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Access to U.S. Department of Veterans Affairs Health Care: How Easy is it for Veterans - Addressing the Gaps.













APRIL 18, 2007

SERIAL No. 110-13

Printed for the use of the Committee on Veterans' Affairs





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BOB FILNER, California, Chairman


VIC SNYDER, Arkansas
JOHN J. HALL, New York
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
TIMOTHY J. WALZ, Minnesota

STEVE BUYER,  Indiana, Ranking
HENRY E. BROWN, JR., South Carolina
BRIAN P. BILBRAY, California




Malcom A. Shorter, Staff Director

MICHAEL H. MICHAUD, Maine, Chairman

VIC SNYDER, Arkansas
PHIL HARE, Illinois
MICHAEL F. DOYLE, Pennsylvania
JEFF MILLER, Florida, Ranking
HENRY E. BROWN, JR., South Carolina

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined.



April 18, 2007

Access to U.S. Department of Veterans Affairs Health Care: How Easy is it for Veterans—Addressing the Gaps


Chairman Michael H. Michaud
      Prepared statement of Chairman Michaud
Hon. Shelley Berkley
Hon. Jerry Moran
Hon. John T. Salazar


U.S. Department of Health and Human Services, Marcia Brand, Ph.D., Associate Administrator,
    Rural Health Policy, Health Resources and Services Administration
        Prepared statement of Dr. Brand
U.S. Department of Veterans Affairs, Gerald M. Cross, M.D., FAAFP, Acting Principal Deputy
    Under Secretary for Health, Veterans Health Administration
        Prepared statement of Dr. Cross

American Legion, Shannon Middleton, Deputy Director for Health, Veterans Affairs and Rehabilitation Commission
        Prepared statement of Ms. Middleton
Disabled American Veterans, Adrian M. Atizado, Assistant National Legislative Director
        Prepared statement of Mr. Atizado
National Rural Health Association, Andy Behrman, Chair, Rural Health Policy Board, and President and
    Chief Executive Officer, Florida Association of Community Health Care
        Prepared statement of Mr. Behrman


Brown, Hon. Corrine, a Representative in Congress from the State of Florida, statement
Brown, Hon. Henry E., Jr., a Representative in Congress from the State of South Carolina, statement
Miller, Hon. Jeff, a Representative in Congress from the State of Florida, statement


Post-Hearing Questions for the Record:

Hon. Michael H. Michaud, Chairman, Subcommittee on Health, to Dr. Michael Kussman, Acting Undersecretary of Health, Veterans Health Administration, U.S. Department of Veterans Affairs, letter dated May 2, 2007
Hon. Joe Donnelly to Dr. Michael Kussman, Acting Undersecretary of Health, Veterans Health Administration, U.S. Department of Veterans Affairs, letter dated May 2, 2007
Hon. Jeff Miller, Ranking Republican Member, Subcommittee on Health, to Dr. Michael Kussman, Acting Undersecretary of Health, Veterans Health Administration, U.S. Department of Veterans Affairs, letter dated April 27, 2007
Hon. Michael H. Michaud, Chairman, Subcommittee on Health, to Maurice Huguley, Legislative Analyst, Office of Deputy Assistant Secretary for Legislation for Human Services, U.S. Department of Health and Human Services, letter dated May 2, 2007 (forwarding question from Hon. Phil Hare)
Andy Behrman, Chair, NRHA Rural Health Policy Board, National Rural Health Association, to Hon. Michael H. Michaud, Chairman, and Hon. Phil Hare, Subcommittee on Health, Committee on Veterans’ Affairs, letter dated June 5, 2007
Steve Robertson, Director, National Legislative Commission, American Legion, to Hon. Michael H. Michaud, Chairman, Subcommittee on Health, Committee on Veterans’ Affairs, letter dated November 28, 2007
Hon. Michael H. Michaud, Chairman, Subcommittee on Health, to Joe Violante, National Legislative Director, Disabled American Veterans, letter dated May 2, 2007


Wednesday, April 18, 2007
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.

The Committee met, pursuant to notice, at 2:20 p.m., in Room 334, Cannon House Office Building, Hon. Michael Michaud [Chairman of the Subcommittee] presiding.

Present:  Representatives Moran, Snyder, Hare, Berkley, Salazar.


Mr. MICHAUD.  Sorry for the delay.  We got called for a vote so we will start.  I would ask unanimous consent that all written statements be made part of the record.  Without objection, so ordered.

I also ask unanimous consent that all members be allowed five legislative days to revise and extend their remarks.  Without objection, so ordered.

I apologize for a lot of the members not being here.  We have a lot of Committee meetings that are going on and we just broke up from a vote and members will be drifting in and out throughout the hearing.

The Subcommittee on Health has a lot of issues that we have to deal with this upcoming session.  The issue of providing rural healthcare affects each of our States in a very different way.  In California, rural communities make up 92 percent of the land mass and eight percent of the population.  In my own state of Maine, over 40 percent of the population lives in rural areas.  It is estimated that 60 million Americans, one in five, live in areas that have been classified as rural.

