. Chairman and Members of the Committee, mahalo nui loa for the 
opportunity to appear before you today to discuss the state of VA care 
in Maui. It is a privilege to be here in Maui--the Valley Isle--to 
speak and answer questions about issues important to veterans residing 
in Maui County.
    First, Mr. Chairman, I would like to thank you for your outstanding 
leadership and advocacy on behalf of our Nation's veterans. During your 
tenures as Chairman and Ranking Member of this Committee, you have 
consistently demonstrated your commitment to veterans. As I will 
highlight later, your vision and support have helped us provide an 
unprecedented level of health care services for veterans throughout 
Hawaii and the Pacific Region. In addition, I appreciate your interest 
in and support of the Department of Veterans Affairs (VA).
    Today, I will briefly review the VA Sierra Pacific Network that 
includes Hawaii and the Pacific Region; provide an overview of the VA 
Pacific Islands Health Care System (VAPIHCS) and the VA clinic here in 
Maui; and highlight issues of particular interest to veterans residing 
in Maui County, including capacity at the VA clinic in Maui and VA 
services on the nearby islands of Molokai and Lanai. I also look 
forward to addressing any questions you might have for me and my staff.

                  VA SIERRA PACIFIC NETWORK (VISN 21)

    The VA Sierra Pacific Network (Veterans Integrated Service Network 
[VISN] 21) is one of 21 integrated health care networks in the Veterans 
Health Administration (VHA). The VA Sierra Pacific Network provides 
services to veterans residing in Hawaii and the Pacific Region 
(including the Philippines, Guam, American Samoa and Commonwealth of 
the Northern Marianas Islands), northern Nevada and central/northern 
California. There were an estimated 1.1 million veterans living within 
the boundaries of the VA Sierra Pacific Network in Fiscal Year 2006 (FY 
2006).
    The VA Sierra Pacific Network includes six major health care 
systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA; 
Sacramento, CA; Fresno, CA; and Reno, NV. Dr. Robert Wiebe serves as 
director and oversees clinical and administrative operations throughout 
the Network. In FY 2006, the Network provided services to 235,000 
veterans. There were about 2.9 million clinic stops and 24,500 
inpatient discharges. The cumulative full-time employment equivalents 
(FTEE) level was 8,400 and the operating budget was about $1.5 billion.
    The VA Sierra Pacific Network is remarkable in several ways. In FY 
2006, VISN 21 was the highest-ranked Network in overall performance 
(based on an aggregation of quality, access, patient satisfaction and 
business metrics). The Network hosts the highest number of Centers of 
Excellence and also has the most highly funded research programs in 
VHA. In the most recent all-employee survey, staffs in VISN 21 reported 
the highest overall job satisfaction in VHA. Finally, VISN 21 operates 
one of four Polytrauma units in VHA that are dedicated to addressing 
the clinical needs of the most severely wounded Operation Iraqi 
Freedom/Operation Enduring Freedom (OIF/OEF) veterans.

            VA PACIFIC ISLANDS HEALTH CARE SYSTEM (VAPIHCS)

    As noted above, VAPIHCS is one of six major health care systems in 
VISN 21. Dr. James Hastings is the director and a practicing 
cardiologist at VAPIHCS. VAPIHCS is unique in several important 
aspects: its vast catchment area covering 2.6 million square-miles 
(including Hawaii, Guam, American Samoa and Commonwealth of the 
Northern Marianas); island topography and the challenges to access it 
creates; richness of the culture of Pacific Islanders; and the ethnic 
diversity of patients and staff. In FY 2006, there were an estimated 
102,000 veterans living in Hawaii (representing 8 percent of the total 
population in Hawaii and 9 percent of total veteran population in VISN 
21).
    VAPIHCS currently provides care in seven locations: the Ambulatory 
Care Center (ACC) and Center for Aging (CFA) on the campus of the 
Tripler AMC in Honolulu; and Community Based Outpatient Clinics (CBOCs) 
in Lihue (Kauai), here in Kahului (Maui), Kailua-Kona (Hawaii), Hilo 
(Hawaii), Hagatna (Guam) and Pago Pago (American Samoa). VAPIHCS also 
has outreach clinics in Molokai and Lanai. The inpatient Post Traumatic 
Stress Disorder (PTSD) unit is now also on the campus of Tripler AMC 
(the unit was formerly in Hilo). In addition to VAPIHCS, VHA operates 
five Readjustment Counseling Centers (Vet Centers) in Honolulu, Lihue, 
Wailuku, Kailua-Kona and Hilo that provide counseling, psychosocial 
support and outreach.
    In FY 2006, VAPIHCS provided services to nearly 22,500 veterans, 
19,000 of whom reside in Hawaii. There were 198,000 clinic stops in 
Hawaii during FY 2006 (7 percent of Network total). The cumulative FTEE 
in FY 2006 for the health care system was 502 employees. The operating 
budget for VAPIHCS (i.e., General Purpose allocation from appropriated 
funds) increased from $68.0 million in FY 2002 to $110 million in FY 
2007--an increase of 62 percent. For comparison, during this same time 
period, the operating budgets for VISN 21 increased 48 percent and VHA 
increased 43 percent. (Please note these amounts do not include 
Specific Purpose Funds and Medical Care Cost Funds [MCCF].)
    VAPIHCS provides or contracts for a comprehensive array of health 
care services. VAPIHCSdirectly provides primary care, including 
preventive services and health screenings, and mental health services 
at all locations. VAPIHCS does not operate its own acute medical-
surgical hospital and consequently, faces challenges in providing 
specialty services. VAPIHCS recently hired specialists in orthopedics, 
ophthalmology, nephrology and inpatient medicine (``hospitalist'') and 
is providing selected specialty care in Honolulu and to a lesser 
extent, in CBOCs. VAPIHCS is actively recruiting additional specialists 
(e.g., Urology) and will continue to refer patients to DOD and 
community facilities.
    Inpatient long-term and acute rehabilitation care is available at 
the CFA. Inpatient mental health services are provided by VA staff on a 
20-bed ward within Tripler AMC and at the 16-bed PTSD Residential 
Rehabilitation Program (PRRP). VAPIHCS contracts for care with DOD (at 
Tripler AMC and Guam Naval Hospital) and community facilities for 
inpatient medical-surgical care.
    The current constellation of VA facilities and services represents 
a remarkable transformation over the past several years. Previously, 
the VAPIHCS (formerly known as the VA Medical and Regional Office 
Center [VAMROC] Honolulu) operated primary care and mental health 
clinics based in the Prince Kuhio Federal Building in downtown Honolulu 
and CBOCs on the neighbor islands that were staffed primarily with 
nurse practitioners. Congress approved $83 million in Major 
Construction funds to build a state-of-the-art ambulatory care facility 
(i.e., ACC) and a long-term care/rehabilitation unit (i.e., CFA) on the 
Tripler AMC campus and these facilities were activated in 2000 and 
1997, respectively. VISN 21 allocated nearly $17 million from FY 1998-
FY 20OO to activate these projects. VISN 21 also provided dedicated 
funds to enhance care on the neighbor islands by expanding/renovating 
clinic space and adding additional staff to ensure there are primary 
care physicians and mental health providers at all CBOCs.

                               MAUI CBOC

    VA operates a CBOC located in Kahului (203 Ho'ohana, Suite 303, 
Kahului, HI, 96732). In FY 2002, VAPIHCS spent $208,000 to renovate the 
clinic. The Maui Vet Center is located in nearby Wailuku.
    The Maui CBOC serves an island veteran population estimated in FY 
2006 to be 9,900. In FY 2006, 2,382 veterans residing in Maui were 
enrolled for care and 1,436 veterans received VA care (``users''). The 
market penetrations for enrollees and ``users'' are 24 percent and 14 
percent, respectively. These are lower than rates elsewhere in Hawaii.
    As I will discuss later, the Maui CBOC has recently increased its 
staffing and currently is authorized to have 19 staff at the clinic. 
For comparison, at the time of your last hearing here in January 2006, 
the authorized staffing was 12.4 FTEE. The authorized primary care 
providers include two physicians, a nurse practitioner and a social 
worker. The authorized mental health providers include a psychiatrist, 
psychologist, social worker, clinical nurse specialist and substance 
abuse counselor. With this staff, the Maui CBOC provides a broad range 
of primary care and mental health services. In addition, VAPIHCS 
provides specialty care services at the clinic by sending VA staff from 
Honolulu and other VA facilities in California. Services provided by 
clinicians traveling to Maui include cardiology, gastroenterology, 
geriatrics, nephrology, neurology, optometry, orthopedics and 
rheumatology. If veterans need services not available at the clinic, 
VAPIHCS arranges and pays for care in the local community (e.g., Maui 
Memorial Hospital), Honolulu (including Tripler AMC) or VA facilities 
in California. In FY 2006, VA spent nearly $3.6 million for non-VA care 
in the private sector (i.e., not including costs at other VA or DOD 
facilities) for residents of Maui.
    In FY 2006, the Maui CBOC recorded 9,217 clinic stops, representing 
a 46 percent increase from FY 2002 (i.e., 6,292 stops). The past year 
has been difficult for the staff and patients served by the Maui CBOC. 
Several staff, including a VA and a contract primary care provider, 
left the clinic for a variety of personal and economic reasons (e.g., 
cost of housing on Maui). VAPIHCS provided coverage with a combination 
of contract and VA staff traveling from Honolulu.
    Some patients, like Mr. Richard Bond were pleased with the 
arrangement. In a letter to an editor, he wrote, ``I want to thank the 
Maui VA clinic. Out of the blue, staff phoned me with a lab appointment 
and a few days later, a doctor's appointment. Dr. Wong [a VA physician 
at the ACC in Honolulu] flew over from Honolulu and I received a 
thorough physical and a flu shot to boot.'' However, VAPIHCS 
understands that other patients were dissatisfied because continuity of 
care was not optimal and waits for appointments lengthened. I am 
pleased to report that with additional staff, the situation has 
improved and the clinic currently has short waiting times for new 
patients with very few veterans waiting more than 30 days for their 
first primary care appointment.

                             SPECIAL ISSUES

Capacity at Maui CBOC
    As noted earlier, in FY 2006 VA provided health care services to 
1,436 veterans who reside in Maui. However, market penetration rates 
for enrollees and ``users'' suggest there is additional demand for VA 
health care. This was corroborated by veterans' advocates during a 
meeting with Drs. Wiebe and Hastings earlier this year in Maui. 
Consequently, VAPIHCS has significantly increased the authorized 
staffing at the Maui CBOC. When the new VA primary care provider 
arrives next month, the clinic will have two full-time VA primary care 
physicians and one fulltime primary care nurse practitioner. Based on 
VA primary care panel size criteria, this would give the clinic a 
theoretical capacity for over 3,000 primary care patients (i.e., 1,200 
patients for each full-time physician and 800 for each full-time nurse 
practitioner). Even considering the special circumstances at the Maui 
CBOC (e.g., lack of VA inpatient facility and limited community health 
care resources on the island), the VA clinic will be able to provide 
high quality and accessible primary care to more than 2,000 patients.
    In addition, the Maui CBOC will soon begin Home Based Primary Care 
(HBPC) services for veterans residing in Maui. HBPC is currently 
available in Oahu, Kauai and the Big Island. HBPC is an important 
component of VA's non-institutional long-term care program designed to 
provide care in the least restrictive setting for veterans.
    There is also a significant demand for mental health services at 
the Maui CBOC. About 32 percent of all patients currently seen at the 
clinic have a documented mental health illness (compared to 19 percent 
for VHA), including a high prevalence of PTSD. In response, VA has 
substantially increased its authorized mental health capacity at the 
Maui CBOC. As you know, Mr. Chairman, Congress has provided several 
hundred million dollars to VA over the past two fiscal years to 
specifically enhance mental health services. In FY 2006 and FY 2007, 
VAPIHCS received nearly $2 million of these funds. These funds are 
being used to hire about 30 new mental health staff in VA facilities 
across Hawaii and the Pacific Region, including five staff here at the 
Maui CBOC. When all of these positions are filled, the Maui CBOC will 
have a psychiatrist, psychologist, clinical nurse specialist, mental 
health social worker, substance abuse counselor, telehealth 
psychologist and telehealth technician. In addition, the Maui 
Readjustment Counseling Center (``Vet Center'') is also recruiting for 
another mental health clinician (i.e., psychologist or social worker).
    The size of the veteran population and number of VA patients in 
Maui limit the feasibility of having a large cadre of medical and 
surgical specialists based in the Maui CBOC. Nonetheless, VA recognizes 
that some veterans in Maui County have needs that go beyond primary 
care and mental health. VA sends specialists from Honolulu and 
California to the clinic on a regular basis. As noted earlier, services 
provided by clinicians traveling to Maui include cardiology, 
gastroenterology, geriatrics, nephrology, neurology, optometry, 
orthopedics and rheumatology. VAPIHCS also refers patients to the local 
community for care at VA expense (when eligibility criteria are met) 
and transports (also at VA expense, when eligibility criteria are met) 
to the VA facility in Honolulu. The Maui CBOC also utilizes telehealth 
technologies to provide specialty services.
Molokai and Lanai
    The islands of Molokai and Lanai are part of Maui County. VA 
provides limited services on these islands with permanent staff (on 
Molokai) and visiting VA staff (to both islands). However, VA is 
assessing options to enhance services in both locations.
Molokai
    VA estimates the veteran population on Molokai to be 649. In FY 
2006, 211 veterans from Molokai were enrolled for VA care and 148 
veterans received VA services. VA formerly established an outreach 
clinic on Molokai in FY 2005. However, Mr. Chairman, with the 
assistance of you and your staff, VA now has established a more formal 
presence on the island. The VA clinic on Molokai is located in shared 
space near Molokai General Hospital and operates two half-day primary 
care clinics per week. The clinic is staffed with a part-time VA 
physician and contract support staff. Although VA has not installed its 
own telehealth equipment in Molokai, VA currently has access to 
videoconferencing equipment. VAPIHCS is hoping to acquire dedicated 
space in Molokai to enable the placement of permanent information 
technology (IT) and telehealth equipment. VA also sends mental health 
staff from the Maui CBOC to Molokai to provide care. Specifically, the 
psychologist travels twice a month and the psychiatrist once a month. 
VAPIHCS is also planning to add tele-mental health services when staff 
(at the Maui CBOC) and equipment are on-board. In addition, VA 
purchases non-VA care in the community (e.g., Molokai General Hospital) 
for eligible veterans residing in Molokai, at a total cost of $280,000 
in FY 2006. Veterans residing in Molokai also are seen at DOD and VA 
facilities in other locations. VA pays for travel expenses for those 
veterans eligible for beneficiary travel.
Lanai
    VA estimates the veteran population on Lanai to be 229. In FY 2006, 
58 veterans residing on Lanai were enrolled for VA care and 30 veterans 
received VA services. VA currently sends a primary care physician from 
Honolulu to Lanai once a month to provide needed primary care services. 
This began in June 2007, and we will reassess the frequency in about 6 
months. VA currently is using space adjacent to the Lanai Community 
Hospital and is negotiating with the hospital to use its 
videoconferencing equipment for telehealth. VAPIHCS is exploring 
options with the nearby local medical clinic (i.e.,Straub Clinic) and 
we hope to relocate our clinic to this space in the next couple of 
months. In addition, VA purchases non-VA care in the community and pays 
beneficiary travel for eligible veterans. VA is exploring other options 
to improve access, including adding an automated pharmacy dispensing 
device and/or telehealth capabilities. We are also having conversations 
with local residents in Lanai City about a possible federally Qualified 
Health Center (FQHC) and how VA might participate in and partner with 
FQHC.

                               CONCLUSION

    In summary, with your support, Mr. Chairman, and other Members of 
Congress, VA is providing an unprecedented level of health care 
services to veterans residing in Hawaii and here in Maui. Although VA 
struggled earlier this year with staffing at the VA clinic in Maui, we 
now have a robust cadre of primary care and mental health 
practitioners. We look forward to a growth of new patients at the Maui 
CBOC and will meet the expectations of veterans for quality and 
timeliness.
    VAPIHCS still faces several challenges, in part due to the 
topography of its catchment area, lack of an acute medical-surgical 
hospital, limited community resources in rural areas and difficulties 
recruiting staff. VAPIHCS will meet these challenges by utilizing 
telehealth technologies, hiring specialists, working with community 
partners and developing new delivery models. I am proud of the 
improvements in VA services in Hawaii, but recognize that our job is 
not done.
    Again, Mr. Chairman and other Members of the Committee, mahalo nui 
loa for the opportunity to testify at this hearing. My staff and I 
would be delighted to address any questions you might have for us.

    And now may I call Mr. Moses, representing the State. Mark 
Moses.

         STATEMENT OF MARK MOSES, DIRECTOR, OFFICE OF 
   VETERANS SERVICES, DEPARTMENT OF DEFENSE, STATE OF HAWAII

    Mr. Moses. Thank you, Mr. Chairman. It's a great privilege 
to testify before your Committee today. I am Mark Moses, 
Director of the Office of Veterans Services, OVS.
    OVS is the state leading agency responsible for the welfare 
of Hawaii's veterans and family members. We act as the 
Governor's liaison to veterans and veterans groups. We serve as 
an intermediary between the Department of Veterans' Affairs. 
And we also provide the state services and benefits that our 
legislature has authorized.
    We have provided services and information to nearly 33,000 
veterans and survivors this past fiscal year. I've attached the 
summary sheet describing some of those services and activities 
made available for your review.
    Mr. Chairman, as you understand, the final service we can 
provide a veteran is interment in a veterans' cemetery with 
appropriate honors. We take this seriously.
    The VA has consistently supported our efforts to expand 
Hawaii's cemetery plots and columbarium space to keep pace with 
need. They are deserving of our gratitude.
    Makawao Veterans Cemetery has sufficient columbarium space, 
and we are looking at the need to expand it for burials and 
plots. It is important to take this opportunity to thank you 
personally, Senator, for your unwavering support for our 
veterans' cemetery program.
    Thank you very much.
    The April 2000 data from the VA Office of Actuary, Office 
of Policy, Planning and Preparedness estimated that there are 
120,000 veterans in Hawaii: about 72 percent on Oahu, 13 
percent on the Big Island, 10 percent on one of the Maui County 
islands, and approximately 5 percent on Kauai.
    Our island state represents unique challenges for the 
Department of Veterans Affairs, but also for our State Offices. 
You heard the testimony this morning about vacancies. We have 
had vacancies. We've had two vacancies we could not fill by law 
because of workers' compensation problems. Both have been 
resolved, and we're hiring right now as of about the last week. 
Our island state presents unique challenges in other ways 
because of our separation.
    I want to share with you comments that we have heard from 
veterans. Now, they speak of the excellence of the VA medical 
care and how VA staff treats veterans with dignity and respect, 
and that the services rendered by the dedicated health care 
professionals are superior to that they received on the 
mainland. These comments are from local veterans and those 
visiting from neighbor islands, as well as from out of state. 
Similar comments are shared about the benefits staff.
    Hawaii VA supports National Guard and Reserves prior to 
deployment and upon their return, as well as all those members 
ending their active military service. As a disabled veteran, I 
can attest to the fact that the services provided by the VA 
locally are among the top in the Nation.
    I've had many of my services here by choice when I could 
have gone to other hospitals. Nevertheless, given the proper 
resources, they are capable of doing better.
    Nearly 30 percent of our veterans live on the neighbor 
islands. Many of them are referred for surgical services on the 
mainland in VA medical facilities or civilian medical 
facilities on Oahu or Tripler Army Medical Center. For neighbor 
island veterans sent to mainland VA hospitals, this can be very 
traumatic.
    They are booked on flights, sent to a big city where they 
may not know their way around, and they're told to find the VA 
facility. They're operated on. And then they're sent back to 
their homes in Hawaii. We ask that sufficient funding be 
provided for direct mainland flights from, and whenever 
possible, back to their neighbor island of residence.
    Changes to 38 U.S.C. 1151, Benefits for persons disabled by 
treatment of vocational rehabilitation, means only facilities 
covered by the law are those over which the VA Secretary has 
direct jurisdiction or a government facility contracted by him.
    Tripler, Straub, Kuakini, Queen's and St. Francis do not 
qualify. A veteran who suffers any additional disability, or 
worse, are on their own, and they must sue the medical facility 
by themselves for damages. It is an overwhelming task for most 
of our veterans.
    We suggest the definitions, as listed in 38 U.S.C. 1701(3) 
and 38 U.S.C. 1151 be changed, allowing Hawaii veterans the 
same protection as veterans receiving care in VA facilities on 
the mainland. At a minimum, veterans must be given the 
opportunity to make informed consent about the benefits and 
shortfalls between having medical procedures performed at a 
mainland VA facility or locally at a non-VA facility.
    Hawaii's neighbor islands must be offered the same level of 
medical care and services as veterans located on Oahu. Neighbor 
island Community Based Outpatient Clinics place veterans on a 
wait list, where they are scheduled for specialty medical care. 
With the use of telemedicine and more frequent visits, this 
problem is being addressed. However, a backlog still exists 
with some veterans waiting months to see a specialist.
    VA has a difficult time recruiting and maintaining 
competent medical staff in these rural areas. VA should be 
allowed to offer a premium to rural medical service providers 
and to contract for additional medical care in rural areas, 
such as the neighbor island.
    With our thousands of National Guardsmen and Reservists 
returning, my desire is that they and those already here 
receive medical and benefit services in a timely matter. We ask 
that VA Health and Benefits Administration be adequately funded 
and staffed to provide medical care and benefits services to 
all of Hawaii's veterans.
    We just received a VA grant to help us with the building 
and now the opening of the Yukio Okutsu Veterans Home. And it's 
supposed to open this year. There have been some delays, and 
we're awaiting the final date of opening. We still don't have 
eligibility criteria, though, for the hospital. And we're 
trying to get that information.
    Eventually, I envision that we will have several veteran 
long-term facilities, preferably at least one per county, if 
not one per island. The need is here. I personally pledge that 
I will look into making use of the beds in other facilities 
under the law that you have just passed. Thank you very much 
for that.
    The present per-day veteran reimbursement rate is only 
$67.71. And that's very low and insufficient to maintain a 
veteran without additional payments. We request the 
reimbursement rate be raised to adequately cover the long-term 
service provided to assist the state in meeting the medical 
care of this very fragile and older group of warriors. The 
actual cost is approximately $300 a day.
    As these veterans pass, many will utilize our state 
veterans' cemetery system. Presently, the state and county are 
reimbursed $300 for each veteran burial. Less than the cost to 
open and close the grave and to provide perpetual care. The 
actual cost is approximately $1,000 per grave.
    This reimbursement rate has not changed in many years. And 
we ask your Committee to look into increasing it to more 
closely reflect the true cost of interments.
    We must continue to take care of those who served.
    They are our sons and daughters. They are Hawaii citizens.
    They are our veterans. I thank you and the Committee for 
this opportunity to testify. And I will respond to any 
questions.
    [The prepared statement of Mr. Moses follows:]

   Prepared Statement of Mark S. Moses, Director, Office of Veterans 
            Services, Department of Defense, State of Hawaii

