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Women, Rural and Special Needs Veterans.

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APRIL 21, 2008

SERIAL No. 110-84

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 21, 2008

Women, Rural and Special Needs Veterans


Chairman Michael Michaud
    Prepared statement of Chairman Michaud
Hon. Jeff Miller, Ranking Republican Member
Hon. Thomas H. Allen


U.S. Department of Veterans Affairs, Brian G. Stiller, Center Director, Togus Veterans Affairs Medical Center, Veterans Health Administration
    Prepared statement of Mr. Stiller

American Legion, Department of Maine, Donald A. Simoneau, Past Commander, and Member National Legislative Council
    Prepared statement of Mr. Simoneau
Disabled American Veterans, Department of Maine, Joseph E. Wafford, Supervisory National Service Officer
    Prepared statement of Mr. Wafford
Doliber, Dana, Sanford, ME
    Prepared statement of Mr. Doliber
Hartley, David, Ph.D., MHA, Director, Maine Rural Health Research Center, and Professor, Muskie School of Public Service, University of Southern Maine, Portland, ME
     Prepared statement of  Dr. Hartley
Maine, State of, Bureau of Veterans' Services, Augusta, ME, Peter W. Ogden, Director, and Secretary, National Association of State Directors of Veterans Affairs
    Prepared statement of Mr. Ogden
Maine Veterans Coordinating Committee, Waldoboro, ME, Gary I. Laweryson, USMC (Ret.), Chairman, Commander, Military Order of the Purple Heart, State of Maine, Judge Advocate, Marine Corps League, and State of Maine, Aide-de-camp to Governor John Baldacci
    Prepared statement of Mr. Laweryson
Maine Veterans’ Homes, Augusta, ME, Kelley J. Kash, Chief Executive Officer,
    Prepared statement of Mr. Kash
Veterans of Foreign Wars of the United States, Department of Maine, James Bachelder, Commander
Vietnam Veterans of America, Maine State Council,  John Wallace, President
    Prepared statement of Mr. Wallace


Monday, April 21, 2008
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.

The Subcommittee met, pursuant to notice, at 10:03 a.m., Sanford Town Hall, 919 Main Street, Sanford, Maine, Hon. Michael Michaud [chairman of the Subcommittee] presiding.

Present:  Representatives Michaud and Miller.

Also present:  Representative Allen.


Mr. MICHAUD.  I would like to call the Subcommittee to order.  I would also like to ask unanimous consent for Mr. Allen to sit at the dais and to be able to ask witnesses questions.  If there are no objections, it is so ordered.

I also would like to thank Sanford, the folks at Sanford Town Hall, for allowing us to use their facility today.  I really appreciate it.  Veterans' issues are extremely important, and this definitely will give us a venue so we can hear from our witnesses today.

I also would like to recognize in the audience Mike Aube who works for Senator Olympia Snowe's office, as well as Bill Vail who works for Senator Susan Collins' office, Kara Hawthorne, who is the new Director of the Office of Rural Health that Congress established a couple years ago, and Dr. Patty Hayes who is a Chief Consultant for Women Veterans' Health.  They are both from Washington, DC.  I want to thank both of you for coming here today to hear what veterans have to say about rural healthcare issues

I also would like to recognize Adam Cote who is an Iraq War veteran.  I don't know if there are any other Iraqi War veterans or Afghanistan War veterans here, but I want to thank you and all the veterans here in this room for your service to our great Nation.  I am very pleased to see you here as well.  I want to thank everyone else who I have not mentioned for coming here today to talk about veterans' issues.

Today, we will examine the U.S. Department of Veterans Affairs (VA) programs regarding rural veterans, women veterans and other special needs population.  I am very happy that it is held here in Sanford, Maine, this morning.  Sanford is home of a long-time veteran advocate, someone who I was honored to call a friend, Roger Landry.  Roger worked and served in the Maine legislature.  He worked very diligently in the veterans service organization (VSO) community here in Maine, and he was very well-liked and respected by all.  Roger served his country and his community with great pride and honor.  Roger died, unfortunately, last year.  He is sorely missed.  I would like to dedicate this hearing to Roger Landry in honor of all of his hard work with and for our veterans here in Maine and all around the country.

It is appropriate that we are having this hearing in my home State of Maine.  Maine is a very rural State.  Because of this, we face many unique challenges in providing healthcare to our veterans.  Many have to travel long distance for care, creating a significant burden for veterans and their families.  The VA has instituted some innovative programs to provide much needed services to our rural veterans, and I look forward to hearing from our panels today about their ideas to improve access and decrease the travel burden for our veterans living in rural communities all across Maine and also all across the country. 

At this hearing, we will also hear about women veterans.  Women make up about 14 percent of the active-duty military; and consequently, they are making up more and more of our veteran population.  Women have some unique healthcare needs.  I look forward to hearing today about the unique needs of women veterans and hear ideas about how the VA can improve their service targeted to women veterans. 

When the United States made a commitment to care for veterans, we made the commitment to care for all veterans:  Male, female, urban, and rural.  Today, I hope that we will learn how the VA is meeting the needs of these populations, what challenges are on the horizon, and what can we do to provide services for these veterans in the most cost-effective manner.

