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Witness Testimony of Ms. Shannon Middleton, Veterans Affairs and Rehabilitation Commission, Deputy Director for Health, American Legion

Mr. Chairman and Members of the Subcommittee:

Thank you for this opportunity to present The American Legion’s view on the several pieces of legislation being considered by the Subcommittee today. In recent years, The American Legion conducted a program, “I Am Not a Number,” that identified many of the access problems identified in these bills.  In addition, The American Legion’s series, A System Worth Saving, has also validated many of the issues addressed.  Research conducted by the Department of Veterans Affairs (VA) indicated that veterans residing in rural areas are in poorer health than their urban counterparts. Providing quality health care in a rural setting has proven to be very challenging, given factors such as limited availability of skilled care providers and inadequate access to care.  The American Legion commends the Subcommittee for holding a hearing to discuss these very important and timely issues.

Improving Timeliness of Healthcare

H.R. 92, Veterans Timely Access to Health Care Act, seeks to establish standards of access to healthcare provided by the Department of Veteran Affairs (VA).  Although timeliness of care is not a challenge unique to rural areas, veterans who reside in rural areas face an additional challenge to accessing care.  Setting standards for timeliness in the delivery of health care and requiring VA to report on how these standards were executed will provide a realistic illustration of the ongoing challenges of rural veterans in gaining timely access to care.  It will allow VA and lawmakers to determine the best ways to improve timely access for rural veterans.  The American Legion supports this endeavor.

H.R. 315, Help Establish Access to Local Timely Healthcare for Your Vets (HEALTHY Vets), would require the VA to contract with community health care providers to improve access to healthcare for veterans in highly rural areas.  The American Legion believes that, where there is very limited access to VA healthcare, it is in the best interest of veterans residing in highly rural areas that local care be made available to them.  Some of these veterans have physical limitations or suffer from conditions that make extensive travel dangerous.  Many veterans have expressed concerns to The American Legion about their limited financial resources prohibiting travel, citing the rising cost of gas, the limitations of the mileage reimbursement rate, and the need to pay for overnight accommodations, as huge obstacles. Providing contracted care in highly rural communities--when VA healthcare services are not possible--would alleviate the unwarranted hardships these veterans encounter when seeking access to VA healthcare.

H.R. 339, Veterans Outpatient Care Access Act of 2007, would improve access at outpatient clinics with exceptionally long waiting periods by allowing veterans to utilize non-VA providers.  The American Legion has no official position on this issue, but believes that more focus should be placed on remedying the causes of the long wait periods to ensure timeliness of care.  Doing otherwise would perpetuate the problem.

Improving Eligibility for Healthcare

H.R. 463, Honor Our Commitment to Veterans Act, discusses lifting the health care enrollment restriction on Priority Group 8 veterans.  A total of 378,495 Priority Group 8 veterans have been denied enrollment from the time the restriction was instituted in January 2003.  The American Legion believes that a more effective method of ensuring that VA can continue to provide quality care to veterans would be to ensure that VA is sufficiently funded to care for their needs, not limiting access for those who have incomes that fall above means tests thresholds.  These veterans are required to make co-payments, in addition to identifying their third-party health insurance that will reimburse VA for reasonable charges.  Many of these Priority Group 8 veterans may very well be VA employees, Medicare beneficiaries, TRICARE or TRICARE for Life beneficiaries, or enrolled in the Federal Employees Health Benefits Program.  The American Legion supports the lifting of the current prohibition on healthcare enrollment restriction for Priority Group 8 and exploring effective means to improve third-party reimbursement collections.   

Improving Access to Healthcare

H.R. 538, South Texas Veterans Access to Care Act of 2007, addresses the health care needs of those who reside in South Texas. Although The American Legion has no official position on this proposal, we believe that VA should do everything in its power to improve access to its health care system for those residing in rural areas.

H.R. 542, bill to Require the Department of Veteran Affairs to Provide Mental Health Services in Languages other than English, seeks to make mental health services available in languages other than English for those who have limited English proficiency.  The American Legion strongly supports English as the official language of the United States.  However, The American Legion believes that VA needs to remove any hindrance that prevents veterans from obtaining the care they have earned through their military service.  This is extremely important issue for family members who may be required, by law, to make medical procedure decisions on behalf of a veteran.   

H. R. 1426, the Richard Helm Veterans’ Access to Local Health Care Options Resources Act, would provide veterans enrolled in the VA health care system the option of receiving covered health services through non-VA facilities.  It also would allow VA to fill prescriptions obtained from non-VA doctors.  The American Legion believes that VA is a Federal health care provider not a Federal health insurer like the Department of Health and Human Services (Centers for Medicare and Medicare Services).  Clearly, there will be unique situations in which VA should and must reimburse other health care providers, but this should be the exception to the rule, not a standard practice.  Veterans should not have to travel hundreds of miles for healthcare or rehabilitation. 