    Chairman Akaka and Members of the Senate Committee on Veterans' 
Affairs, I am Mark Moses, Director of the Office of Veterans Services 
(OVS). The office is the single State lead agency responsible for the 
welfare of Veterans and their family members. We act as the Governor's 
liaison to veterans, veterans groups and organizations, and serve as an 
intermediary between the Department of Veterans Affairs and Hawaii's 
veterans. The office serves in partnership with the VA to provide state 
services and benefits. We provided services and information to nearly 
33,000 veterans and eligible survivors this past fiscal year. I have 
attached a summary sheet describing some services and activities made 
available through the office for your review.
    The final service we can provide a veteran is interment in a 
veteran's cemetery with appropriate honors. The Veterans Administration 
has consistently supported our efforts to expand Hawaii's cemetery 
plots and columbarium space to keep pace with need. They are deserving 
of our gratitude.
    Additionally, it is important and proper to take this opportunity 
to thank you, Senator Akaka for your unwavering support for our 
veteran's cemetery program. We are particularly grateful for your 
assistance in obtaining the new grant for the West Hawaii Veterans 
Cemetery located in Kona. State veterans cemeteries are the only 
cemeteries accepting full body burials on a consistent basis in Hawaii. 
This VA grant will assure that West Hawaii will be the cemetery we all 
have envisioned it to be.
    Based on April 2000 data from the Office of the Actuary, Office of 
Policy, Planning and Preparedness, Department of Veterans Affairs, 
there are an estimated 120,000 veterans in Hawaii. The majority, about 
72 percent live on Oahu, 13 percent reside on the island of Hawaii, 10 
percent live on one of the three islands which comprise Maui County, 
and approximately 5 percent live on Kauai. Hawaii, an island state 
located in the middle of the Pacific Ocean, presents unique challenges 
for the Department of Veterans Affairs.
    Before I discuss some of these challenges, I want to share with you 
comments that my staff and I hear from veterans about VA health care 
and benefit services. These individuals speak to the excellence of VA 
medical care; that VA's staff treats veterans with dignity and respect, 
and that the services rendered by the dedicated health care 
professionals are superior to the care they received on the mainland 
United States. These comments are expressed by local veterans as well 
as by veterans who visit Hawaii and have a need to seek services from 
Spark M. Matsunaga medical staff. Similar types of comments are shared 
about the VA Benefit staff.
    This ``new'' VA exemplifies the well known phrase of ``supporting 
our troops.'' Hawaii's VA supports our National Guard members and 
Reservists prior to deployment and upon their return. They also offer 
services to military members who are ending their military service. As 
a disabled veteran, I can attest to the fact that the services provided 
by the VA locally are top in the Nation. Nevertheless, given the proper 
resource they are capable of doing better.
    As mentioned earlier, Hawaii presents unique challenges to the VA. 
We are an island state with one large population center on Oahu. Nearly 
30 percent of Hawaii's veterans live on the neighbor islands. Presently 
many of our veterans are referred for surgical services to mainland VA 
medical centers, civilian medical centers on Oahu, or to Tripler Army 
Medical Center. This can be very traumatic for neighbor island veterans 
who are sent to other VA hospitals. They are booked on flights, sent to 
a big city to find the VA facility, operated on and sent back to their 
home in Hawaii. We ask that funding be provided so that those who 
reside on neighbor islands be provided direct flights to the mainland. 
We also propose that whenever possible, return flights fly directly to 
the veteran's island of residence.
    Another issue that affects Hawaii and Alaska involves changes that 
were made to 38 U.S.C. 1151, Benefits for persons disabled by treatment 
of vocational rehabilitation. With this change the only facilities 
covered by the law are those over which the Secretary of Veterans 
Affairs has direct jurisdiction, or Government Facilities contracted by 
the Secretary. Tripler Army Medical Center and other medical facilities 
in Hawaii, such as Straub, Kuakini, Queens, and St. Francis do not 
qualify under the present law. Veterans suffering an unlikely event 
causing any additional disability or worse are on their own and must 
sue the medical facility for damages. For most, obtaining an attorney 
to pursue this option is overwhelming.
    We suggest that the definitions as listed in 38 U.S.C. 1701(3) and 
38 U.S.C. 1151, be changed so that veterans in Hawaii treated outside 
VA facilities are afforded the same protection as veterans who receive 
VA medical care in VA facilities on the mainland. Hawaii's veterans 
must have the same right to redress as veterans treated at mainland VA 
facilities. At a minimum, veterans must be given the opportunity to 
make informed consent about the benefits and shortfalls of choosing 
between having surgeries or other medical procedures performed at a VA 
facility on the mainland or in non-VA facilities locally.
    Hawaii's neighbor islands must be offered the same level of medical 
care and services as veterans located on Oahu. Presently neighbor 
island Community Based Outreach Clinics place veterans on a wait list 
where they are scheduled for specialty medical care. With the use of 
Telemedicine and more frequent visits, this problem is being addressed; 
however, backlogs still exist. Veterans have been known to wait several 
months before they see a specialist. Additionally, VA has a difficult 
time recruiting and maintaining competent medical staff in these rural 
areas. To address these needs, the VA should be allowed to offer a 
premium to rural medical service providers and consider contracting for 
additional medical care in rural areas such as the neighbor islands.
    As you are aware, Hawaii has received thousands of its returning 
National Guardsmen and Reservists. As Director of the Office of 
Veterans Services, my desire is that these returning military members 
and those already here be able to access medical and benefit services 
in a timely manner. We ask that VA Health and Benefits Administrations 
be adequately funded and staffed to provide medical care and benefit 
services to all veterans who make Hawaii their home.
    Hawaii has received a grant from the VA to build its first 
Veteran's Home. The Yukio Okutsu Veterans Home is scheduled to open 
within a few months. Our concern is with the reimbursement rate that 
the VA pays for veterans who will be residing at the home. The present 
reimbursement is insufficient to maintain a veteran without payment of 
additional funds. We in Hawaii are not alone in requesting that the per 
day reimbursement rate be raised so that it adequately covers long-term 
care services supplied by the facility. We envision that the Yukio 
Okutsu Veterans Home will be the first of several veterans' long-term 
care facilities, preferably at least on per county due to inherent 
island produced isolation. Adequate per resident reimbursement will 
assist the state in meeting the medical care needs of this frail group 
of older warriors.
    As these veterans pass, many will utilize our State Veteran's 
Cemetery system. Presently the state and county are reimbursed $300 for 
each veteran burial, but the cost to open and close the grave site and 
provide perpetual care greatly exceeds this amount. This reimbursement 
rate has not changed in many years. We ask that your Committee look 
into increasing the present amount so that it more closely reflects the 
true cost associated with full body and urn burials.
    We must continue to take care of our veterans. We must support our 
Soldiers, Sailors, Airmen, Marines, and Coast Guard members at home and 
abroad. They are our veterans, our sons and daughters, our citizens of 
Hawaii.
    I thank the Committee for this opportunity to speak on this matter 
and I will respond to any questions that you may have.
    [The prepared statement of Mr. Moses follows:]
                                 ______
                                 
    [Note: the following is a summary of services and activities being 
offered by the Hawaii Office of Veterans Services.]
                   Hawaii Office of Veterans Services

                                MISSION

    The Office of Veterans Services (OVS) is the principal state office 
responsible for the development and management of policies and programs 
related to veterans, their dependents, and/or survivors. The OVS acts 
as a liaison between the Governor and veterans' organizations and also 
between the Department of Veterans Affairs and individual veterans. Our 
objectives are to assist veterans in obtaining State and Federal 
entitlements, to supply the latest information on veterans' issues and 
to provide advice and support to veterans making the transition back 
into civilian life.
    OVS is the State's primary advocate of veterans applying for and 
receiving benefits and services. The OVS may take action on behalf of 
veterans, their families and survivors to secure appropriate rights, 
benefits and services. This process includes the reception, 
investigation and resolution of disputes and complaints.
    The OVS serves all eligible veterans, Reservists, National Guard 
members, active-duty military personnel and their dependents (including 
stepchildren). (See List of Services at end.)

                        STATE PROVIDED BENEFITS

Special Housing for Disabled Veterans
    Payment by the State of up to $5,000 to each qualified, totally 
disabled veteran for the purpose of purchasing or remodelling a home to 
improve handicapped accessibility.
Burials
    Burials for qualified veterans (including U.S. war allies) and 
their dependents in Veterans Cemeteries on Oahu, Hawaii, Kauai, Maui, 
Molokai, or Lanai.
Vital Statistics
     Free certified copies of vital statistics forms when needed for 
veterans' claims.
License Plates
    For the same cost as regular license plates, qualified veterans can 
acquire distinctive veterans' license plates for their car or 
motorcycle. Currently available are: ``Veteran,'' ``Combat,'' ``Combat 
Wounded,'' ``Pearl Harbor Survivor,'' ``Former POW,'' 'World War II 
Veteran,'' ``Korean War Veteran,'' and Vietnam Veteran.''
Tax Exemptions
    Applies to real property that is owned and occupied as a home by a 
totally disabled veteran or their widow(er). Also applies to passenger 
cars when they are owned by totally disabled veterans and subsidized by 
the Department of Veterans Affairs.
Employment and Re-employment
    Preference is given to veterans, Vietnam-era veterans, service-
connected, disabled veterans and their widow(er)s for civil service 
positions, training programs, job counseling and referrals to civilian 
jobs by the Workforce Development Division, Department of Labor and 
Industrial Relations. Re-employment rights for veterans, Reservists or 
National Guard members who leave a position within State or County 
government for training or active military service.

We encourage you contact the Office of Veterans Services to have your 
questions answered. The sooner we begin the process together, the 
sooner you will see results. Please contact the OVS office nearest you. 
Walk-ins are welcome, and appointments are recommended. Home, worksite 
and hospital visits are available if necessary, as are Group 
presentations.
Office of Veterans Services--Oahu
    Office: Tripler Army Medical Center E-Wing
    Address: Office of Veterans Services, 459 Patterson Road,
      E-Wing, Room 1-A103, Honolulu HI 96819-1522.
    Telephone: (808) 433-0420; Fax: (808) 433-0385.
    E-mail: OVS@ovs.hawaii.gov.
    Hours: Monday-Friday, 7:45 a.m.-4:00 p.m.
Office of Veterans Services--Kauai
    Address: 3215 Kapule Hwy., #2, Lihue, HI 96766.
    Telephone: (808) 241-3346; Fax: (808) 241-3818.
    E-mail: KOVS@ovs.hawaii.gov.
    Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
Office of Veterans Services--Hawaii
    Address: 101 Aupuni Street, Room 212, Hilo, HI 96720.
    Telephone: (808) 933-0315; Fax: (808) 933-0317.
    E-mail: HOVS@ovs.hawaii.gov.
    Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
Office of Veterans Services--Maui
    Address: 333 Dairy Road, Suite 201-A, Kahului, HI 96732.
    Telephone: (808) 873-3145; Fax: (808) 243-5820.
    E-mail: MOVS@ovs.hawaii.gov.
    Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
            list of services for veterans, active military, 
                         spouses and dependents
    Assist in preparation of VA claims.
    Help individuals file VA Appeals.
    Represent veterans at VA hearings.
    Obtain veteran birth, marriage, divorce and death certificates
      nationwide.
    Assist with burial
    Provide notary.
    Assist indigents.
    Maintain DD214s.
    Refer individuals not qualified for VA benefits to other agencies.
    Legal name change.
    Review active service record.
    Assist active medical boards.
    Hawaii Veterans Newsletter.
    Hawaii Veterans Roster.
    Hawaii Veterans Website.
    Governor's Liaison to veterans.
    Legislative Advocate for veterans--State and Federal.
    Yukio Okutsu Hilo Veterans Home--development and oversight.
    State Veterans cemeteries statewide--grants and expansion.
    Grant-in-Aid for all veteran related items--veterans' cemeteries,
      Arizona Memorial, Aviation Museum, Veterans Centers
      statewide, etc.
    Tri-annual report for State Monuments.
    Coordinate veterans organizations to clean the Korean and
      Vietnam Memorials on Capitol grounds.
    Coordinate Memorial and Veterans Day ceremonies annually
      at Hawaii State Veterans Cemetery.
    Assist with Memorial and Veterans Day ceremonies at National
      Cemetery of the Pacific (Punchbowl).
    Coordinate leis for veterans cemeteries on Memorial Day.
    Staff the Advisory Board on Veterans Services.
    Hawaii Veterans Memorial Fund.
    Maintain presence on neighbor islands.
    Validate Military Service for Employee Retirement System.

    Senator Akaka. Thank you very much, Mark Moses.
    Now we will receive the testimony of Dr. Michael Shepherd.

        STATEMENT OF MICHAEL SHEPHERD, M.D., PHYSICIAN, 
OFFICE OF HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL, 
                DEPARTMENT OF VETERANS AFFAIRS; 
 ACCOMPANIED BY JULIE WATROUS, R.N., REGIONAL DIRECTOR, OFFICE 
             OF HEALTHCARE INSPECTIONS, OFFICE OF 
           INSPECTOR GENERAL, DEPARTMENT OF VETERANS 
                            AFFAIRS

    Dr. Shepherd. Mr. Chairman, mahalo. Thank you for the 
privilege to testify on access to health care for the veterans 
on Maui. I'm accompanied by Julie Watrous, Director of the 
OIG's Office of Health Care Inspections, Los Angeles office. 
Today I will briefly discuss challenges and opportunities for 
providing health care to veterans on the island of Maui.
    As have been mentioned by previous speakers, staffing with 
primary care providers at the Maui CBOC has been a major 
concern during the past year. Despite efforts at recruitment, 
the Maui CBOC has been without a full-time VA primary care 
physician for a 9-month period until May 2007. During this time 
period, the clinic relied on the informal triage system for 
scheduling patient appointments. Despite the efforts of 
remaining staff, waiting lists accrued for nonurgent care 
leading at times to frustration on the part of veterans and 
impacting staff morale.
    Although part-time contract providers were utilized, 
continuity of care remained a significant issue. Currently, 
there is a full-time VA physician day position, as well as a 3-
day per week contract position to see patients at the CBOC. In 
the near term, a second contract physician reportedly will be 
increasing hours in order to see walk-in patients and OEF/OIF 
veterans.
    A July 2004, VHA directive provides guidance on the maximum 
number of active patients, or panel size, for whom a provider 
should provide primary care. On Maui, primary care providers 
have a greater reliance on fee basis and consult specialty care 
in the absence of a full service VA, which impacts the real 
time availability of medical information and may have bearing 
on the appropriateness of panel size relative to a mainland 
nonrural location.
    Furthermore, replacing providers at rural facilities is 
generally difficult and may be even more so in light of the 
real estate market on the island. We found that despite 
national VA panel size guidelines, the system has responded to 
a recent gap in primary care continuity by hiring a second 
full-time primary care physician for the Maui CBOC, who will 
begin seeing patients within the next month.
    During the past year, the Maui clinic has had a full-time 
psychiatrist and psychologist, but has been experiencing an 
ongoing increase in the number of patients seen for mental 
health visits. Approximately 28 percent of visits in the last 
year were for mental health. The system leadership is presently 
recruiting for several clinical positions to augment mental 
health and telemental health services.
    In addition to serving veterans on Maui, the CBOC supports 
veterans on the islands of Molokai and Lanai. Service to 
veterans on Lanai was also significantly impacted during the 9-
month period in which the Maui CBOC was experiencing staffing 
difficulties. In response, the system began sending providers 
from Oahu to serve veterans residing on Lanai. System 
leadership is subsequently considering permanently supporting 
the VA services on Lanai from Oahu rather than from the Maui 
CBOC. The system has also begun partnering with the local 
hospital on the island.
    Subsequent to your January 2006 field hearings, a part-time 
VA physician residing on Molokai is available a few days per 
week to see patients. The leadership reported having made 
contractual arrangements for VA to use telehealth equipment 
that is owned and located at a non-VA clinic on Molokai. 
Telemental health equipment will be operational when the 
recruited telehealth staff positions are filled at the Maui 
CBOC.
    The Veterans' Millennium Health Care and Benefits Act of 
1999 directed VA to provide certain services to veterans in 
their homes or in community settings, including the adult day 
health care, homemaker and home health aids and home based 
primary care, among others.
    In 2006, at your request, the OIG was asked to determine 
what restrictions placed on noninstitutional care services were 
appropriate in light of the intent of the Millennium Act. We 
reported that the system restricted contract adult day health 
care and homemaker and home health aids to highly service 
connected veterans, did not provide outpatient respite prior to 
June 2005, and offered home based primary care only to veterans 
living within a 50-mile radius to the system.
    We specified the need for the VHA to make sure that 
facilities eliminate local restrictions and where possible and 
expand coverage to geographic areas that currently do not offer 
noninstitutional care services. On Maui, VA clinicians reported 
that homemaker and home health aids and contract adult care 
services and purchased skilled home health services are 
presently available to veterans without restrictions on service 
connection or other non-medical eligibility.
    Although there are no restrictions to home based primary 
care, the system is still in the process of recruiting a nurse 
practitioner to provide this service.
    A gerontologist has resumed coming to the Maui CBOC every 
other month to perform comprehensive geriatric evaluations and 
management, and access is not restricted to this service as 
long as patients have met program criteria. At present, respite 
care is only available on Oahu and on an inpatient basis.
    In summary, Mr. Chairman, over the past year, VA Pacific 
Islands Healthcare System leadership has taken action to 
improve access to care for veterans on Maui and to enhance the 
consistency and continuity of care that will be provided. 
Although recruitment and programming to enhance future access 
are presently in progress, some obstacles to access still 
remain for veterans on Maui.
    Mr. Chairman, thank you again for this opportunity to 
testify. Your leadership and service on behalf of our Nation's 
veterans is inspiring. And I'm honored to testify before you 
and the veterans present in this room today.
    Thank you again.
    [The prepared statement of Dr. Shepherd follows:]

  Prepared Statement of Michael Shepherd, M.D., Physician, Office of 
Healthcare Inspections, Office of the Inspector General, Department of 
                            Veterans Affairs

    Mr. Chairman and Members of the Committee, thank you for the 
opportunity to testify today on access to health care for veterans on 
Maui. I am accompanied by Julie Watrous, R.N., Director, Los Angeles 
Regional Office, Office of Healthcare Inspections, Office of Inspector 
General (OIG). Today I will discuss the challenges and opportunities 
for providing health care to veterans on the island of Maui. These 
challenges can be viewed as those concerns shared with Veterans Health 
Administration (VHA) facilities nationwide, those in common with other 
rural and/or remote areas, and those unique to Maui.

               PRIMARY CARE STAFFING ISSUES AT THE MAUI 
                COMMUNITY BASED OUTPATIENT CLINIC (CBOC)

    Staffing at the Maui CBOC has been a major concern since the 
departure of the full-time nurse practitioner, relocation of the full-
time physician to the mainland, and the subsequent departure of a part-
time contract primary care provider in 2006. Despite efforts at 
recruitment, the Maui CBOC was without a full-time VA primary care 
physician for a 9-month period until May 2007. During this time period, 
a full-time VA nurse practitioner who was hired in the summer of 2006 
was the only consistent provider of primary care at the Maui CBOC.
    During this period, the clinic relied on an informal triage system 
for scheduling patient appointments, based on urgency of medical 
complaint, service connection, Operation Enduring Freedom/Operation 
Iraqi Freedom (OEF/OIF) service, and lack of veteran financial means to 
access care elsewhere. Non-service connected veterans with private 
insurance were encouraged to see providers in the private sector. Some 
patients were co-managed by VA and non-VA providers depending on the 
type of service or care needed. Wait lists accrued for non-urgent care 
such as semiannual or annual physical examinations, leading at times to 
frustration on the part of veterans and impacting, in turn, staff 
morale. In the interim, part-time fee basis providers were utilized to 
provide care that was helpful, though continuity of care remained a 
significant issue. A fee basis primary care physician was hired as a 
full-time VA employee at the CBOC in May 2007, and since then the wait 
list has reportedly been improving. In addition to this now full-time 
VA physician, a part-time fee basis physician continues to see patients 
3 times per week, and a second fee basis physician has been seeing 
patients twice a month. In the near term, this second fee basis 
physician reportedly will be working weekly to see walk-in patients and 
OEF/OIF veterans.
    VHA Directive 2004-031, Guidance on Primary Care Panel Size, from 
July, 6, 2004, provides guidance on the maximum number of active 
patients (panel size) for whom a provider should deliver primary care 
with the aim of establishing a primary care system that balances 
productivity with quality, access, and patient service. The VHA 
directive recognizes that expected panel sizes will vary from site to 
site depending upon patient characteristics of the primary care 
population and the level of system support. The directive also 
recognizes that panel sizes for specialized panels may need to be 
smaller than for undifferentiated primary care panels, and adjustments 
to panel size should be made at a local level, incorporating guidance 
from national programs where available.
    On Maui, primary care providers have a greater reliance on fee 
basis and consult specialty care in the absence of a full service VA, 
which impacts the real time availability of medical information and 
provider efficiency. In addition, the generation of paperwork and 
arrangement of outside consultation, the absence of an in-house full 
service pharmacy, and the need for outside referral for certain 
radiology tests may also have a bearing on the appropriateness of panel 
size relative to a suburban mainland location.
    Replacing providers at rural facilities is generally difficult and 
may lead to prolonged gaps in continuity. This challenge may be further 
exacerbated by relative real estate prices on Maui compared to many 
locations on the mainland. For these reasons, in addition to panel 
size, in certain locations where there are unique geographic factors 
that impact access and where a high percentage of complex patients are 
in need of frequent appointments, expanded full-time primary care 
provider staffing may be a salient consideration that might assure 
greater continuity and minimize disruption to care in the event that a 
full-time provider leaves VA employment. We found that the VA Pacific 
Islands Health Care System has proactively responded to the recent gap 
in primary care physician continuity by hiring a second full-time 
primary care physician for the Maui CBOC. This physician will begin 
seeing patients at the Maui CBOC within the next month.

            ACCESS TO OUTPATIENT MENTAL HEALTH CARE ON MAUI

    During the past year, the Maui clinic has had a full-time 
psychiatrist and psychologist. The psychiatrist reported that the CBOC 
has been experiencing an ongoing increase in the number of patients 
seen for mental health visits. The VA Pacific Islands Health Care 
System is presently recruiting applicants for several new positions at 
the Maui CBOC including a telehealth clerk, an addictions therapist, a 
psychology technician, and a psychologist to serve as a telehealth 
coordinator. In addition, a clinical nurse specialist with a mental 
health focus, who is presently assigned to the Kona CBOC, will 
reportedly be assigned to the Maui CBOC to provide patient care.
    Cognitive behavioral therapies including prolonged exposure therapy 
are among the best evidence supported treatments for Post Traumatic 
Stress Disorder. However, nationally, there is a relative shortage in 
both the VA and private sector of clinicians trained in specific 
cognitive behavioral techniques. The VA Pacific Islands Health Care 
System reported having recently contracted with a psychologist from the 
University of Pennsylvania to train VA psychologists in prolonged 
exposure therapy.

                      ACCESS ON MOLAKAI AND LANAI

    In addition to serving veterans on Maui, the CBOC supports veterans 
on the islands of Molokai and Lanai. A part-time physician and a mental 
health clinician are available a few days per week to see patients on 
Molokai. At the U.S. Senate Committee on Veterans' Affairs field 
hearings in Hawaii in January 2006, VA representatives committed to 
funding for telehealth capabilities with non-VA providers and announced 
that Molokai veterans would get telehealth equipment. VA Pacific 
Islands Health Care System primary care leadership reported having made 
contractual arrangements for veteran use of telehealth equipment that 
is owned and located at a non-VA clinic on Molakai. The equipment will 
be utilized when the telehealth positions are filled, and staff at the 
non-VA clinic will assist veterans and VA staff with its use. Service 
to veterans on Lanai was significantly impacted during the 9-month 
period in which the Maui CBOC was experiencing primary care staffing 
difficulties. In response, the VA Pacific Islands Health Care System 
began sending providers from Honolulu to serve the 55 veterans residing 
on Lanai. System leadership reports that subsequently a primary care 
physician has been seeing patients in Lanai on a regular basis. System 
leadership is subsequently considering permanently supporting VA 
services on Lanai from the medical center in Oahu rather than via the 
Maui CBOC. The VA Pacific Islands Health Care System has also recently 
begun partnering with a local hospital.

                 ACCESS TO NON-INSTITUTIONAL SERVICES 
                      PROVIDED TO VETERANS ON MAUI

    The Veterans Millennium Health Care and Benefits Act of 1999 
clarified requirements for VHA to provide non-institutional care for 
veterans in response to the changing needs of aging veterans. The Act 
directed VA to provide veterans eligible for medical services with 
certain services that are provided to veterans in their own homes or in 
community settings. VHA implemented policies requiring medical 
facilities to provide non-institutional care services to all eligible 
veterans and to include the services in the VHA medical benefits 
package. These services include: home based primary care; purchased 
skilled home health care; homemaker and home health aides (H/HHA); 
adult day health care; geriatric evaluation and management; respite 
care; and hospice and palliative care. In addition, VHA measures 
facility use of care coordination and telehealth services (CCHT).
    In 2006, at the request of Senator Akaka, the OIG was asked to 
determine what restrictions were being placed on veterans for access to 
certain non-institutional care services and whether these restrictions 
were appropriate or were inconsistent with the intent of the Millennium 
Act. The OIG report, Review of Access to Care in the Veterans Health 
Administration, found that the VA Pacific Islands Health Care System 
restricted contract adult day health care and H/HHA to highly service-
connected veterans, provided no outpatient respite prior to June 2005, 
and offered home based primary care only to veterans living within a 
50-mile radius of the VA Pacific Islands Health Care System or the Kona 
and Hilo clinics. The OIG report specified the need for VHA to make 
sure that facilities eliminate local restrictions limiting eligible 
veteran access to non-institutional care and, where possible, expand 
coverage to geographic areas that currently do not offer non-
institutional care services. VA clinicians reported that subsequent to 
the time of the U.S. Senate Committee on Veterans' Affairs field 
hearings in January 2006, both homemaker and home health aides and 
contract adult day health care services no longer have restrictions on 
service connection, and non-service connected veterans are eligible if 
they meet the medical qualifications for these programs.
    The VA Pacific Islands Health System primary care leadership 
reported that contract adult day health care is available on Maui, and 
additional funding has been allocated to bolster H/HHA services. There 
are no restrictions to home based primary care, however, the VA Pacific 
Islands Health Care system is presently recruiting for a nurse 
practitioner to provide the home based primary care to medically 
eligible veterans. CBOC staff report that purchased skilled home health 
services are available on Maui. In addition, a gerontologist has 
resumed working at the Maui CBOC every other month to perform 
comprehensive geriatric evaluation and management, and there are no 
restrictions to access as long as patients meet the program criteria. 
VA Pacific Islands Health Care System primary care leadership reported 
that they have begun consideration of ``health buddies'' and CCHT 
services for incorporation in future programming once the nurse 
practitioner to provide home based primary care is on board. At 
present, respite care is only available on Oahu and on an inpatient 
basis.

                ACCESS FOR VETERANS TO NON-VA SPECIALTY 
                       AND HOSPITAL CARE ON MAUI

    Another challenge concerns veteran access to non-VA fee basis 
specialty or sub-specialty care. Some specialty providers may have full 
practices and are no longer taking new patients or may not accept the 
reimbursement rate provided by VA fee basis. Additionally, though the 
CBOC benefits from indirect access to specialty care through the 
sharing agreement with the Tripler Army Medical Center, the Maui CBOC 
does not derive the direct access benefit experienced from physical co-
location experienced by veterans at the Matsunaga Medical Center. To 
address this issue, the VA Pacific Islands Health Care System primary 
care leadership is examining possible future telehealth alternatives, 
such as tele-optometry and tele-dermatology to provide certain 
outpatient specialty care services.
    A further challenge facing the VA Pacific Islands Health Care 
System is the limited medical infrastructure on Maui. Maui Memorial 
Hospital is presently the only hospital on the island. When veterans 
are admitted to the hospital, which is a state run facility, they are 
admitted on a rotational (on-call) basis to the service of local 
physicians at Maui Memorial Hospital. VA staff reported that some non-
VA health care entities have hired hospitalists to care for their 
patients admitted to Maui Memorial Hospital. A hospitalist is a doctor 
who specializes in the care of hospitalized patients, whose focus is 
treating health conditions for which patients are often hospitalized, 
and whose office is usually located within the hospital. Whether or not 
the number and medical complexity of veterans admitted to Maui Memorial 
Hospital would justify hiring or contracting for the services of a 
hospitalist is a question for further study by the VA Pacific Islands 
Health Care System leadership.