Rural populations tend to be older than urban populations and they tend to exhibit poor health behaviors.  Economic factors also add to the challenges facing rural populations.  Rural veterans make up 41 percent of the U.S. Department of Veterans Affairs' (VA’s) patient work load.  Access and resources present serious challenges to providing high quality care for these veterans.  VA care can be second to none.  Unfortunately the quality of care is not always the same throughout the VA system.  For many veterans living in rural States like Maine, accessing that care is a significant challenge.  For certain more complex procedures veterans in Northern Maine must endure four days of travel to and from the VA facility in Boston to receive care.

Addressing the distance to care and the travel burden in rural areas is extremely important.  However, given the smaller population and frequency of certain complex procedures it does not make sense for VA to maintain a daily in-house capacity in every facility for something that is used on an infrequent basis.

This problem is not unique to VA.  It is a problem facing many rural areas across the country while smaller patient population limit the resources available to rural hospitals, which in turn limits the services that hospitals can support and provide.  Rural areas face difficulties in providing what has been termed "core healthcare services" by the Institute of Medicine.  These services include primary care in the community, emergency medical service, hospital care, long term care, mental health and substance abuse services, oral healthcare, and public health services.

For a variety of reasons, rural areas also face a greater problem recruiting and retaining healthcare professionals.  These problems must be addressed because the demand of services from our veterans in rural areas is only going to increase.  We have an aging population that will need long-term care.  Over 40 percent of the new generation of veterans returning from Afghanistan and Iraq are from rural areas.  They have their own unique needs including loss of limb, traumatic brain injury, and mental health concerns.

One important approach to providing access to care is the VA system and Community Based Outpatient Clinics (CBOCs) which currently number more than 650.  We have five CBOCs in Maine.  The Capital Asset Realignment for Enhanced Services (CARES) Commission recommends a sixth CBOC in the Lewiston, Auburn area along with five part time health access points.  Only one of these facilities is close to opening while the CBOC is not expected to open until 2008 at the earliest.

During the CARES process, 250 CBOCs were identified by the VA as being needed, of which 156 were designated as priority.  Since the CARES decision, VA has opened 12 of the 156, less than eight percent.  At this pace it will take VA over 30 years to open all the priority clinics.  VA has also opened 18 clinics not on the CARES priority list, which calls into question the decision process and the ability of CARES to assist in decisions in the future.

The VA has also designated facilities as Veterans Rural Access Hospitals designed to provide inpatient service to veterans in rural areas in which these services can be supported.  The VA has made great strides in exploring the use of tele-medicine and other technological means of providing healthcare services.  I would like to hear how these efforts are improving care and how we can help.

One of the problems we face in the area of recruitment and retention is the isolation that is often felt by healthcare professionals working in rural communities.  I would like to explore how technology might be used to overcome these feelings of isolation and thus improve recruitment and retention.

Is the VA, and our rural communities, ready to meet the increasing and changing needs of our veterans and their families?  What is the VA in rural America going to look like in the future?  We must keep in mind that VA healthcare does not operate in a vacuum but it is integral part of our national healthcare system.  I would also like to know when the priority CBOCs are going to be built or if the VA no longer intends to follow the CARES process. 

Today the Subcommittee hearing will provide us with the opportunity to begin this exploration, to begin to examine issues concerning access and the provision of care and the proper expectation of veterans in rural areas regarding the care that they can expect from the VA system.

At this point in time I would like to recognize the Acting Ranking Member, Mr. Moran.

[The statement of Chairman Michaud appears in the Appendix.]


Mr. MORAN.  Mr. Chairman, thank you, very much.  I appreciate you recognizing me.  I am delighted to be here this afternoon, although I have several meetings that are intruding.  I am happy to be here to support your efforts.  And I would like for you, Mr. Michaud, to consider me an ally.  We share many similarities in our districts despite one is in New England and one is in the middle of the country, Midwest.  I represent a district of approximately 60,000 square miles.  There is not a VA hospital in the district.  And we very much are interested in trying to find ways to improve access for our veterans.

Your remarks about CBOC I think are right on point.  I am very interested in knowing what the plans are by the Department of Veterans Affairs to increase the number of CBOC.  We have significant needs in that regard and particularly troubled to learn about the issue of not being on the priority list and still having CBOC when those that are on the priority list are still waiting.

I also would encourage you and the Subcommittee to take seriously a piece of legislation that I introduced earlier this year, the Rural Veterans Access to Care Act, giving veterans the opportunities of utilizing their local healthcare providers both hospitals and physicians, clinics, in the circumstances when a VA hospital is miles, hundreds of miles away from where the veteran lives and where the CBOC is as well.

And I am hopeful that this Committee will take that form of legislation, that theory behind that legislation seriously and work with me to see that we address the needs of our veterans who are miles away.  I spoke on the House floor recently about this topic, veterans who are told to drive 260 miles to get their prescriptions for their eye glasses when there’s an optometrist on Main Street three blocks away.

We need assistance when it comes to filling prescriptions and issuing the script.  The idea that our veterans must travel hundreds of miles, particularly our World War II veterans at ages 80 and 90's, to simply to have an examine so that their prescription can be refilled in many cases it is physically not possible.

I also am interested in hearing what Dr. Petzel has to say as his in his role as Director of VISN 23 in regard to the Project Hero.  And that VISN includes six Kansas Counties and I am interested in knowing the status and findings of that pilot program.

