Mr. Chairman, Ranking Member Miller, Distinguished Members of this Subcommittee, and guests, my name is John W. Wallace. I am a combat veteran who is presently Vietnam Veteran of America Maine State Council President. I serve on the Maine VHA MiniMac, BigMac, and Network Communications Council. I also serve on the Maine Veterans Coordinating Committee, the Caribou Veterans Cemetery Committee, the Maine Veterans Home Liaison Committee in Caribou and I participate in the Commanders Call with the Governor/General.
Today I will briefly discuss with you some of the health related issues facing veterans in the state of Maine, which is home of more than 154,000 veterans and their families.
Mr. Chairman, the Maine Department of Veterans Affairs Medical Center is located in Togus, six miles east of Augusta. Opened in 1866, Togus was the first national home for disabled volunteer soldiers. This VA Medical Center provides medical, surgical, psychiatric, and nursing home care. The VA operates community-based outpatient clinics in Bangor, Calais, Caribou, Rumford, and Saco to provide better access to care for veterans living in rural areas. In 2007, the VA opened a part-time clinic in Lincoln. There is also a Mental Health Clinic located in Portland.
More than 1,400 active-duty service members and veterans of the Global War on Terror have sought VA health care in Maine. Many veterans from the conflicts in Iraq and Afghanistan have visited VA counseling centers in Bangor, Caribou, Lewiston, Portland, and Springvale. These community-based Vet Centers are an important resource for veterans who, once home, often seek out fellow veterans for help transitioning back to civilian life. Over six million veterans live in rural areas across America, and most fall below the poverty line. They travel hours to get to the nearest VA medical facilities. At a hearing of the Subcommittee on Health, Mr. Chairman, you pointed out that although 20 percent of the nation’s populace lives in rural areas, 40 percent of veterans returning from deployments in Afghanistan and Iraq live in rural communities. This leads to “significant challenges maintaining ‘core health care services.” The average distance for rural veterans to access care is 63 miles, according to the National Rural Health Association.
The difficulty of accessing health care is a significant problem for many of Maine’s veterans. Although Togus is centrally located in Augusta, the state's geographic expanse makes it a problem for many veterans to use the hospital as their primary health-care provider. In a 2004 report, a government commission expressed concern that only 59 percent of Maine’s veterans were living within its geographic guidelines for access to care, which ranged from 60 minutes for urban areas to 120 for very rural areas.
Furthermore, research by the National Rural Health Association underscores the problem. The association found that about 44 percent of service recruits come from rural areas whose population comprises 19 percent of Americans. The disparity was far less during World War II and the Vietnam War.
Of Maine’s six CBOC with two more planned under CARES, the closest CBOC is over eighty miles from its hub and the farthest is two hundred sixty miles. For primary care this is ok, but for specialty care services veterans have to travel to Togus or Boston. The distance a veteran may have to travel is more than three hundred miles, which is clearly outside the 75-mile radius established by the VA. To make matters worse, most rural medical care providers, weary of the paperwork and long delays involved in the federal benefits system, often do not accept TRICARE, the military health insurance for active-duty soldiers and their families. The program offers a 180-day transitional benefit for soldiers after discharge.
There is evidence that the VA has known for some time about the need to focus more on rural care. A 2004 VA study of 750,000 veterans found that those living in rural areas tended to have more serious and costly health problems than their urban counterparts. Perhaps the VA could reach a lot of the veterans who live in rural Maine by expanding the use of fee-basis care, in which the VA contracts its services out to a third-party provider. Certainly, the myriad issues involved in providing healthcare for rural veterans must be addressed by the VA’s new Office of Rural Health, which has been slow to get started.
Veterans Health Administration Office of Rural Health
In accordance with Section 212 of the Pubic Law 109-461, VA established an Office of Rural Health. The mission of the office is to develop policies and identify and disseminate best practices and innovations to improve services to veterans who reside in rural areas. The law states:
- Section 212 c(3) ‘‘To designate in each Veterans Integrated Service Network (VISN) an individual who shall consult on and coordinate the discharge in such Network of programs and activities of the Office for veterans who reside in rural areas of the United States.