                                SUMMARY

    Over the past year, the VA Pacific Islands Healthcare System 
leadership has taken actions to improve access to care for veterans on 
Maui and to enhance the consistency and continuity of care that will be 
provided. Although staff recruitment and programming to enhance future 
access are in process, some obstacles to access remain for veterans on 
Maui.
    Mr. Chairman, thank you again for this opportunity to testify. I 
would be pleased to answer any questions that you or other Members of 
the Committee may have.

    Senator Akaka. Thank you very much, Dr. Shepherd, for your 
testimony. And now I have some questions for the witnesses.
    Dr. Kussman, in recent years, VA has made significant 
strides in telemedicine. And telemedicine capabilities in 
Hawaii already have helped many people. When do you expect to 
fully implement telemedicine capabilities of the neighbor 
islands of Molokai and Lanai?
    Dr. Kussman. Sir, as we discussed yesterday when we were 
visiting Lanai, and you'll see tomorrow with Molokai, that this 
is a work in progress. I think I'd have to refer to Dr. 
Hastings on this specific dates. But as we're doing here in 
Maui, the program in hiring the appropriate telemedicine 
people, this is a very important program for us, as you know. 
Because it allows us the leverage technology to get the 
services to the veteran, rather than having to get the veteran 
to the services.
    And the VA has been a leader nationally in the 
implementation of telemedicine. So we're very proud of what 
we're doing. And we'll continue working very hard to increase 
the capability on the island.
    Senator Akaka. Dr. Hastings, will you comment further on 
that.
    Dr. Hastings. Yes. Thank you very much, Senator.
    This is clearly an area that we have--that the VA has great 
interest in, and, I think, is actually leading the country in 
many areas in developing this technology to improve access and 
quality care.
    Of course, delivering care to more isolated places is the 
challenge. And I can tell you that we have developed the 
capability of delivering telemedicine to both of those islands. 
And the challenge that we face right now is to educate our 
providers in the best utilization of this technology. We have 
it set up. We're ready to make the connections. Indeed, we've 
made the connections. We've had very good cooperation from the 
state and from Hawaii Health Systems Cooperation in allowing us 
to work with them and use their equipment.
    And so really the challenge that we face now is to have all 
of our physicians make use of the technology, learn how to use 
it, learn when to use it. And I think we ought to move ahead 
smartly on this within the next year or two.
    Thank you very much.
    Senator Akaka. Thank you for that, Dr. Hastings.
    Dr. Kussman or Dr. Wiebe, staffing at the Maui clinic is an 
ongoing issue for veterans. While your testimony speaks to the 
need for an additional providers of the clinic and the addition 
of a home care program, when can we expect these changes to 
take effect?
    Dr. Kussman. Mr. Chairman, thank you for the question. As 
was mentioned, the second full-time person will be here on the 
7th of September, I believe. But the larger issue of 
recruiting, as was mentioned by the first panel and ourselves, 
has been a puzzle to me, actually. And we've had a chance to 
talk about that.
    This is such a wonderful place to live and such a wonderful 
area that it's been strange that we haven't been able to get 
people who wanted to come here. And there are a lot of issues 
related to where you are in your stage of life and the housing, 
and all of that. But even with offering enticements and things, 
we've been challenged to do that.
    And we're working hard to find out what are the issues that 
don't allow us to hire people, or they don't want to come here.
    This is not unique to Maui. It is a problem throughout the 
islands. Even getting people to come to Oahu, for the cost of 
living and things. So we're working they hard on that and 
looking for innovative ways to encourage people to come.
    I don't know. Bob, if you would like to add anything no 
that.
    Dr. Wiebe. I'll just add, in addition to the primary care 
physician who will join us next month, we're currently 
recruiting for the home-based primary care nurse. As Dr. 
Kussman indicated in his testimony, we are recruiting to fill 
the five mental health care providers that will be at the 
clinic. And as noted by earlier witnesses, we will be hiring a 
psychologist, hopefully, at the Vet Center very soon.
    Senator Akaka. Dr. Wiebe, at the field hearing we held last 
year on Maui, you and I discussed the fact that, in light of 
network budget constraints, certain types of care were being--
let me use the word rationed. You stated at the time that you 
would look into the situation and work to correct it. Is the 
full VA benefit's package now available to all veterans on 
Maui?
    Dr. Wiebe. Thank you for the question, Mr. Chairman. As you 
know, several years ago, the VA faced formidable resource 
constraints and budget challenges. In response, we implemented 
referral criteria for non-VA care, including noninstitutional 
long-term care services.
    Fortunately, and thanks to your leadership on this 
Committee, VA funding has substantially increased since we last 
met. And as we have noted, we've hired additional staff at the 
Maui clinic for primary care, mental health and telehealth. In 
addition, we have increased the number of patients we're 
referring to the Maui community, and increased the amount of 
money we're spending in the Maui community.
    Specifically, as Dr. Shepherd noted, compared to 
noninstitutional long-term care services last year, we have 
increased over 30 percent the average daily census in 
noninstitutional care in fiscal year 2007. And specifically, we 
have doubled the average daily census for the homemaker health 
aids.
    So mahalo again for this question. But more importantly, 
mahalo for your leadership on this Committee, as well as your 
support for the Department of Veterans Affairs.
    Senator Akaka. Thank you, Dr. Wiebe.
    Dr. Shepherd, what is your assessment of the current status 
of the access to both primary and specialty care on Maui?
    Dr. Shepherd. Currently, the access to primary care is in a 
stabilization phase. And hopefully, with Dr. Chin onboard and a 
new physician coming, hopefully for patients over the next 
three or four months, the clinic will move from a stabilization 
phase to a more fluid phase of care.
    Some of the veterans on the first panel have brought up 
some issues, including those related to travel expense for 
speciality appointments.
    When veterans are admitted in Maui Memorial, there is a 
discontinuity of care because there's not a VA provider caring 
for them at the hospital. So I think there's still some access 
to specialty care issues that the system needs to continue to 
look at and evaluate.
    Senator Akaka. On mental health care on Maui, do you 
believe that it's up-to-par?
    Dr. Shepherd. I believe it is with the addition of the five 
new clinicians coming in. I think in the broader picture, one 
of the major challenges the VA has is that surprisingly over 
the past three, four years, about 75 percent of new mental 
health patients for the system, as a whole, are the aging 
Vietnam era veterans.
    I think one of the challenges the system is going to face 
as a whole and on Maui is tracking the rates of change in both 
the returning OIF/OEF population that's going to need mental 
health services and the aging Vietnam veteran population, and 
really trying to stay ahead of those rates of change.
    Senator Akaka. Dr. Shepherd, access to long-term care is 
another issue that is of great concern to me and to many 
veterans here as overall capacity in Hawaii, as we know, is 
strained. What is your assessment of the current availability 
of noninstitutional care on Maui?
    Dr. Shepherd. Over the past year, access to 
noninstitutional care has improved.
    As mentioned by other panelists, once nurses are onboard to 
provide a home-based primary care this will also lead to 
further improvement in access.
    Senator Akaka. Finally, I just want to ask if any of you 
has any final statements to make before we adjourn.
    Dr. Kussman?
    Dr. Kussman. Mr. Chairman, again, thank you for the 
opportunity to be here, to listen and to learn, and to continue 
to partner with you. We're very fortunate to have you as the 
Chairman of the Senate Committee on Veterans' Affairs. As you 
know, we pledge to work with you regularly and the VSOs and 
anyone who wants better care for veterans.
    And again, mahalo.
    Senator Akaka. Thank you. And thank you very much, all of 
you, for your testimony. It's been very helpful. And we look 
forward to working together to help the veterans of our 
country. This hearing is adjourned.
    [Whereupon, at 1:05 p.m., the Committee was adjourned.]

                            A P P E N D I X

                              ----------                              

                                                   August 22, 2007.

    Re: Allowing private mental health doctors to assist veterans.

    The VA bureaucracy has become so thick that many Vets are 
discouraged from getting the mental and physical help they need. As a 
result we have Vets killing their families and themselves.
    It is a well known fact that the VA does not have sufficient mental 
health resources throughout the system. However, there are many 
qualified mental health providers who would love to do their patriotic 
duty and help injured vets. I don't understand why the VA will 
willingly outsource to medical doctors and dentist but not to mental 
health specialist, whom they need the most.
    The VA does outsource their C&P evaluations to assist the VA to 
process claims, but they do not out source to private mental health 
specialist to assist vets, they only outsource to assist the VA.
    It would be cost effective because the outsource doctor's will only 
be paid on an as needed basis. No extra monies need to be spent on 
facilities or employee benefits making this approach more cost 
effective than maintaining the high cost of clinics with their 
administration and maintenance cost.
    Now we can only get help during regular office hours, however most 
of our problems happen in the non-office hours. The expensive clinic is 
useless 2/3's of the time, but the government pays for it 24/7. I think 
most suicides occur in non -office hours when the mental help is not 
available. Lack of immediate attention has directly caused veteran 
suicides, like it did recently at Tripler.
    Maui has maintained a high cost clinic and much of the time there 
isn't even a doctor there to treat the vets. Please remember only the 
doctor's provide the life saving treatment, not the facilities that 
cost the most. On Maui after hours and on weekends we are told to call 
911 and go to hospital emergency room. This is very expensive and over 
triples the cost of our care, and there is no continuity of care. Why 
can't we go directly to private doctors and not wait for clinic hours 
and face a long wait period or go to the ER at extra expense to the 
government.
    Lastly, we would like to thank you for your kind consideration and 
real help you have provided us over the years. We are especially 
impressed at how you jump in and work to help us when we ask for your 
help. You had a major role in correcting a problem we were having with 
our C&P process. We offer our heartfelt gratitude and appreciation.
                                       Concerned Maui Diabled Vets.


 HEARING ON ACCESS TO VA HEALTH CARE AND BENEFITS IN KONA AND OUTREACH 
                   TO THE GUARD AND RESERVE IN HAWAII

                              ----------                              


                        MONDAY, AUGUST 27, 2007

                               U.S. Senate,
                    Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 1:00 p.m., in 
Sheraton Keauhau Bay, Kailua Kona, Hawaii, Hon. Daniel K. 
Akaka, Chairman of the Committee, presiding.

     OPENING STATEMENT OF HON. DANIEL K. AKAKA, CHAIRMAN, 
                    U.S. SENATOR FROM HAWAII

    Senator Akaka. The panel field hearings of Senate Committee 
on Veterans' Affairs will come to order.
    Aloha. Before I make my opening remarks, you've witnessed 
the presentation of a check, and for those of you who may not 
know and who may not have heard the news, the VA has approved a 
grant to make significant improvements to the West Hawaii Vet 
Center here in Kona. VA Under Secretary Bill Tuerk, who is Gene 
Castagnetti's boss, advised the Committee of this development 
during his testimony at our hearing in Honolulu. I could not be 
more pleased that we're able to get this done for the veterans 
here on the Big Island.
    I'd like to welcome all of you to this hearing. This is our 
third and final official hearing of the Senate Committee on 
Veterans' Affairs that I'm chairing here in Hawaii.
    We held similar hearings at the beginning of 2006. Much has 
improved since that time for which I am very, very grateful. 
However, it is important for the Committee to understand the 
remaining challenges that we now face.
    The focus of this hearing will be on access to VA health 
care for veterans living in Kona, and on the effectiveness of 
VA's outreach to redeploying and separating members of the 
Guard and Reserve in Hawaii.
    We are all aware that after Vietnam and other wars some 
servicemembers who honorably served their Nation were not 
provided with the care and services that they needed to 
reintegrate into society. Caring for returning servicemembers 
must be considered part of the continuing costs of war.
    It is important that we look not only at the quality of 
care that is provided, but also at the outreach process to 
notify separating servicemembers of what they're entitled to 
and what VA can do for them. We must ensure that adequate 
levels of care and services are available to those that leave 
the Armed Forces, including members of the Guard and Reserve. 
We have learned that the earlier a veteran receives care after 
separation from the military, the lower the risk of him or her 
developing a long-term problem. An important part of the 
Dignified Treatment of Wounded Warriors Act, which recently 
passed the U.S. Senate is my provision to extend the period of 
eligibility for VA health care for combat veterans of the 
Persian Gulf War and subsequent wars from 2 years to 5 years 
after discharge or release.
    The Senate bill includes Veterans' Affairs Committee-
endorsed provisions that will improve access to mental health 
care, extend the application period for dental benefits 
following discharge, and designate the National Guard and 
Reserves as integral components of VA's outreach program.
    The Dignified Treatment of Wounded Warriors Act was truly a 
collaborative effort between the Senate Veterans' Affairs 
Committee and the Senate Armed Services Committee. I want to 
tell you that this is the Hawaiian spirit and Hawaiian style of 
doing business. I'm so delighted that this collaboration 
between two Committees made that happen quickly.
    Finally, I note that there are many veterans here today who 
would like to testify. We cannot accommodate everyone's request 
to speak. However, I do want to hear your views. The Committee 
is accepting written testimony, which will be reviewed and made 
part of the record of today's hearing. If you have brought 
written testimony with you, please give it to Committee staff 
who are seated at the table back there, or located also in 
other places in the room, but we have a table on this side. If 
you do not have written testimony but would like to submit 
something, Committee staff will assist you. In addition, the 
Committee staff is joined by VA staff who can respond to the 
questions, concerns, and comments that you raise.
    We are fortunate today that we have top people here from 
Federal and state government. Coming from the Federal 
Government we have VA staff. We also have Mark Moses from the 
state here.
    Once again, I want to say mahalo to all of those who are in 
attendance today, and I look forward to hearing the testimony 
of our witnesses today. I want to welcome the first panel to 
today's hearing. Thank you for being here today. First, I want 
to welcome David Ferreira. David Ferreira is the director of 
the Hilo Family Assistance Center and retired member of the 
National Guard. I also welcome First Sergeant Allison T. Yano, 
who was deployed in Operation Iraqi Freedom. Your full 
statements will appear in the record of the Committee.
    So, Mr. Ferreira, will you begin with your testimony.

 STATEMENT OF DAVID T. FERREIRA, FAMILY ASSISTANCE SPECIALIST, 
                   HAWAII ARMY NATIONAL GUARD

    Mr. Ferreira. Mr. Chairman, these are my comments based on 
my experience as a family----
    Senator Akaka. Let me interrupt. Can you folks hear him? 
You can? Thank you.
    Mr. Ferreira. Through my experiences as a family assistance 
specialist on the Big Island. It takes too long for VA to 
determine the disability to receive treatment and compensation. 
Many Guard and Reserve soldiers that return from deployment are 
anxious to go home, often do not disclose conditions that would 
normally be treated during their out processing and delay their 
return home. Once separated, they realize the condition has 
worsened or requires treatment. This causes problems with their 
civilian jobs and prevents them from seeking employment.
    Both Hilo and Kona both lack services and specialty care in 
the remote areas. The Community Based Outpatient Clinics in 
Hilo and Kona provide much needed services, but at times they 
lack the staffing or the specialist required. Members are 
required to either wait for specialists to come in or travel to 
Oahu.
    Although VA has expended their services to families, the 
Vet Caenters here lack the credentialed or licensed counselors 
to provide services to family, and when it's available, it's 
only for a limited time. This has been particularly true of 
both centers here and in Kona. I've had several servicemembers 
tell me that they went to the clinic and there were no 
counselors there at that time, especially for family members.
    The VA has done a good job in dealing with traditional 
problems of active duty veterans, but they're not prepared for 
the large influx of Guard and Reserve servicemembers that 
return from deployment.
    Our citizen soldiers and family members pose a unique set 
of problems. Our active duty counterparts return to a 
relatively stable environment, military environment, whereas 
Guard and Reserve members deal with returning back to the 
civilian sector. Returning Guard and Reserve servicemembers 
have the same stresses of active duty members, but they also 
have the additional stresses of returning to their civilian 
jobs. Sometimes they require retraining, requalification. There 
are different people working there. In some cases they have to 
go into different positions. They also have to deal with their 
families that were disrupted.
    The families on the outside islands in remote areas become 
instant military families when the Guard and Reserve members 
get mobilized. We lack the military infrastructure of places 
such as Oahu with large military installations. We have to rely 
on the civilian sector, which is ill prepared to deal with 
these requirements. Even our schools were unsure of how to deal 
with children who have parents or family members and in some 
cases multiple family members deploying.
    The VA, the Guard, and Reserves needs to continue to expand 
its outreach for our servicemembers and encourage them to 
utilize the services provided. One of the problems in our Guard 
and Reserve members is overcoming the stigma or perception of 
going to the VA. Many worry that it will affect their civilian 
jobs and are reluctant to come in.
    On a final note, I feel that in the past several years the 
VA's greatly improved and expanded its services and it's 
largely due to the oversight of this Committee. Thank you.
    [The prepared statement of Mr. Ferreira follows:]

               Prepared Statement of David T. Ferreira, 
        Family Assistance Specialist, Hawaii Army National Guard

    Dear Mr. Chairman:
    My name is David T. Ferreira, I am a retired Sergeant First Class 
with 30 years in the Hawaii Army National Guard, of which I served 24 
years on Active Guard (AGR) as a Senior Human Resource Sergeant. I am 
presently the Family Assistance Specialist, Hawaii Army National Guard 
for the island of Hawaii. I am also a DEER/RAPIDS administrator and 
issue I.D. Cards to Military Servicemembers of all branches, DOD 
Civilians, Retirees, Disabled American Veterans (DAV) and their 
dependents.
    The following are comments/issues:
    It takes too long to determine disability, to receive treatment and 
compensation. Many Guard and Reserve soldiers that return from 
deployment are anxious to go home, often do not disclosed conditions 
that would normally be treated during their out-processing and delay 
their return. Later once separated they realize the condition has 
worsened, and requires treatment, this causes problems with their 
civilian jobs or prevents them from seeking employment.
    Lack of service and specialty care in remote areas, the Community 
Based Outpatient Clinics in Hilo and Kona provide much needed services, 
but many times they lack the staffing or specialist required. Services 
members are required to either wait for a specialist to come in or 
travel to Oahu.
    Although the VA has expanded services to families, the Vet Centers 
here lack credentialed/licensed counselors to provide that service to 
families, and when available it is only for a limited time. This has 
been particularly true of both Vet Centers here in Hilo, and Kona. I 
have had several servicemembers and families tell me that they refuse 
to see the counselor at the Hilo Vet Center, they were very critical of 
the individual there.
    The VA has done a good job in dealing with the traditional problems 
of active duty veterans, such as physical injuries or PTSD. But they 
were not prepared for the large influx of Guard and Reserve 
servicemembers returning from deployments, our citizen soldiers/airmen 
and family members posed a unique set of problems.
    Our active duty counterparts return to a relatively stable military 
environment versus Guard and Reserve members have to deal with 
returning to the civilian sector. Returning Guard and Reserve 
servicemembers have the same stresses as active duty members, but they 
also have the additional stresses of returning to their civilian jobs 
(some require retraining, qualification, different personnel, and in 
some cases different positions), and disrupted families.
    Families on the outside islands and remote areas became instant 
military families, upon the mobilization of their Guard/ Reserve 
members. They lack the military infrastructure (such ACS, etc.) of 
places like Oahu with large military installations. They have to rely 
on the civilian sector which was ill prepared to deal with the 
deployments. Even our schools were unsure of how to deal with children 
that had a parent or other family member (in some cases multiple family 
members) deploying.
    The VA, Guard and Reserve needs to continue to expand its outreach 
to our servicemembers and encourage them to utilize the services 
provided. One of the problems with our Guard and Reserve member is 
overcoming the stigma or perception of going to the VA, many worry it 
will affect their civilian jobs and are reluctant to come in.
    On a final note, I feel that in past several years the VA has 
greatly improved and expanded its services to our veterans and their 
families largely due to the oversight and concern by Members of this 
Committee.

    Senator Akaka. Thank you. Thank you very much, Mr. 
Ferreira.
    And now, Mr. Yano.

 STATEMENT OF FIRST SERGEANT ALLISON T. YANO, OPERATION IRAQI 
                        FREEDOM VETERAN

    1st Sgt. Yano. Mr. Chairman, thank you for this opportunity 
to appear before you today to present my personal experiences 
and observations with the VA as a Guardsman returning from 
Operation Iraqi Freedom.
    Streamlined access to VA health care benefits must get to 
all combat veterans. The Iraq-Afghanistan Post-Deployment 
Screen was initiated throughout the Department of Veterans' 
Affairs in 2004 to identify OEF/OIF veterans who may have had 
the need or clinical intervention for conditions such as PTSD, 
depression, alcohol abuse, chronic and infectious diseases. 
Early intervention was a goal to identify those who screened 
positive for these conditions.
    The inability to complete the post deployment survey with 
the VA soon after their war experience hampered the opportunity 
to prevent a quality transition and readjustment to civilian 
life, as well as identify those with possible PTSD, depression, 
alcohol/substance abuse, or other psychological issues as a 
result of our National Guard service within the combat zone.
    The screening is conducted only with OEF/OIF veterans who 
have enrolled with the VA. As of two months ago, not all 
soldiers who returned from our deployment enrolled, and only a 
small number of combat veterans who signed up for VA benefits 
were contacted and received the screening. A vast majority of 
combat veterans failed to receive early intervention. We're 
only now getting our soldiers enrolled.
    This was due to a recent incident involving a fellow 
soldier and the failure of qualitative counseling by the VA 
after returning from a combat zone. Coupled with this is a lack 
of streamline process of continued care with the VA, as well as 
stressing the importance to the soldier in following up with 
their recommended care. Only after this incident were we able 
to put into perspective the importance in enrolling and 
utilizing the services of the VA health care system.
    Additionally, we had to make our own coordination for 
readjustment counseling, educational briefings with the VA, 
which should have been completed during the demobilization 
process. Furthermore, the insufficient number of social workers 
available to handle the large number of OEF/OIF veterans 
prevented the screenings from being conducted.
    A recommendation would be to make the enrollment to VA 
health care system mandatory and part of our demobilization 
process. This would allow VA to administer the Iraq-Afghanistan 
Post-Deployment Screen to a greater number of returning 
veterans at an earlier point after deployment.
    Also, the lack of medical specialists in our geographical 
location is another concern. The islands of Hawaii, Maui, 
Molokai, Lanai, and Kauai do not have the same resources of 
medical specialists as on Oahu; therefore, veterans who reside 
on these islands are referred to see specialists on the island 
of Oahu and are asked to pay for our transportation costs. This 
is a deterrent to having soldiers get the necessary 
examinations we need.
    A recommendation is to have referred visits to specialists 
paid for by the VA, or to have specialists flown to the outer 
islands on a periodic schedule. I would like to acknowledge the 
efforts of the staff of the VA Hilo Community Based Outpatient 
Clinic in assisting myself and fellow combat veterans in 
providing the best service they can with the minimal staffing 
they have.
    In closing, there are needed adjustment to ensure that 
access to VA health care and benefits get to all combat 
veterans. Although there are other concerns that are in the 
minds of my fellow combat veterans, what is provided in this 
testimony is of the greatest concern. It is hoped that this 
testimony, along with others being given today, will expedite 
necessary changes.
    Mr. Chairman, this concludes my statement. I would be 
pleased to answer any of your questions.
    [The prepared statement of 1st Sgt. Yano follows:]

         Prepared Statement of First Sergeant Allison T. Yano, 
                    Operation Iraqi Freedom Veteran

    Mr. Chairman, thank you for the opportunity to appear before you 
today to present my personal experiences and observations with the VA 
as a Hawaii Army National Guardsman returning from Operation Iraqi 
Freedom III.
    Streamlined access to VA health care and benefits must get to all 
combat veterans. The Iraq-Afghanistan Post-Deployment Screen was 
initiated throughout the Department of Veterans Affairs in 2004 to 
identify OEF/OIF veterans who may have had the need for clinical 
intervention for conditions such as PTSD, depression, alcohol abuse, 
chronic and infectious diseases (ID). Early intervention was the goal 
to identify those who screened positive for mental health conditions 
and to refer others to specialty care for ID or chronic medical 
conditions. The inability to complete the post deployment survey with 
the VA, soon after their war experience hampered the opportunity to 
prevent a quality transition and readjustment to civilian life as well 
as identify those with possible PTSD, depression, alcohol/substance 
abuse or other psychological issues as a result of our National 
Guardsmen's and women's service within a combat zone. The screening is 
conducted only with OEF/OIF veterans who have enrolled with the VA. As 
of two months ago, not all soldiers who returned from our deployment 
enrolled and only a small number of combat veterans who signed up for 
VA benefits were contacted and received the screening. A vast majority 
of combat veterans failed to receive early intervention. We are only 
now getting our soldiers enrolled. This was due to the recent incident 
involving a fellow soldier and the failure of qualitative counseling by 
the VA after returning from a combat zone. Coupled with this is the 
lack of a streamlined process of continued care with the VA as well as 
stressing the importance to the soldier in following up with their 
recommended care. Only after this incident were we able to put in 
perspective the importance in enrolling and utilizing the services of 
the VA health care system. Additionally, we had to make our own 
coordination for readjustment counseling and educational briefings with 
the VA, which should have been completed during the demobilization 
process. Furthermore, the insufficient number of Social Workers 
available to handle the large number of OEF/OIF veterans prevented the 
screenings to be conducted.
    A recommendation would be to make enrollment in the VA health care 
system mandatory and part of the demobilization process. This would 
allow the VA to administer the Iraq-Afghanistan Post-Deployment Screen 
to a greater number of the returning veterans at an earlier point after 
deployment.
    The lack of medical specialists and our geographical location is 
another concern. The islands of Hawaii, Maui, Molokai, Lanai, and Kauai 
do not have the same resources of medical specialist as on Oahu, 
therefore, veterans who reside on these islands and referred to see 
specialists on the island of Oahu, are asked to pay for their 
transportation cost. This is a deterrent to having soldiers get the 
necessary examinations and help.
    A recommendation is to have referred visits to specialist paid for 
by the VA or to have specialist flown to the outer islands on a 
periodic schedule.
    I would like to acknowledge the efforts of the staff at the VA Hilo 
Community Based Outpatient Clinic in assisting myself and other fellow 
combat veterans in providing the best service they can with the minimal 
staffing that they have.
    In closing, there are needed adjustments to ensure that access to 
VA health care and benefits get to all combat veterans. Although there 
are other concerns that are in the minds of my fellow combat veterans, 
what is provided in this testimony is of the greatest concern. It is 
hoped that this testimony along with others being given today will 
expedite necessary changes.
    Mr. Chairman, this concludes my statement. I would be pleased to 
answer any questions you or other Members of the Committee may have.