Last December, legislation was signed creating the VA Office of Rural Health Care.  And I have not heard from the VA as to the status of the implementation of that office.  Whether it is being staffed and what role it is now playing or is foreseen to play.  And finally I would raise a point that we have been pushing for a long time, the opportunity access also includes, particularly in rural America, the access to other providers than a physician and chiropractic care continues to be inadequate in many of our VISNs across the country.  And, I hope to be here to ask some questions of our Department of Veterans Affairs witnesses.

Again, Mr. Michaud, you have been a champion in regard to rural healthcare.  I would like to be your ally.  And look forward to working with you to see that we accomplish the goal of meeting the needs of veterans who live across the country, regardless of whether they are in the same community as a VA hospital.  Thank you.

Mr. MICHAUD.  Thank you very much, Mr. Moran.  I will work very closely with you on these issues, and I agree with your comments.  We have scheduled a hearing, I don’t know if the notice has been sent to your office yet, for one of your bills on April 26th at ten o’clock.  And we will be sending you a notice to testify.

Mr. Salazar?


Mr. SALAZAR.  Thank you, Mr. Chairman.  And I thank you Mr. Moran for your fine comments.  I associate myself with both of your comments.  I think all of us share some commonalities in that we all represent some very rural areas in our distant communities in Kansas and in Colorado for example.

But I want to thank you, Mr. Chairman, for you calling this important hearing.  I think that a 2004 study by the Under Secretary of Veterans Health found that veterans living in rural areas in fact are in poor health, in poorer health than those living in urban areas.  And because of the distances, as Mr. Moran referred to, and other difficulties associated with obtaining care, many rural veterans put off preventative healthcare.

I think last Congress the Office of Rural Health and the VA was created to better focus on our veterans in rural areas.  I am looking forward to today’s testimony.  But in reality, over 25 percent of the veterans, I believe, live in rural areas.  And I believe it is a fair expectation that the men and women who sacrifice for us are taken care of.

I am heartened today that we got notice from Secretary Nicholson that, it is not really CBOC, but it is called a Community Based Outreach Center which is actually going to be installed in Craig, Colorado, one of the remotest areas in Colorado.  Veterans have to travel five hours over the mountains to try to get to Grand Junction for healthcare.

I want to thank the Secretary for that.  We do indeed share many, many issues when it comes to veterans' healthcare.  I think, though, that if we find that the VA is incapable of providing that care to all of our veterans, that we can’t afford it, then I think we must look for a new direction.  And I agree with Mr. Moran on possibly looking at trying to address the issues of allowing our veterans to obtain healthcare from our local physicians.

But I want to thank you, Mr. Chairman, once again.  And I look forward to today’s testimony.  Thank you.

Mr. MICHAUD.  Thank you, Mr. Salazar.  On our first panel is Dr. Marcia Brand who is Associate Administrator of Rural Health Policy, Health Resources and Service Administration, of the U.S. Department of Health and Human Services.  Dr. Brand?

Dr. BRAND.  Thank you.

Mr. MICHAUD.  Thanks for coming this afternoon.  I look forward to hearing your testimony.


Dr. BRAND.  Mr. Chairman, members of the Subcommittee, thank you for the opportunity to meet with you today on behalf of Dr. Elizabeth Duke.  She is the Administrator of the Health Resources and Services Administration.  Thank you.  We welcome this opportunity to discuss rural health access issues and what is being done to meet the healthcare needs of the nations rural populations.  We appreciate your interest in and support for rural healthcare and access to healthcare for rural veterans.

The Health Resources and Services Administration, which I will call HRSA, is the primary Federal agency for improving access to healthcare services for people who are uninsured, isolated, or medically vulnerable.  HRSA grantees provide healthcare to the uninsured, people living with HIV and AIDS, and pregnant women, mothers and children.  They train health professionals and improve systems of care in rural communities.

For HRSA, the Health Center Program, the National Health Service Corp, and rural healthcare needs are priorities.  For more than 40 years, the Health Center Program has been a major component of the healthcare safety net for the Nation’s indigent populations.  Health Center’s lead the Presidential initiative to increase healthcare access in the Nation’s most needed communities.  Health Centers provide regular access to high quality, family oriented, comprehensive primary and preventative healthcare regardless of one’s ability to pay.

President Bush’s initiative to expand the Health Centers began in 2002.  The initiative will significantly effect over 1,200 communities through the support of new or expanded access points.  In 2001 HRSA funded 3,317 Health Center sites across the Nation.  We expect the number of Health Centers sites to grow to 4,053 by the end of 2008.

Just over half of all the Health Center grantees serve rural populations.  Besides the new access points, HRSA has distributed 385 grants to expand the medical capacity of our existing delivery sites and another 340 grants to existing grantees to add or expand oral health, mental health and substance abuse services.  And these are special challenges for our rural communities.

Through these efforts, the number of patients treated annually with Health Centers has grown from 10.3 million in 2001 to an estimated 16.3 million patients by the end of 2008.  The National Health Service Corps improves the health of the Nation’s under served by uniting communities in need with caring health professionals.  Currently more than half the National Health Service Corps doctors, dentist, nurses, and mental health and behavioral health providers serve in Health Centers around the Nation.  And about 60 percent of them work in areas.