I also want to thank Congressman Miller, who is the Ranking Member of the Subcommittee on Health of the Committee on Veterans' Affairs.  Congressman Miller is from Florida.  He has been a strong advocate for veterans' issues.  We deal with the healthcare-related veterans' issues in Congress.  And I know that this is actually a holiday here in Maine and Massachusetts, and I know that Mr. Miller has a lot of work in his home State that he has to do.  We really appreciate him taking the time to come here, along with Committee staff, to hear what veterans have to say.  Indeed, he is a true advocate for veterans' issues.

So, I would turn it over to Mr. Miller for an opening statement.

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


Mr. MILLER.  Thank you very much, Mr. Chairman.  I am, in fact, very pleased to be here in your great State of Maine to examine how VA is addressing the healthcare needs of women, rural needs and special needs veterans.  It is appropriate that we are here today on Patriots Day because I truly do believe that there is no greater patriot than the veteran, a person who has worn the uniform in defense of this Nation for all the things we stand for.  It is great to be here with my friend and colleague, Tom Allen.  We have had numerous opportunities to do things legislatively in Washington.  We have traveled together as well.  It is a great pleasure to be with you here today. 

I know that rural America does have a strong military tradition.  A lot of people don't think of Florida as being a rural State, but actually Maine and Florida are ranked in the top 18 in the States in this country that, in fact, have access issues.  The veterans in my district, which is Pensacola to Destin, northwest Florida, my veterans have to travel three, three and a half hours to get to a hospital.  Most people don't think about that when they are thinking about the State of Florida because the veteran population—I have—I actually have the largest veteran population of any Congressional district in the country, and I am proud to represent those individuals in Washington, DC.  Certainly being here today to have a chance to hear from the folks from Maine and surrounding areas about how you are being dealt with or not being dealt with I think is very important.  I do have a statement that I would like to have entered into the record.

I would also like to add that the Chairman has continued to promise me a taste of Moxie, and I have yet to get it.  I continue to wait with great anticipation.  So, it is a pleasure. 

Mr. MICHAUD.  You definitely will have an opportunity to have Moxie.  As a matter of fact, I see it coming down the aisle right now.  And I want you to know that, actually, Moxie is the official soft drink here in the State of Maine.  So, enjoy.

[Whereupon Congressman Miller was handed a can of Moxie.]

Mr. MILLER.  I like it.

Mr. MICHAUD.  Well, I am glad you like it.  There are plenty more. 

It is now my distinct pleasure to introduce my colleague from the State of Maine who actually is in this district.  I appreciate your willingness also, Congressman Allen, to take the time out today to hear what people have to say about rural veterans' issues, and also thank you for putting forward the name for our first witness. 

So, I will turn it over to Mr. Allen.


Mr. ALLEN.  Thank you, Mr. Chairman.  It is nice to say those words in Mike Michaud's case.  Thank you, Mr. Chairman, for holding, organizing this hearing, and also for allowing me to participate, even though I am not a Member of the Veterans' Affairs Committee.

I do want to welcome Congressman Jeff Miller.  It is a real pleasure to have him here.  He and I were on a trip together to Afghanistan and Iraq and Pakistan last August.  And you get to know people pretty well when you are on a trip like that.  And I think we both came away with an enormous respect for what the young men and women in the armed services are doing over there under extraordinarily difficult and challenging circumstances.  And I just want you all to know, many of you veterans from other conflicts, and I see Adam Cote here who is an Iraq veteran, many of you from other conflicts that appreciate and understand how challenging and difficult the work there really is.

I also want to welcome today's witnesses to the hearing.  I look forward to their testimony about how we can improve care for veterans in Maine and across the country. 

Finally, I want to welcome and express my thanks to all of the veterans who are here today.  I want to thank you for your brave and honorable service to this country.  I thank you for your service and thank you for being here. 

Maine is home to over 150,000 veterans who have sacrificed for our country.  I have been honored for the last 12 years to represent the veterans in the 1st District of Maine.  And I pledge to you I will continue my work in Congress to keep the promises we have made to those who have defended us past and present.

Today's hearing will focus on the particular needs of women veterans, veterans in rural areas and other special populations, including veterans with mental health needs.  The percentage of women serving in the armed forces, their scope of responsibility, and their exposure to danger have all grown dramatically in recent years.  Therefore, we must work even harder to ensure that the VA is ready to serve women veterans.  Women who have served in the military must receive the same benefits as their male counterparts, but they also must have access to healthcare targeted to their specific needs, including gynecological care and mammography, an issue that given my wife's illness, I am more aware of than ever before.

Another important component of care for women veterans is the availability of military sexual trauma counseling at Togus' Women's Clinic and the VA Vet Centers throughout Maine.  Vet Centers and community-based outpatient clinics (CBOCs) have been extremely important for our rural State.  Because of the progress of these centers and clinics, most veterans no longer have to travel for hours to get the healthcare benefits that they have earned, though they still in many cases have to travel some distance.

I am glad that Congress recently increased the mileage rate from a meager 11 cents per mile that it was to 28.5 cents per mile.  The rate is still, as you know, far less than actual costs and I am sure we can do better.

We are extremely proud of the dedicated VA employees here in Maine working under the direction of Director Brian Stiller.  The VA is doing whatever it can to address the healthcare requirements of veterans with special needs.  The post traumatic stress disorder (PTSD) program at Togus has been extremely helpful.

I recently introduced legislation to help veterans applying for disability compensation for post traumatic stress disorder.  The Full Faith in Veterans Act would change the VA standard of proof for veterans who suffer from PTSD.  The bill creates a common sense approach that is long overdue.