Public Law 109-461 -- Sec. 822. Business Plans For Enhanced Access To Outpatient Care In Certain Rural Areas
(a) Requirement- Not later than 180 days after the date of the enactment of this Act, the Secretary of Veterans Affairs shall submit to the Committee on Veterans' Affairs of the Senate and the Committee on Veterans' Affairs of the House of Representatives a business plan for enhanced access to outpatient care (as described in subsection (b)) for primary care, mental health care, and specialty care in each of the following areas:
(1) The Lewiston-Auburn area of Maine.
(2) The area of Houlton, Maine.
(3) The area of Dover-Foxcroft, Maine.
(4) Whiteside County, Illinois.
(b) Means of Enhanced Access- The means of enhanced access to outpatient care to be covered by the business plans under subsection (a) are, with respect to each area specified in that subsection, one or more of the following:
(1) New sites of care.
(2) Expansions at existing sites of care.
(3) Use of existing authority and policies to contract for care where necessary.
(4) Increased use of telemedicine.
Mr. Chairman, we are in an emergency situation in Maine, and VVA is seeking your help in Congress to expedite the provision stated in P.L. 109-461. Otherwise, our disabled veterans’-- both young and old-- will be forced to continue their long-distance travel for care and treatment to the nearest VHA Medical Center, clinic, or hospital. We pioneered the first rural or rural-rural VA clinic as I like to call it, in the country. It covers an area bigger than the states of Connecticut and Rhode Island. It sits about two hundred and sixty miles north of Togus VAMC. We quickly went from one day a week to five days a week with three providers and staff treating over three thousand veterans a month. There are also two mental health providers on board with tele-medicine health two days a week. This was a great start to the VA’s commitment to its veterans. But we veterans had to fight for this every step of the way. In the beginning we were told this would never happen.
If you travel into the farm towns of any state in the union, you see lots of veterans who need help and are having difficulty finding it. Should we lose veterans who protected this nation so honorably because our government was unwilling to look past politics? I think not!
Since 1982, Vietnam Veterans of America has been a leader in championing appropriate and quality health care for all women veterans. Additionally, although women veterans are authorized the same benefits, services and compensation as their male counterparts, many women do not know their rights as veterans, and they do not know how to access VA programs. Some concerns remain in the treatment, delivery, and monitoring of services to women veterans.
WOMEN VETERAN PROGRAM MANAGERS
The duties, responsibilities, advocacy, oversight and reporting of the VA Women Veteran Program Managers, as defined in their handbook (1330.2), are substantial. VVA calls for the VA to provide the Women Veteran Program Managers with a minimum of 20 hours per week to accomplish the responsibilities of the position. VVA believes that these significant duties and responsibilities are essential and should not be minimized in light of the collateral duties they usually must perform. Further, we believe that while each VISN must designate, support, and utilize one of its Medical Center Woman Veteran Program Managers as the VISN Women Veteran Program Manager, we believe additional time must be allocated for these increased duties and responsibilities.
PTSD AND SUBSTANCE ABUSE
The VA counts PTSD as the most prevalent mental health malady (and one of the top illnesses overall) to emerge from the wars in Iraq and Afghanistan, but the VA is facing a wave of returning veterans who are struggling with memories of a war where it’s hard to distinguish civilians from enemy fighters and where the threat of suicide attacks and roadside bombs hovers over the most routine mission. Moreover, the return of so many veterans from Afghanistan and Iraq is squeezing the VA's ability to treat yesterdays’ soldiers. Top VA officials have said that the agency is well-equipped to handle any onslaught of mental health issues and that it plans to continue beefing up mental health care and access under the administration’s budget proposal released in mid-February.