HRSA’s Office of Rural Health Policy is charged with informing and advising the Department of Health and Human Services on matters effecting rural hospitals and healthcare.  We coordinate rural healthcare activities and maintain a national rural health and human services information clearinghouse.  HRSA, with the Office of Rural Health Policy, is the leading Federal proponent for better healthcare services for the 55 million people who live in rural America.

ORHP promotes State and local empowerment to meet the country’s rural health needs in several ways.  I would like to highlight a couple of our grant programs.  We manage the Medicare Rural Hospital Flexibility Grant Program which provides funding to State governments to work with 1,300 small rural hospitals.  We work with the State Office of Rural Health.  There are 50 State offices of Rural Health.

Additionally, we support a number of community based grant programs that increase access to primary care or improve rural healthcare services.  As you can see, HRSA administers a range of programs that serve rural communities.  HRSA also provides staff support to the Department’s cross-cutting rural efforts.  This includes the HHS Rural Taskforce which has representatives from each of HHS’s agencies and staff offices.

Effective coordinated healthcare improves the health and well-being of American’s regardless of where they live.  However, effective coordination is especially critical in rural communities where services and providers are limited and resources are scarce.  The challenges of providing healthcare for rural communities is compounded by higher rates of poverty, a lack of insurance.  Rural people are a little bit older and they have higher rates of chronic disease.  And there are significant transportation barriers.

We take great pride in the work that we do to provide better healthcare services for our rural populations.  However, we are humbled by the significant challenges that remain for healthcare in rural areas and the under served.  We are pleased that the Department of Veterans Affairs is establishing an Office of Rural Health to assist the Under Secretary in issues affecting rural veterans.

We have contacted the individuals who are creating this Office and their charge sounds very familiar.  With 20 years of experience, we have some expertise around rural and policy making and research.  And we look forward to collaborating with the new Office.  And we offer our assistance. 

And, I would be pleased to answer any questions at this time, sir.

[The statement of Dr. Brand appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Doctor, for your testimony.  You had mentioned that the Office of Rural Health, which is getting under way within the VA System, and the fact that HHS has 20 years of experience in this area.  What would you tell the VA would be the number one problem that your agency encountered in dealing with rural healthcare issues as far as access goes?

Dr. BRAND. I think that it would be difficult to say that there is a single issue that is most challenging around access.  In rural communities we face a lot of the challenges that we face nationwide in access—it’s just that much more difficult because it is rural.  It is harder to recruit and retain providers because infrastructure is not there and the folks who use those services have higher healthcare needs and lower rates of insurance.

Mr. MICHAUD.  Okay.

Dr. BRAND.  It has over the past several years become clearly a significant problem to provide mental health services for rural communities and also to provide oral healthcare.  It is very difficult to recruit and retain providers.

Mr. MICHAUD.  Has it been a problem trying to find qualified staff to work in the rural healthcare arena?

Dr. BRAND.  There are a number of different programs that seek to improve recruitment and retention of providers for rural communities.  A number of them focus on the fact that folks who are from rural communities are more likely to go back there and practice.  And so a number of State programs and several of the Federal programs try to recruit folks from rural communities, encourage them to go to health profession schools, and then return to practice in those areas.

Also the National Health Service Corps.  Roughly 60 percent of the folks in the National Health Service Corps practice in rural communities.  So that is another affect of Federal program.

Mr. MICHAUD.  You are familiar with the CARES process that the VA went through a number of years ago?

Dr. BRAND.  Sir, I read the materials in preparation for this hearing, but I wouldn’t consider myself familiar with it.

Mr. MICHAUD.  A lot of time and effort that went into the CARES process, and I commend everyone who put all the effort in there.  My concern is that that is pretty much it.  We haven’t seen, at least in VISN 1, any movement or much movement in that particular area.

My question is, when you look at rural healthcare, what you are doing at HHS and if you look at what the CARES process actually recommends, a lot of—there are a lot of areas that are very similar.  Do you think that that is something that your agency could work very closely with the VA to actually speed up the process under the CARES process? 

And a good case in point is, one of the clinics under the CARES process that was recommended in Maine, the VA actually was working with the local hospital, was working with the healthcare clinic in the region.  And at the very last minute they decide to go it alone.

So now we have a situation where we have a hospital that is expanding in a rural area.  You have a Federally qualified healthcare clinic that is building a new facility in a rural area.  And then you have the VA building a new facility in the rural area in the same town, which I think is a waste of Federal dollars.  And I think there should be some collaboration going on.

So I hope you would actually look at the CARES process as far as where they are recommending clinics or CBOCs and see how you might have facilities out there where we used additional Federal dollars in other areas to be able to help collaborate with the VA and to move forward in a collaborative way so we can take care of veterans in rural areas.  At the same time it will help out rural healthcare providers as well.

Dr. BRAND.  I think that we have a significant investment in expanding the Health Centers and certainly there are opportunities for collaboration with the Health Centers.  There are also 3,500 rural health clinics located in those areas.  And some where around 1,300 small rural hospitals that we call critical access hospitals.  And given the fact that resources in rural communities are so scarce, it would be—I would be hopeful that we would be able to find ways to collaborate more effectively.  And we are certainly willing to try to do that.