And as you may know, as many of you know, when veterans seek treatment and disability benefits for PTSD, they bear the burden of proof to establish, first, that they have a diagnosis of PTSD; and second, that the PTSD causing event happened during their service.  To prove the second factor, they must produce existing military documentation about the event that proves the event happened and that they were present, or they have to come up with two buddy statements that attest to these facts.

Often, however, particularly in the case of Vietnam vets, no records were created at the time that document the event.  In many cases, moreover, finding a veteran's buddy who was at the scene is difficult, and the military services have not been especially helpful.  This has led to situations where it is clear to medical professionals that a veteran's  PTSD was caused by an event during the individual's service, but the veteran is not eligible to receive disability compensation because the veteran's military records are inadequate. 

As I have learned from our veterans here in Maine, too many of our Nation's heroes are denied benefits because of gaps in military documentation that are not their fault.  Forcing veterans to jump through these hoops to receive compensation they had earned while serving their country is simply unacceptable.  Under my bill, a certified mental health professional could make a logical connection between the diagnosis of PTSD and the veteran's military service, and a service connection must be granted.  The bill also directs the VA to improve their procedures for evaluating and treating PTSD.

I want, again, to thank Chairman Michaud for cosponsoring this legislature with me and working to ensure that this legislation gets considered by the full House of Representatives for a vote.  I want to thank you all for being here again today.  And, Mr. Chairman, I yield back.

 Almost forgot, but not quite.  Dana Doliber—

Mr. DOLIBER.  Yes, sir.

Mr. ALLEN. —is one of my constituents.  He lives here in Sanford.  He is a Vietnam veteran.  He doesn't need much by way of introduction because he is going to tell his story.  In many ways, I was saying to Dana earlier, he is the poster-child for the legislation that I have recently introduced about PTSD.  And in a few minutes, you will understand why.

Dana, thank you very much for being here.

Mr. DOLIBER.  Thank you, sir.

Mr. ALLEN.  You have to turn on the microphone.


Mr. DOLIBER.  First, let me say what an honor and a privilege it is to be here to provide this testimony for you.

In 1971, I filed my first claim with the VA.  As PTSD was not a known accepted condition at that time, I was denied.  In 1985, at my wife's urging, I began seeing Robert Paige, LCSW, for what in a short time was diagnosed by Mr. Paige and Dr. John Scammon as PTSD.  A claim was again filed with the VA for service connected PTSD for service in Vietnam for service from 1967 to 1968. 

From 1985 to 1992, despite documentation, the VA routinely ruled against my claim.  The VA did not provide the veteran with assistance acquiring records when requested or ruled in the veteran's favor providing the benefit of the doubt in favor of the veteran or ruled in favor of the veteran without a preponderance of the evidence to disprove what the veteran provided as evidence.  Those three of the VA's own regulations were not followed in every denial of the veteran's claim.

The VA's own record was inaccurate in its portrayal of the veteran's branch of service, birth date, and personal record prior to service.  Doctors at the VA routinely diagnosed other conditions than PTSD due to their not being given the paperwork submitted providing stressors, which would have permitted the diagnosis of PTSD, as that is what eventually happened.  It reached a point that I felt I needed the serial number of the round being fired at me to prove my case, a standard that the VA seems to not have a problem requiring from many veterans.

With the submission of documentation of the combat action ribbon awarded in 1992, I was granted a percentage rating with service connection.  From 1992 to the year 2000, the issue of clear CUE, or clear and unmistakable error, and retroactivity of date of service connection, along with percentage of disability was the issue which dealt with the past issues from 1985 to 1992.  In 2000, I was awarded 100 percent PNT, that's permanent and total, retroactive to 1985.  I agreed to drop the CUE case and retroactivity to 1971 as I felt this would drag the case out another 10 years.  Claims for skin rashes and sores and hearing loss were also denied by the VA in much the same manner.

The VA has a choice to either be part of the problem or part of the solution.  As part of the solution, the VA should improve claim processing being mindful to be proactive for the veteran, abiding by the laws as passed by Congress as the will of the people for the veteran as in the Haas Case, and to be proactive regarding veteran medical care.  If doctors ask for equipment in the rehab of a veteran, provide it.  If surgeries require rehab for the healing process, provide it. 

The other part of the solution comes from both houses of the legislature, not with fancy pro-veteran sounding bills that are anti-veteran, such as the Noble Warrior Act or the America's Wounded Warrior Act, but proactive veteran legislation is what is required.  Servicemen and women understand and expect that if they need help when they come home, that help will be there.  America's veterans provided the—providing the freedoms that we have deserve no less than the full support of the VA and the Congress.  The American people expect no less than your full support of our veterans.  We should not disappoint them by a lack of action.  Thank you.

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

Mr. MICHAUD.  Thank you, Mr. Doliber.  I really appreciate your willingness to come here today to give your testimony. 

I guess my question is are you currently accessing the VA care for your PTSD?

Mr. DOLIBER.  Yes.

Mr. MICHAUD.  Do you have trouble getting appointments within the VA system to see your provider?

Mr. DOLIBER.  For other medical problems that are ongoing, there seems to be extending waiting periods.  If, for instance, two or three years ago I fell on the ice and I had a multiple compound fracture of my left arm.  After getting treated at Henrietta D, Goodall Hospital, I was—and having notified the VA of the accident and everything like that, I called up the VA to request help with their rehab services and the follow-up appointment to have somebody from orthopedic to attend to my multiple compound fracture of my left arm.