    Senator Akaka. Thank you, Allison Yano, for your testimony.
    I do have some questions for both of you. I'm so glad to 
hear some of your concerns that will help us try to continue to 
improve whatever has been improved already. My question to both 
of you has to do with servicemembers and their families. I want 
you to tell us what the challenge is, and if you have a 
solution in mind, also mention that, because we are looking for 
solutions.
    So here is the question: Do you believe that servicemembers 
and families are sufficiently informed about VA benefits and 
services? Mr. Ferreira.
    Mr. Ferreira. We try to make sure they're informed, both 
families and soldiers. But like I said, a lot of them are 
reluctant to go to the VA because they still have to go back to 
their civilian jobs, and a lot of times I guess it's basically 
a perception problem that, oh, you went to see the VA, that you 
have some kind of disability, you know, where it may or may not 
affect his job, but it's just a perception that it will.
    On the family side, VA was not ready for families with 
problems. We had instant military families, and when they went 
to VA, the counselors there were more geared to deal with 
soldiers with physical injuries and maybe PTSD-type problems, 
not marital problems, separation anxiety problems, or even 
children with problems dealing with the deployment of their 
parents.
    In some cases both parents were deployed. We've had several 
people with both parents deployed and the kids were with the 
grandparents or aunties and uncles and there really were not 
enough counselors qualified to deal with them.
    How would we fix the problem? That part I really don't 
know, other than providing more trained counselors that would 
be a great help.
    Senator Akaka. Thank you very much, David.
    Allison Yano.
    1st Sgt. Yano. Sir, we did receive some briefings after 
deployment, post-deployment process, and at that time I don't 
think the briefings were standardized to all the different 
units, and I don't think it was conducted at a time that was 
right.
    Everyone--again, like Mr. Ferreira stated in his testimony, 
everyone is in a rush to get back to their families, so hearing 
some of this information at that time was not a priority. What 
I found in my experiences dealing with the VA is that the 
perfect briefing I think was already there. The VA's 
orientation briefing that you receive when you register with VA 
would have been the ideal briefing to receive. However, again, 
a lot of people just put registering with the VA on the side, 
in the back of their minds because all they wanted to do is get 
back into their civilian life.
    Recently we held some briefings that brought out these 
points and we had help from Helping Hands Hawaii, a nonprofit 
association, that conducted briefing for us, and with those 
briefings we were able to get a number of our combat veterans 
registered with the VA. We're still in the process of 
increasing the numbers, and also bringing that out to the 
families.
    So we're working with the FRGs to make this information 
available to them as well, and that is our work toward the 
solution to this problem. I think it's just a matter of getting 
the right information out at the right time.
    Senator Akaka. Thank you very much. You're not the first to 
tell us that when a person is being separated, their priority 
is to get home and get back to their family. This is something 
we have to take into consideration. And as David mentioned, the 
word reluctance, some of them are reluctant to seek the help. 
I'm hoping these sessions that we have here, and with your help 
and others, and Helping Hands' help, that we'll be able to get 
veterans to feel easy enough to know that VA is there to help 
them, and that they should be able to contact VA.
    Here's another question to both of you, and this has to do 
with families. And as you pointed out, VA really has not had a 
focus on family, because they focus on veterans and not 
veterans' families. But with this war and also with 
deployments, and also with the fact that more veterans are now 
married, about 38 percent of servicemembers have families. We 
know how important families are to the troops, so we need to 
help take care of families as well. We hope that in the future 
programs we'll be able to put more focus on helping families.
    You are aware that the well-being of families plays an 
important role in the well-being of veterans. How can families 
be more effectively included in the transition process and in 
caring for veterans? David?
    Mr. Ferreira. I guess both the VA, Guard, and Reserve would 
have to, when they do their out processing, we actually have--
when the soldiers return back to their home islands, rather 
than--you know, all the out process is done in a military 
installation, and families are not physically present there. 
They may have visited but they're not physically there, so they 
don't really hear anything about the benefits available. I know 
I myself is guilty of--a lot of times I get told stuff and I 
would never go tell my wife, oh, yeah, we need to do this. So 
maybe if they have a briefing back here again--we had 
briefings, but, again, not with the family around, the soldier 
is there. If part of out processing is at their home station, 
that might help get the word out better.
    Senator Akaka. Thank you. Allison.
    1st Sgt. Yano. I think that's a good suggestion. A lot of 
families were not even told about a lot of this from their 
soldiers returning. Even ego issues or embarrassment issues, 
those play a little part of it. But I think somewhere along the 
line of the post employment period that we can have a period 
where the families can come in and receive this briefing, that 
will help the situation.
    Senator Akaka. As I mentioned, improvements have been made 
in services, but I repeat again, we are here to try to learn 
more about what further improvements can be made. Helping 
servicemembers adjust may take more than VA can provide. You 
mentioned Helping Hands--I'm so glad that we're finding 
veterans organizing to help themselves and their families, 
which is really great here in Hawaii.
    Are you aware of local groups partnering with VA and 
military to enhance access to services for returning veterans?
    David?
    Mr. Ferreira. The National Guard have a retirees group that 
work kind of closely with the VA, but that's the only group 
that I know of that works closely with the VA. Part of their 
members are part of the VA, the DAV, and they're both retired 
Guardsmen and belong to the DAV, so they work pretty closely 
with the VA to do outreach type of work.
    Senator Akaka. Yes.
    1st Sgt. Yano. I've been aware just recently with Mr. Park, 
with Helping Hands Hawaii, and through working with him, along 
with the VA, we've been able to get the education and 
information out to the soldiers. But, again, this is just a 
small amount.
    We worked on a unit, because the individual that I 
mentioned was within my unit as a co-worker, so it was a big 
issue for us. But working with these other organizations helped 
to get the information out, and I think if we can continue to 
do this, you'll see greater improvements and involvement by our 
families and so forth.
    Senator Akaka. My final question to both of you. I am aware 
that the Family Assistance Centers of the Hawaii Department of 
Defense provide a broad range of services to families of the 
Hawaii National Guard. What services do you offer to families 
transitioning from active duty to civilian life, and which 
services have been most important to families? David.
    Mr. Ferreira. I normally provide a referral service. 
Although I belong to the Hawaii Army Guard, we deal with all 
services, even Coast Guard people come in. I also issue ID 
cards for servicemembers and their dependants, also 100 percent 
disabled veterans, and I normally do a referral service. If 
they need legal-type counseling, we refer them to people we 
have on the list, or specifically a lot of times we refer them 
to the Military Family Life Consultants for counseling 
services. They've been a real good resource on this island. And 
we've recently lost that individual. For whatever reason, his 
contract was terminated. I'm not really sure why. He was here 
and he was willing to do counseling for the entire island. He's 
actually out of--he actually works up in Waimea, but somehow he 
lost the contract.
    I'm not sure why he was taken off. A lot of the families 
really liked that individual as far as going to see him for 
counseling. He dealt with families and their children a lot of 
times. And that was kind of a great loss for this island, I 
know that.
    Senator Akaka. Thank you. Mr. Yano.
    1st Sgt. Yano. The big service that we've been using lately 
is the Vet Center, which was instrumental in getting a lot of 
other soldiers that we identified as having some issues, 
resolution to the issues and helping them readjust and get back 
into the civilian life and their families. Some family members 
also took place in that conference, and that was key for us. 
Other than that, Military OneSource was another route that we 
sent people to.
    Senator Akaka. Well, you know, I want to thank you so much 
for your testimony and also your responses to the questions 
I've asked. I want to tell you that you've been helpful to what 
we're trying to do, and together we can continue to improve 
services to veterans. So, again, I want to thank our first 
panel very much.
    [Applause.]
    Senator Akaka. Now, I want to welcome our second panel of 
witnesses. First, I welcome Brigadier General Gary Ishikawa, 
who is the Deputy Adjutant General, Hawaii Army National Guard. 
I also welcome Colonel Gerald Gibbons, Chief of Staff of the 
9th Regional Readiness Command, he is accompanied by Colonel 
Floresita Quarto. I want to thank both of you for being here. 
Your full statement will appear in the record of this 
Committee. We look forward to your testimony.
    So will you please begin with your testimony, General 
Ishikawa.

         STATEMENT OF BRIGADIER GENERAL GARY ISHIKAWA, 
      DEPUTY ADJUTANT GENERAL, HAWAII ARMY NATIONAL GUARD

    General Ishikawa. General Akaka, Members of the Committee, 
aloha. Good afternoon.
    Senator Akaka. Aloha.
    General Ishikawa. Thank you for having us here. I have to 
profess upfront that in my mad rush to get here, I have 
misplaced my written testimony.
    Fortunately, I've read it three or four times and I 
remember the salient points, so I will forward to your staff my 
official written testimony.
    Senator Akaka. We'll make that part of the record.
    General Ishikawa. Thank you, Senator Akaka.
    I'm here on behalf of Major General Bob Lee, the Adjutant 
General for the State of Hawaii, and he testified on August 21 
on Oahu. And it's my distinct pleasure and honor to be here in 
Kona representing the State Department of Defense.
    I'm Gary Ishikawa. I'm the Deputy Adjutant General for the 
State of Hawaii. Let me start off by saying the Department of 
Defense is broken down or organized into four major divisions, 
that's the Hawaii Army and the Hawaii Air National Guard, State 
Civil Defense, and most important and relevant to these 
hearings is the Office of Veterans Services, the State of 
Hawaii office. Now, our new head person there is a retired 
Major, Mark Moses. I believe he'll be testifying also as part 
of the panels to follow. So I won't go into some of the areas 
he's scheduled to talk about.
    I will add that since the State Office of Veterans Services 
is part of the State Department of Defense, it's been really my 
privilege and honor to really work hard with that agency to 
create a very effective newsletter, and that's something funded 
by the State legislature and is growing more and more. I'm not 
naive enough to believe that that's the only mechanism to 
communicate, but I think it's a very important mechanism 
besides, of course, the State Department of Defense web site, 
has some important links with information. Again, it's not only 
going to be one or two methodologies. It has to be many, many 
efforts to communicate to our veterans the benefits as they are 
available to them and the newer benefits that's becoming--
thanks to your great help becoming--made a state of law.
    At this point in time, nine out of ten reservists, and I 
include the Army Reserves and the Army National Guard, have 
deployed to Iraq or Afghanistan. At one point in time part of 
our total veterans population was decreasing, and that's 
because a lot of them in large numbers were passing away each 
day, especially from the Second World War and on into Korea. 
But because of the recent deployments, we're staying fairly 
level as far as the total number of veterans that we have, the 
newest veterans being, of course, the recent deployments.
    I bring two concerns, and, again, I'd like to in short form 
capture what General Lee has shared. The two concerns I bring 
to the table, you've heard it before and you're going to hear 
it continuously, is access in remote areas, access to help.
    I do want to share with the Chairman that last year I had 
the honor of serving with the Chief of Staff of the Army for 
funeral for a fallen warrior in American Samoa. I did have a 
chance to go and visit with the 100th Battalion who deploys 
with the 29th to Iraq, and in that time they were having a lot 
of problems.
    I want to thank VA for opening up a clinic in American 
Samoa, and I think that will go a long way in at least 
identifying some of the problems.
    There are, however, other small islands in the Pacific that 
probably need a good, strong look at, and at a minimum some 
visiting teams to conduct assessments for some of the soldiers 
of the 100th Battalion that deployed. I think this is going to 
be a huge challenge, but I think that we as a Nation, it's 
something that we can overcome if we put our minds to it.
    The other issue that was brought up that I'd like to go 
over real quickly is the classic need for paperwork, and the 
recertification of some of our combat veterans when they 
already were certified for combat awards or badges, and I refer 
to it as a big check when they get awarded the CIB, the CAB, 
Purple Heart, and things like that. It seems like you really 
don't have to go through the paperwork again to recertify 
something that's already been certified.
    In a small way, when I look at this, it tells me that we 
have some resources that perhaps would be better focused to 
some of the harder problems that we face, especially in the 
areas of mental health or brain damage.
    That basically summarizes my testimony, and, Senator, I see 
my testimony right there. I put it behind me when I received 
the check, so I will be filing it with your Committee. Thank 
you again very much for being here. I appreciate the 
opportunity to testify.

   Statement of Brigadier General Gary M. Ishikawa, Deputy Adjutant 
General of the State of Hawaii before the Senate Committee on Veterans' 
         Affairs, Relating to State of VA Health Care in Hawaii

    Chairman Akaka, Senator Craig and Members of the Senate Committee 
on Veterans' Affairs, I am Brigadier General Gary Ishikawa, The Deputy 
Adjutant General for the State of Hawaii.
    Within the State Department of Defense, there are four major 
divisions: the Hawaii Army and Air National Guard, State Civil Defense 
and the Office of Veterans' Services (OVS). The Director of Office of 
Veterans Service is Mr. Mark Moses, a retired Marine major and a former 
state legislator.
    The Office of Veterans' Services is the single office in the State 
government responsible for the welfare of our veterans and their 
families. OVS serves as the liaison between Governor Linda Lingle and 
the veterans groups and organizations. They also act as an intermediary 
between the Department of Veterans Affairs and Hawaii's veterans.
    Veterans make up more that ten percent of Hawaii's total 
population. The majority of them--about 72%--live on the island of 
Oahu. About 13% reside on the island of Hawaii, 10% live on one of the 
three islands that comprise Maui County, and about 5% live on the 
island of Kauai.
    Within this large veteran population are many World War II 
veterans, many members of the famed 100th Battalion and the 442nd 
Regimental Combat Team. Hawaii's overall numbers were declining because 
many veterans of this era, most in their 80s, are passing on in large 
numbers.
    But since September 11, 2001, mobilizations have involved nine of 
every ten Army National Guard and Reserve soldiers. They served 
honorably in Iraq, Afghanistan and other locations; and have returned 
to Hawaii after their 12-15 month activations. Air National Guard 
members supported Operations Iraqi Freedom and Hawaii's overall veteran 
population has increased.
    We must insure these new veterans return to their civilian lives in 
good health. The Office of Veterans Services partners with the Veterans 
Administration here during the soldiers demobilization process. This 
partnership works to insure no one or no benefit falls through the 
crack.
    The United States government has an obligation to our military 
members from enlistment, through their service years, to veterans' 
benefits and finally, death benefits. We must insure that all veterans 
receive all entitled benefits now and in the years to come.
    The National Guard Bureau recently issued a memorandum authorizing 
both the Army and Air National Guard to release medical records to the 
Department Veterans Affairs without the veteran's signature. This new 
procedure speeds the Department of Veterans Affairs adjudication of 
veterans' claims and provides medical care to Guard members.
    I come to you with two concerns.
    My first and most important concern is the Veterans Affairs 
services to all our veterans, especially, on our neighbor islands and 
our Pacific Islander veterans from Tinian, Rota and Saipan. In July 
2007, a VA clinic opened in American Samoa that supports our veterans 
there. However, veterans from other Pacific islands must pay the high 
cost of airline and hotel accommodations to receive follow-on VA 
medical treatment. In Hawaii, a similar situation occurs when neighbor 
island veterans must come in to Tripler Army Medical Center or the 
Matsunaga VA Hospital in Honolulu for treatment. We must work to find a 
solution to this situation.
    My next concern deals with the certification of a disability by the 
Department of Veterans Affairs. Often a servicemember is awarded a 
decoration recognizing the specific incident that is associated with an 
injury or disability. However, when filing for a disability, the VA 
requires a complete recertification of the incident causing the injury 
or disability. Approval and certification of this letter of 
determination is required prior to providing any services.
    My final concern is the staff of VA hospitals. For example, the 
Post Deployment Health Reassessment Program (PDHRA) requires an initial 
appointment within 30 days of VA registration. On average, the VA 
hospital schedules initial appointments as much as 90-120 days from the 
registration date. Our local VA hospital staff has been doing their 
best to provide services to all our veterans. They have stretched their 
limited health care provider resources to their support mission 
requirement to all the veterans in the Pacific Basin.
    In closing, I want to thank the Committee for their continuing 
support of our veterans. Thank you for coming to Hawaii to conduct 
these hearings.
    Are there any questions?

    Senator Akaka. Thank you very much, General Ishikawa, for 
your testimony.
    Now we'll look to Colonel Gerald Gibbons.

   STATEMENT OF COLONEL GERALD GIBBONS, CHIEF OF STAFF, 9TH 
         REGIONAL READINESS COMMAND, U.S. ARMY RESERVE

    Colonel Gibbons. My name is Colonel Gerry Gibbons, and I'm 
Chief of Staff for the 9th Regional Readiness Command. I'm here 
representing Brigadier General Alexander Kozlov, Commander, 9th 
Regional Readiness Command, who is off island. I have submitted 
a copy of my written testimony for the record.
    Senator Akaka. It will be included in the record.
    Colonel Gibbons. This afternoon I'll limit my comments to 
issues of returning 9th Regional Readiness Command Army Reserve 
veterans and the necessity for collaboration between the 
Department of Defense and the Veterans Health Administration to 
prepare for and care for their future needs.
    As you are probably aware, the 9th Regional Readiness 
Command is responsible for Army Reserve units in American 
Samoa, Guam, Saipan, Alaska, and Hawaii. Since 9/11, 
approximately 2,400 9th Regional Readiness Command soldiers 
have answered the call to duty and were mobilized in support of 
Operation Iraqi Freedom and Operation Enduring Freedom. Within 
the past two years over two-thirds of the Pacific based 9th 
Regional Readiness Command soldiers will have served on active 
duty in support of the Global War on Terrorism. Currently there 
are 460 soldiers of the 9th Regional Readiness Command still 
mobilized and deployed. Deployed soldiers are serving in Iraq, 
Kuwait, and the Philippines.
    As soldiers return from theater, they complete a Post-
Deployment Health Assessment before being released from active 
duty. At 3 to 6 months after coming home from theater they are 
then given a Post-Deployment Health Reassessment. Our findings 
from these health reassessments show that 62 percent of the 
soldiers are referred for additional assessment or care and 
treatment. Almost without exception these referrals are all 
evaluated by the VA.
    If a soldier requires evaluation and/or treatment of mental 
health or behavioral health problems, which have significant 
impact on the performance of their duty, they may be brought 
back on active duty status and assigned to an Army warrior 
transition unit.
    Currently, we have 23 Army Reserve soldiers in the warrior 
transition unit at Tripler Army Medical Center. Initial 
assignment to the warrior transition unit is for 179 days, but 
that assignment can be extended until the soldier is found fit 
for duty.
    Soldiers diagnosed with Post Traumatic Stress Disorder 
requiring inpatient care are enrolled in a 7-week VA PTSD 
residential recovery program. In the last year, we have had 43 
soldiers complete the program, and I should emphasize this 
primarily happened because of the VA's constant support. 
Currently, we have 12 soldiers programmed for the next PRRP 
session scheduled to begin this week.
    On July 21, 2007, the VA Pacific Islands Health Care System 
held a dedication ceremony for a new Community Based Outpatient 
Clinic in Pago-Pago, American Samoa. The opening of this clinic 
is largely the result of a successful partnership between the 
Army Reserve and the VA. With the opening of this clinic, we 
know there will be an increase in efficiencies and more timely 
access to health care and treatment for veterans in American 
Samoa.
    While it may not be possible to predict the specific number 
of Army Reserve soldiers who will need to access Veterans 
Health Administration Services in the future, it's critical 
that we continue to work with the VA to ensure that we 
understand the processes and procedures to enable our returning 
soldiers to receive care through the current VA system in the 
9th Regional Readiness Command's area of operations.
    Thank you. I would be pleased to answer any questions you 
have.
    [The prepared statement of Colonel Gibbons follows:]

     Prepared Statement of Colonel Gerald Gibbons, Chief of Staff, 
           9th Regional Readiness Command, U.S. Army Reserve

    Good Morning. I appreciate being given the opportunity to speak 
before the Senate Committee on Veterans' Affairs. I am Colonel Gerald 
Gibbons and I am the Chief of Staff with the 9th Regional Readiness 
Command (RRC). As you are probably aware, the 9th RRC is responsible 
for Army Reserve units in American Samoa, Guam, Saipan, Alaska, and 
Hawaii. Additionally, many of our members live and work in Japan, 
Korea, other Pacific Rim countries, and CONUS. We are responsible for 
3,400 soldiers serving proudly in the Pacific and other parts of the 
world.
    This morning I will limit my comments to the issues of returning 
9th RRC Army Reserve veterans and the necessity for collaboration 
between the Department of Defense and the Veterans Health 
Administration to prepare and take care of their future needs.
    Since 9/11, 9th RRC Reserve soldiers have answered the call and 
were mobilized and deployed in support of Operation Iraqi Freedom (OIF) 
and Operation Enduring Freedom (OEF).
    There have been approximately 2,440 9th RRC Soldiers returned from 
active duty and there are approximately 460 9th RRC Soldiers still 
mobilized and deployed. Within the past 2 years, over \2/3\ of the 
Pacific based 9th RRC Soldiers will have served on active duty in 
support of the Global War on Terrorism.
    As Soldiers returned from theater, they completed the Post 
Deployment Health Assessment (PDHA) before being Release From Active 
Duty (REFRAD) and approximately 838 soldiers have completed the 
required Post Deployment Health Reassessment (PDHRA) at 3-6 months 
after coming home from theater.
    There are currently 23 Army Reserve Soldiers in the Warrior 
Transition Unit (WTU) at Tripler Army Medical Center (TAMC). These 
Soldiers are being continued or brought back on Active Duty status for 
evaluation and/or treatment for medical, mental health or behavioral 
health problems which have significant impact on their performance of 
duty. Assignment to the WTU is for 179 days with a possibility of 
extensions until they are found fit for duty.
    Soldiers diagnosed with Post Traumatic Stress Disorder (PTSD) 
requiring in-patient care are enrolled in the PTSD Residential Recovery 
Program (PRRP), a VA Pacific Health Care System, at the TAMC Campus. 
There are currently 6 Soldiers in the program.
    The VA Pacific Islands Health Care System Community Based 
Outpatient Clinic was recently dedicated on July 21, 2007 in Pago Pago, 
American Samoa and is scheduled to be fully activated in the very near 
future.
    While it may not be possible to predict the specific number of Army 
Reserve Soldiers who will need to access VHA services in the future, it 
is critical that we continue to work with the VA to ensure that we 
understand the processes and procedures to enable our returning 
Soldiers to receive care through the current VHS system in the 9th 
RRC's area of operations.
    Thank you. I would be pleased to answer any questions you may have.