Yet according to a GAO report issued in November 2006, the VA did not spend all of the extra $300 million budgeted to increase mental health services and failed to keep track of how some of the money was used. The VA launched a plan in 2004 to improve its mental health services for veterans with PTSD and substance-abuse problems. To fill gaps in services, the department added $100 million for mental health initiatives in 2005 and another $200 million in 2006. That money was to be distributed to its regional networks of hospitals, medical centers, and clinics for new services. But the VA fell short of the spending by $12 million in 2005 and about $42 million in fiscal 2006, said the GAO report. It distributed $35 million in 2005 to its 21 health care networks but did not inform the networks the money was supposed to be used for mental health initiatives. VA medical centers returned $46 million to headquarters because they could not spend the money in FY’06.
More troubling, however, is the fact that the VA cannot determine to what extent about $112 million was spent on mental health services improvements or new services in 2006. In September 2006, the VA said that it had increased funding for mental health services, hired 100 more counselors for the Vet Center program, and subsequently was not overwhelmed by the rising demand. That money is only a portion of what VA spends on mental health. The VA planned to spend about $2 billion on mental health services in FY’06. But the additional spending from existing funds on what the VA dubbed its Mental Health Care Strategic Plan was trumpeted by VA officials as a way to eliminate gaps in recent and future mental health.
Furthermore, VVA believes there is a need for increased VA research specifically focused on women veterans’ mental health issues. For example, as of August 2006 VA data showed that 25,960 of the 69,861 women separated from the military during fiscal years 2002-06 sought VA services. Of this number approximately 35.8 percent requested assistance for “mental disorders” (i.e., based on VA ICD-9 categories) of which 21 percent was for PTSD, with older female vets showing higher PTSD rates. Also, as of early May 2007, 14.5 percent of female OEF/OIF veterans reported having endured military sexual trauma (MST). Although all VA medical centers are to have MST clinicians, very few clinicians within the VA are prepared to treat co-occurring combat-induced PTSD and MST. These issues need to be addressed.
The VA will need to directly identify its ability and capacity to address these issues along with providing oversight and accountability to the delivery of their services. VVA believes that the VA has twelve programs that address PTSD in women veterans, but they are not exclusively for MST (some are general PTSD programs) and not all are gender-specific programs.
A concern for the environment of the delivery of services also exists in the residential programs of the VA. Most if not all residential programs are designed for treatment of mental health problems. The veterans of these programs are a very vulnerable population. This was particularly brought to our attention in regard to women veterans, who, in light of the high incidence of sexual trauma, rape, MST, and domestic violence find it difficult, if not impossible, to share residential programs with male veterans. They openly discuss their concern for a safe treatment setting, especially on units where the treatment unit layout does not provide them with a physically segregated, secured area. They also discuss the need for gender- specific group sessions, in light of the nature of some of their personal and trauma issues. VVA asks that all residential treatment areas be evaluated for the ability to provide this environment; that medical center facilities develop cost plans to address this accommodation; that these facilities report the findings for consideration to their respective VISN and to VA Central Office, Office of the Under Secretary for Health.
This submission points to the need for a well-conceived and well-implemented long-range plan for healthcare services and delivery for our women veterans. To VVA’s knowledge no such plan exists. Although the VA has taken great strides in the past 15 years toward improvement of the quality of care for female veterans, there is always room for improvement. While it is fair to say that the quality of care at most VA facilities is equal to that of any other medical system in the world, it does not help women veterans who cannot access that fine care because services aren’t available.
In closing, VVA would like your support of H.R. 4107, Women Veterans Health Care Improvement Act, introduced by Rep. Herseth Sandlin, Stephanie (D-SD) and S. 2799 Women Veterans Health Care Improvement Act of 2008, introduced by Senator Patty Murray (D-WA).
Mr. Chairman and members of the Subcommittee, on behalf of Vietnam Veterans of America, and the Veterans in Maine, I thank you for your continued hard work and dedication to this issue. I will be happy to answer your questions.