I was told that I would probably have to wait a month or two for that.  The physicians here in town felt that the medical help that was needed needed to be done within a week, not a month or two.

Mr. MICHAUD.  And the services that you have received from the VA, do you think that they have been helpful to you?

Mr. DOLIBER.  What I term the VA medical care is benign neglect.  They do not—they do not intentionally with malice, I believe, do these things.  It is just that that's the way their system is set up.  That's the way that the veteran, when he is seeking help, can find himself in a long waiting line.

It is not beneficial for the veteran who is seeking the aid and assistance from the VA for medical conditions or even for conditions for PTSD to be put off.  Usually, for instance, like the PTSD, that's post traumatic stress disorder.  That means that it has already gone past the point of where it needs to be dealt with.  The veteran finally has to deal with it.  And when they seek help from the VA, a lot of times you have to be put in a line or there is a waiting situation that has to happen because they have to get the doctor there.  Sometimes you will see a physician assistant.  There needs to be more proactive work from the VA toward the veteran.

Mr. MICHAUD.  My last question is whether you have talked to other veterans who have the same problem, being put on a waiting list?

Mr. DOLIBER.  Yes, yes.  I talked with an Iraqi veteran when I was up at the VA about a month and a half ago.  And he was there for traumatic head injury, and he was in the pay office and I was talking with him.  And in the middle of the conversation with him, he stopped in mid-sentence and it was as if the lights were on, but there is nobody home.  And he was there trying to seek help from the VA.  And his wife is beside him, she's in tears.  They are going financially broke.  He is not being—he is only 40-percent disabled.  That is the rating that the VA gave him.  That is on the VA.  He deserves far more attention.

Mr. MICHAUD.  Thank you.  Mr. Miller?

Mr. MILLER.  Thank you very much.  I appreciate your willingness to come forward and testify.

What did the VA tell you when they said it would take time for you to get into rehab?  Just that there were no slots?

Mr. DOLIBER.  They said the earliest that they could—the earliest that the appointment could be made for would at least be a month, possibly two.  The orthopedic doctor that had set my arm and had operated on it said I needed to see a doctor a week after that.  Okay?  I couldn't wait a month.  As a result of that, I incurred the expense from the orthopedic doctor and all of the rehab services after that on my own.

Mr. MILLER.  Do you think a solution is a fee-for-service type issue, where when you cannot get an appointment within an acceptable amount of time you have the ability to continue to use the physician that set your arm until you can get into the VA system?

Mr. DOLIBER.  Yes, sir.  Yes, I do.  Fee-for-service has worked very well for a lot of veterans.  It has been cut back because of lack of funding, because of budget cuts.  And if I could, I would like to address the budget cuts part of it.

I had a conversation at one time up at the VA regarding budget cuts with the then director, Mr. Sims.  And he said that the budget cuts are the responsibility of the Congress.  And at that time, the VA budget and the U.S. Department of Housing and Urban Development (HUD) budget were both tied-in at the same time when they were being considered.  Well, since then, that has changed.  The HUD budget and the VA budget, from what I understand, are two different things.

The problem was that I found out that the VA budget that gets submitted to the Congress, the requests, come from the directors of the Veterans Administration regional offices.  In other words, if they are not asking for the increase in funding, the Congress has no way of knowing that an individual regional office needs that increase in funding.  And to my knowledge, that is the way it is still being run.

Mr. MILLER.  The budget process works where the President or the Administration submits a budget to Congress, but we are in fact—one of the main things we do is pass appropriation bills.  So, Congress does have a very large impact.  As you said, if the information doesn't get to us—

Mr. DOLIBER.  Right.

Mr. MILLER. —that is why these field hearings are so critical.  Sometimes the request is not made and we don't know, but we do, in fact, have control of the purse strings—

Mr. DOLIBER.  Yes, sir.

Mr. MILLER. —in DC.  What other things, what other types of outreach do you think that the VA can use, especially in rural areas, to get the word out to those special needs veterans or to other groups of veterans?

Mr. DOLIBER.  Well, the Vet Centers—I have never been to a Vet Center.  Initially, when I began my PTSD therapy, it was being funded by the Vet Center in Portland.  I had never gone to the Vet Center in Portland, but the Vet Center here in Sanford requested the funding from them.  That soon was cut because their budgets were cut.  So, the therapist I was seeing at the time began seeing me pro bono, and he saw me for years pro bono because the VA would not approve the funding for my therapy.

Outreach centers need to be there.  They do provide a helpful service to the veteran, especially in rural communities.  The funding, again, the 900 pound gorilla in the room is money, and that is what it comes down to.  Now, the American people know that the funding—they want the funding for their veterans.  They know the veterans need the funding.  The VA needs to provide the request to the Congress for the funding.  And to be penny-wise and pound foolish doesn't seem to make a whole lot of sense.  And the first thing that can be done in rural areas is to have the Vet Centers because they do provide a needed service.

Mr. MICHAUD.  Congressman Allen?

Mr. ALLEN.  Dana, thank you for being here.  I just have a comment about the funding issues.  I sit on the Budget Committee, and I did want to make one clarification.  Often the regional directors will be asking for more money than they actually get in the present budget, because the Office Management and Budget—

Mr. DOLIBER.  Right.