    Senator Akaka. Thank you very much, Colonel. I do have 
questions for both of you, but before I continue with the 
questions, I just want to remind our veterans in the room that 
if you have anything that you want to talk about that is a 
problem for you and you need to talk to our staff, I just want 
to remind you that they're seated in the back of the room. Even 
as we talk here you should feel free to get up and seek their 
help.
    So to our witnesses, do you believe that there is a stigma 
associated with seeking care for mental health disorders? If a 
servicemember did come forward with mental health concerns, how 
would his or her career be impacted? General.
    General Ishikawa. There is a perceptional reality about 
mental health. This is something not only in the military, but 
in society overall, and we've done a lot of good things as far 
as education. From my perspective, it should not impact a 
soldier's career whatsoever, as long as they can get the proper 
treatment, but there is that perception.
    Senator Akaka. Thank you very much. Colonel.
    Colonel Gibbons. I agree with General Ishikawa. There is a 
perceived stigma associated with PTSD; however, our soldiers 
are coming forward by somewhat significant numbers to attend 
the VA's PTSD residential recovery program.
    Additionally, we hear a consistent message from our 
soldiers in remote areas that they would like greater access to 
mental health practitioners. The point I would like to make is 
that regardless if there is a stigma associated with PTSD, our 
soldiers are seeking help.
    Senator Akaka. General and Colonel, what is your best 
estimate of number of Guard and Reserve members here on the Big 
Island who have served in Iraq and Afghanistan? Your best 
estimate.
    General Ishikawa. Not to make light of it, Senator, but 
over 90 percent of the Hawaii Army National Guard has deployed 
to either Iraq or Afghanistan. The small percentage that did 
not is on Oahu, and as once in a while we say, actually the 
band is the only element or unit that is not. So all of the 
soldiers or a huge majority of the Army National Guard on the 
Big Island has in fact deployed.
    Senator Akaka. Colonel Gibbons.
    Colonel Gibbons. I would say the same thing. Both units we 
have on this island, elements of the 411th Engineer Battalion 
and the 100/442nd Infantry Battalion, have deployed. For 
numbers I would estimate 20, 25 Infantry soldiers and 
approximately 75 engineers have deployed. So, with the 
exception of a few stay-behind folks, all USAR soldiers from 
this island have deployed.
    Senator Akaka. To both of you, last year DOD expanded the 
post-deployment health assessment by including a breathing 
assessment. How is the Hawaii National Guard conducting the 
required post-deployment health assessments and reassessment? 
Has this been an effective program, and does it reach all 
members of the Guard in Hawaii as well? General?
    General Ishikawa. Just overall it's three to six months, 
and it's normally conducted on a unit level, and a lot of it is 
done by our family support organizations. And keeping in mind 
my original statements about perceptions of the stigma 
attached, I think that it has, in fact, contributed to sharing 
of information and the end result is more and more of the 
soldiers are coming forward.
    Senator Akaka. This is a follow-up question. Have the 
soldiers experienced difficulty in getting follow-up medical 
appointments?
    General Ishikawa. Yes, that's still a huge problem. I think 
when you made an employment it's supposed to be 30 days that 
you're supposed to get. We're averaging anywhere from 90 to 
120. I think there's going to be some testimony, I hope, today 
with a lot of vacancies, and some of the ideas that may be when 
you serve in a remote location there might be a premium 
attached to that. I think when you look at rural medicine 
overall that's a true statement.
    Senator Akaka. Colonel.
    Colonel Gibbons. I think the Post-Deployment Health 
Reassessment has been a success story for the Army Reserve. At 
the national level they have contracted with a medical 
organization to come out and assist us in conducting these 
reassessments. I know on Oahu the VA also participates, and 
sometimes we get immediate care. On the remote islands, we do 
get medical practitioners that come with this contracted 
assessment team from the mainland. So, the PDHRA has been 
helpful for us. And, as I mentioned in my opening remarks, 62 
percent of the soldiers surveyed have been referred to VA for 
further assessment and treatment.
    Senator Akaka. To both of you, DOD recently launched a 
Turbo TAP, a web-based program intended to assist separating 
servicemembers with the transition process. Do you believe this 
website meets the needs of transitioning servicemembers? What 
can be done to improve the transition process? General 
Ishikawa.
    General Ishikawa. I need to pass on that one, Senator. I'm 
not really familiar with that web site, so I'll pass.
    Senator Akaka. Colonel.
    Colonel Gibbons. I think that's an interesting question, 
and I don't have the answer to that either. So I would like to 
get back to the organization and we'll follow up on that.
    Senator Akaka. Fine. Thank you. We'd like to have your 
responses shortly.
    General Ishikawa. We will respond.
    Senator Akaka. General Ishikawa, as a result of problems at 
Walter Reed Army Medical Center, much has been written about 
care for members of the Guard and Reserves and medical holdover 
detachments. Are you satisfied with the care for wounded 
warriors from your units who are assigned to the Tripler 
Medical holdover detachment and what improvements would you 
recommend?
    General Ishikawa. I think because of the incident at Walter 
Reed it's been improved mightily, and I haven't had any recent 
complaints, coming to me anyway, as far as the medical 
holdover. I normally don't like to bring up problems where I do 
have some idea of solutions, but let me just put it on the 
table. In active duty you can return to your units and it's 
kind of like a home. On our medical hold units, especially if 
they're not from Oahu, it becomes a challenge. I think that--
and, again, I'm not sure how this can be solved, but if there's 
a way where we can perhaps bring the families periodically.
    We have Air National Guard aircraft, but I believe there's 
regulations that won't let us do that. I think things like that 
could help us get the families more involved. Short of that, 
they have to go through this process to be cured, so I think 
maybe some help getting the families there would be 
appreciated.
    Thank you.
    Senator Akaka. To both of you, it has been recommended that 
DOD and VA develop a joint separation physical. From your 
perspectives, do you believe that all servicemembers separated 
from active duty should receive a physical examination? Do you 
believe it makes sense to combine VA and DOD separation exams?
    General Ishikawa?
    General Ishikawa. I would go one step further besides just 
join. I know that Tripler use as lot of contract professional 
doctors within the community. I think that all military leaving 
the service should get a very thorough physical, and I think 
that joint combined type of organization is very appropriate. 
It's a matter of best resources doing the job.
    Colonel Gibbons. Senator, during deployment, when soldiers 
come off active duty, a physical is included as part of the out 
processing procedures. I don't know the detail of the medical 
review or how it differs from what VA provides. But, it would 
seem to me that there is added value in a more detailed 
composite physical.
    Senator Akaka. General Ishikawa, we know the activated 
members of the Guard and Reserve do not have access to TRICARE, 
and in some cases have nowhere to turn for health cares besides 
VA. What other issues do the Guard and Reserve face that are 
not shared by their active duty counterparts?
    General Ishikawa. That question is not overall Guard 
differences, so I guess it's more in reference to benefits and 
access. I think the Guard, by its nature, being a community-
based organization that really is in rural areas, I think that 
adds a special challenge, as opposed to having a big military 
base like Schofield where you have the capability of putting 
more resources on base. I think our remoteness and the way 
we're situated is the biggest difference as far as access to 
support.
    Senator Akaka. Colonel?
    Colonel Gibbons. Another challenge for Guard and Reserve 
soldiers is the transition back to their civilian job. We've 
got the Employer's Support of the Guard and Reserve (ESGR), who 
actively support our Guard and Reserve members when they get 
off active duty. But, to list on issue in addition to the 
change in the health care that is provided, I would add return 
to civilian employment.
    Senator Akaka. Well, you know with what we're doing today 
we're very concerned about the Guard and the Reserves, because 
there are so many things that we need to look at and try to 
improve on what has been there, and part of that is they've 
been deployed so many times. So there are some differences as 
to how we need to deal with the National Guard and the Reserve 
units. We look forward to any resolutions that you think might 
help us.
    I want to thank you so much Brigadier General Gary Ishikawa 
and Colonel Gerald Gibbons, and Colonel Floresita Quarto also. 
Thank you for being here with us. Thank you.
    General Ishikawa. Thank you, Mr. Chairman.
    [Applause.]
    Senator Akaka. I want our audience to know that we have a 
third panel that may be able to respond to some of the 
challenges that were mentioned. I want to welcome a third panel 
of witnesses, and the panel consists of representatives from 
VA.
    First, I welcome Dr. James Hastings. Dr. Hastings is the 
Director VA Pacific Islands Health Care System. He is 
accompanied by Felipe Sales, team leader of the Kona and Hilo 
Vet Centers. I also welcome Mark Moses, who is the Hawaii State 
Director of Office of Veterans Services. Finally, I want to 
welcome Gregory Reed, Director of the Honolulu Regional Office 
of the Veterans Benefits Administration.
    I want to thank all the witnesses for being here today. 
Your full statements will be included in the record of the 
Committee.
    Dr. Hastings, will you please begin with your testimony.

 STATEMENT OF JAMES E. HASTINGS, M.D., F.A.C.P., DIRECTOR, VA 
      PACIFIC ISLANDS HEALTH CARE SYSTEM, VETERANS HEALTH 
            ADMINISTRATION, DEPARTMENT OF VETERANS 
                            AFFAIRS

    Dr. Hastings. Yes, thank you very much, Mr. Chairman. 
Mahalo nui loa for the opportunity to appear before you today 
to discuss the state of VA care in Hawaii. It is a privilege to 
be here on the island of Hawaii, the Big Island, to speak and 
answer questions about issues important to veterans residing in 
Hawaii. I would like to request my written statement be 
submitted for the record.
    Senator Akaka. Without objection, it will be included in 
the record.
    Dr. Hastings. Thank you, sir. Before I begin, Mr. Chairman, 
I would like to thank you personally for your leadership and 
assistance in helping VA care for Hawaii veterans. Your vision 
and commitment are truly noteworthy and deeply appreciated.
    The VA operates CBOCs, Community Based Outpatient Clinics, 
and Vet Centers in both Kailua-Kona and Hilo. The Big Island 
CBOCs served an estimated island veteran population in fiscal 
year 2006 of 14,291. Of these, 5,081 were enrolled for care, 
and 2,936 received care. Since our last hearings in Hawaii, the 
VA relocated the clinic here to Kailua-Kona. In fiscal year 
2006 the Kailua-Kona CBOCs treated 1,055 patients and recorded 
6,779 clinic stops.
    The VAPIHCS, VA Pacific Islands Health Care System, now 
leases about 5,000 square feet for the new clinic and spent 
approximately $500,000 to renovate the existing facility. 
Although the current configuration and size is a vast 
improvement over the prior clinic location, parking at the new 
clinic is very limited. Currently, we are working with an 
outside firm to provide an additional 15 to 20 parking spaces.
    Kailua-Kona CBOCs is actively recruiting for a psychiatry 
position. In the interim, mental health coverage is provided by 
a mental health clinical nurse specialist from the Maui CBOC 
and a visiting psychiatrist and nurse from the Hilo CBOC. Our 
clinics spent approximately $100,000 in fiscal year 2001 to 
remodel the Hilo CBOC and further renovated it in fiscal year 
2006. In fiscal year 2006 the Hilo CBOC treated 1,683 veterans 
and recorded 8,843 clinic stops. The VA estimates that up to 
15,000 Hawaiians have been deployed to serve in Operation 
Enduring Freedom and Operation Iraqi Freedom as active duty 
personnel, Reservists, or members of the Hawaii National Guard.
    The VA Pacific Islands Health Care System has an active 
outreach program to inform OIF and OEF veterans about the 
availability and scope of VA health care services. A team of 
clinical and non-clinical staff from our health care system 
attend all Post-
Deployment Health Reassessment events. Those are the PDHRAs. At 
these events the VA staff answers questions, enrolls veterans, 
and schedules appointments for those who are interested.
    The VA Pacific Islands Health Care System has a dedicated 
OIF/OEF program manager who helps veterans receive the services 
they need, and an OIF/OEF case manager. OIF/OEF veterans 
requiring inpatient treatment for PTSD will be admitted to the 
PTSD residential rehabilitation program in Honolulu.
    In fiscal year 2006 the VA Pacific Islands Health Care 
System provided care and services to 1,137 OIF/OEF veterans. 
This group has special needs. For example, about 18 percent 
have a diagnosis of PTSD, and women comprise a larger segment 
of the population. A significant proportion of OIF/OEF veterans 
have been exposed to blasts, placing them at risk for Traumatic 
Brain Injury.
    VA aggressively screens patients for TBI, Traumatic Brain 
Injury, PTSD, and other conditions. We also are training staff 
and hiring additional specialists to ensure we exceed the 
expectations of these brave warriors.
    The VA Pacific Islands Health Care System and the veterans 
we proudly serve benefit from our relationship with academic 
institutions. One of our most important partnerships is with 
the John A. Burns School of Medicine, University of Hawaii. 
Prior to my appointment as Director of VA Pacific Islands 
Health Care System, I served as Chairman of the Department of 
Medicine at the medical school. I've seen both sides of this 
relationship and truly appreciate its value.
    In summary, with support, Mr. Chairman, the VA is providing 
an unprecedented level of health care services to veterans 
residing in Hawaii and here on the Big Island. I am proud of 
the improvements in VA services in Hawaii, but recognize that 
our job is not done. We must continue providing exemplary care 
to all veterans, including the brave soldiers of the Guard and 
Reserve who proudly served in OIF and OEF.
    Again, Mr. President, Mr. Chairman, mahalo nui loa for the 
opportunity to testify at this hearing. I will be delighted to 
address any questions you may have.

  Prepared Statement of James E. Hastings, M.D., F.A.C.P., Director, 
VA Pacific Islands Health Care System, Veterans Health Administration, 
                     Department of Veterans Affairs

    Mr. Chairman and Members of the Committee, mahalo nui loa for the 
opportunity to appear before you today to discuss the state of VA care 
in the Hawaii. It is a privilege to be here on the Island of Hawaii--
The Big Island--to speak and answer questions about issues important to 
veterans residing in Hawaii.
    First, Mr. Chairman, I would like to thank you for your outstanding 
leadership and advocacy on behalf of our Nation's veterans. During your 
tenures as Chairman and Ranking Member of this Committee, you have 
consistently demonstrated your commitment to veterans. As I will 
highlight later, your vision and support have helped us provide an 
unprecedented level of health care services for veterans throughout 
Hawaii and the Pacific Region. In addition, I appreciate your interest 
in and support of the Department of Veterans Affairs (VA).
    Today, I will briefly review the VA Sierra Pacific Network that 
includes Hawaii and the Pacific Region; provide an overview of the VA 
Pacific Islands Health Care System (VAPIHCS) and the VA clinics here on 
the Big Island; highlight issues of particular interest to veterans 
residing in Hawaii, including outreach to the National Guard and 
Reserves, Compensation and Pension examinations, new State Veterans' 
Home in Hilo and our important affiliations with our academic partners. 
I also look forward to addressing any questions you might have for me.

                  VA SIERRA PACIFIC NETWORK (VISN 21)

    The VA Sierra Pacific Network (Veterans Integrated Service Network 
[VISN] 21) is one of 21 integrated health care networks in the Veterans 
Health Administration (VHA). The VA Sierra Pacific Network provides 
services to veterans residing in Hawaii and the Pacific Region 
(including the Philippines, Guam, American Samoa and Commonwealth of 
the Northern Marianas Islands), northern Nevada and central/northern 
California. There were an estimated 1.1 million veterans living within 
the boundaries of the VA Sierra Pacific Network in Fiscal Year 2006 (FY 
2006).
    The VA Sierra Pacific Network includes six major health care 
systems based in Honolulu, HI; Palo Alto, CA; San Francisco, CA; 
Sacramento, CA; Fresno, CA; and Reno, NV. Dr. Robert Wiebe serves as 
director and oversees clinical and administrative operations throughout 
the Network. In FY 2006, the Network provided services to 235,000 
veterans. There were about 2.9 million clinic stops and 24,500 
inpatient discharges. The cumulative full-time employment equivalents 
(FTEE) level was 8,400 and the operating budget was about $1.5 billion.
    The VA Sierra Pacific Network is remarkable in several ways. In FY 
2006, VISN 21 was the highest-ranked Network in overall performance 
(based on an aggregation of quality, access, patient satisfaction and 
business metrics). The Network hosts the highest number of Centers of 
Excellence and also has the most highly funded research programs in 
VHA. In the most recent all-employee survey, staffs in VISN 21 reported 
the highest overall job satisfaction in VHA. Finally, VISN 21 operates 
one of four Polytrauma units in VHA that are dedicated to addressing 
the clinical needs of the most severely wounded Operation Iraqi 
Freedom/Operation Enduring Freedom (OIF/OEF) veterans.

            VA PACIFIC ISLANDS HEALTH CARE SYSTEM (VAPIHCS)

    As noted above, VAPIHCS is one of six major health care systems in 
VISN 21. I am the director and a practicing cardiologist at VAPIHCS. 
VAPIHCS is unique in several important aspects: its vast catchment area 
covering 2.6 million square-miles (including Hawaii, Guam, American 
Samoa and Commonwealth of the Northern Marianas); island topography and 
the challenges to access it creates; richness of the culture of Pacific 
Islanders; and the ethnic diversity of patients and staff. In FY 2006, 
there were an estimated 102,000 veterans living in Hawaii (representing 
8 percent of the total population in Hawaii and 9 percent of total 
veteran population in VISN 21).
    VAPIHCS currently provides care in seven locations: the Ambulatory 
Care Center (ACC) and Center for Aging (CFA) on the campus of the 
Tripler AMC in Honolulu; and Community Based Outpatient Clinics (CBOCs) 
in Lihue (Kauai), here in Kahului (Maui), Kailua-Kona (Hawaii), Hilo 
(Hawaii), Hagatna (Guam) and Pago Pago (American Samoa). VAPIHCS also 
has outreach clinics in Molokai and Lanai. The inpatient Post-Traumatic 
Stress Disorder (PTSD) unit is now also on the campus of Tripler AMC 
(the unit was formerly in Hilo). In addition to VAPIHCS, VHA operates 
five Readjustment Counseling Centers (Vet Centers) in Honolulu, Lihue, 
Wailuku, Kailua-Kona and Hilo that provide counseling, psychosocial 
support and outreach.
    In FY 2006, VAPIHCS provided services to nearly 22,500 veterans, 
19,000 of whom reside in Hawaii. There were 198,000 clinic stops in 
Hawaii during FY 2006 (7 percent of Network total). The cumulative FTEE 
in FY 2006 for the health care system was 502 employees. The operating 
budget for VAPIHCS (i.e., General Purpose allocation from appropriated 
funds) increased from $68.0 million in FY 2002 to $110 million in FY 
2007--an increase of 62 percent. For comparison, during this same time 
period, the operating budgets for VISN 21 increased 48 percent and VHA 
increased 43 percent. (Please note these amounts do not include 
Specific Purpose Funds and Medical Care Cost Funds [MCCF].)
    VAPIHCS provides or contracts for a comprehensive array of health 
care services. VAPIHCS directly provides primary care, including 
preventive services and health screenings, and mental health services 
at all locations. VAPIHCS does not operate its own acute medical-
surgical hospital and consequently, faces challenges in providing 
specialty services. VAPIHCS recently hired additional specialists in 
Orthopedics, Ophthalmology, Nephrology and inpatient Medicine 
(``hospitalist'') and is providing selected specialty care in Honolulu 
and to a lesser extent, CBOCs. VAPIHCS is actively recruiting 
additional specialists (e.g., Urology) and will continue to refer 
patients to DOD and community facilities.
    Inpatient long-term and acute rehabilitation care is available at 
the CFA. Inpatient mental health services are provided by VA staff on a 
20-bed ward within Tripler AMC and at the 16-bed PTSD Residential 
Rehabilitation Program (PRRP). VAPIHCS contracts for care with DOD (at 
Tripler AMC and Guam Naval Hospital) and community facilities for 
inpatient medical-surgical care.
    The current constellation of VA facilities and services represents 
a remarkable transformation over the past several years. Previously, 
the VAPIHCS (formerly known as the VA Medical and Regional Office 
Center [VAMROC] Honolulu) operated primary care and mental health 
clinics based in the Prince Kuhio Federal Building in downtown Honolulu 
and CBOCs on the neighbor islands that were staffed primarily with 
nurse practitioners. Congress approved $83 million in Major 
Construction funds to build a state-of-the-art ambulatory care facility 
(i.e., ACC) and a long-term care/rehabilitation unit (i.e., CFA) on the 
Tripler AMC campus and these facilities were activated in 2000 and 
1997, respectively. VISN 21 allocated nearly $17 million from FY 1998-
FY 2000 to activate these projects. VISN 21 also provided dedicated 
funds to enhance care on the neighbor islands by expanding/renovating 
clinic space and adding additional staff to ensure there are primary 
care physicians and mental health providers at all CBOCs.

                            BIG ISLAND CBOCS

    VA operates CBOCs in both Kailua-Kona (75-377 Hualalai Road, 
Kailua-Kona, HI 96740) and Hilo (1285 Waianuenue Avenue, Suite 211, 
Hilo, HI 96720). VHA also operates Readjustment Counseling Centers 
(``Vet Centers'') in Kailua-Kona (73-4976 Kamanu Street, Suite 207, 
Kailua-Kona, HI 96740) and Hilo (126 Pu'uhonu Way, Suite 2, Hilo, HI 
96720).
    The Big Island CBOCs serve an estimated island veteran population 
in FY 2006 of 14,291. In FY 2006, 5,081 veterans were enrolled for care 
on the island and 2,936 received care (``users'') at Big Island VA 
facilities. The market penetrations for enrollees and ``users'' are 36 
percent and 21percent, respectively, and compare favorably with rates 
within VISN 21 and VHA.
Kailua-Kona CBOC
    Since the last time this Committee held hearings on the Big Island 
(i.e., January 2006), VA relocated the clinic here in Kailua-Kona. 
VAPIHCS now leases about 5,000 square-feet for the new clinic and spent 
about $500,000 to renovate the existing facility. Although the current 
configuration and size is a vast improvement over the prior clinic 
location, parking at the new clinic is very limited. VAPIHCS is 
currently working with an architect/engineering firm to provide an 
additional 15-20 new parking spaces.
    The current authorized FTEE level at the Kailua-Kona CBOC is 12.0, 
including a full-time primary care physician, psychiatrist and nurse 
practitioner. Currently, the psychiatry position is vacant and we are 
actively recruiting to fill it. In the interim, mental health coverage 
is provided by a mental health clinical nurse specialist (on ``loan'' 
from the Maui CBOC) and visiting psychiatrist for the Hilo CBOC. With 
this staff, the Kailua-Kona CBOC provides a wide array of primary care 
and mental health services. The Kailua-Kona CBOC also has a formal 
home-based primary care (HBPC) program that provides clinical services 
in the homes of veterans.
    VAPIHCS provides specialty care services at the clinic by sending 
VA staff to Kailua-Kona from Honolulu and other VA facilities in 
California. Services provided by clinicians traveling to Kailua-Kona 
include cardiology, gastroenterology, nephrology, neurology, optometry, 
orthopedics and rheumatology. If veterans need services not available 
at the clinic, VAPIHCS arranges and pays for care in the local 
community (e.g., Kona Community Hospital) and Honolulu (including 
Tripler AMC). In FY 2006, VA spent more than $7.8 million in non-VA 
care in the private sector (i.e., not including costs at other VA or 
DOD facilities) for residents of the Big Island.
    In FY 2006, the Kailua-Kona CBOC treated 1,055 patients and 
recorded 6,779 clinic stops. The clinic has short waiting times for new 
patients with very few veterans waiting more than 30 days for their 
first primary care appointment. The Kailua-Kona HBPC program recorded 
598 clinic stops for providing home care to veterans residing on the 
west side of the island.
Hilo CBOC
    VAPIHCS spent about $100,000 in FY 2001 to remodel the Hilo CBOC 
and spent additional funds in FY 2006 to further renovate the clinic. 
The current authorized FTEE level at the Hilo CBOC is 15.0, including 
two full-time primary care physicians and a psychiatrist. This is an 
increase of four staff since January 2006 and reflects the reassignment 
of staff from the PRRP that was relocated from Hilo to Honolulu. With 
this staff, the Hilo CBOC provides a broad range of primary care and 
mental health services. The Hilo CBOC also has a formal HBPC program 
that provides clinical services in the homes of veterans.
    VAPIHCS provides specialty care services at the clinic by sending 
VA staff to Hilo from Honolulu and other VA facilities in California. 
Services provided by clinicians traveling to Hilo include cardiology, 
gastroenterology, nephrology, neurology, optometry, orthopedics and 
rheumatology. If veterans need services not available at the clinic, 
VAPIHCS arranges and pays for care in the local community (e.g., Hilo 
Medical Center), Honolulu (including Tripler AMC) or VA facilities in 
California. As noted before, in FY 2006, VA spent more than $7.8 
million in non-VA care in the private sector (i.e., not including costs 
at other VA or DOD facilities) for residents of the Big Island.
    In FY 2006, the Hilo CBOC treated 1,683 veterans and recorded 8,843 
clinic stops. The clinic has short waiting times for new patients with 
very few veterans waiting more than 30 days for their first primary 
care appointment. The Hilo HBPC program recorded 641 clinic stops for 
providing home care to veterans residing on the east side of the 
island.

                             SPECIAL ISSUES

OIF/OEF outreach
    VA estimates up to 15,000 residents of Hawaii have been deployed to 
Afghanistan and Iraq as active duty personnel, Reservists or Hawaii 
National Guard. All VAPIHCS sites of care, including CBOCs, are 
authorized to provide care to DOD beneficiaries as TRICARE providers 
under the national ``Seamless Transition'' initiative between VA and 
DOD.
    VAPIHCS has an active outreach program to inform OIF/OEF veterans 
about the availability and scope of VA health care services. As an 
example, a team of clinical and non-clinical staff from VAPIHCS attend 
all Post Deployment Health Reassessment (PDHRA) events. PDHRA is a 
program managed by DOD and is designed to provide education, screening, 
assessment and access to care for military personnel who have returned 
from deployment. The assessment generally occurs 3 to 6 months after 
returning from deployment. At the PDHRA events, VA staff is available 
to answer questions and to enroll and make appointments for interested 
veterans.
    All VA health care systems, including VAPIHCS, have dedicated OIF/
OEF program managers, who help OIF/OEF veterans receive the services 
they need. VAPIHCS also has an OIF/OEF case manager and support from a 
Transition Patient Advocate in VISN 21. OIF/OEF veterans who need 
inpatient treatment for PTSD will be admitted to the PRRP program in 
Honolulu. Veterans residing in Hawaii also have access to the 
Polytrauma Unit at the VA Palo Alto Health Care System. This is one of 
four specialized units designed to meet the needs of the most severely 
injured OIE/OEF veterans and active duty personnel.
    The total number of OIF/OEF veterans seen in VA health care 
facilities is a relatively small proportion of the total ``user'' 
population; however, the number is increasing. In FY 2002, VAPIHCS 
treated 225 OIF/OEF veterans; in FY 2006, the number of OIF/OEF 
veterans seen at VAPIHCS facilities increased to 1,137. Very few OIF/
OEF veterans are waiting more than 30 days for an appointment.
    VA recognizes that our newest group of veterans has special needs. 
About 18 percent of OIF/OEF veterans seen in VHA have a diagnosis of 
PTSD. There are more women veterans in the OIF/OEF cohort than the 
general veteran population. A significant proportion of OIF/OEF 
veterans has been exposed to blasts and might suffer from Traumatic 
Brain Injury (TBI). Musculo-skeletal problems (e.g., low back pain) are 
common and constitute the most prevalent reason for seeking VA health 
care. In response, VA is aggressively screening patients (e.g., for 
TBI), training staff and hiring additional specialists (e.g., mental 
health, rehabilitation) to ensure we will meet the needs and 
expectations of these brave warriors.
Compensation and Pension (C&P) examinations
    Veterans Benefits Administration (VBA) relies heavily on the 
medical evidence and expert opinion provided by C&P examinations to 
adjudicate veterans' claims. Consequently, the quality and timeliness 
of C&P examination results provided by VHA is very important. The 
quality of C&P examinations performed at VAPIHCS is very good, as 
measured by Compensation and Pension Examination Program scores (an 
external review of examination completeness and quality), insufficiency 
rates and remand rates.
    Regrettably, for the past several months, there is a backlog of 
examination requests and the timeliness of examinations has not met VHA 
standards of 35 days. The underlying causes of the delays include a 
surge of requests from VBA, staffing vacancies coupled with recruitment 
challenges (especially, in more remote locations such as Guam), and 
space constraints in the ACC.
    VAPIHCS is highly motivated to resolve these barriers and has 
developed a credible plan. VAPIHCS now has made additional examiners 
available to the C&P unit by reassigning staff, ``borrowing'' VA 
physicians from mainland facilities and hiring contract staff. VAPICHS 
is also conducting C&P clinics on some Saturdays and has plans to 
renovate the ACC to relieve space constraints. Assuming the number of 
requests from VBA remains stable (i.e., about 500 requests each month), 
VAPIHCS is confident it can eliminate the backlog and maintain 
timeliness standards by fall 2007.
State Veterans Home
    The State of Hawaii is planning to open its first State Home in 
Hilo later this year. This will be the first State of Hawaii facility 
to provide nursing home and domiciliary care to eligible veterans. The 
95-bed facility is on the site of the former Hilo Hospital on the Hilo 
Medical Center campus. VA awarded a grant of about $20 million for the 
project to complement state funding. VA is excited about this project 
and looks forward to our continuing collaboration with the State of 
Hawaii. I commend the State Advisory Board on Veterans Services for the 
recommendation to name the facility in honor of Mr. Yukio Okutsu. As 
you know, Mr. Chairman, Mr. Okutsu was a resident of Hilo and a 
recipient of our Nation's highest award for valor, the Medal of Honor, 
for his heroism during World War II.
Academic affiliations
    VAPIHCS and the veterans we proudly serve benefit from an array of 
balanced relationships with academic institutions. One of our most 
important partnerships is with the John A. Burns School of Medicine, 
University of Hawaii. Prior to my appointment as Director, VAPIHCS, I 
was fortunate to have served as Chairman, Department of Medicine at the 
Medical School. I have seen from both ``sides'' the value of a strong 
relationship between VA and academic medicine. VAPIHCS serves as a 
training site for medical students, post-graduate housestaff (i.e., 
interns, residents and fellows), dentists, nurses, pharmacists, 
psychologists and social workers. We also work with the Medical School 
in recruiting physicians and research investigators. Our patients and 
staff also benefit from the training programs and other academic 
programs at Tripler AMC.

