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Submission For The Record of The American Legion

STATEMENT FOR THE RECORD OF
THE AMERICAN LEGION

BEFORE THE
SUBCOMMITTEE ON HEALTH
COMMITTEE ON VETERANS’ AFFAIRS
UNITED STATES HOUSE OF REPRESENTATIVES

ON

PROVISION OF CARE TO NATIVE AMERICAN VETERANS AND RURAL VETERANS IN NORTHERN MICHIGAN THROUGH THE DEPARTMENT OF VETERANS AFFAIRS

AUGUST 27, 2014

Recent struggles by the Department of Veterans Affairs (VA) to deliver timely care to veterans has cast into sharp focus the problems many veterans face receiving care from VA.  Often the veterans who are most at risk are rural veterans, and in particular, Native American veterans who can often face extra challenges dealing with accessing care because of the unique challenges they face due to living on reservations.  

The American Legion works diligently to ensure all veterans are properly served by the agency dedicated to provide their care – the VA.  The American Legion has, for the past decade, conducted a program to study care at VA facilities called the System Worth Saving (SWS) Task Force.  The SWS Task Force was founded in 2003 specifically to determine areas where VA could improve care for veterans, as well as to determine what areas of excellence could be replicated throughout the healthcare system.  

In January and February of 2012 the SWS Task Force conducted a dedicated study of Native American health care for veterans in the Southwest, and throughout the Arizona and New Mexico regions.  While there are vast differences between tribes and reservations, and each region presents its own unique challenges, many of the lessons learned through that research are applicable across the country where Native American veterans, a unique and honorable cohort of veterans, seek care.

The 2012 report found the following:

Background:

The Native American and Alaskan Native veterans served honorably in the United States Armed Services during all wars.  There are many specific health issues that affect the Native American and veteran population such as depression, substance abuse, and various other mental health illnesses.  

It is important to take into account the differences Native American veterans exhibit when trying to provide assistance to the Native American community.  Even some of the most well intentioned federal regulations can inadvertently be in conflict with the exercise of their religious freedoms, culture, and century old traditions.  They use their own Indian Health Services (IHS) because has been historically proven to be a more understanding system of their culture and personal health. It is important that the VA/IHS or other agencies take these cultural beliefs into consideration when conducting outreach and/or providing health care services.

According to the VA Medical Center’s Native American Program Coordinator, understanding the complicated Native American culture and health care needs is fundamental for delivering proper health care to the community.  This is accomplished by integrating health care through partnerships and collaborations with Indian Health Services (IHS), tribal medical centers, Intertribal councils, tribal Department of Veterans Affairs, and the Department of Veteran Affairs (VA).

According to the 2010 United States Census, there are 200,000 Native American veterans residing in over 565 recognized tribal entities across the country. The VA Office of Tribal Government Relations was created in January 2011 in response to President Clinton’s Executive order 13175, and President Obama’s Memorandum on Tribal Consultation dated November 5, 2009. The VA officially established the Office of Tribal Government Relations (OTGR) in January 2011 as result of an increased Native American veteran population in order to connect tribal leaders of federally recognized Indian tribes, pueblos, bands, villages, and nations to better provide services and benefits to a unique population of Native American and Alaska Native veterans. According to the VA Office of Tribal Government Relations, Native Americans and Alaska Native Americans have one of the highest representations in the armed forces when compared to other minority groups.

It is also important to fully understand the dynamic relationship between IHS and VA in regards to providing healthcare to Native American veterans.  On June 24, 2003 and October 10, 2010 VA signed a memorandum of understanding (MOU) with IHS in order to accomplish several goals for Native Americans and their healthcare which include:

•    Cultural awareness among native American veterans
•    Improve communication among the VA, Native American veterans and Tribal governments with assistance from Indian Health Services
•    Encourage partnerships and sharing agreements among the Veteran Health Administration (VHA)
•    Ensure appropriate resources are available to support programs for Native American veterans
•    Improve health-promotion and disease prevention services
•    Improve access to quality health care and services

The 2010 MOU continues to be implemented with various workgroups to put into place sharing agreements, and other interagency efforts that are contained under the current IHS and the VA current agreement. The workgroups between IHS and VA are to improve services for Native American veterans in regards to benefits, coordination of care, health information technology, and new technologies (i.e. telehealth). By not making Native American veterans travel far through use of technologies such as telehealth initiatives, IHS and VA have enrolled and treated 700 new veterans, including 400 veterans accessing the mental health services. This has been accomplished by the innovative way the VA has introduced telehealth services in the health care facilities on the reservations.  

According to the US Department of Health and Human Services Administration for Native Americans stated that many challenges facing Native Americans veterans are similar to those veterans of all ethnicities.  Some of the needs are as follows: access to healthcare, unemployment, homelessness, and mental health issues including post-traumatic stress disorder (PTSD), depression, and substance abuse.

An American Legion System Worth Saving site visit was conducted on January 30- February 3, 2012 and included Past National Commander Ron Conley; The American Legion Director of Veterans Affairs and Rehabilitation, Verna Jones; Media Marketing Director, Phillip (Marty) Callaghan; and VA Office of Tribal Government Relations (OTGR), Thomas Birdbear -Southwest Specialist to the tribal lands on the Navajo Nation Reservation in Chinle; Window Rock, Arizona; Pueblo of Laguna; and Pueblo of Santo Domingo in New Mexico, to learn more about and better understand how access and quality of healthcare services are delivered and are available to rural Native American veterans, and to find ways to help improve the provision of VA services for Native American (NA) veterans.