Mr. MICHAUD.  Great.  Well thank you very much, Dr. Brand.  Mr. Salazar?

Mr. SALAZAR.  Thank you, Mr. Chairman.  Dr. Brand, my questions are similar to Mr. Michaud’s questions.  It just seems to me to make a lot of sense that if you have to transport veterans over a 250 mile range, that it would make more sense to be able to provide them the same opportunity as normal residents have in rural communities, for example.

What are the obstacles to VA refunding or making the payments for a patient who is a veteran who would go to a local hospital to get the same kind of treatment?  Is there a rule making process that has to take place or is it just rules within VA or is it something that the members of Congress could actually do to change the—

Dr. BRAND.  I can speak to the Health Centers and certainly to small rural hospitals.  Our Health Centers, frankly at this moment don’t ask veterans’ status.  And so they do not know who is a veteran.  And similarly I think for many small rural hospitals when someone presents either through the outpatient departments or coming through the emergency department it is not asked.

And, so I think that frankly opportunities to improve collaboration are missed because Health Centers and critical access hospitals don’t know who is a veteran and who might be eligible for benefits.  I think also it is important to note that the Health Centers will see someone regardless of their ability to pay or their veteran status.  So if they present at the health center, they would be seen.

Mr. SALAZAR.  Well what about preventative healthcare?  Like, for example, just to be able to go to the local primary care physician—do you have any mechanism for veterans in rural areas to be able to do that?

Dr. BRAND.  They could certainly present at any of those facilities.  Whether or not those would be reimbursed by the Veterans— through their veterans benefits, I think is just depending upon a pre-existing relationship.  And I am sure my colleagues from Veterans Affairs could speak to that more effectively than I can in terms of what those relationships might be.

Mr. SALAZAR.  Okay.  Thank you.

Mr. MICHAUD.  Thank you, Mr. Salazar.  Ms. Berkley?


Ms. BERKLEY.  Thank you very much, Mr. Chairman.  I am very glad that we are here to discuss access to VA healthcare, which is obviously a very important issue to our veterans across the country.

As you are aware I represent a very urban district and I just want to emphasize that access to healthcare is not, for our veterans, is not only a rural issue.  With 218,000 veterans in Southern Nevada, we have no VA healthcare facilities.  And of course because of the CARES study, finally the CARES Commission determined that with 218,000 veterans and no healthcare facilities, that perhaps Las Vegas ought to have it’s own healthcare facility.

So many of my veterans, aside for the fact that they have got 80-year old veterans standing in 110 degrees temperature waiting for a shuttle to take them from one temporary location, to another awaiting the building of our VA hospital, outpatient clinic, long-term care facility.  So many of my veterans that have more specialized problems have to continue to go to Long Beach to get their healthcare needs taken care of.  And it is just so difficult because oftentimes they are in a very low-income bracket.  Their families cannot afford to accompany them.  They go there by themselves.  Many of them are Korean War veterans and World War II vets.  And this is an issue that is bigger than our rural areas.  It is pervasive across the United States.

I have got 1,600 Nevada veterans who have just returned from Iraq and Afghanistan.  And we are estimating that there will be at least another 2,100 coming back in the next year or two.  I can’t be here for the third panel, but I think what I would ask you as Chairman if you could please ask the third panel how is the VA preparing to meet the needs of the growing number of returning servicemembers who will need increased healthcare and mental healthcare as well?

Right now in Las Vegas, we don’t have facilities to handle what we have.  In 2011, which is when they are anticipating that the facilities will be completed, is an awfully long time to have to wait if you are a World War II vet, if you are a disabled vet and have to keep going to Long Beach or if you are returning from Afghanistan or Iraq and it is 2007.  And you are coming home to nothing.

So those are the questions that I would like addressed and I am just sorry I won’t be here to hear the answers.  But I thank you very much for letting me talk to you about my extraordinary frustration and, frankly, shame that we send young men and women to war and when they come back, we don’t do what we have promised that we are going to do.  And don’t adequately fund this VA healthcare center.  As I have said, the healthcare system—as I have said before, veterans healthcare and other benefits is the cost of war.  And we ought to be taking this into account because the men and women that are coming back from Iraq and Afghanistan we are going to be taking care of their healthcare needs and mental healthcare needs for many decades to come.  And we can’t handle the load we have now.

So I would like to know how the VA intends to take care of these people.  Thank you, Mr. Chairman.

Mr. MICHAUD.  Thank you very much.  You have been a true advocate for veterans.  Your questions are the same that a lot of us have as well, and you can be assured that they will be asked.  Thank you.

Mr. Hare?

Mr. HARE.  Thank you, Mr. Chairman.  Thank you very much for having the hearing.

Dr. Brand, I just have a couple questions.  One, you know, I represent an area, a congressional district, with a lot of rural areas.  And you know you were talking about transportation.  And you mentioned in your testimony that there are significant transportation barriers that affect the coordination of services.  And I am wondering if you could elaborate on that and what HHS has done to address the issue of providing transportation to rural patients?

Dr. BRAND.  Transportation is a significant challenge in rural communities.  And HHS has a process to try to improve coordination and collaboration around transportation.  And it would be my pleasure to submit that information to you after the hearing, sir.