Mr. ALLEN. —the presidential operation will trim down those requests.  And then the regional VA director's kind of stuck with the number that they have been given.  Maybe not the number they asked for privately, but the number that they have been given by the Aadministration.

But as Representative Miller said, ultimately the decision is going to be made in the Congress.  And I agree with him that the information that we get from our constituents is fundamentally important to understanding how we can drive that budget, as we did last year, in a much more positive direction.

I have a question; you indicated that you provided documentation to the VA to support your claim of service connection for your PTSD over all those years when you were trying to get—

Mr. DOLIBER.  Yes, sir.

Mr. ALLEN. —trying to get benefits, but there were certain gaps in the documentation that led to your claim being denied.

Can you talk a little bit more about what those gaps were, what it was you were being told you had to provide but could not?

Mr. DOLIBER.  Well, the main requirement was to provide what the VA would term a stressor.  Now, a stressor could be handling wounded, a stressor could be being shot at or being around explosions going off.

I provided pictures of my ship high-lining wounded from my ship to the hospital ships, Repose and Sanctuary.  I provided documentation from my ship, albeit sketchy, and from the U.S.S. St. Paul cruiser that we operated with, the U.S.S. Newport News, another heavy cruiser that we operated with, and the U.S.S. Collette, another destroyer, where they spell-out in their record and their ship's log our receiving counter-battery from coastal defense units from North Vietnam and South Vietnam.  We operated almost up to the Hai Phong Harbor in North Vietnam.

A lot of the American people believe that our participation in Vietnam stopped at the demilitarized zone (DMZ).  We were routinely—and it wasn't any real big deal for us to be north of the DMZ.  We received fire from islands off of the DMZ, from North Vietnamese, coastal batteries.  I am at a loss as to how those records could be misrepresented on the ship that I was on, and yet to be so complete in the other vessels that we operated with.

Mr. ALLEN.  Did you think at some level was there any chance the VA was thinking, well, you were on a ship, you weren't on the ground on the shore?  Was that a piece of it?

Mr. DOLIBER.  Well—

Mr. ALLEN.  Or how would you try to explain it?

Mr. DOLIBER.  Let me explain it this way.  I had a conversation with a veteran's service officer at the VA.  And he was an on-the-ground marine in Vietnam, and more power to him.  When he heard that I had been onboard ship, he at that time would not take my case because in his words, we were on a cruise.  It was if we were on the Queen Mary.

This was no Queen Mary.  We were—we provided gunfire support for the 3rd Marine Division at the Battle of Hu?.  We were anchored in the Perfume—at the mouth of the Perfume River.  I was in the rangefinder.  I was looking through.  I was watching it.  I was providing—I was pressing the button on the rangefinder that fired the guns.  This is no Queen Mary.  They don't call them destroyers for nothing, and we did a damn good job.

Mr. ALLEN.  Thank you very much.

Mr. DOLIBER.  Thank you.

Mr. ALLEN.  Thank you for your testimony.

Mr. MICHAUD.  Thank you very much, Dana.  Without objection, I would ask anything that has been said and for all the written testimony to be submitted in full for the record.  Hearing none, it is so ordered.

I want to ask the second panel to come on up.  While they are coming up, I just want to let you know, Dana, that in your written testimony you had asked that this Subcommittee be assured that there be no retribution against you for your testimony today.  I assure you that there will not be any retribution.  I want to thank you once again for coming here today.

Mr. DOLIBER.  Thank you, sir.

Mr. MICHAUD.  So, if the second panel could come forward.  While they are coming forward, the second panel is Peter Ogden, who is the Director of Bureau of Veterans' Services for the State of Maine.  We have Gary Laweryson, who is the Chairman of the Maine Veteran Coordinating Committee.  Kelley Kash, who is the Chief Executive Officer of the Maine Veterans' Homes (MVH).  And David Hartley, who is the Director of the Maine Rural Health Research Center.  I want to thank all four of you for coming here today to give your testimony.  We look forward to hearing your testimony here today.

We will begin with Mr. Ogden.  Please proceed.



Mr. OGDEN.  Chairman Michaud, Congressman Miller, Congressman Allen, thank you for this opportunity to speak today on three extremely important issues for Maine's veterans:  Access to rural healthcare, women's issues—

Mr. MICHAUD.  Excuse me, sir.  Is your microphone on?

Mr. OGDEN.  The light's on.  Okay.  Should we start over?  Okay.

Chairman Michaud, Congressman Miller and Congressman Allen, thank you for the opportunity to speak today on three extremely important issues for Maine veterans:  Access to rural healthcare, women veterans, and outreach to veterans for benefits.  My testimony today comes from three perspectives:  The Director of the Bureau of Maine Veterans' Services, the Secretary of the National Association of State Directors of Veterans' Affairs, and as a disabled combat veteran who uses the VA healthcare system in Maine. 

I will begin with some facts that are key to understanding Maine and its veterans.  First, in 2000, Maine had the largest per capita veteran population in the Nation and is still at number two.

Second, Togus Medical Center is the oldest VA hospital in the Nation.

Third, Maine's aging veteran population is geographically dispersed across a large land area.  Veterans living in northern Maine can drive five to six hours and up to 260 miles to reach the one VA Medical Center at Togus.

