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Ms. Shannon Middleton

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

Mr. Chairman and Members of the Subcommittee:

Thank you for this opportunity to present The American Legion’s views on access to quality health care for veterans in general and veterans in rural communities in particular. Research conducted by the Department of Veterans Affairs (VA) indicated that veterans residing in rural areas are in poorer health than their urban counterparts. It was further reported that nationwide, one in five veterans who enrolled to receive VA health care lives in rural areas. Providing quality health care in a rural setting has proven to be very challenging, given factors such as limited availability of skilled care providers and inadequate access to care. Even more challenging will be VA’s ability to provide treatment and rehabilitation to rural veterans who suffer from the signature ailments 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.

Community Based Outpatient Clinics (CBOC)

A vital element of VA’s transformation in the 1990s, was the creation of CBOCs to move access closer to the veterans’ community.   A recent VA study noted that access to care might be a key factor in why rural veterans appear to be in poorer health. CBOCs were designed to bring health care closer to where veterans reside. Over the last several years, VA has opened up hundreds of CBOCs throughout the system and today there are over 700 that provide health care to the nation’s veterans. By and large, CBOCs have been pretty 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 Assets Realignment for Enhanced Services (CARES) recommendations 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, a shortage of health care providers and bad weather. The Veterans Integrated Services Networks (VISNs) rely heavily upon CBOCs to close the gap.

The provision of mental health services in CBOCs is even more critical today with the ongoing wars 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 a returning veteran seeks VA health care. 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 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 health care 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. 

The Presidential Task Force to Improve Health Care Delivery for Our Nation’s Veterans made several recommendations for DoD and VA, one of which:  VA and DoD should declare that joint ventures are integral to the standard operations of both Departments.  (Recommendation 4.8)  Since this Task Force’s final report in May 2003, none have materialized -- yet there are military bases in many rural communities.    

Traumatic Brain Injury Patients

In a July 2006 report entitled Health Status of and Services for Operation Enduring Freedom and Operation Iraqi Freedom 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/OEF veterans who suffered from traumatic brain injury (TBI).  Fifty-two patients from around the country—including Montana, Colorado, North Dakota, and Washington state—were interviewed at least one year after completing inpatient rehabilitation from a Lead Center (Minneapolis, MN; Palo Alto, CA; Richmond, VA; and Tampa, FL) included those who lived in states with rural veteran populations. 

Many of the obstacles for the TBI veterans and their family members were similar. Forty-eight percent of the patients indicated that there were few resources in the community for brain injury-related problems.  Thirty-eight percent indicated that transportation was a major obstacle.  Seventeen percent indicated that they did not have money to pay for medical, rehabilitation, and injury-related services. 

Some of the challenges noted by family members who care for these veterans in rural settings include: the necessity for complicated special arrangements and the absence of VA rehabilitative care in their communities. 

Case managers working at Lead Centers and several secondary centers noted limited ability to follow patients after discharge to rural areas and lack of adequate transportation.

These limitations place undue hardship on the veterans’ families as well.  Those contributing to the report, as well as veterans who have contacted The America Legion, have shared many examples of the manner in which families have been devastated by caring for TBI injured veterans.  They have sacrificed financially, have lost jobs that provided the sole income for the family, and have endured extended separations from children.  It is The American Legion’s belief that VA needs to continue to improve access to quality primary and specialty heath care services for veterans residing in rural and highly rural areas.

Vet Centers

Vet Centers are another important resource, especially for combat veterans experiencing readjustment issues who do not live in close proximity to a VA medical facility.  Because Vet Centers are community based and veterans are assessed the day they seek services, they receive timely care and are not subjected to wait lists.  Some of the services provided include: individual and group counseling; family and marital counseling; military sexual trauma counseling; and, bereavement.

Realizing the value of Vet Centers to those who may encounter obstacles when seeking mental health care in the VA medical facilities, The American Legion decided to get a glimpse of services and needs of Vet Centers nationwide. The American Legion’s 2007 System Worth Saving report, a compilation of information gathered from site visits conducted by field service representatives and the System Worth Saving Task Force members, will focus on Vet Centers, as well as poly trauma centers.  The American Legion staff selected a sample of Vet Centers that were located near demobilization sites throughout the country to ascertain the effects of the number of returning veterans on the services provided by the centers.  The report will illustrate the types of veterans utilizing the respective Vet Centers, as well as services requested by these veterans and outreach services offered. 

 The American Legion believes veterans should not be penalized or forced to travel long distances to access quality health care because of where they choose to live. We urge VA to improve access to quality primary and specialty health care services, using all available means at their disposal, for veterans living in rural and highly rural areas.

Although “access” is an important measure, The American Legion believes “timeliness of access” is just as critical.  For an example, VA established its own acceptable access standard for primary care at 30 days, but to most Americans with private health care plans – 30 days would be unacceptable.  Unfortunately, the continued disparity between demand for services and available resources continues to cause delays in the delivery of health care.  The current global war on terror has placed even more demands on the VA health care system to meet its obligation to the men and women of the armed forces – past, present, and future.  As a grateful nation welcomes with opened arms the newest generation of wartime veterans, veterans of previous conflicts and the Cold War are being denied enrollment and, therefore, access to their health care delivery system of choice.