                               CONCLUSION

    In summary, with your support, Mr. Chairman, and other Members of 
Congress, VA is providing an unprecedented level of health care 
services to veterans residing in Hawaii and here on the Big Island. Our 
goal is to provide safe, effective, efficient and compassionate care to 
all veterans. We are committed to and active in our outreach efforts to 
veterans, including the brave soldiers in the Guard and Reserve, who 
proudly served in OIF/OEF.
    However, VAPIHCS still faces several challenges, in part due to the 
topography of its catchment area, lack of an acute medical-surgical 
hospital, limited community resources in rural areas and difficulties 
recruiting staff. VAPIHCS will meet these challenges by utilizing 
telehealth technologies, hiring specialists, working with community 
partners and developing new delivery models. I am proud of the 
improvements in VA services in Hawaii, but recognize that our job is 
not done.
    Again, Mr. Chairman and other Members of the Committee, mahalo nui 
loa for the opportunity to testify at this hearing. I would be 
delighted to address any questions you might have for me.

    Thank you.
    Senator Akaka. Thank you very much, Dr. Hastings.
    And now I call on Mark Moses for his testimony.

         STATEMENT OF MARK MOSES, DIRECTOR, OFFICE OF 
      VETERANS SERVICES, DEPARTMENT OF DEFENSE, STATE OF 
                             HAWAII

    Mr. Moses. Thank you, Mr. Chairman. I'm very privileged to 
testify before your Committee today. I am Mark Moses, the 
Director of the Office of Veterans Services, OVS. OVS is the 
State lead agency responsible for the welfare of veterans and 
family members. We have a counselor stationed in each county 
and we touch each island. We have counselors that have regular 
appointments on every island in the state.
    As the Governor's liaison to veterans and veteran groups we 
serve as an intermediary between the Department of Veterans 
Affairs and provide access to state services and benefits. We 
have provided services and information to nearly 33,000 
veterans and survivors this past fiscal year. I've attached a 
summary sheet providing some services and activities made 
available for your review.
    The final service we can provide a veteran is interment in 
a veteran cemetery with appropriate honors. The VA has 
consistently supported our efforts to expand Hawaii's cemetery 
plots and columbariums in order to keep pace with need. They're 
deserving of our gratitude.
    It is important and proper to take this opportunity to 
personally thank you for your support of our veterans in 
general and our cemetery system in particular. We are very 
grateful for your assistance in obtaining a new grant for the 
West Hawaii Veterans Cemetery. This VA grant ensures the 
cemetery will have all that we have envisioned. The West Hawaii 
Veterans Cemetery will be known as the most expensive cemetery 
in the Nation, even with the personal sacrifices made by 
veterans and community volunteers of time and energy. My 
special thanks go to John Grogin and the West Hawaii Veterans 
Cemetery Association. Thank you, gentlemen.
    The effort of the volunteers were greatly enhanced through 
material and financial support of the local business community. 
Nurseries, construction firms, hotels, and the Carpenters 
Union. Particularly noteworthy is our good neighbor Kukio. 
Their individual contributions ensure the cemetery is the oasis 
that it is today, and their commitment of water supply, which, 
I understand, they have tripled, Mr. Chairman, ensure the 
further expansion of the cemetery, as well as the ability to 
have restroom facilities.
    To all of you, thank you. We look forward to your 
continuing participation as we work to expand the West Hawaii 
Veterans Cemetery.
    Mr. Chairman, the April 2000 data from the VA Office of the 
Actuary Office of Policy, Planning, and Preparedness estimated 
120,000 veterans in Hawaii. About 72 percent are on Oahu, 13 
percent on the Big Island, 10 percent on one of the Maui County 
islands, and approximately 5 percent on Kauai. Our island state 
presents unique challenges for the Department of Veterans 
Affairs. Despite these challenges, I want to share with you 
comments that we hear from veterans.
    They speak of the excellence of VA medical care, how VA 
staff treats veterans with dignity and respect, and that the 
services rendered by the dedicated health care professionals 
are superior to that that they received on the mainland. These 
comments are from local veterans and those visiting Hawaii that 
seek care in the Spark M. Matsunaga Medical Center.
    Similar comments are heard about the VA benefits staff. 
Hawaii's VA supports the Guard and Reserve prior to deployment, 
and upon their return, as well as their family members while 
they're in military service. As a disabled veteran, I can 
attest to the fact that the services provided here by the VA 
are top in the Nation. Nevertheless, given the proper 
resources, they're capable of doing better.
    Recall that nearly 30 percent of the veterans live on the 
neighbor islands. Many of them are referred for surgical 
services to mainland VA medical centers, civilian medical 
facilities on Oahu, or to Tripler Army Medical Center. For 
neighbor island veterans sent to mainland VA hospitals, this 
can be very traumatic. They're booked on flights, sent to a big 
city, and they're told find a VA facility. They're operated on 
and then they're sent back to their homes in Hawaii. We ask 
that sufficient funding be provided for direct mainland flights 
from and, whenever possible, return flights to the veteran's 
island of residence.
    Hawaii's neighbor islands must be offered the same level of 
medical care and services as veterans located on Oahu. Neighbor 
Island Community Based Outreach Centers place veterans on a 
wait list where they are scheduled for specialty medical care. 
With the use of telemedicine and more frequent visits, this 
program is being addressed. However, backlogs still exist. With 
some veterans waiting several months to see a specialist.
    VA has a difficult time recruiting and maintaining 
competent medical staff in these rural areas. VA should be 
allowed to offer a premium to rural medical service providers 
and to contract for additional medical care in rural areas such 
as the neighborhood islands.
    Thousands of National Guard and Reservists have returned. 
My desire is that they, and those already here, receive medical 
and benefit services in a timely manner. We ask that VA Health 
Administration and VA Benefits Administration be adequately 
funded and staffed to provide medical care and benefit services 
to all Hawaii's veterans.
    Hawaii received a VA grant to help build the Yukio Okutsu 
Veterans Home, opening this year. I envision that eventually 
we'll have several veterans long-term care facilities, 
preferably at least one per county. This need is here now, and 
I understand that you have legislation which offers bed spaces 
in other hospitals, and that's greatly appreciated.
    The present per day veteran reimbursement rate, however, in 
the VA care home is $67.71 per day. It's insufficient to 
maintain a veteran without additional payment. We request the 
reimbursement rate be raised to adequately cover long-term care 
services provided to assist the State in meeting the medical 
care needs of this frail group of our older warriors. The 
actual cost is approximately $300 per day.
    As many veterans pass, many will utilize our State 
veterans' cemetery system. Presently the State and County are 
reimbursed $300 for each veteran burial, less than the cost to 
open and close the grave site.
    This reimbursement rate has not changed in many years, and 
we ask your Committee look into increasing it to more closely 
reflect the true cost of interments, which is approximately 
$1,000. We must continue to care for those who served. They are 
our sons and our daughters, our Hawaii citizens, our veterans. 
I thank the Committee and you for this opportunity to testify, 
and I'll respond to any questions.
    [The prepared statement of Mr. Mark Moses follows:]

   Prepared Statement of Mark S. Moses, Director, Office of Veterans 
            Services, Department of Defense, State of Hawaii

    Chairman Akaka and Members of the Senate Committee on Veterans' 
Affairs, I am Mark Moses, Director of the Office of Veterans Services 
(OVS). The office is the single State lead agency responsible for the 
welfare of Veterans and their family members. We act as the Governor's 
liaison to veterans, veterans groups and organizations, and serve as an 
intermediary between the Department of Veterans Affairs and Hawaii's 
veterans. The office serves in partnership with the VA to provide state 
services and benefits. We provided services and information to nearly 
33,000 veterans and eligible survivors this past fiscal year. I have 
attached a summary sheet describing some services and activities made 
available through the office for your review.
    The final service we can provide a veteran is interment in a 
veteran's cemetery with appropriate honors. The Veterans Administration 
has consistently supported our efforts to expand Hawaii's cemetery 
plots and columbarium space to keep pace with need. They are deserving 
of our gratitude.
    Additionally, it is important and proper to take this opportunity 
to thank you, Senator Akaka for your unwavering support for our 
veteran's cemetery program. We are particularly grateful for your 
assistance in obtaining the new grant for the West Hawaii Veterans 
Cemetery located in Kona. State veterans cemeteries are the only 
cemeteries accepting full body burials on a consistent basis in Hawaii. 
This VA grant will assure that West Hawaii will be the cemetery we all 
have envisioned it to be.
    Based on April 2000 data from the Office of the Actuary, Office of 
Policy, Planning and Preparedness, Department of Veterans Affairs, 
there are an estimated 120,000 veterans in Hawaii. The majority, about 
72 percent live on Oahu, 13 percent reside on the island of Hawaii, 10 
percent live on one of the three islands which comprise Maui County, 
and approximately 5 percent live on Kauai. Hawaii, an island state 
located in the middle of the Pacific Ocean, presents unique challenges 
for the Department of Veterans Affairs.
    Before I discuss some of these challenges, I want to share with you 
comments that my staff and I hear from veterans about VA health care 
and benefit services. These individuals speak to the excellence of VA 
medical care; that VA's staff treats veterans with dignity and respect, 
and that the services rendered by the dedicated health care 
professionals are superior to the care they received on the mainland 
United States. These comments are expressed by local veterans as well 
as by veterans who visit Hawaii and have a need to seek services from 
Spark M. Matsunaga medical staff. Similar types of comments are shared 
about the VA Benefit staff.
    This ``new'' VA exemplifies the well known phrase of ``supporting 
our troops.'' Hawaii's VA supports our National Guard members and 
Reservists prior to deployment and upon their return. They also offer 
services to military members who are ending their military service. As 
a disabled veteran, I can attest to the fact that the services provided 
by the VA locally are top in the Nation. Nevertheless, given the proper 
resource they are capable of doing better.
    As mentioned earlier, Hawaii presents unique challenges to the VA. 
We are an island state with one large population center on Oahu. Nearly 
30 percent of Hawaii's veterans live on the neighbor islands. Presently 
many of our veterans are referred for surgical services to mainland VA 
medical centers, civilian medical centers on Oahu, or to Tripler Army 
Medical Center. This can be very traumatic for neighbor island veterans 
who are sent to other VA hospitals. They are booked on flights, sent to 
a big city to find the VA facility, operated on and sent back to their 
home in Hawaii. We ask that funding be provided so that those who 
reside on neighbor islands be provided direct flights to the mainland. 
We also propose that whenever possible, return flights fly directly to 
the veteran's island of residence.
    Another issue that affects Hawaii and Alaska involves changes that 
were made to 38 U.S.C. 1151, Benefits for persons disabled by treatment 
of vocational rehabilitation. With this change the only facilities 
covered by the law are those over which the Secretary of Veterans 
Affairs has direct jurisdiction, or Government Facilities contracted by 
the Secretary. Tripler Army Medical Center and other medical facilities 
in Hawaii, such as Straub, Kuakini, Queens, and St. Francis do not 
qualify under the present law. Veterans suffering an unlikely event 
causing any additional disability or worse are on their own and must 
sue the medical facility for damages. For most, obtaining an attorney 
to pursue this option is overwhelming.
    We suggest that the definitions as listed in 38 U.S.C. 1701(3) and 
38 U.S.C. 1151, be changed so that veterans in Hawaii treated outside 
VA facilities are afforded the same protection as veterans who receive 
VA medical care in VA facilities on the mainland. Hawaii's veterans 
must have the same right to redress as veterans treated at mainland VA 
facilities. At a minimum, veterans must be given the opportunity to 
make informed consent about the benefits and shortfalls of choosing 
between having surgeries or other medical procedures performed at a VA 
facility on the mainland or in non-VA facilities locally.
    Hawaii's neighbor islands must be offered the same level of medical 
care and services as veterans located on Oahu. Presently neighbor 
island Community Based Outreach Clinics place veterans on a wait list 
where they are scheduled for specialty medical care. With the use of 
Telemedicine and more frequent visits, this problem is being addressed; 
however, backlogs still exist. Veterans have been known to wait several 
months before they see a specialist. Additionally, VA has a difficult 
time recruiting and maintaining competent medical staff in these rural 
areas. To address these needs, the VA should be allowed to offer a 
premium to rural medical service providers and consider contracting for 
additional medical care in rural areas such as the neighbor islands.
    As you are aware, Hawaii has received thousands of its returning 
National Guardsmen and Reservists. As Director of the Office of 
Veterans Services, my desire is that these returning military members 
and those already here be able to access medical and benefit services 
in a timely manner. We ask that VA Health and Benefits Administrations 
be adequately funded and staffed to provide medical care and benefit 
services to all veterans who make Hawaii their home.
    Hawaii has received a grant from the VA to build its first 
Veteran's Home. The Yukio Okutsu Veterans Home is scheduled to open 
within a few months. Our concern is with the reimbursement rate that 
the VA pays for veterans who will be residing at the home. The present 
reimbursement is insufficient to maintain a veteran without payment of 
additional funds. We in Hawaii are not alone in requesting that the per 
day reimbursement rate be raised so that it adequately covers long-term 
care services supplied by the facility. We envision that the Yukio 
Okutsu Veterans Home will be the first of several veterans' long-term 
care facilities, preferably at least on per county due to inherent 
island produced isolation. Adequate per resident reimbursement will 
assist the state in meeting the medical care needs of this frail group 
of older warriors.
    As these veterans pass, many will utilize our State Veteran's 
Cemetery system. Presently the state and county are reimbursed $300 for 
each veteran burial, but the cost to open and close the grave site and 
provide perpetual care greatly exceeds this amount. This reimbursement 
rate has not changed in many years. We ask that your Committee look 
into increasing the present amount so that it more closely reflects the 
true cost associated with full body and urn burials.
    We must continue to take care of our veterans. We must support our 
Soldiers, Sailors, Airmen, Marines, and Coast Guard members at home and 
abroad. They are our veterans, our sons and daughters, our citizens of 
Hawaii.
    I thank the Committee for this opportunity to speak on this matter 
and I will respond to any questions that you may have.
                                 ______
                                 
    [Note: the following is a summary of services and activities being 
offered by the Hawaii Office of Veterans Services.]
                   Hawaii Office of Veterans Services

                                MISSION

    The Office of Veterans Services (OVS) is the principal state office 
responsible for the development and management of policies and programs 
related to veterans, their dependents, and/or survivors. The OVS acts 
as a liaison between the Governor and veterans' organizations and also 
between the Department of Veterans Affairs and individual veterans. Our 
objectives are to assist veterans in obtaining State and Federal 
entitlements, to supply the latest information on veterans' issues and 
to provide advice and support to veterans making the transition back 
into civilian life.
    OVS is the State's primary advocate of veterans applying for and 
receiving benefits and services. The OVS may take action on behalf of 
veterans, their families and survivors to secure appropriate rights, 
benefits and services. This process includes the reception, 
investigation and resolution of disputes and complaints.
    The OVS serves all eligible veterans, Reservists, National Guard 
members, active-duty military personnel and their dependents (including 
stepchildren). (See List of Services at end.)

                        STATE PROVIDED BENEFITS

Special Housing for Disabled Veterans
    Payment by the State of up to $5,000 to each qualified, totally 
disabled veteran for the purpose of purchasing or remodelling a home to 
improve handicapped accessibility.
Burials
    Burials for qualified veterans (including U.S. war allies) and 
their dependents in Veterans Cemeteries on Oahu, Hawaii, Kauai, Maui, 
Molokai, or Lanai.
Vital Statistics
     Free certified copies of vital statistics forms when needed for 
veterans' claims.
License Plates
    For the same cost as regular license plates, qualified veterans can 
acquire distinctive veterans' license plates for their car or 
motorcycle. Currently available are: ``Veteran,'' ``Combat,'' ``Combat 
Wounded,'' ``Pearl Harbor Survivor,'' ``Former POW,'' 'World War II 
Veteran,'' ``Korean War Veteran,'' and Vietnam Veteran.''
Tax Exemptions
    Applies to real property that is owned and occupied as a home by a 
totally disabled veteran or their widow(er). Also applies to passenger 
cars when they are owned by totally disabled veterans and subsidized by 
the Department of Veterans Affairs.
Employment and Re-employment
    Preference is given to veterans, Vietnam-era veterans, service-
connected, disabled veterans and their widow(er)s for civil service 
positions, training programs, job counseling and referrals to civilian 
jobs by the Workforce Development Division, Department of Labor and 
Industrial Relations. Re-employment rights for veterans, Reservists or 
National Guard members who leave a position within State or County 
government for training or active military service.

We encourage you contact the Office of Veterans Services to have your 
questions answered. The sooner we begin the process together, the 
sooner you will see results. Please contact the OVS office nearest you. 
Walk-ins are welcome, and appointments are recommended. Home, worksite 
and hospital visits are available if necessary, as are Group 
presentations.
Office of Veterans Services--Oahu
    Office: Tripler Army Medical Center E-Wing
    Address: Office of Veterans Services, 459 Patterson Road,
      E-Wing, Room 1-A103, Honolulu HI 96819-1522.
    Telephone: (808) 433-0420; Fax: (808) 433-0385.
    E-mail: OVS@ovs.hawaii.gov.
    Hours: Monday-Friday, 7:45 a.m.-4:00 p.m.
Office of Veterans Services--Kauai
    Address: 3215 Kapule Hwy., #2, Lihue, HI 96766.
    Telephone: (808) 241-3346; Fax: (808) 241-3818.
    E-mail: KOVS@ovs.hawaii.gov.
    Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
Office of Veterans Services--Hawaii
    Address: 101 Aupuni Street, Room 212, Hilo, HI 96720.
    Telephone: (808) 933-0315; Fax: (808) 933-0317.
    E-mail: HOVS@ovs.hawaii.gov.
    Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.
Office of Veterans Services--Maui
    Address: 333 Dairy Road, Suite 201-A, Kahului, HI 96732.
    Telephone: (808) 873-3145; Fax: (808) 243-5820.
    E-mail: MOVS@ovs.hawaii.gov.
    Hours: Monday-Friday, 7:30 a.m.-4:30 p.m.

            LIST OF SERVICES FOR VETERANS, ACTIVE MILITARY, 
                         SPOUSES AND DEPENDENTS

    Assist in preparation of VA claims.
    Help individuals file VA Appeals.
    Represent veterans at VA hearings.
    Obtain veteran birth, marriage, divorce and death certificates
      nationwide.
    Assist with burial
    Provide notary.
    Assist indigents.
    Maintain DD214s.
    Refer individuals not qualified for VA benefits to other agencies.
    Legal name change.
    Review active service record.
    Assist active medical boards.
    Hawaii Veterans Newsletter.
    Hawaii Veterans Roster.
    Hawaii Veterans Website.
    Governor's Liaison to veterans.
    Legislative Advocate for veterans--State and Federal.
    Yukio Okutsu Hilo Veterans Home--development and oversight.
    State Veterans cemeteries statewide--grants and expansion.
    Grant-in-Aid for all veteran related items--veterans' cemeteries,
      Arizona Memorial, Aviation Museum, Veterans Centers
      statewide, etc.
    Tri-annual report for State Monuments.
    Coordinate veterans organizations to clean the Korean and
      Vietnam Memorials on Capitol grounds.
    Coordinate Memorial and Veterans Day ceremonies annually
      at Hawaii State Veterans Cemetery.
    Assist with Memorial and Veterans Day ceremonies at National
      Cemetery of the Pacific (Punchbowl).
    Coordinate leis for veterans cemeteries on Memorial Day.
    Staff the Advisory Board on Veterans Services.
    Hawaii Veterans Memorial Fund.
    Maintain presence on neighbor islands.
    Validate Military Service for Employee Retirement System.

    Senator Akaka. Thank you very much, Mr. Moses. Now we'll 
receive testimony of Gregory Reed.

         STATEMENT OF GREGORY REED, DIRECTOR, HONOLULU 
 REGIONAL OFFICE, VETERANS BENEFITS ADMINISTRATION, DEPARTMENT 
                      OF VETERANS AFFAIRS

    Mr. Reed. Chairman Akaka, it is my pleasure to be here 
today to discuss our efforts to meet the needs of veterans 
residing in the Pacific Region. The Veterans Benefits 
Administration, VBA, is responsible for administering a wide 
range of benefits and services for veterans, their families, 
and their survivors.
    Today I will discuss the important services we provide at 
the Honolulu Regional Office. I will also discuss actions VA is 
taking to expedite the processing of claims from our Operations 
Iraqi and Enduring Freedom veterans and VBA's national hiring 
initiative that will improve Honolulu's ability to provide more 
timely, accurate, and consistent determinations on veterans' 
claims.
    The Honolulu Regional Office is responsible for delivering 
VA benefits and services to veterans residing in the Pacific 
Region, including Hawaii, Guam, American Samoa, and the 
Commonwealth of the Northern Marianas. We provide disability 
compensation, dependency and indemnity compensation, disability 
and death pension, and burial benefits to eligible veterans, 
dependents, and survivors. In addition, we offer vocational 
rehabilitation employment services, home loan guarantees, and 
Native American direct loans.
    The Regional Office also provides extensive outreach to 
veterans and dependents throughout the Pacific Region. One of 
our most successful benefit packages is the Native American 
Direct Loan Program. Initially a pilot program, which you, 
Senator, helped to make permanent in 2006 by way of Public Law 
109-233, the Native American Direct Loan Program. This has 
effectively provided quality homes in the U.S. territories and 
Hawaii homelands. At present, the Honolulu Regional Office 
holds 75 percent of all Native American direct loans 
nationwide.
    More than 107,000 veterans are served by the dedicated 
employees of the Honolulu Regional Office. Approximately 16,700 
of these veterans are receiving disability compensation. This 
fiscal year, through July, the Honolulu Regional Office 
provided approximately 4,314 veterans with decisions on their 
disability claims. Through aggressive outreach and public 
contact activities, Regional Office employees have conducted 
nearly 9,000 personal interviews and over 2,300 telephone 
interviews, and briefed 850 separating servicemembers so far 
this year.
    We recently extended telephone service, benefits 
counseling, and other interisland itinerate services to the 
South Pacific area encompassing the Federated States of 
Micronesia. Telephone service is also provided to veterans 
residing in the Republic of Palau and the Marshall Islands. Our 
Veterans Service Center at the RO has a designated Military 
Service Coordinator, who performs many of the outreach 
functions provided to returning servicemembers. The Military 
Service Coordinator conducts regular briefings covering the 
full range of VA benefits as part of the Military Transition 
Assistance Program, better known as TAP. A Veterans Service 
Representative is also out based in Guam to provide TAP 
briefings there. In addition, the Military Service Coordinator 
conducts briefings for members of the Army or Navy being 
discharged for medical disabilities.
    Our Vocational Rehabilitation and Employment employees work 
very closely with military facilities in Hawaii to ensure that 
outreach is extended to as many returning servicemembers as 
possible. A VA employment specialist from the Honolulu Regional 
Office is staffed at the Tripler Army Medical Center's 
Deployment Health Center to assist returning Reservists and 
National Guard members.
    In addition to providing information about VA services, the 
employment specialist sometimes refers recuperating soldiers to 
the local Disabled Veteran Outreach person for employment 
briefings offered by the Department of Labor.
    We also provide monthly briefings at the TAP sessions at 
Pearl Harbor Naval Hospital and Schofield Barracks. Our 
vocation rehabilitation division also provides over 1,000 
servicemembers and recently discharged veterans vocational and 
educational counseling. We are the third highest in the country 
providing that service.
    The Honolulu Regional Office has been a major player in the 
success of the Native American Direct Loan Program. Since 1993 
VA has made almost 600 loans to Native American veterans for 
the purchase, construction, or improvement of homes on Federal 
trust land under this program. Over 75 percent of all loans 
made in this program have been to Native American veterans 
living on the homeland territories of American Samoa, Guam, 
Hawaii, and the Commonwealth of the Northern Marianas. Much of 
the credit for this achievement is due to our ongoing 
partnerships with the Department of Hawaiian Homelands, the 
Community Development Bank of American Samoa, the Territorial 
Government of Guam, and the Commonwealth of the Northern 
Marianas Cultural Affairs Office.
    With the ongoing activation of Reserves and National Guard 
members in support of the military operation in Iraq and 
Afghanistan, servicemembers are becoming eligible for VA home 
loan benefits faster and in greater numbers. Instead of the 
time and service requirement of 6 years for members of the 
Reserves or National Guard, eligibility is established under 
the loan guarantee and Native American Veteran Direct Loan 
Program after 90 days or more of active wartime service.
    Further, as a result of Public Law 108-454, veterans are 
eligible for VA guaranteed and direct loans equal to the 
Freddie Mac conforming loan limit. As of January 2006, that 
rate increased to 625,000 for high cost areas such as Hawaii 
and Guam.
    Mr. Chairman, I will now discuss two VA-wide initiatives 
which the Honolulu Regional Office is actively participating. 
The first of these is priority processing of claims submitted 
by veterans of Operation Iraqi Freedom and Operation Enduring 
Freedom.
    Since the onset of the combat operations in Afghanistan and 
Iraq, VA has provided expedited and case management services 
for all seriously injured OIF and OEF veterans and their 
families. Records show that the Honolulu staff has assisted a 
total of 57 OIF/OEF seriously injured veterans. This 
individualized service begins at the military medical 
facilities where the injured servicemembers, separating under 
the VA medical care and benefit system, are streamlined into 
our benefits system overall, as well as the VA health care 
system.
    Beginning in February 2007, VA has provided priority 
processing for all OIF/OEF veterans' disability claims. This 
initiative covers all active duty, National Guard, and Reserve 
veterans who were deployed in the OIF/OEF theaters or in 
support of these combat operations, as identified by the 
Department of Defense, DOD. As a result, all the brave men and 
women returning from the OIF/OEF theaters who were not 
seriously injured in combat, but who, nevertheless, have a 
disability incurred or aggravated during their military service 
enter the VA system and begin receiving disability benefits as 
soon as possible after separation.
    I am especially pleased today to be able to discuss VA's 
national hiring initiative. VA has already added more than 800 
new employees since April, and plans call for adding a total of 
3,100 new employees by the end of next year. These employees 
will be placed in critically needed positions in VA regional 
offices throughout our Nation. In order to have these new 
employees online and productive within a few months, VA is 
providing them with accelerated training that focuses on 
specialized areas of claims processing. This initial training 
will be followed by ongoing, carefully structured, and 
progressively complex training until full journeymen expertise 
is achieved.
    The Honolulu Regional Office been authorized to increase 
its staffing level by over 10 percent as a result of this 
hiring initiative. A number of the new employees are already on 
board, and the regional office is in the process of filling 
another five vacancies. The training of our new employees is 
going well. We sought the assistance of the San Diego Regional 
Office and temporarily detailed one of their senior specialists 
for about 6 weeks to assist with training in forming a nucleus 
of expertise. Our employees were tremendously helped by this 
expertise and continue to thrive on it. These additional 
resources will enable Honolulu Regional Office employees to 
make great strides in improving the delivery of benefits and 
conducting more outreach in the Pacific Region.
    We thank you for your assistance, and with your continued 
support we intend to deliver best service possible to veterans 
who reside in the Pacific Region.
    Mr. Chairman, this concludes my testimony. I greatly 
appreciate being invited to testify here today and look forward 
to any questions you may have, sir.
    [The prepared statement of Mr. Reed follows:]