Fourth, 65 percent of our veterans are age 55 or older.  This percentage should reach about 70 percent between 2020 and 2025, and these are the veterans that are most likely to need and use the VA healthcare system.

Fifth, 73 percent of our veteran population served during a wartime, which means they have more benefits available to them.

Last, we have over 52,000 or 36 percent of our veterans enrolled in the VA healthcare system, and about 38,500 who actively use the VA healthcare in Maine.

A lot of my speech will talk about the Capital Asset Realignment for Enhanced Services (CARES)  program.  The CARES market plan, the Far North Market—and Maine is unique because Maine as a State has its own market identified by the CARES plan—developed by Veterans Integrated Services Network (VISN) 1 recognized Maine's unique geographic characteristics, limited transportation infrastructure, and rural nature.

The CARES Commission Report made several points about access to VA healthcare in Maine, the Far North Market, that are relevant to this hearing.  Less than 60 percent of our enrolled veterans are currently within the VA's access standards for hospital care.  Inpatient medicine workload is projected to increase 209 percent by 2012.  Only 59 percent of the veterans residing in this largely rural area are within the CARES plan guidelines are set for access to primary care.  VISN 1 proposed only five new CBOCs, Community-Based Outpatient Clinics, all of them in Maine.  In short, to improve rural access for veterans to VA healthcare in Maine and the Nation, implement CARES in Maine and in other rural States, and implement it as soon as possible.

Any conversation about aging veterans and access to healthcare should include the importance of State Veterans' Home Programs and the service they provide to our veterans.  Maine is fortunate to have Maine Veterans' Homes with their six facilities spread across the State providing excellent care at the most reasonable cost.  It is important that Congress continue to fund the State Veterans' Home Construction Program until each State has the capacity to provide long-term care to its veterans. 

Maine has over 10,000 women veterans with less than 1,800 using the VA healthcare system.  Quality or availability of types of care for women veterans does not seem to be as much of an issue as the access and outreach to those women veterans to know about their benefits.  Approximately 40 percent of the women veterans using the VA healthcare system receive it at the CBOCs.  So, access at the local area is important.  The addition of the new CBOC in the Lewiston/Auburn area and the access points in Houlton, Dover-Foxcroft and in Farmington will allow more women veterans to receive care closer to home and this will increase the usage numbers for all of our veterans. 

While growth has occurred in VA healthcare due to improved access to CBOCs, many areas of Maine and the country are still shortchanged due to the geographic and due to the veterans' lack of information and awareness of their benefits.  VA and State Departments of Veterans Affairs must reduce this inequity by reaching out to the veterans regarding their rights and entitlements.  Maine and the National Association of State Directors of Veterans Affairs support the implementation of a grant program that would allow the VA to partner with the State Department of Veterans Affairs to perform outreach at the local level.

There is no excuse to veterans not receiving benefits to which they are entitled simply because they are unaware of those benefits.  I would encourage the Committee to support S. 1314, the "Veterans Outreach Act of 2007," to help us with that.

State governments are the Nation's second largest provider of services to veterans next to the VA, and this role will continue to grow.  We believe it is essential for Congress to understand this role and ensure we have the resources to carry out our responsibilities.  The States partner very closely with the Federal Department of Veterans Affairs in order to best serve our veterans.  And as partners, we need to continuously strive to be more efficient in delivering those services.

As I finish my testimony rather rapidly, I would like to once again thank you for the opportunity to speak to you today and thank you on behalf of Maine's veterans and the Nation's veterans for all you are doing to ensure they receive the proper healthcare and the benefits they have earned through their service to the Nation.  Thank you.

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

Mr. MICHAUD.  Thank you very much.  Mr. Laweryson?


Mr. LAWERYSON.  Congressman Michaud, Congressman Miller, Congressman Allen, the Maine Veterans Coordinating Committee wants to thank you for allowing us to testify again.  Our organization is made up of 14 different groups that do their best to work for all the veterans in the State of Maine.

As I testified on August 1st, 2005, on the CARES program, and you will see a lot of this overlaps everybody else, it has been two and a half years and we have opened one clinic, Houlton, possibly in June.  And in that interim time period, there's been a CBOC opened down in Connecticut, which wasn't even on the table at that time.  The rural veterans are not getting the care that they deserve or need.

At that time, we discussed the cost of fuel, the cost of living up here in Maine.  And since that time, I bet it has tripled.  The gas is out of sight, the fuel oil is out of sight.  These people are working on a fixed income.  They are not able to travel.  And when they do go down to Togus, there is a cost share on the travel pay, they lose half of it, and it is already putting a tremendous burden on them as it is.  I think we need to look at that again.

With Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) troops coming back, and they have been extended through a five-year term with the VA.  And I think that boots out after they redeploy again, which is another issue.  The older veterans aren't getting the word that they can get in there.  So, they don't come down because OIF/OEF has a first run on this or their assumption is that they do. 

We discussed communications last time with the VA getting out the proper word to clear up the fog.  That hasn't happened yet.  We need to get more of the VA out into local communities putting out these town meetings to pull these rural veterans in.  While Maine is a rural State, there is a subsection of rural up there, and you will speak with Mr. Rural Rural later.  That is where a large majority of your veterans are, especially your combat veterans.  They like to be out and about away from the hustle and the bustle.  We need to find out what's taking so long for VISN to get our other clinics open.  And we need to get that moving, especially in the rural areas first. 

