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Hon. Michael H. Michaud, Chairman, Subcommittee on Health

The Subcommittee on Health will come to order.  I would like to thank everyone for coming today.

The issue of providing rural health care is one that affects each of our states and in very different ways.  In California, rural communities make up 92 percent of the landmass, and 8 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 communities tend to be older than urban populations, and they tend to exhibit poorer health behaviors.  Economic factors also add to the challenges facing rural populations.

Rural veterans make up 41 percent of VA’s patient workload.  Access and resources present serious challenges to providing high quality health 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, and 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 VA facilities 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 infrequency 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 where smaller patient populations 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 have been termed “core health care services” by the Institutes of Medicine.  These services include primary care in the community, emergency medical services, hospital care, long-term care, mental health and substance abuse services, oral health care, and public health services. 

For a variety of reasons, rural areas also face a greater problem recruiting and retaining health care professionals.

These problems must be addressed because the demand for services from our veterans population 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’s system of community-based outpatient clinics, which currently number more than 650.

We have five CBOCs in Maine.  The CARES commission recommended a sixth 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 8 percent.  At that 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 the CARES to assist in decisions in the future.

The VA has also designated facilities as “Veterans Rural Access Hospitals,” designed to provide inpatient services to veterans in rural areas where these services can be supported. 

The VA has taken great strides in exploring the uses of telemedicine and other technological means of providing health care services.  I would like to hear how these efforts are improving care and how we can help.

One of the problems in the area of recruitment and retention is the separation from other health care professionals often felt by those working in rural communities.  I would like to explore how technology might be used to overcome this feeling of isolation and thus improve recruitment and retention.

The questions I would like to start to answer today are:  Is the VA, and really are our rural communities, ready to meet the increased and changing needs of our veterans and their families?  What is the VA in rural America going to look like in the future?

And we must keep in mind that VA health care does not operate in a vacuum, but is an integral part of our national health system.

I would also very much like to know when the priority CBOCs are going to be built or if VA no longer intends to follow CARES.

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