[The information was provided by the U.S. Department of Health and Human Services to Mr. Hare in the post hearing questions for the record, which appears in the Appendix.]

Mr. HARE.  Thank you very much.  And then you were talking about hospital care.  You said that out of the 2,000 hospitals, I believe 1,500 have fewer than 50 beds.

Dr. BRAND.  Yes, sir.

Mr. HARE.  And just a couple of questions.  Can you describe the type of care that is provided there and have you run into problems finding qualified people to staff and to work at the small hospitals?

Dr. BRAND.  Of the 2,000 hospitals, about 1,500 have less than 50 beds.  And those hospitals typically provide some access to primary care through outpatient services and then standard services such as laboratory, radiology.  They have an emergency department they meet Medicare conditions of participation, but most of the patients that are seen are those patients with less complex conditions.  And historically, lots of those patients are places where individuals come and are first assessed and then it is important to have a good relationship with the next level of hospital, the referral hospital for those conditions that are more complex.

And so there are—

Mr. HARE.  Thank you.

Dr. BRAND.  —part of a system or a network of hospitals.

Mr. HARE.  And then specifically, what do you think are the benefits and the disadvantages of running a hospital that has fewer beds?

Dr. BRAND.  I beg your pardon, sir?

Mr. HARE.  What are the benefits and disadvantages of running a hospital with fewer beds from your perspective?

Dr. BRAND.  I think that the benefits are that you could have contact—you can have an access point closer to where people live.  That they don’t necessarily have to drive 50, 100 miles to get to a hospital.  The challenges of a small rural hospital is that the challenges are that with a limited, a low volume, it is always hard to ensure that you have that financially you are in the positive margin, because you don’t have a lot of patients to provide care for.

Mr. HARE.  Okay.  And I am sorry, Doctor, I think you answered this and I was jotting a note.  Have you found it difficult to staff hospitals?  To find people to staff at the smaller hospitals?

Dr. BRAND.  Yes, sir.

Mr. HARE.  Okay.

Dr. BRAND.  It is difficult to recruit and retain physicians and nurses.  It is a challenge to effectively staff your business office and your housekeeping and your dietician department.  It is the same challenge that all small rural hospitals face—

Mr. HARE.  Sure.

Dr. BRAND.  —in retaining workers.

Mr. HARE.  Any ideas from your end on how we can do a better job of doing that or how we can—

Dr. BRAND.  A number of the States have been very innovative in the programs that they have developed for recruiting and retaining providers using their academic Health Centers and their community colleges.

The National Health Service Corp is another fairly effective tool for getting folks out into those communities.  I suspect that as long as there are remote areas, we are going to struggle to find ways to staff up those facilities.

Mr. HARE.  Okay.  Thank you, Doctor.  I yield back.

Mr. MICHAUD.  Thank you, Mr. Hare.  Dr. Snyder?

Mr. SNYDER.  Thank you, Mr. Chairman.  Dr. Brand, I am curious what is your Ph.D. in?

Dr. BRAND.  My Ph.D. is in higher education.  My original discipline was dental hygiene, but I couldn’t sit still.

Mr. SNYDER.  Oh, yeah.  Yeah.  I see it.  About half the time people with Ph.D. either don’t know what the subject field is or simply don’t understand the title of the theses.  But I am always trying to educate myself.

I have two questions.  When we had our discussion in the Armed Services Committee, one of the issues that we had difficulty with about two, three, or four years ago with the TRICARE system was an adequate number of obstetricians that had signed up to provide TRICARE services to military families.

And I think a lot of it was a reimbursement problem.  And I think that has dramatically improved, at least our TRICARE contractors are saying it has dramatically improved.  And I think it was something they learned from our Committee system.

So when they testified from our Committee hearings over the last couple of years, so when they testified in the last month and I asked them, where do they see their gap is now?  They testified they think their biggest gap is in mental health services.  To the point that they have just gone out and contracted with a provider for full time, that they would assign to different geographic areas because they just can’t find services in such an area.

And that shouldn’t be—I am sure that is not a surprise to you as somebody who works in rural health a lot.  Because before we had the war in Iraq or Afghanistan we had, I think, big gaps in mental health services throughout the country, both urban and rural.  Would you agree with that?  Yeah. 

And now this niche of people, we have military veterans and military families with these mental health things.  I may have missed it in your written statement, but I didn’t really see much of a discussion about mental health.  And because it seems to me the challenge we are talking about making it easier for veterans but we are trying to do that in a system that has big gaps in care for non-veterans also.

When you talk about the mental health, where do you see that going?

Dr. BRAND.  Yes, sir.  One of the grants—

Mr. SNYDER.  Would you pull that in a little closer?  Maybe it is just my old ears or something.

Dr. BRAND.  Is this better?

Mr. SNYDER.  Yeah, it is.

Dr. BRAND.  Sorry.  One of the programs that we manage in our Office is an Outreach Services Grant Program and it provides resources for communities to define what their need is and then they write to that particular program need rather than being categorical like so many of the grants. 

And if you look at the applications that the community submits the gap that they are trying to fill, is the mental health services gap.  A significant number of them try to fill that gap.  It is—I have heard it suggested that, you know, our jails become the waiting rooms for our mental health facilities in rural communities because there is just not enough care to provide folks who meet those challenges.