The first location visited was the Navajo Nation in Chinle, Arizona. During this visit the SWS representatives met and interviewed tribal leaders, tribal veteran officers and veterans about access to healthcare.  The Navajo Nation was established on June 1, 1868,  and is a semi-autonomous Native American governed territory that covers over 27,000 square miles in northeastern Arizona, southeastern Utah, and northwestern New Mexico. The Navajo Nation is divided into 16 chapters where approximately 10,000 veterans are living on the reservations. The veterans who reside on the reservation in Chinle have to travel four to six hours to the nearest Department of VA located in Phoenix; Prescott; and Tucson, Arizona.

They also met with tribal leadership and veterans at the Pueblo of Laguna reservation located in west-central New Mexico which is approximately an hour and a half to the VA Medical Center in Albuquerque. There are six tribes and 8,500 members within the reservation in which 450 are veterans. Overall, the Pueblo of Laguna tribal veterans were satisfied with the VA’s delivery of primary care that was offered at the rural Native American reservation.    

Challenges:

There are several challenges that Navajo veterans face while trying to access VA benefits and services.  The American Legion believes that better coordination is needed between the tribes and VA services, such as Veterans Health Administration (VHA), Veterans Benefits Administration (VBA), and National Cemetery Administration (NCA) programs.  Veterans also lack consistent and dependable transportation to VA health care and/or integrated IHS/VA health care services while residing on the reservations.  Training and accreditation of Navajo Nation Tribal Veteran Service Officers located in Arizona, New Mexico, Colorado and Utah on Veteran Benefits Administration (VBA) programs was also identified as problematic.   

The American Legion also identified restriction of state government in caring for Native American veterans that live in other states as a problem, and there is a greater need to integrate Native American cultural and traditional medicine into the IHS/VA health care regimen, which is primarily more Western-based.  The American Legion believes that VA needs to identify patterns/paths for veterans’ preferences for health care, and identify referral patterns/paths of VA providers to non-VA providers for health care to veterans.

In order to provide a more integrated and streamlined system, VA should involve VA Community Based Outpatient Clinics (CBOCs) that are on or near tribal land areas for the purpose of triage of care to veterans.  Also, they should integrate VA Long-Term Care placement efforts with tribal health and IHS providers for placement of Veterans in nursing homes/long term care facilities while developing and maintaining routine dialogue and communication with Veteran service staff and officers on tribal lands.  

VA and HIS need to fully understand dual eligibility status (between IHS and VHA) and its application to veterans.  According to the Office of Tribal Government Relations, although Native American veterans can receive health care from either VA and/or IHS they are four times more likely than other veterans to report unmet health care needs.

Several other barriers that Native American veterans residing in rural, or highly rural areas face while attempting to access healthcare include the challenge of having to travel great distances to access VA health care services, technological barriers that other cohort groups don’t have due to lack of computer, internet, and in some cases, even telephone service.  And the additional challenges of scheduling early healthcare appointments for veterans, which can cause a veteran to get up at 4 am and leave their homes for an 8 am or 9 am appointment at Vet Centers or VA Medical Centers.

Finally, the extremely high percentages of homelessness among the Native American Veteran Community which, in many cases can be attributed to the severe lack of local employment opportunities, lack of shelters for women veterans with children, and lack of affordable housing.   Unfortunately, the native American culture does not allow easy access to programs such as building homes or having transitional homes for homeless veterans due in large part to the property restrictions on the reservations. One example is that Native American reservations are considered sacred land to the Native American community, and not eligible for building.  

Recommendations

•    Better coordination is needed between the tribes and VA services such as Veterans Health Administration (VHA), Veterans Benefits Administration (VBA) and National Cemetery Administration (NCA) programs.
•    Consistent and dependable transportation to VA health care and/or integrated IHS/VA health care services that are available on the reservations.
•    Training and accreditation is needed for Native American Tribal Veteran Service Officers on Veterans Benefits Administration (VBA) program.
•    IHS and VA need to continue to improve education and outreach to the Native American veteran population, so they become aware of their entitled federal and state benefits.
•    IHS and VA need to provide Native American veterans that reside on reservations equal access to IHS/VA physicians, and mental health care professionals, in order to obtain VA healthcare benefits while respecting and addressing cultural differences.
•    VA and IHS need to collaborate with local Tribes in an effort to utilize the existing  Native American health care infrastructure in order to effectively serve the Native American veteran population who reside on reservations.
•    IHS and VA need to train Tribal Veterans Service Officers on the reservations to be certified, and or accredited, in order to provide benefit claims and related assistance to Native American veterans.

Conclusions:

The American Legion site visits across the country have found several of these key points to remain critical areas of focus:

•    As always, VA coordination with agencies outside VA remains an area in need of improvement.  Much as with the Department of Defense, VA would benefit from improved communication plans with Indian Health Services.
•    As in most rural regions, transportation remains problematic.
•    Better training and outreach will improve access and use of services, and will maximize efficiency of services used.
•    Better utilization of on-reservation HIS and VA coordinated care can meet the unique cultural needs of Native American veterans.

Native Americans serve in this country’s armed forces at a higher percentage per capita than any other ethnic group.  Their long tradition of honorable service cannot be met with substandard service from the VA and IHS services designed to serve them.

The American Legion thanks the Committee for their attention to this critical issue, and extends our offer to work with the Committee and the community to find solutions for these veterans and ensure their needs are met.  Questions regarding this topic or testimony should be directed to The American Legion Legislative Division through Ian de Planque at ideplanque@legion.org or (202) 263-5755.