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STATEMENT OF
CATHLEEN C. WIBLEMO, DEPUTY DIRECTOR
VETERANS AFFAIRS AND REHABILITATION DIVISION
THE AMERICAN LEGION

TO THE

SUBCOMMITTEE ON HEALTH
VETERANS’ AFFAIRS COMMITTEE
UNITED STATES HOUSE OF REPRESENTATIVES
ON
VETERANS ACCESS TO QUALITY HEALTH CARE IN
RURAL COMMUNITIES

JUNE 27, 2006

Mr. Chairman and Members of the Subcommittee:

Thank you for this opportunity to present The American Legion’s views on the ongoing efforts of the Department of Veterans Affairs (VA) to provide high quality health care to veterans in rural communities. Research shows us that those veterans residing in rural areas are in poorer health than their urban counterparts. We also know that soldiers and Marines from rural areas are dying at twice the rate of military personnel from the cities and suburbs. According to a report published in April 2004, 44 percent of all soldiers killed during Operation Iraqi Freedom (OIF) were from communities under 20,000. Further, in October 2004, it was reported that nationwide, one in five veterans who enrolled to receive VA health care lives in rural areas.

Providing quality health care in a rural setting has proven to be very tough given factors such as limited availability of skilled care providers and inadequate access to care. VA’s efforts need to be especially focused on this problem.

Rural Health Care Policies

On October 15, 2004, the VA Office of Inspector General (VAOIG) released the “Evaluation of Department of Veterans Affairs Policies and Procedures Addressing the Location of New Offices and Other Facilities in Rural Areas”. This report examined VA’s policies and procedures to give first priority to locating new offices and other facilities in rural areas, as outlined in the Rural Development Act (RDA) of 1972.

The report determined that despite not having formal policies in place, VA did make a significant effort to improve access to VA services for veterans living in rural areas. Mostly this was done through the placement of community based outpatient clinics and related health care services. The report went on to say that VA’s actions to address health care needs of veterans in rural areas meets the intent of the RDA requirements.

The Capital Asset Realignment for Enhanced Services (CARES) Commission Report which found that the prioritization methodology used to identify new clinic locations in VA’s Draft national CARES Plan (DNCP) was disproportionately disadvantageous to veterans living in rural areas that are underserved and lack appropriate access to care. In response to the CARES Commission findings, VA completed a Veterans Rural Access Directive. The directive established a policy defining the clinical and operational characteristics of small and rural facilities within the Veterans Health Administration (VHA).

VA has also been involved with the National Rural Development Plan (NRDP) since 1992. The NRDP is composed of 40 State Rural Development Councils (SRDCs), a National Rural Development Council, and a central national policy office in the Department of Agriculture. Its purpose is to assess the impact of Federal policies and programs on community and economic development in rural areas. VA is represented on over half of the 40 SRDCs.

Additionally, VA collaborates with the Department of Health and Human Services (HHS) and the Indian Health Service to establish partnerships and sharing agreements that facilitate programs that benefit both veterans and Native Americans.

Community Based Outpatient Clinics (CBOC)

A VA study released in October 2004 said access to care might be a key factor in why rural veterans appear to be in poorer health.

CBOCs were designed to bring health care closer to where the veteran resides. Over the last several years VA has opened up hundreds of CBOCs throughout the system and today there are over 700 that provide health care to the nation’s veterans. By and large, CBOCs have been pretty successful, however, of concern to The American Legion is that many of the CBOCs are at or near capacity and many still do not provide adequate mental health services to veterans in need.

There is great difficulty serving veterans in rural areas. Veterans in states such as Nebraska, Iowa, North Dakota, South Dakota, Wyoming and Montana face long drives, a shortage of health care providers and bad weather. The Veterans Integrated Services Networks (VISNs) rely heavily upon CBOCs to close the gap. The CARES decision released in May 2004, called for 156 priority CBOCs to be implemented by the year 2012 pending availability of resources and validation with the most current data available. 21 of the priority CBOCs are located in VISN 23, a very rural VISN in the aggregate.

The provision of mental health services in CBOCs is even more critical today with the ongoing wars in Iraq and Afghanistan. It has been estimated that nearly 30 percent of the veterans who are returning from combat suffer from some type of mental stress. Further, statistics show that mental health is one of the top three reasons a returning veteran seeks VA health care.

The American Legion believes VA needs to continue to emphasize to the facilities the importance of mental health services in CBOCs and we urge VA to ensure the adequate staffing of mental health providers in the CBOC setting.

The American Legion is pleased that VA is proposing to open 25 new CBOCs by the end of this year. However, of the 25, only ten appeared to be on the CARES CBOC priority list of 2004.

CBOCs are not the only avenue with which VA can provide access to quality health care to rural veterans. Enhancing existing partnerships with communities and other Federal agencies such as the Indian Health Service will help to alleviate some of the barriers that exist such as the high cost of contracting for care in the rural setting. Coordinating services with Medicare or with other healthcare systems that are based in rural areas is another way to help provide quality care.

The American Legion believes veterans should not be penalized or forced to travel long distances to access quality health care because of where they choose to live. We urge VA to improve access to quality primary and specialty health care services, using all available means at their disposal, for veterans living in rural and highly rural areas.

Again, thank you Mr. Chairman for giving the American Legion this opportunity to present its views on such an important issue. The hearing is very timely and we look forward to working with the subcommittee to bring an end to the disparities that exist in access to quality health care in rural areas.