One of the things that HRSA is hopeful to do is improve the whole location of primary care and mental health services.  And there has been a significant expansion of Health Centers and mental health services.  And the idea is if you can have both of those services provided in the same facility it is much easier for the patients and for the clients.  And frankly, in the rural communities where there is significant stigma, you can pull your car up in front of the clinic and no one knows if you are taking your child in for a well baby visit or if you are accessing the mental health services.

So you are right, sir, the recruitment of providers and the provision of mental health services is a significant challenge.

Mr. SNYDER.  I don’t think it has helped at all by this.  What I think is just an invisible public health policy that a lot of private insurance companies take in terms of their reimbursement on mental health services.  There is not much of an incentive for a small rural—well a typical rural practice of three to five physicians and maybe a nurse practitioner and maybe a deal.  There is not much incentive to put in a full-time mental health worker with very poor reimbursement for the kinds of services that people could benefit from.

I notice we had this occur with regard to the Iraq War was, as guard members and reserve component members were being activated, and then their families were being put on to TRICARE as their healthcare system.  They were then going to their local doctor and finding out that the doctor just didn’t accept TRICARE.  A lot of times I think it was because they just didn’t know that there were people in their area that would benefit from that.

Is that an issue that you have dealt with at all or do you have any kind of—I think it has gotten better as word has gotten around to physicians.  They really do need to sign up for this program in the spirit of patriotism.

Do you have an information network that you could disseminate information out there to providers about, here’s the, you know, consider this, sign up for this?

Dr. BRAND.  I believe that the Health Centers have a way of communicating.  They have sort of a list serve system.  And a number of the small rural hospitals do.  In terms of whether or not they have been encouraged to participate in TRICARE and other programs, I don’t know.

Mr. SNYDER.  One of the problems that we had with that was hospitals signed up, but there were no physicians that had signed up.

Dr. BRAND.  I see.

Mr. SNYDER.  And so there was no one to take care of them while they were there.  Thank you, Mr. Chairman.

Mr. MICHAUD.  Thank you very much, Dr. Snyder.  And just to follow up on your last question about TRICARE, I know there is an issue regarding reimbursement rates, particularly as they relate to critical access hospitals getting lower reimbursements.  This is a problem.

But I do want to thank you once again, Dr. Brand, for your testimony.  There will probably be additional questions—

Dr. BRAND.  Yes, sir.

Mr. MICHAUD.  —for you to answer in writing and look forward to our continuing working relationship.  And on a closing comment, as you heard from Mr. Moran and other members here and from those members who aren’t here, access to healthcare in rural areas is a big concern.  It is an extremely big concern about the CARES process moving so slowly to a point where I have heard other members talking about authorizing another agency to do delivery on the CARES process versus the VA.

So I look forward to working with you and thanks again for your testimony.

Dr. BRAND.  Thank you, sir.

Mr. MICHAUD.  At this time I would like to welcome the second panel, Andy Behrman who is Chairman of the Rural Health Policy Board for the Nation Rural Health Association.  Shannon Middleton who is Deputy Director of the Health Care for the American Legion.  And Adrian Atizado who is the Assistant National Director for the Disabled American Veterans.

I want to thank our panelist for coming today and look forward to your remarks.  And we will start off with Andy.



Mr. BEHRMAN.  Mr. Chairman, distinguished members of this Subcommittee, I am Andy Behrman, President of the Florida Association of Community Health Centers and the Chair of the National Rural Health Associations Rural Health Policy Board.  I am also a veteran.  And I have proudly served the United States Navy.  I want to thank you for the opportunity to speak and testify on behalf of the National Rural Health Association and for my fellow veterans.

NRHA is a national, non-profit and non-partisan membership organization and our mission is to improve the health of rural Americans and to provide leadership on rural health issues.  NRHA members have long maintained concern for the health and mental healthcare needs of rural veterans.

Since our Nation’s founding, rural Americans have always answered the call when America has gone to war.  And whether motivated by their values, patriotism, or economic concerns the picture has not changed much in 230 years.  Simply put, rural Americans serve at rates higher than the proportion of the population.  Though only 19 percent of the Nation lives in rural areas, 44 percent of our recruits are from rural America and nearly one-third of those who died in Iraq are from small towns and communities across the Nation.

There is a national misconception that all veterans have access to comprehensive care.  This is simply not true.  Access to the most basic primary care is often difficult, sometimes impossible, in rural America.  Combat veterans returning to their rural homes in need of specialized care due to war injuries, both physical and mental, likely will find access to that care extremely limited.

What this means is that because there is a disproportionate number of rural Americans serving in the military, there is a disproportionate need for veterans care in rural areas.  Additionally, we must all be mindful of long-term needs.  And while NRHA is pleased that both the House and the Senate for fiscal 2008 budget calls for greater increases in VA medical care spending than in past years, long-term healthcare planning is critical.  The wounded veteran who returns today won’t need care for just the next few fiscal years, they will need care for the next half century.

To meet those long term needs, the NRHA respectfully makes the following recommendations to the Committee: One:  Increase access by building on current successes.  CBOCs opened the door for many veterans to obtain primary care services within their home community and outreach Health Centers help meet the needs of many rural veterans.