  Prepared Statement of Gregory C. Reed, Director, Honolulu Regional 
   Office, Veterans Benefits Administration, Department of Veterans 
                                Affairs

    Chairman Akaka, it is my pleasure to be here today to discuss our 
efforts to meet the needs of veterans residing in the Pacific Region.
    The Veterans Benefits Administration (VBA) is responsible for 
administering a wide range of benefits and services for veterans, their 
families, and their survivors. Today I will discuss the important 
services we provide at the Honolulu Regional Office. I will also 
discuss actions VA is taking to expedite the processing of claims from 
Operations Iraqi and Enduring Freedom (OIF/OEF) veterans and VBA's 
national hiring initiative that will improve Honolulu's ability to 
provide more timely, accurate, and consistent determinations on 
veterans' claims.

                        HONOLULU REGIONAL OFFICE

    The Honolulu Regional Office is responsible for delivering VA 
benefits and services to veterans residing in the Pacific Region, 
including Hawaii, Guam, American Samoa, and the Commonwealth of the 
Northern Marianas. We provide disability compensation, dependency and 
Indemnity compensation, disability and death pension, and burial 
benefits to eligible veterans, dependents, and survivors. In addition, 
we offer vocational rehabilitation and employment assistance, home loan 
guaranties, and Native American direct home loans. The regional office 
also provides extensive outreach to veterans and dependents throughout 
the Pacific Region.
    One of our most successful benefit packages is the Native American 
Direct Loan Program. Initially a pilot program, which you helped to 
make permanent in 2006 by way of Public Law 109-233, the Native 
American Direct Loan Program has effectively provided quality homes on 
in the U.S. Territories and Hawaiian Home Lands. Currently, the 
Regional Office has closed 315 loans, and refinanced 161 loans, 
totaling $30,557,365 and $13,716,700, respectively. Our Loan Guaranty 
division has an additional 33 homes under construction with loan 
obligations totaling $6,686,919. At present, Honolulu holds 95 percent 
of all Native American Direct Loans, nationwide.
    More than 107,000 veterans are served by the dedicated employees of 
the Honolulu Regional Office. Approximately 16,700 of these veterans 
are receiving disability compensation. This fiscal year through July, 
the Honolulu Regional Office provided approximately 4,314 veterans with 
decisions on their disability claims.

                       OUTREACH AND COMMUNICATION

    Through aggressive outreach and public contact activities, regional 
office employees have conducted nearly 1,350 personal interviews and 
2,250 telephone interviews, and briefed approximately 850 separating 
servicemembers so far this year. We recently extended telephone 
service, benefits counseling, and other inter-island itinerant services 
to the South Pacific area encompassing the Federated States of 
Micronesia. Telephone service is also provided to veterans residing in 
the Republic of Palau and the Marshall Islands.
    The Veterans Service Center at the RO has a designated Military 
Services Coordinator who performs many of the outreach functions 
provided to returning servicemembers. The Military Services Coordinator 
conducts regular briefings, covering the full range of VA benefits, as 
part of the military Transition Assistance Program (TAP) at various 
military installations in Hawaii. A Veterans Service Representative is 
also outbased in Guam to provide TAP briefings there. In addition, the 
Military Services Coordinator conducts briefings for members of the 
Army or Navy being discharged for medical disabilities. These 
briefings, which are part of the Physical Evaluation Board 
orientations, are conducted at Pearl Harbor Naval Regional Medical 
Center and Tripler Army Medical Center.

          VOCATIONAL REHABILITATION AND EMPLOYMENT ACTIVITIES

    Our Vocational Rehabilitation and Employment (VR&E) employees work 
very closely with military facilities in Hawaii to ensure that outreach 
is extended to as many returning servicemembers as possible. A VA 
Employment Specialist from the Honolulu Regional Office is staffed to 
the Tripler Army Medical Center's Deployment Health Center to assist 
returning Reservists and National Guard members. In addition to 
providing information about VA services, the Employment Specialist 
sometimes refers recuperating soldiers to the local Disabled Veteran 
Outreach Program for employment briefings offered by the Department of 
Labor. VR&E employees participate in a program at the Schofield 
Barracks Army Base's Soldier and Family Assistance Center, which 
provides one-stop service for returning servicemembers and their 
families. We also provide monthly briefings at Disabled Transition 
Assistance Program (DTAP) sessions at Pearl Harbor Naval Base and 
Schofield Barracks.
    Our Vocational Rehabilitation Division also provides over 1,000 
servicemen and recently discharged veterans vocational/educational 
counseling, the third highest in the country.

                      HOME LOAN GUARANTY SERVICES

    The Honolulu Regional Office has been a major player in the success 
of the Native American Veteran Direct Loan Program. Since 1993 VA has 
made almost 600 loans to Native American veterans for the purchase, 
construction, or improvement of homes on Federal Trust lands under this 
program. Over 75 percent of all loans made under this program have been 
to Native American veterans living on the homeland territories of 
American Samoa, Guam, Hawaii, and the Commonwealth of the Northern 
Marianas.
    Much of the credit for this achievement is due to our ongoing 
partnerships with the Department of Hawaiian Homelands, the Community 
Development Bank of American Samoa, the Territorial Government of Guam, 
the Commonwealth of the Northern Marianas (CNMI), the CNMI Department 
of Community and Cultural Affairs Veterans Affairs Office, and the 
Mariana Islands Housing Authority. These offices have played crucial 
roles in assisting with outreach and delivery of the VA home loan 
benefit to veterans located throughout the South Pacific. They have 
acted as our partners in assisting with loan packaging, appraisals, and 
construction-related inspections, and have provided crucial 
communication links between our staff and the veterans we serve.
    With the ongoing activation of Reserve and National Guard members 
in support of the military operations in Iraq and Afghanistan, 
servicemembers are becoming eligible for VA home loan benefits faster 
and in greater numbers. Instead of the time-in-service requirement of 6 
years for members of the Reserves or National Guard, eligibility is 
established under the Loan Guaranty and Native American Veteran Direct 
Loan Programs after 90 days or more of active wartime service. Further, 
as a result of P.L. 108-454, veterans are eligible for VA-guaranteed 
and direct loans equal to the Freddie Mac conforming loan limit. As of 
January 2006, that rate increased to $625,500 for high cost areas such 
as Hawaii and Guam. We think this will make VA guaranteed home loans 
much more attractive to veterans served by the Honolulu Regional 
Office, and we anticipate continued growth in the Loan Guaranty Program 
and Native American Direct Loan Program in the Pacific Region as a 
result.

                PRIORITY PROCESSING FOR OIF/OEF VETERANS

    Mr. Chairman, I will now discuss two VA-wide initiatives in which 
the Honolulu Regional Office actively participates. The first of these 
is priority processing of claims submitted by veterans of Operation 
Iraqi Freedom and Operation Enduring Freedom (OIF/OEF).
    Since the onset of the combat operations in Afghanistan and Iraq, 
VA has provided expedited and case-managed services for all seriously 
injured OIF/OEF veterans and their families. Records show the Honolulu 
staff has assisted a total of 57 OEF/OIF seriously injured veterans. 
This individualized service begins at the military medical facilities 
where the injured servicemembers return for treatment, and continues as 
these servicemembers are medically separated and enter the VA medical 
care and benefits systems. VA assigns special benefits counselors, 
social workers, and case-managers to work with these servicemembers and 
their families throughout the transition to VA care and benefits 
systems, and to ensure expedited delivery of all benefits.
    Beginning in February 2007, VA has provided priority processing for 
all OIF/OEF veterans' disability claims. This initiative covers all 
active duty, National Guard, and Reserve veterans who were deployed in 
the OIF/OEF theatres or in support of these combat operations, as 
identified by the Department of Defense (DOD). As a result, all the 
brave men and women returning from the OIF/OEF theaters who were not 
seriously injured in combat, but who nevertheless have a disability 
incurred or aggravated during their military service, enter the VA 
system and begin receiving disability benefits as soon as possible 
after separation.
    The Honolulu Regional Office is currently processing 74 OEF/OIF 
veteran claims. None are designated as seriously injured. Currently, 
our average time to process these claims is less than 180 days. On 
occasion, specialty exams or add on conditions will necessarily extend 
the time required to process a claim.
    VA expanded outreach programs for National Guard and Reserve 
components and its participation in OIF/OEF community events and other 
information dissemination activities. An OIF/OEF team at VBA 
Headquarters addresses OIF/OEF operational and outreach issues at the 
national level and provides support to the newly designated OIF/OEF 
managers at each regional office, including Honolulu.
    To ensure that VA benefits information is provided to all 
separating servicemembers, including Reserve and Guard members, VA 
works with DOD to expand its role in DOD's military pre-separation 
process. Specifically, VA now 5 provides ``Claims Workshops'' in 
conjunction with many VA benefits briefings for separating 
servicemembers. At these workshops, groups of servicemembers are 
instructed on how to complete the VA application forms. Personal 
interviews are also conducted with those applying for VA disability 
benefits.
    In addition to providing ongoing TAP/DTAP briefings at the major 
military bases on Oahu, the Regional Office OIF/OEF Manager 
collaborates with the Veterans Health Administration on special 
outreach events. Most recently, on August 7, 2007, a multi-disciplinary 
``New Patient Orientation'' was conducted for OEF/OIF veterans. 
Approximately 30 veterans participated and our staff reported it was a 
very successful event. Our OEF/OIF Coordinator and Manager are working 
on sponsoring ``Claims Workshops'' in collaboration with the Warrior 
Transition Units at TAMC, Schofield, and MCBH. I would also like to 
point out that our out based satellite office in Guam is also actively 
engaged in services such as these, serving the veterans who reside on 
Guam and the Commonwealth of the Northern Marianas Islands. Our Guam 
staff has also been responsible for providing benefits counseling 
services to veterans in Micronesia, at the special ``request of the 
Ambassador of the Federated States of Micronesia.

                       NATIONAL HIRING INITIATIVE

    I am especially pleased today to be able to discuss VA's national 
hiring initiative, VA has already added more than 800 new employees 
since April, and plans call for adding a total of 3,100 new employees 
by the end of next year. These employees will be placed in critically 
needed positions in VA regional offices throughout the Nation.
    In order to have these new employees ``on-line'' and productive 
within a few months, VA is providing them with accelerated training 
that focuses on specialized areas of claims processing. This initial 
training will be followed by ongoing, carefully structured, and 
progressively complex training until full journey expertise is 
achieved.
    The Honolulu Regional Office has been authorized to increase its 
staffing level by over ten percent as a result of this hiring 
initiative. A number of the new employees are already on board, and the 
regional office is in the process of filling another five vacancies. 
The training of our new employees is going well. We sought the 
assistance of the San Diego Regional Office and temporarily detailed 
one of their senior specialists for about six weeks to assist with 
training and forming a nucleus of expertise. Our employees were 
tremendously helped and have ongoing access to this expertise.
    These additional resources will enable Honolulu Regional Office 
employees to make great strides in improving the delivery of benefits 
and conducting more outreach in the Pacific Region. We thank you for 
your assistance, and with your continued support, we intend to deliver 
the best service Possible to Veterans who reside in the Pacific Region.
    Mr. Chairman, this concludes my testimony. I greatly appreciate 
being invited to testify here today and look forward to answering your 
questions.

    Senator Akaka. Thank you very much, Director Reed.
    Again, I want to remind you, if you have any messages to 
pass on, any written statements, please take it to the staff 
who are here, even as we talk. Before I ask questions of the 
witnesses, I'd like to ask Felipe Sales, who is accompanying 
Dr. Hastings, if he wants to say something about the Vet 
Centers?
    Mr. Sales. Thank you, Mr. Chairman, for allowing me to be 
here. Yes, I need to, in a sense, clarify some of the things 
that I think often get misconstrued in terms of what we do at 
the Vet Centers. The Vet Center is the outreach center of the 
VA. We do outreach, where the VA usually doesn't go out and 
talk to or get to veterans, especially those from the combat 
theater. We are mandated to provide counseling to combat 
veterans and their families. And in the instance of the units 
on the Big Island that were deployed, we in fact went to and 
their units and talked to them prior to deployment, explaining 
to them and letting them know what were the benefits and 
resources available for them and their families who were 
remaining behind, and then what may be available to them on 
their return.
    Also, on their return, we also went and made contact with 
the units, letting them know what was available in terms of 
counseling for the veteran and their families. There's also a 
family support group that the Guard units and the Reservists 
have. We have gone out to them and talked to their families in 
terms of the resources and benefits that are available for 
them. Hilo Vet Center was involved with both the deployment 
health survey, and we conducted--I think we saw about 135 
veterans that came back. And since then, the follow up we've 
done in terms of counseling--veterans that have come in for 
counseling and their families--we've seen approximately 20 
families now.
    So we let them know that we're available. We even had 
extended hours for those that work. The only thing we ask is 
that they call. I don't think we've turned down any one of them 
that have applied or called for counseling. Thank you.
    Senator Akaka. Thank you very much, Felipe. Now, questions 
to each one of the panelists. It has been recommended, and 
you've heard this question before today, that DOD and VA 
develop a joint separation physical. From your perspective, do 
you believe that it makes sense to combine VA and DOD 
separation exams?
    Dr. Hastings.
    Dr. Hastings. Thank you, Mr. Chairman. I saw this one 
coming when you had asked the previous group.
    It's a complicated question because the DOD and the VA are 
looking at different things when those exams are done. But as I 
think about it, to have one very complete and comprehensive 
evaluation done on somebody that's separating from the 
military, I think would be a good thing.
    The DOD separation physical is traditionally quite brief. 
The VA physical examination for rating purposes is 
extraordinarily detailed. And we need to train our people 
extensively in order to meet the high standards that the VA 
maintains for those physical exams.
    So this would be a significant investment, I think, for the 
system, combined DOD/VA system, in order to meet this 
requirement. It's an investment in the future. If you look, as 
I do, at the VA as being the health care provider for these 
people who are separating for the rest of their lives, I think 
to have a benchmark as to what their issues were is a 
worthwhile investment for the country. Thank you.
    Senator Akaka. Thank you, Dr. Hastings. Mr. Moses.
    Mr. Moses. Thank you, Mr. Chairman. Of course I'm not in 
the medical field myself. I think it would be beneficial to 
have some of the issues identified at the time of discharge, 
but I know out of just observations and personal history all 
the issues don't show themselves immediately upon discharge.
    Post Traumatic Stress Disorder is one that might not appear 
for a few years. That doesn't mean you can't at the time of 
discharge try to indicate the types of combat or other 
situations that you were involved with. I don't know if we can 
get those listed, though, at the time of a medical examination. 
They should more appropriately be in the active duty records. 
If they could come up, that would be good.
    I can see one other problem. We have the luxury here in 
Hawaii with having the VA and Tripler co-located. You don't 
have that in all instances in other states, but also we have 
Makalapa and we have facilities at the Marine Corps Base 
Kaneohe. We don't have that co-located with VA. So I can see a 
lot of logistics problems in just getting everybody together at 
the appropriate time. When a VA doctor travels to one of these 
other facilities, he's not serving VA patients. This is a 
complicated issue.
    Senator Akaka. Gregory Reed, I know you're not a doctor, 
but you're the director of the Regional Office. Let me ask you 
for your comments on this.
    Mr. Reed. No, Senator. I believe it would help us expedite 
the claims if we could do this. As Mark pointed out, it may 
not, you know, pick up PTSD and things of that nature, but as 
far as physical, I think it would be very beneficial for us.
    Senator Akaka. As I mentioned earlier, this has been 
recommended. I'm just asking our witnesses to comment on this. 
And this is part of a whole move to try to have seamless 
transition between active and civilian life. We are thinking 
seriously about this and looking for comments from all of you.
    Mr. Moses, what is the State of Hawaii doing to assist 
members of the Guard and Reserves as they transition to 
civilian life?
    Mr. Moses. Well, briefly, Mr. Chairman, I have to go a step 
further. We help active duty while they're still active duty. 
We have active duty veterans coming in regularly into the 
office from all branches of the service, but that includes the 
Guard and the Reserve. We try to attend the returning 
ceremonies, the post-deployment gatherings of all the veterans, 
we try to have a counselor available. We also are getting more 
involved in actually providing the information, as you've seen 
attached to the testimony, the list of the services that we 
provide, we find that not all members understand that those 
services are available.
    And I can go back to my own history. When I was active 
duty, I never thought of going to a state Office of Veterans 
Services for anything, let alone the VA. There was active and 
there was my command and that's who took care of me. We're 
trying to break through that, and this goes toward your 
seamless idea, to make them understand that we are there. We're 
there for many things that can be done while they're still in 
service, and at the time of their discharge or release we need 
to get out to them more and more and tell them what's 
available.
    We do try this through newsletter, web site, and, as I 
said, we have counselors go to their post-deployment 
gatherings, whether it's formal or informal, there are 
debriefings and there are regular--I don't know what word to 
use for it other than gatherings, but the National Guard and 
the Reserves do talk to all of their returning soldiers and 
airmen about what's going on and what they should expect. We're 
trying to be there as part of it.
    I think it's fortunate that we are part of the National 
Guard. We're directly under the National Guard in this state, 
and that helps us because we know the events that are happening 
and we know when units are returning, and even as individuals 
return we have access to that information and we can be there.
    Senator Akaka. Thank you, Mark Moses.
    Mr. Reed, VA's timely access to veteran's DD-214 and 
medical records continues to be a serious problem.
    Please explain the process by which the Veterans Benefits 
Administration obtains these records. And does delayed access 
slow claims processing at the Honolulu Regional Office?
    Mr. Reed. In reference to that accessing the DD-214s, are 
you speaking about from the Records Maintenance Center in St. 
Louis? That's where we normally access the 214s from. Is that 
what you're referring to?
    Senator Akaka. No.
    Mr. Reed. I'm unaware of younger veterans having difficulty 
obtaining their 214s for VA.
    Senator Akaka. Let me rephrase my question. Are they 
bringing in their DD-214s to you as they come in?
    Mr. Reed. Yes, they are, sir, when they're filing original 
claims.
    Senator Akaka. One of the things that we're going with this 
idea of seamless transition is to try to eliminate some of the 
problems that develop into problems of access and getting 
records----
    Mr. Reed. Yes.
    Senator Akaka [continuing].--from the active duty.
    Mr. Reed. Sir, we've had a problem or a challenge in 
getting records from the National Guard, but we have recently 
become signatories, or I have, and I believe everybody else on 
this panel has with the Hawaii National Guard. We had one of 
the representatives come over and meet with Susan Bauman, and 
we signed off on that and we looked to that to be improved 
greatly.
    Senator Akaka. Dr. Hastings, a key provision of the 
Senate's Dignified Treatment of Wounded Warriors Act is the 
extension of automatic access to care for separating combat 
veterans from two to five years after separation. How will this 
affect health care for veterans in Hawaii?
    Dr. Hastings. Senator, first of all, I applaud this idea, 
because as we are identifying problems with the individuals 
that are coming back, some of them are not picked up initially. 
The classic one of course that you've heard about is the PTSD, 
but this is also true of the TBI, and there are others as well. 
So it's very clear to us that there are problems that are not 
being identified initially, and also it's taking us a while to 
work through the natural history of these diseases in carrying 
for these veterans. I applaud the efforts of the Senate to 
extend that eligibility for a period of three more years.
    My organization is growing. We have been growing at 5 to 6 
percent per year, and as a result we're improving access, we're 
adding staff, we're improving specialty care, and of course 
adding--this is an additional workload to us. My guess is that 
this will increase our workload by probably 6 or 7 percent, 
which on the aggregate would increase my growth rate probably 
the equivalent of 1 or 2 percent per year, which is in line 
with the growth that we're sustaining right now.
    I think this is something that we will handle in the normal 
course of events, as long as we continue on the growth curve 
that we have experienced in the past few years, and I don't see 
any reason why we shouldn't. You have provided and the Senate 
has provided increased resources to us, and we are offering 
more care today to the veterans in our area of operation. I 
would expect that will--or I hope that ends up continuing, with 
your support. Thank you, sir.
    Senator Akaka. Thank you, Dr. Hastings.
    Dr. Hastings and Mr. Reed, what measures have you 
undertaken to educate separating servicemembers about the VA 
benefits and services available to them? Let me call on Mr. 
Reed first.
    Mr. Reed. Senator, as I mentioned in my testimony, we are 
actively engaged with separating the servicemembers at all the 
military facilities on Oahu, as well as out on Guam, in getting 
them TAP sessions and also we're involved in the DTAP sessions. 
I think we're doing a very good job there.
    Dr. Hastings. Senator, we're involved also at the TAP 
sessions and at the DTAP sessions, and in addition, we are 
actively involved with the PDHRAs.
    Of course, the other thing we have done is once we have 
veterans that have signed up with us, we have begun inviting 
them in to orient them again. Now, the issue there is if they 
didn't sign up with us at one of these original events, then 
they may not be picked up. But when we have gone out to 
advertise with these sessions where we sort of have an 
orientation for them once they've signed up, we sort of open it 
up and say, please bring your friends, it's not an exclusive 
thing, and indeed when we've done that--we actually signed up 
some more veterans that we had missed in our first rounds. But 
there's no doubt that outreach for us is a continuing effort, 
and it's going on both here and on Oahu.
    It's going on at our CBOCs. It's going on throughout our--
you know, throughout our organization, and of course we're 
getting help from the Vet Centers. A lot of veterans are coming 
in through the Vet Centers, and we have very good close working 
relationships between our Vet Centers and our CBOCs, and so 
they will refer back patients--or refer back and forth when 
they identify individuals.
    Senator Akaka. I have one more question to ask Dr. 
Hastings. Before I do that, I just want to tell the panelists 
that following that question I'm going to ask each member of 
the panel to make any final comments.
    I want also those of you who are here to know that although 
we continue to talk about challenges and looking for 
improvements. We all know that many improvements have been made 
over the few years back, but we still want to improve what is 
happening. We still have people that have concerns as well. 
This is what we're trying to do with these hearings and 
meetings that we're holding. As I asked the first panel, as you 
remember, if they had any solutions or recommendations, to 
mention it.
    We are looking, because you folks are the ones that have 
these concerns and we may have a simple answer to whatever your 
concern is. You can leave it with some of the staff that are in 
the back of the room. I just want to mention it because I was 
talking to Jim Asing, who is sitting in the first row here, who 
is a Vietnam veteran and a musician who set up a foundation. 
And this is, again, about people who are trying to help 
veterans. He set up a foundation, and their approach is to help 
veterans through music therapy. That's the kind of solution 
that we may be able to use in the future.
    I'd like for you to think about these innovative ideas, and 
if you have any, we would be glad to hear them. And of course 
if we can work it in the system, you know, we certainly would 
like to look at that.
    Dr. Hastings, I am aware that members of the National Guard 
and Reserve are not eligible for TRICARE, and if I'm wrong, 
correct me, must turn to VA for health care. Are members of the 
Guard and Reserve who come to be soldiers in Hawaii receiving 
the care they need?
    Dr. Hastings. You're talking about the OIF/OEF veterans, is 
that it? I believe that the OIF and OEF veterans that are 
coming to us, once they've been identified, are being seen, are 
being taken care of. We monitor this. We monitor the waiting 
times. We try to keep them under 30 days, and I think we're 
succeeding in that the majority of the time.
    We are challenged when we're dealing with some of the outer 
islands and some of the more distant locations in the Pacific. 
There's no doubt about that. That's a continual challenge for 
us, and that has been mentioned by some of the earlier 
testimony today, and that's the challenge that we face in 
building a health care system in an area of the world that is 
the geographically separated by oceans. And so that's--that's 
our challenge. It's what we're doing.
    We have been able to improve using all the tools available 
to us. We have been able to improve specialty consultation to 
our--to our beneficiaries. So am I totally satisfied with how 
well we're doing today? No, I'm not. Do I think we can do 
better? Yes, I do. Is it a matter of money and resources? No. 
You have provided for me the money necessary.
    The problem is building complex systems, and that's the 
challenge that I face is building complex health care systems 
to work in this kind of harsh environment we live in.
    Senator Akaka. Thank you, Dr. Hastings. I would like to ask 
Felipe about the Vet Centers.
    Are Vet Centers staff meeting regularly with demobilized 
Guard and Reserve members as they come together for drills or 
otherwise get together? And do you have sufficient resources to 
do such outreach?
    Mr. Sales. No, we don't do it regularly. It's been offered. 
We've talked to the point of contacts at the Guard units, 
letting them know of our availability and our willingness to go 
in and talk with them. Our regular hours are 8 to 4:30, with 
extended hours in the evening to take care of anyone who works, 
but we have gone down to the Guard units on the weekends also 
to do talks for them. Like the previous incident that occurred 
with one of their members, we went down and helped debrief and 
talked with them and got some of them to come in for counseling 
services. So we're readily available.
    We'll go there, or if they call, more than willing to see 
them in the office.
    Senator Akaka. Felipe, what is your assessment of how the 
Guard and Reserve members and their families are learning about 
their benefits?
    Mr. Sales. Aside from the briefings, just from how they 
either call either our office or the CBOC or the visit, we have 
a benefits counselor that now comes into our office once a 
month, and we take sign-ups and if they have questions they can 
ask there, but we've gone out to them and talked to them about 
the benefits that are available and allow them to know that.
    We're a resource, and we're a resource that can attach them 
to other resources in the VA that can help them with any other 
problems that they might be having.
    Senator Akaka. Well, thank you very much. I'm asking all of 
this because you know that I feel that Vet Centers are 
important to veterans. I thank you so much for what you're 
doing.
    Let me ask for each of the witnesses to make their final 
comments and for any responses they may have. I'm going to 
start Greg Reed, the Director of the Regional Office.
    Mr. Reed. Thank you, Senator. I just wanted to once again 
thank you for all the support you've given the Honolulu VA 
Region Office. You know, sir, without your intervention, 
without your support, we would not be where we are today with 
the additional hires, as well as doing the itinerate visits to 
the outer islands. That was put on hold because of travel fund 
constraints, and we also an opportunity to go out to Micronesia 
and do two town hall meetings out there, which were very 
successful. We have a representative that works for us in Guam. 
He went to the islands of Micronesia, and he has also has done 
briefings for National Guard units on Saipan and also on Guam.
    Thank you very much.
    Senator Akaka. Thank you. Mark Moses.
    Mr. Moses. Thank you, Mr. Chairman. Some of the problems I 
heard at the beginning , was lack of outreach, lack of 
outreach, lack of knowledge and where to get help. We do 
outreach, as I mentioned, in the newsletter. There's 8 veterans 
organizations registered with us. We send them regular 
briefings.
    We send them newsletters, what's going on. We have the 
website. As I said, we have counselors located in each county 
and they make trips to each of the islands within the county, 
or like on the Big Island, my counselor Keith there makes trips 
over to Kona regularly. We also attend all the transition 
assistance programs.
    And more than just outreach, we try to tell them to come 
into us we'll help you prepare documents. We'll help brief you 
in detail on your particular case, and we do help prepare their 
actual documents before they submit them to the VA. I think we 
do a very good job of getting it right the first time, which 
helps the VA, because it cuts down on repeats. And if they do 
have an appeal, we represent the veterans at the appeal.
    The question about the DD-214s, as each veteran separates, 
he's asked what state are you going to, and the DD-214 is sent 
to that state. And the state offices are called various things, 
but in Hawaii it's the Office of Veterans Services. The DD-214s 
are sent to us. And if the veteran comes in, of course he has 
one, but if he needs another one, he can come to us and we'll 
give him a copy. And the veteran service organizations, we can 
do the same thing. So we can provide that DD-214. If he didn't 
put down Hawaii, put down some other state, we will get it from 
the other state and we'll provide them with a certified copy 
that can be used by the VA.
    Senator Akaka. Thank you very much, Mr. Moses.
    Dr. Hastings.
    Dr. Hastings. Thank you, Mr. Chairman. We are faced with 
many challenges, and I mentioned to you the obvious one that 
you know very well, and that is that we live in this very 
challenging geographic area. My area of interest covers million 
square miles and encompasses a number of different cultures 
that we must figure out how to deliver health care in.
    At the same time, we're faced with an evolving system 
that's evolving very, very fast. Health care is changing. The 
science of health care is changing. The sociology of health 
care is changing. And then the very nature of warfare is 
changing, and so the new veterans that we are seeing today have 
different challenges from the veterans we saw from each of the 
encounters that our country has had to deal with in the past 50 
or 75 years, and the VA must change in order to meet those 
challenges.
    An example is women veterans. We recently, as you know, had 
the opportunities to open a new clinic in American Samoa, and 
we've heard about that today. And I was at a town hall down 
there and a woman came up to me and asked me what are you 
providing for women veterans in American Samoa? I must admit, I 
was a little embarrassed. I didn't realize how many we had. And 
I asked her, how many women veterans do we have down here? And 
she said between 300 and 400. I didn't know that. And that's a 
challenge for me. How do I build a system to take care of that 
group of veterans that I didn't even really recognize I had 
responsibility for.
    This whole area of Traumatic Brain Injury, this is the 
signature illness of this war. We are just learning about it. 
We really are. I'm actually a little embarrassed to tell you 
that also. And in saying that, I'm reflecting on the science of 
medicine and where we stand and how much information we have.
    And we are rapidly trying to understand this and integrate 
it into our health care system. What are the long-term 
implications of this--of this traumatic process that our 
soldiers are coming back with. And it's hard for us to know 
exactly how to do this. So we're building the system to do 
these things.
    We're living in a rapidly evolving system on many realms. I 
think--I think we're doing pretty well, all things considered, 
but there's no doubt that we have a lot of challenges ahead of 
us in the next few years to build a health care system that's 
going to meet the needs of our veterans into the future. We're 
going to continue to need to be resourced and supported as we 
go forward from this point on. And I want to thank you very 
much for the support that you've given to our veterans with 
your leadership and support over the past several years, and I 
look forward to working with you into the future.
    Senator Akaka. Thank you very much, Dr. Hastings.
    You've heard from our person in charge of benefits for 
Hawaii. And you've heard from the person who represents the 
State of Hawaii, Office of Veterans Services. I want to tell 
you that the State of Hawaii has really been instrumental in 
helping veterans. Mark Moses now is in charge of the veterans 
affairs for Hawaii, so remember him. As he was pointing out, 
they want to do all they can to help Hawaii's veterans. And, of 
course, Dr. Hastings is our health person, and Felipe is our 
Vet Center person.
    In closing, I again want to thank all of our witnesses for 
appearing today. I'm always so pleased to hear directly from 
Hawaii's veterans on issues affecting the veterans of this 
State. I truly appreciate your taking the time to share your 
perspectives on the issues that our service men and service 
women are facing, and on ways to support them. My hope is that 
today's hearing will promote more thoughtful and focused 
assistance for the veterans of our State.
    I'm so happy to have all of you here. I want to wish you 
well, and thank you so much for your service to our great 
country. And of course we are grateful for all of those who are 
now serving us in harm's way, and we have so much aloha for 
those families who have lost loved ones who were serving our 
country.
    And so with that, I want to say aloha to all of you. God 
bless you. God bless America. This hearing is adjourned.
    [Whereupon, at 3:05 p.m., the Committee was adjourned.]