The VA and Togus, we support, as we did back then.  The past director, Jack Sims, was doing a great job with what he had.  The new director has got a challenge and we are going to hold his feet to the fire, but he is doing a great job.  We have a meeting with the Coordinating Committee once a month.  He is there, he is an integral part of this.  We get the word, we pass the word.  And if there's any issues, we take it up and deal with them, not in a public meeting place but a private matter.  Very effective, and Mr. Stiller is very receptive to that.  We are lucky to have him. 

We have done something in Maine that the other States haven't done yet, and that is called “Operation I Served.”  We put that package together.  It has been very effective.  And we are putting it out now in doctor's offices, waiting rooms of hospitals because the veterans do get that.  They are allowed to call in.  We have worked with the Bureau of Veterans Services in Maine, publish this, update it every year or so.  It is a tremendous tool, and we just need to get more of that out in the public.  And that goes along with what my brother, Pete, was talking about that that would be a tremendous, tremendous way to get this information out and if we can get the VA onboard and do more town meetings in the rural areas. 

Women veterans.  They are combat veterans.  A veteran's a veteran.  They have special needs.  There's special needs veterans out there with amputations and traumatic brain injuries.  There is no difference.  They are veterans, and they should have first-care priority to any area, and that's the rural areas.  Now, if we can't get them in out there, we could temporarily take care of them with fee services until we can get them down to the master hospital at Togus.  Getting short on time here.

And the Coordinating Committee's opinion is still that VA should be a full-service hospital.  We should not have to run down to Boston.  It is counterproductive and it is not in the best interest of the veterans or their families.  It wasn't before, and it especially isn't now with the cost of transportation and fuel. 

We appreciate what you are doing for our veterans.  We continue to look forward to working with you.  And we will hold your feet to the fire to keep up the good work.  Thank you.

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

Mr. MICHAUD.  Thank you. Mr. Kash?


Mr. KASH.  Mr. Chairman and Members of the Committee, thank you for the opportunity to testify this morning. 

I am the Chief Executive Officer of the Maine Veterans' Home.  MVH operates six long-term care nursing facilities providing 640 skilled nursing, long-term nursing, and domiciliary beds.  The facilities are relatively small, each in size, 30 to 150 beds each.  This allows them to be located throughout the State of Maine, allowing greater ease of access to our facilities by veterans living in the most rural parts of Maine.

MVH is part of a vital national system of State Veterans' Homes.  The State Veterans' Homes system is the largest provider of long-term care to our Nation's veterans and provides 52 percent of the VA's total long-term care workload at well below the cost of care in a VA facility for civilian contract providers.  The State Veterans' Homes provide long-term medical services at a cost to the VA of only $71.00 per day, compared to approximately $225.00 per day to the VA for the placement of a veteran at a contract nursing home, or over $560.00 per day in its own VA facilities.  As such, the State Veterans' Homes play an irreplaceable role in assuring that eligible veterans receive benefits, services, and quality long-term healthcare that they have rightfully earned by their service and sacrifice for our country.

Traditionally, State Veterans' Homes residents have been primarily male.  However, more and more women are being admitted to State Veterans' Homes as veterans themselves reflecting the large and increasing numbers of women who have served in the military since the Korean War and before.

While our experiences in the Gulf War and present conflicts have given tremendous attention to post traumatic stress disorder, the reality and effects of PTSD have been present in every conflict.  State Veterans' Homes provide a common culture, reassuring surrounding, greater appreciation, and understanding of the veterans' experiences and issues; however, much more can be learned in treating PTSD in general.  

We feel strongly that the State Veterans' Homes should play a major role in meeting the many rehabilitative care needs for veterans and that we should be treated as a resource integrated more fully with the VA long-term care program.  Here is one example of how the VA can partner with the State Veterans' Homes.

The State of Maine enacted legislation earlier this month to establish a veterans' campus at Bangor, Maine.  The concept is to create a one-stop shop for veterans to receive most of their healthcare and social service needs.  The proposed project will locate a new, larger, and more capable VA community-based outpatient clinic next to the MVH Bangor facility.  Other veteran service organizations will be co-located at the campus, bringing a wide range of veteran services to a single campus, making it more efficient and convenient for veterans, families, and the various agencies that serve veterans' healthcare and social service needs.

The Bangor Veterans' Campus is a pioneering effort and it is the first of its kind in the Nation.  It should receive special interest in our Nation's Capitol.  The VA should streamline its awards process and its success should be replicated throughout the Nation. 

The VA chronically has been slow to implement enacted legislation.  Legislation directing the VA to pay the full cost of care for veterans with service-connected disabilities rated 70 percent or greater and to provide veterans with service-connected disabilities rated 50 percent or greater with prescription medications while residing in State Homes has yet to be implemented by the VA, even though Federal law required these provisions to take effect by March 2007.  The result has been tremendous confusion and frustration for the many thousands of veterans who are waiting for these services and for the State Veterans' Homes which will be required eventually to provide these services. 

Regarding VA grant funding, the administration has proposed cutting State Veterans' Home construction matching grant funding by almost 50 percent from $165 million in fiscal year 2008 to $85 million in fiscal year 2009.  The backlog of construction projects to repair, rehabilitate, expand, and build new State Veterans' Homes is now approaching $1 billion dollars.  Over $200 million of this backlog are life-safety projects.