The American Legion believes veterans should not be penalized or forced to travel long distances to access quality health care because of where they choose to live.  It is more important that VA is adequately funded at a level that would allow it to service the needs of veterans and to improve access to quality primary and specialty health care services, using all available means at their disposal, for veterans living in rural and highly rural areas.

The American Legion also supports VA pharmacy benefits for enrolled veterans when prescribed by an authorized VA physician or provider in the course of providing medical care.

Improving Healthcare and Treatment

H.R. 1470, the Chiropractic Care Available to All Veterans Act, seeks to make chiropractic care available at all VA medical centers.  The American Legion has no official position on this issue.

H.R. 1471, Better Access to Chiropractors to Keep our Veterans Health Act (BACK Veterans Health Act), would allow eligible veterans direct access to chiropractic care.  The American Legion has no official position on this issue.

H. R. 1527, the Rural Veterans Access to Care Act, would allow highly rural veterans who are enrolled in the VA health care system to receive covered health care services through non-VA providers. It would also allow VA to fill non-VA prescriptions for highly rural veterans.  As stated previously, The American Legion believes that, when there is no other acceptable VA healthcare option veterans residing in highly rural and rural areas should be able to receive healthcare services through non-VA providers. 

The American Legion supports VA pharmacy benefits for enrolled veterans when prescribed by an authorized VA physician or provider in the course of providing medical care.

 Draft Discussion, Rural Veterans Health Care Act of 2007, discusses a pilot program utilizing mobile Vet Centers in rural area for a period of five years.  The provisions in this bill are essential in addressing the challenges to providing quality care for rural veterans: 

Section 2 establishes mobile Vet Centers.  The mobile Vet Centers would provide a glimpse of health issues affecting rural veterans, while providing care to mitigate the problem of inaccessibility. 

Section 3 establishes a health information technology program.  The health information technology program would ensure that rural veterans receive continuum of care. 

Section 4 describes the establishment and duties of an advisory committee.  The Advisory Committee on Rural Veterans would regularly assess the needs of rural veterans and identify gaps in policy and care.

Section 5 addresses research and training.  Rural health research, education and clinical care centers would afford VA the opportunity to build strategies to improve its system of care for rural veterans, as well as educate and train healthcare professionals on health issues prevalent in specific rural veteran populations.  It also mandates the designation of centers for rural health research, education and clinical activities.

Section 6 addresses homelessness.  It identifies that homeless veterans in rural areas have more challenges in obtaining local resources.

Section 7 discusses rotations and medical residents in rural areas, establishing programs to enhance education/training/recruitment and retention of nurses and allied health professionals in rural areas.  Since VA has had challenges with finding providers who can furnish the types of services needed by veterans in rural areas, this section offers a remedy that would result in the ability of VA to provide quality care to rural veterans in their communities.

H.R. 1944, Veterans Traumatic Brain Injury Treatment Act of 2007, seeks to have certain veterans screened for symptoms of traumatic brain injury.  It also discusses the creation of a comprehensive program for long-term care and rehabilitation that includes residential, community and home-based components.  The American Legion believes that the provisions in this bill are both necessary and timely.  Symptoms of traumatic brain injury may not be obvious and may be dismissed or may occur over time.  Screening those who were known to have been subjected to blast trauma in theater--even if they have no visible physical wounds—would aid in diagnosing injuries more quickly.  Early diagnosis would also help to mitigate the effects of the trauma and improve the chances of a successful rehabilitation.

Mr. Chairman, a critical element in screening veterans from traumatic brain injury will begin with the quality of the military health records.  The Department of Defense (DoD) and VA must work in close harmony on this newest identified medical condition.  DoD health care providers must work to identify and document “blast injuries”, especially non-penetrating traumatic brain injury.  DoD and VA established the Defense and Veterans Brain Injury Center.  However, there remains little expertise to formulate an effective definition, clinical guidelines, and treatment for returning Operation Enduring Freedom and Operation Iraqi Freedom veterans.

In most cases, not only is the diagnoses of the less visible injuries of war difficult, physical wounds may “mask” the accurate diagnosis and treatment of traumatic brain injury.  Blast impacts, may not be properly documented and consequently the patient may have potential brain injuries that may very well go undetected until much later after behavioral changes become more evident.

Currently, DoD does not measure individual cognitive ability upon enlistment or pre-deployment; therefore, it is much more difficult to measure any decrease in cognitive ability after deployment that is due to military service.  This clearly complicates diagnosis, treatment, and service-connection determinations.

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