                            A P P E N D I X

                                ------                                

Prepared Statement of Michael Kilpatrick, M.D., Deputy Director, Force 
 Health Protection and Readiness, Office of the Assistant Secretary of 
           Defense for Health Affairs, Department of Defense
    Thank you, Mr. Chairman, for the opportunity to speak to you today 
on behalf of the Assistant Secretary of Defense for Health Affairs 
regarding the health care needs of returning Servicemembers and new 
veterans.
    The satisfaction with medical care that a Servicemember has after 
becoming ill or injured in the combat theater will be the measure of 
success of cooperation between the Department of Defense (DOD) and the 
Department of Veterans Affairs (VA) in providing facilities, treatment, 
rehabilitation and support for Servicemembers and their families.
    Today I will highlight some of the significant programs that our 
two Departments have together put in place to provide the world-class 
medical care that our men and women in uniform deserve. The medical 
innovations such as body armor, buddy care, far-forward surgical care, 
and medical air transportation with intensive care in the air have 
saved American lives. However, the severity of wounds, the rapidity of 
movement between medical care locations, and the necessity for long-
term rehabilitation have created new challenges for the medical systems 
and for the systems that support our Servicemembers and veterans when 
they have medical problems. As needed changes are instituted to meet 
these challenges, we must always keep the focus on the patient and the 
family.
    DOD and VA have had many independent and internal groups evaluate 
our abilities to support and care for our ill and injured 
Servicemembers and veterans, culminating in almost 400 recommendations. 
Even as these groups were preparing those recommendations, the 
Secretary of Defense and the Secretary of Veterans Affairs chartered a 
Senior Oversight Committee (SOC) to systematically address concerns 
about the treatment of wounded, ill, and injured Servicemembers and 
veterans. DOD and VA are already working toward the prompt 
implementation of the recommendations of the President's Commission on 
Care for America's Returning Wounded Warriors. In addition, the SOC 
will ensure that the recommendations of the Secretary of Defense's 
Independent Review Group, DOD's Mental Health Task Force, and the VA's 
Task Force on Returning Global War on Terror Heroes, and others, are 
promptly consolidated and properly aligned, integrated, coordinated, 
resourced, and implemented.
    To do this, the SOC will collect all recommendations, evaluate 
feasibility, break down the recommendations into actionable parts, 
associate those actionable parts with timelines and milestones, 
establish priorities, and apply resources to support rapid 
implementation. The Deputy Secretary of Defense and the Deputy 
Secretary of Veterans Affairs chair the SOC. Reporting to the SOC is an 
Overarching Integrated Product Team (OIPT), chaired by the Principal 
Deputy Under Secretary of Defense for Personnel and Readiness and the 
Principal Under Secretary for Benefits (VA). The OIPT has chartered 
eight discrete lines of action (LoA), each tasked with analysis and 
improvement of a specific part of both Departments' integrated programs 
for treatment and support of wounded, ill, or injured Servicemembers, 
veterans, and their families.
    DOD's collective focus is centered on LoAs that leverage the 
experience and capabilities of both the DOD and the VA to enable each 
to more effectively serve its beneficiary populations. We are convinced 
the continued cooperation of both Departments will greatly improve the 
quality of health care provided to all beneficiaries.
    LoA 1 has DOD and VA working closely to provide a seamless and 
transparent disability process that is jointly administered by both 
organizations. The Departments will support one Disability Evaluation 
System that will be flexible enough to evolve as trends in injuries and 
supporting medical documentation and treatment necessitate.
    For LoA 2, DOD and VA are working together to respond to a myriad 
of recommendations about the identification, treatment, recovery, and 
follow-up for Traumatic Brain Injury (TBI) and post-traumatic stress 
disorder (PTSD) and other psychological health (PH) issues. A group of 
DOD and VA subject matter experts were temporarily assigned to a ``Red 
Cell'' to develop a comprehensive program to address all aspects of 
recommendations and concerns about these issues, including establishing 
Centers of Excellence for both PH and TBI. Through this collaborative 
effort, we are focusing on clinical research, prevention, education and 
patient/family support. The Red Cell will involve the Services in 
assessing their TBI and PH/PTSD plans and programs for responsiveness 
to the SOC-approved planned and prioritized actions of LoA 2.
    LoA 3 addresses recommendations to improve coordination and 
collaboration of DOD/VA health care delivery and support to all 
Servicemembers and their families through the continuum of care. The 
LoA 3 team is assessing optimal approaches for delivery of an 
integrated, comprehensive DOD/VA case management program that will 
provide timely, proactive, longitudinal, seamless, collaborative 
coordination of quality health care and social services to the 
individual Servicemembers and their families in a manner that promotes 
positive outcomes and quality of life throughout the continuum from 
active duty to veteran status.
    The goal of this program is to provide individualized, integrated, 
interagency and intergovernmental support for the wounded, injured, or 
ill Servicemember and his/her family throughout the process of 
treatment, rehabilitation, and renewal. These efforts will strive to 
minimize fragmentation of Federal services, improve coordination of 
medical and rehabilitative care provided by DOD and VA and enhance 
access to needed support.
    LoA 4 focuses on the DOD and VA commitment to full, bidirectional 
exchange of each Department's electronic medical records. The goal is 
to ensure the Departments' vast array of shared beneficiary data, 
medical records, and other health care information is visible, 
accessible, and readily understandable through secure and interoperable 
information systems, essential in supporting a seamless continuum of 
care.
    Our current focus is building a common inpatient application for 
both Departments to further enhance patient-centric health care 
delivery. DOD and VA have recently contracted a study to identify 
common processes and requirements for a joint inpatient electronic 
health record. Currently, the requirements are being assessed and a 
recommendation will be made on how to create a joint inpatient system. 
In the meantime, further integration of the current systems is taking 
place.
    LoA 5 addresses concerns and recommendations associated with 
adequacy of facilities to support medical hold and holdover 
Servicemembers at DOD installations.
    LoA 6 will provide Departmental leadership recommendations for a 
redesign of policies, regulations and laws, processes, and course 
directions. The philosophy behind this LoA is holistic, beginning with 
a blank sheet of paper, and setting aside all limitations presented by 
existing public law, departmental policy and organizational lines to 
deliver and implement a seamless continuum of care for Servicemembers 
and their families from the battlefield to return to productive life.
    LoA 7 develops the public affairs strategies necessary to 
successfully implement changes through legislative proposals approved 
by the Administration and submitted to Congress. The primary goal is to 
ensure that the Departments have the authority and capability to 
provide the world's best medical care for our Servicemembers, veterans, 
and their families.
    LoA 8 seeks to provide solutions to ensure compassionate, timely, 
accurate and standardized personnel, pay, and financial support 
practices for wounded, injured, or ill personnel. Ensuring appropriate 
data sharing, quality control, and support benefits will further 
support these objectives. Together with the Small Business 
Administration, we are working to provide more timely and accurate 
personnel and fiscal support at all critical patient flow locations and 
points of Service support to include reintegration.

                     OVERALL DOD-VA SHARING EFFORTS

    Over the last several years, the DOD and VA have made significant 
strides in coordinating and developing common health care and support 
services along the entire continuum of care. Both agencies are making 
concerted efforts to work closely to maintain and foster a more 
effective, aligned Federal health care partnership.
    In April 2003, a DOD/VA Joint Executive Council (JEC), chaired by 
the Under Secretary of Defense for Personnel and Readiness and the 
Deputy Secretary of the Department of Veterans Affairs, was established 
to jointly set strategies, goals and plans to better align and 
coordinate the health and benefit services of the two Departments. The 
JEC meets quarterly to review progress against the mutually developed 
plans.
    The VA/DOD Joint Strategic Plan reflects common goals from both the 
VA Strategic Plan and the Military Health System (MHS) Strategic Plan--
and specifically articulates the shared goals and objectives developed 
and ratified by DOD/VA leadership. Progress on the Joint Strategic Plan 
objectives is tracked on a monthly basis and reported to the co-chairs 
of the JEC, and the plan is revised annually.
    The spectrum of DOD/VA collaboration and sharing activities 
encompasses clinical services, education and training, research and 
development, patient administration, and information/data technology 
sharing.
    Section 721 of the National Defense Authorization Act for FY 2003, 
required the Departments to establish, and fund on an annual basis, an 
account in the Treasury referred to as the Joint Incentive Fund (JIF). 
The JIF provides a means to eliminate budgetary constraints as a 
possible deterrent to sharing initiatives by providing designated 
funding to cover the startup costs associated with innovative and 
unique sharing agreements. There are now 48 JIF projects underway or 
completed, accounting for $88.9 million of the $90 million in the fund. 
The 2006 projects cover such diverse areas of medical care as mental 
health counseling, Web-based training for pharmacy technicians, cardio-
thoracic surgery, neurosurgery, and increased physical therapy services 
for both DOD and VA beneficiaries.
    We also are jointly staffing a number of Federal health facilities. 
These include:

     The Center for the Intrepid--opened in January 2007, 
provides a state-of-the-art facility in San Antonio, Texas, explicitly 
to rehabilitate wounded warriors.
     Augusta--coordinated staffing and assignment to hire, 
train, and share staff.
     Integrated DOD/VA operations at eight locations: North 
Chicago (Great Lakes Naval Station); New Mexico (Kirtland AFB); Nevada 
(Nellis AFB); Texas (Fort Bliss); Alaska (Elmendorf AFB); Florida (NAS 
Key West); Hawaii (Tripler AMC); and California (Travis AFB).
     At the end of FY 2006, DOD military treatment facilities 
and Reserve Units were involved in sharing agreements with 157 VA 
Medical Centers, enabling improved visibility of medical needs in the 
VA for reservists entitled to VA care after returning from combat 
operations.

    This year, both Departments plan to integrate services within 
market areas, not just facility operations, in major population 
centers.

                         COORDINATED TRANSITION

    For Servicemembers who transition directly from DOD military 
treatment facilities to VA medical centers (436 individuals as of June 
2007), DOD and the VA implemented the Army Liaison/VA Polytrauma 
Rehabilitation Center Collaboration program--also called ``Boots on the 
Ground''--in March 2005. This program ensures that severely injured 
Servicemembers who are transferred directly from a military medical 
treatment facility to one of the four VA Polytrauma Centers--in 
Richmond, Tampa, Minneapolis, and Palo Alto--are met by a familiar face 
and a uniform. A staff officer or non-commissioned officer assigned to 
the Army Office of the Surgeon General is detailed to each of the four 
locations, to provide support to the family through assistance and 
coordination with a broad array of such issues as travel, housing, and 
military pay. This coordination process has been working exceptionally 
well. However, this transition has not worked as well when 
Servicemembers were transferred to other locations around the country.
    In response, the VA opened 17 additional Polytrauma Network Sites 
to improve continuity of care to injured Servicemembers. The Department 
deeply values the sacrifices that these veterans and their families 
have made. Through the efforts of the LoAs, we are actively doing all 
we can to improve the coordination and care management plan for 
Servicemembers transitioning to any VA facility.
    The VA also is placing personnel in our medical facilities. The 
Joint Seamless Transition Program, established by the VA in 
coordination with the military Services, facilitates more timely 
receipt of benefits for severely injured Servicemembers while they are 
still on active duty. There are 12 VA social workers and counselors 
assigned at 10 military treatment facilities, including Walter Reed 
Army Medical Center and the National Naval Medical Center in Bethesda. 
These social workers ensure the seamless transition of healthcare, 
including a comprehensive plan for treatment. Veterans Benefits 
Administration counselors visit all severely injured patients and 
inform them of the full range of VA services, including readjustment 
programs, educational and housing benefits. As of June 29, 2007, VA 
social worker liaisons had processed 7,760 new patient transfers to the 
Veterans Health Administration from participating military hospitals.
    Finally, the VA has placed liaisons in each of our three TRICARE 
Regional Offices in Washington, DC, San Antonio, TX, and San Diego, CA, 
providing an important communications and coordination link between the 
DOD and VA to better support our shared beneficiaries.
Mental Health
    Although the Mental Health Task Force's findings indicate that we 
have work to do in expanding our Mental Health programs, we have in 
place several programs that already make a difference. Mental health 
services are available for all Servicemembers and their families 
before, during, and after deployment. Servicemembers are trained to 
recognize sources of stress and the symptoms of distress in themselves 
and others that might be associated with deployment. Combat stress 
control and mental health care are available in-theater. In addition, 
before they return home, we brief Servicemembers on how to manage their 
reintegration into their families, including managing expectations, the 
importance of communication, and the need to control alcohol use.
    After returning home, Servicemembers are provided easy and direct 
access to mental healthcare services following a continuum of care 
model. Same-day appointments and daily walk-in appointments are 
available in military mental health clinics, and behavioral healthcare 
providers are integrated into primary care clinics in both the DOD and 
the VA. TRICARE also is available for 6 months after return for Reserve 
and Guard members and TRICARE Reserve Select programs are available for 
continuing health insurance coverage for Reserve and Guard members and 
their families after the 6-month transition period. To facilitate 
access for all Servicemembers and family members, especially Reserve 
Component personnel, the Military OneSource Program--a 24/7 referral 
and assistance service--is available by telephone and on the Internet. 
In addition, we provide face-to-face counseling in the local community 
for all Servicemembers and family members. DOD provides this non-
medical counseling at no charge to the member, and it is completely 
confidential. For clinical care, family members can access mental 
health services directly in the TRICARE network. Up to eight sessions 
are available without a referral from a primary care manager and 
without pre-authorization requirements from TRICARE.
    The Periodic Health Assessment (PHA) was added to the continuum of 
assessments in February 2006. This annual requirement for all 
deployable members of the Department includes a robust mental health 
section that complements the deployment health assessment process, 
allowing the opportunity for assessment, referral to care, and 
treatment outside the deployment cycle.
    To supplement mental health screening and education resources, we 
added the Mental Health Self-Assessment Program (MHSAP) in 2006. This 
program provides Web-based, phone-based, and in-person screening for 
common mental health conditions and customized referrals to appropriate 
local treatment resources. The program also includes parental screening 
instruments to assess depression and risk for self-injurious behavior 
in their children, along with suicide prevention programs in DOD 
schools. Spanish versions of the screening tools are available, as 
well.
Traumatic Brain Injury (TBI)
    The Department is working on a number of measures to evaluate and 
treat Servicemembers affected or possibly affected by Traumatic Brain 
Injury (TBI). For example, in August 2006, a clinical practice 
guideline for management of mild TBI in-theater was developed and 
fielded for the Services. Detailed guidance was provided to Army and 
Marine Corps line medical personnel in the field to advise them on ways 
to assess, diagnose, and treat TBI. The clinical practice guideline 
includes a standard Military Acute Concussion Evaluation (MACE) tool to 
assess and document TBI for the medical record. TBI research in the 
inpatient medical area is also underway.
    As part of the LoA 2 effort, DOD has modified the questions asked 
during the Post-Deployment Health Assessment, the Post-deployment 
Health Reassessment, and the Periodic Health Assessment to help 
identify individuals who may have suffered a TBI. In April, VA began 
TBI screening of OEF/OIF veterans seeking care in the VA. While there 
is no currently validated clinical screening instrument for TBI, the VA 
is screening for events that increase risk for TBI, immediate symptoms 
at the time, new or worsening symptoms after the event, and current 
symptoms.

             HEALTH INFORMATION TECHNOLOGY AND DATA SHARING

    Although LoA 4 actions will improve DOD and VA data sharing, we 
have already engaged in a number of important efforts to share 
essential clinical and management information in support of health care 
services to our wounded servicemembers and all eligible former military 
members who seek care from the VA.
    The work of capturing and sharing relevant clinical information 
between the DOD and VA begins on the battlefield. Data is being 
captured and sent to the DOD electronic health record, AHLTA. By 
December 2007, theater clinical data will be accessible by VA providers 
for patients presenting to VA for care.
    In September 2005, DOD began monthly transmission of the electronic 
Pre- and Post-Deployment Health Assessment information to the VA, 
followed in November 2006 with monthly transmission of Post-Deployment 
Health Reassessments (PDHRAs) for separated Servicemembers and 
demobilized National Guard and Reserve members. Weekly transmission of 
PDHRAs for individuals to be referred to the VA for care or evaluation 
started in December 2006. As of June 2007, VA has access to more than 
1.7 million assessment forms on more than 706,000 separated 
Servicemembers and demobilized Reserve and National Guard members.
    The Bidirectional Health Information Exchange (BHIE) enables the 
real-time sharing of allergy, outpatient pharmacy, demographic, 
laboratory, and radiology data between all DOD and all VA treatment 
facilities for patients treated in both DOD and VA facilities. Today, 
all DOD sites and all VA sites can view allergy information, outpatient 
pharmacy data, radiology reports, and laboratory results (chemistry and 
hematology) on shared patients, as well as computable data in the 
Clinical Data Repository/Health Data Repository.
    Supporting all of these collaborative efforts, we will continue to 
grow, enhance, align, and integrate the technology infrastructure that 
supports both systems, enabling greater access to clinical and 
administrative information for the benefit of the people we serve. Our 
greatest mission is to honor our Servicemembers by providing the best 
quality care and ensuring a compassionate, fair, and timely disability 
adjudication process to enable them to return to the fullest, most 
productive and complete quality of life possible.