In conclusion, I will quickly reiterate the issues facing the State Veterans' Homes.  First, thank you for your continued support in the VA per diem payment to the State Veterans' Homes.  The loss or reduction of the VA per diem would place Homes in an untenable financial position and could lead to the closure of many State Homes, ultimately impacting our aging veterans.

Second, we believe Congress must increase funding for construction grants to State Veterans' Homes to at least $200 million dollars to address the growing backlog of projects.

Third, we believe Congress must require the VA to promulgate long-overdue regulations to strengthen State Veterans' Homes and the veterans they serve.

Finally, we believe that the State Veterans' Homes can play a more substantial role in meeting the long-term care needs of veterans.  We support the national trends towards de-institutionalization and the provision of long-term care in the most independent and cost-effective setting.  We would be pleased to work with the Committee and the VA to explore options to develop pilot programs, such as the proposed Bangor Veterans' Campus, providing innovative care and for more closely integrating the State Veterans' Homes program into the VA's overall healthcare system for our veterans. 

Thank you for the opportunity to address you today, and thank you for your commitment to long-term care for veterans and for your support of the State Veterans' Homes as a central component of that care.

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

Mr. MICHAUD.  Thank you very much, Mr. Kash.

Dr. Hartley?


Mr. HARTLEY.  Well, thank you.  Mr. Chairman, Mr. Allen, Mr. Miller, thank you for the opportunity to testify before this Committee.  My testimony is based on my 12 years as a manager of substance abuse treatment programs in rural areas, and 15 years as a rural health researcher with a focus on access to mental health services in rural America.  I would like to make four points in my testimony.

First, as you know, many veterans are returning from OEF and OIF with mental health issues including PTSD, depression, and traumatic brain injuries, TBI.  A recent report from the RAND Center for Military Health Policy Research refers to these as the invisible wounds of war and reports that 31 percent of servicemen deployed since 2001 have reported symptoms of one or more of these injuries.  This report I have here with me, it is very long.  It just came out a few days ago, and I highly recommend it.  What is not mentioned in the RAND Report is the significant portion of these combat vets who are from rural areas, nearly half are recent recruits.

My second point.  The Veterans' Healthcare System has unique expertise and resources to devote to the healing of these injuries.  In recent—excuse me.  The VA also has an integrated health information network.  I am sorry, my notes are out of order.  I am going to have to switch to my other notes.  Excuse me.  (Pause.)  In recent years, the VA has opened more community-based outpatient clinics, or CBOCs, to make their expertise and these resources available to veterans who live at significant distances from VA medical centers.  We now have six CBOCs in Maine.

The VA also has an integrated health information network in the Nation, the best in the Nation, with evidence-based, patient-centered performance measures and a monitoring system to assure that all patients receive high quality care.  That system gets very good outcomes for those veterans who receive care from VA clinics and from CBOCs and from contract providers.

There are several reasons why a veteran in need of help might not seek care at one of these facilities.  While CBOCs have improved access in many rural areas, there remain vast remote areas in our most rural States, including Maine, where VA facilities are out of reach.  Also, some veterans prefer to seek care from a non-VA system provider for a variety of reasons.  This RAND report found that only half of those with these injuries actually seek help for them.

My third point.  The Federal Government, through the Health Services and Resource Administration, has created several programs to attract providers to under-served areas to support them.  These include Federally qualified health centers, critical access hospitals, and rural health clinics.  Some rural areas are also served by community mental health centers.  Most of these programs exist in areas that are designated as under-served.  While many of these programs are focused on primary care, it is common in rural areas to seek mental health services from primary care sites. 

We have the technology and the expertise to help these rural sites provide care to rural veterans that is of the same high quality that urban vets receive.  This can be done through telehealth, through the VistA information system which is now available to non-VA providers, through direct and clinical consultation between the expert clinicians in VA medical centers and rural providers, and through the placement of VA providers in these non-VA rural sites, creating veterans' access points.  Such cooperation between VA and non-VA providers must be encouraged.

My final point.  To facilitate collaboration between Health Resources and Services Administration (HRSA) and the VA, this Committee should encourage HRSA's Office of Rural Health Policy and the VA's new Office of Rural Health to collaborate on demonstrations and on interagency research bringing HRSA's Rural Health Research Center and the VA's researchers together to explore options for improving access to high quality care for rural vets.

Thank you.  I will be happy to answer your questions.

And I would like to add that I am accompanied today by my colleague, Dr. David Lambert, who is also an expert in rural mental health.  Thank you.

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

Mr. MICHAUD.  Thank you very much, Dr. Hartley.

Once again, I would like to thank the four panelists here. 

Mr. Laweryson, you had mentioned the CARES process and CBOCs, and we are very much familiar with that whole process.  We keep that book, I know I do, right on my desk in Washington to keep updated on how much progress we are making. 

Former Secretary of the VA, Tony Principi said in order to move forward in the CARES process, that they would need about a billion dollars a year.  That has not happened, unfortunately.  However, I think that if you listened to all the comments made here thus far today, as well as in Washington, relating to rural healthcare issues and access to healthcare, I think the CARES process would actually quite frankly solve a lot of problems with access points in rural areas.

My question is it is an expensive process.  Part of that expense is establishing some major hospitals that could cost $500 million dollars to establish compared to a $50 million dollar CBOC or access clinic.

What would you recommend?  Should the Subcommittee focus on some of the lower-cost access points and put off maybe for a year or whatever