NRHA applauds these efforts and supports the expansion of these successful programs.

Two:  Increase access by collaborating with non-VHA facilities.  Many rural veterans cannot access VHA care simply because the facilities are too far away.  Linking quality VA services with rural civilian services can vastly improve access to healthcare for rural veterans.  As long as quality standards of care and evidence based medicine guide treatment for rural veterans, the NRHA supports collaborative efforts with a number of organizations.

First, Federally Qualified Community Health Centers.  Community Health Centers serve millions of rural Americans and provide high quality community based primary care and preventative healthcare.  And most importantly they are located where most rural veterans live.

A limited number of collaborations between the VHA and Community Health Centers already exist and have proven to be prudent cost effective solutions to serving veterans in rural areas.  These successful models should be expanded to reach all of rural America.

Critical Access Hospitals.  These facilities provide essential comprehensive services to rural communities.  If these facilities were linked with VA services and model the quality, access to care would be greatly enhanced for thousands of rural veterans.

And Rural Health Clinics.  These clinics serve populations in rural medically underserved areas.  And in many rural and frontier communities these clinics are the only source of primary care available.

The third recommendation is to increase Traumatic Brain Injury care.  Unfortunately it appears that traumatic brain injuries, TBI, will most likely become the signature wound of the Afghanistan and Iraqi wars.  Such wounds require highly specialized care.  The current VHA TBI Case Managers Network is vital, but has limited access for rural veterans.  We need to expand this program.

Four: Target care and services to rural veterans.  Rural veterans have an especially strong bond with their families.  Returning veterans adjusting to disabilities and the stresses of combat need the security and support of their families in making their transition back in to civilian life.

Vet Centers do a tremendous job in assisting veterans, but their resources are limited.  The NRHA supports increases in funding for counseling services for veterans and their families.  And more women today serve in active duty than any other time in our Nation’s history.  And unfortunately, more women are then wounded or are war casualties then ever before in our Nation’s history.

We must target care for today’s women veterans and culturally competent care to meet the unique needs of rural minority and female veterans.

And finally, Mr. Chairman, the NRHA calls on the Congress and the Veterans Administration to fully implement the functions of the newly created Office of Rural Veterans to develop and support on going mechanisms for study and articulate the needs of rural veterans and their families.

Mr. Chairman, thank you again for this opportunity.  The National Rural Health Association looks forward to working with you and this Committee to improve rural healthcare access for the millions of veterans who live in rural America.  Thank you.

[The statement of Mr. Behrman appears in the Appendix.]

Mr. MICHAUD.  Thank you very much, Mr. Behrman.  Ms. Middleton?


Ms. MIDDLETON.  Mr. Chairman, and members of the Subcommittee, thank you for this opportunity to present the American Legion’s views on access to quality healthcare for veterans in rural communities.

Research conducted by the Department of Veteran Affairs indicated that veterans residing in rural areas are in poor health than their urban counterparts.  It was further reported that nationwide, one in five veterans who enrolled to receive VA healthcare lives in rural areas.  Providing quality healthcare in a rural setting has been—has proven to be very challenging, given factors such as a limited availability of skilled care providers and inadequate access to care.

Even more challenging would be VA’s ability—excuse me—to provide treatment and rehabilitation to rural veterans who suffer from the signature illness of the on-going Global War on Terror—traumatic blast injuries and combat related mental health conditions.

VA’s efforts need to be especially focused on these issues.  A vital element of VA’s transformation in the 1990's was the creation of CBOCs or Community Based Outpatient Clinics.  The creation of CBOCs to move access closer to the veterans communities.  A recent VA study noted that access to care might be a key factor in why rural veterans appear to be in poor health.

CBOCs were designed to bring care closer to—I’m sorry.  I already said that.  Over the last several years VA has established hundreds of CBOCs throughout the system, and today there are over 700 that provide healthcare to the Nation’s veterans.

CBOCs have been very 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.

One of the recommendations of the Capital Assess Realignment for Enhanced Services or CARES was for more, not less, CBOCs across the Nation.  The American Legion strongly supports this recommendation, especially those identified for rural areas.  However, limited VA discretionary funding has limited the number of new CBOCs each fiscal year.

There is great difficulty serving veterans in rural areas.  Veterans in States such as Nebraska, Iowa, North Dakota, South Dakota, Wyoming, and Montana face extremely long drives and a shortage of healthcare providers and also in bad weather.  The Veterans Integrated Service Networks or VISN, rely heavily upon CBOCs to close this gap.

The provisions of mental health services and CBOCs is even more critical today with the ongoing war 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 our returning veterans seeks VA healthcare.

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

CBOCs are not the only avenue with which VA can provide access to quality healthcare 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. 

In the July 2006 report entitled, “Health Status of and Services for Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans After Traumatic Brain Injury Rehabilitation,”  the Department of Veterans Affairs Office of Inspector General examined the Veterans Health Administration’s ability to meet the needs of OIF and OAF veterans who—sorry—who suffered from traumatic brain injury.

Fifty-two patients from around the country were interviewed at least one year after completing inpatient rehabilitation from a Lead Center.  Some of them did reside in States with rural populations.  Many of the obstacles for the TBI veterans and their families remain, they were very similar.  Fort