Since the decision within VA to begin transformation from an inpatient-base health care delivery system to an integrated health care delivery system in the early 1990s and Congress’ enactment of eligibility reform in 1996, access to VA health care has increased dramatically.  In 1990, the patient population of the VA medical system was somewhere in the neighborhood of 2 million.  Today, VA’s patient population is closer to 6 million with a total enrollment of approximately 8 million veterans.

In fact, by 2003, former VA Secretary Anthony Principi decided to terminate the enrollment of any new Priority Group 8 veterans; therefore, prohibiting access to VA medical care to hundreds of thousands of Priority Group 8 veterans due primarily to limited resources.  The American Legion disagrees with the decision to deny access to any eligible veterans.  Many of these veterans are Medicare-eligible or have other third-party health insurance that could reimburse VA reasonable charges for services rendered.  Yet little has been done to improve third-party reimbursements from private insurers and nothing has been done to allow VA to begin receiving third-party reimbursements from the nation’s largest health care insurer, the Centers for Medicare and Medicaid Services(CMS).

Both the Department of Defense (DoD) medical system and Indian Health Services (IHS) are authorized to bill, collect, and receive third-party reimbursements from the Centers for Medicare and Medicaid Services, yet VA continues to face the restriction from billing CMS.  Repeatedly, VA’s average cost-per-patient remains well below Medicare’s average cost-per-patient (and the billions of dollars VA saves Medicare is not even calculated into Medicare’s final funding levels).

The restriction of enrollment for Priority 8 veterans creates another “access gap” for recently separated veterans who did not serve in a combat setting.  Some recently separated veterans must wait until their VA disability claims are approved in order to enroll.  For others, unless they are economically indigent, they are prohibited from enrolling.  Those recently separated veterans that successfully transition may very well never be eligible to enroll in the nation’s best health care delivery system.  None of these situations are very welcoming messages to the men and women currently serving in the nation’s armed forces.

Over the years, VA has transformed itself into the nation’s best health care delivery system and probably the most cost-efficient as well.  There are many reasons why the VA health care system has become the best health care option for eligible veterans:

  • Quality of care,
  • Patient safety,
  • Electronic medical records,
  • Cost-efficient formulary,
  • Accessibility,
  • World-class specialized services,
  • State-of-the-arts medical and prosthetics research, and
  • Minimal fraud, waste, and abuse.

For these and many other intangible reasons, VA is a “health care magnet” attracting veterans, many of which have never used the VA health care delivery system before.  As the veteran population continues to age and the health care industry evolves, more and more veterans on fixed incomes turn to VA as their best health care option – even those with other health care options such as Medicare, TRICARE, or private health insurance coverage.  Many of these veterans are combat veterans of World War II, Korea, and Vietnam.  Although their transition from active-duty to civilian life may have been “seamless” for many years, they now believe their individual health care needs would be better met by VA. 

Returning Operation Enduring Freedom and Operation Iraqi Freedom  (OEF/OIF) Veterans

The American Legion fully supports the decision to provide recently separated veterans from OEF/OIF to access to the VA health care delivery system for two years after separation.  However, now that they have been presented with conditions having delayed onset, like Post Traumatic Stress Disorder (PTSD) and symptoms of Traumatic Brain Injury (TBI), The American Legion supports extending those two years to five years.   The American Legion also believes that VA must ensure that it makes every effort to outreach to eligible reservists components, who sometimes endure multiple deployments, to keep them aware of their eligibility for access to the VA health care system and provide them with timely access to care.

Although they were promised priority due to their combat service, OEF/OIF veterans are encountering obstacles when trying to access the system.  We are beginning to hear stories.  One veteran was told to call back the following week for an appointment, only to be told when he called back, that he had to wait 30 days later for an appointment.  Another OIF veteran reported having his appointment cancelled and rescheduled 30 days later.  Many conditions experienced by these veterans may not qualify as emergencies, but are urgent enough to require immediate care.

Inpatient Bed Requirements

VA continues to ignore the Federal mandate for inpatient care, especially in the area of long-term care.  The American Legion believes VA is focused on shifting long-term care from VA to the State Veterans’ Homes and private nursing home industry.  Access to long-term care is often translated into being placed on a waiting list that may very well exceed the life expectancy of the veteran placed on the list.  The Veterans’ Millennium Health Care Act clearly set the bar, but VA seems to have ignored this Federally mandated statute.

During the CARES process, long-term care and mental health were not included in the initial decision-making process.  In other words, two critical elements were included after rather than during the final recommendations for the future infrastructure of VA.  The American Legion was extremely critical of that decision, especially when the closing recommendations revealed medical facilities with primarily long-term care and mental health missions.  In addition, the facilities were primarily in rural communities.

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