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98–690 2016

REALIZING QUALITY RURAL CARE THROUGH 

APPROPRIATE STAFFING AND IMPROVED CHOICE 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

TUESDAY, SEPTEMBER 1, 2015 

Serial No. 114–35 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.fdsys.gov 


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COMMITTEE ON VETERANS’ AFFAIRS 

JEFF MILLER, Florida, Chairman 

DOUG LAMBORN, Colorado 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

DAVID P. ROE, Tennessee 

DAN BENISHEK, Michigan 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

JACKIE WALORSKI, Indiana 

RALPH ABRAHAM, Louisiana 

LEE ZELDIN, New York 

RYAN COSTELLO, Pennsylvania 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

CORRINE BROWN, Florida, Ranking 

Minority Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

DINA TITUS, Nevada 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

TIMOTHY J. WALZ, Minnesota 

JERRY MCNERNEY, California 

JON TOWERS, Staff Director 

DON PHILLIPS, Democratic Staff Director 

SUBCOMMITTEE ON HEALTH 

DAN BENISHEK, Michigan, Chairman 

GUS M. BILIRAKIS, Florida 

DAVID P. ROE, Tennessee 

TIM HUELSKAMP, Kansas 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

RALPH ABRAHAM, Louisiana 

JULIA BROWNLEY, California, Ranking 

Member 

MARK TAKANO, California 

RAUL RUIZ, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

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. 


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C O N T E N T S 

Tuesday, September 1, 2015 

Page 

Realizing Quality Rural Care Through Appropriate Staffing and Improved 

Choice .................................................................................................................... 1 

OPENING STATEMENT 

Dan Benishek, Chairman ........................................................................................ 1 

Prepared Statement ......................................................................................... 29 

Julia Brownley, Ranking Member .......................................................................... 2 

WITNESSES 

Aaron A. Payment MPA, Chairperson, Sault Ste. Marie Tribe of Chippewa 

Indians .................................................................................................................. 3 

Prepared Statement ......................................................................................... 31 

Anthony Harrington, Veteran Sault Ste. Marie, Michigan .................................. 5 

Prepared Statement ......................................................................................... 32 

David W. Pearce, Commander, Post 3676, Veterans of Foreign Wars of the 

United States ........................................................................................................ 7 

Prepared Statement ......................................................................................... 33 

Don Howard, Commander, American Legion Post 3 ............................................ 8 

Jacqueline Haske, Chippewa County Veteran Service Officer ............................ 9 

Prepared Statement ......................................................................................... 34 

Gina Capra, Director, Office of Rural Health, VHA, U.S. Department of 

Veterans Affairs ................................................................................................... 16 

Prepared Statement ......................................................................................... 34 

Accompanied by: 

James Rice, Acting Network Director, Veterans Integrated Service 

Network 12, VHA, U.S. Department of Veterans Affairs 

And 

Gail McNutt M.D., Chief of Staff, Oscar G. Johnson VAMC, Iron 

Mountain MI, Veterans Integrated Service Network 12, VHA, 

U.S. Department of Veterans Affairs 

STATEMENT FOR THE RECORD 

American Federation of Government Employees, Iron Mountain Local ............. 38 

American Osteopathic Association ......................................................................... 40 


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REALIZING QUALITY RURAL CARE THROUGH 

APPROPRIATE STAFFING AND IMPROVED 

CHOICE 

Tuesday, September 1, 2015 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON VETERANS’ AFFAIRS, 

SUBCOMMITTEE ON HEALTH, 

Washington, D.C. 

The subcommittee met, pursuant to notice, at 10:05 a.m., in National Guard Armory, 1170 East Portage Avenue, Sault Ste. Marie, 

Michigan, Hon. Dan Benishek [chairman of the subcommittee] presiding. 

Present: Representatives Benishek and Brownley. 

OPENING STATEMENT OF CHAIRMAN DAN BENISHEK 

Dr. BENISHEK. As you know, I am Dr. Dan Benishek, and it has 

been my honor to be both your congressman and the chairman of 

the Subcommittee on Health for the Committee on Veterans’ Affairs of the United States House of Representatives. 

Before I was elected to Congress, I was privileged to serve for 20 

years as a physician at the Oscar G. Johnson VA Medical Center 

at Iron Mountain, overseeing the VA community-based outpatient 

clinic here in Sault Ste. Marie. During my time there, veteran patients would tell me every day about the challenges and the frustrations that they faced when attempting to get care through the 

VA, the VA which is, by the way, the government’s second largest 

bureaucracy, with a budget and staff that trails only the Department of Defense in size. 

Let me be clear: our veterans fought for our freedom; they 

shouldn’t have to fight government bureaucrats too. 

The subcommittee members and our staff work hard every day 

to break down the barriers between the VA bureaucracy and the 

veterans that this bureaucracy should be serving here in the UP 

and across the country. 

I am joined here today by Congresswoman Julia Brownley, the 

ranking member of the Subcommittee on Health, and a representative from the 26th District in California, just north of Los Angeles. 

Needless to say, she has traveled quite a distance to be here today 

with us, and we are grateful for her willingness to join us in Sault 

Ste. Marie this morning and for being such a strong and effective 

voice on the subcommittee. Thank you very much. 

[THE PREPARED STATEMENT OF CHAIRMAN DAN BENISHEK APPEARS IN THE APPENDIX] 


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OPENING STATEMENT OF JULIA BROWNLEY 

Ms. BROWNLEY. Thank you. 

[Applause.] 

Dr. BENISHEK. The purpose of today’s hearing is to make sure 

that the care that you and your fellow veterans receive in the Eastern UP is timely, accessible, and high quality. Unfortunately, we 

all know that at times the VA has failed to meet those measures, 

and in doing so has fallen short of providing the treatment that our 

veterans have earned and deserve. 

An example of how the VA has fallen short here in Sault Ste. 

Marie can be seen in the VA’s inability for the past two years to 

recruit a physician to staff the VA community-based outpatient 

clinic here. The veterans that I have spoken to, some of whom you 

will be hearing from this morning, are understandably concerned 

about the lack of a physician at this facility and the impact that 

the VA’s failed recruitment efforts have had on the quality of care 

at the clinic. I share those concerns; and today, we are going to get 

some answers. 

During this morning’s hearing we will discuss efforts that the VA 

has taken in this community and around the country to ensure 

that rural clinics like the one here in Sault Ste. Marie are properly 

staffed and that rural veterans are able to access care in the community or through tribal health centers where VA funding is unable to provide the care that our veterans need and when our veterans would prefer to receive care elsewhere. 

We will hear testimony from the VA, from local tribal leaders 

and local veterans whose input, expertise and advice are critical to 

the work that we do in Washington. I am grateful to all our witnesses for being here and look forward to their testimony. 

Before that, I will take a moment to recognize the men and 

women that we are here today to serve. Will the veterans in our 

audience right now please stand, if you are able, or raise your hand 

and be recognized? 

[Applause.] 

Dr. BENISHEK. Thank you so much for serving our country and 

for being with us here this morning. 

I would like to take a moment to recognize and thank the Armory staff for allowing us to use their facility this morning and for 

their assistance in setting up for the hearing. Thank you for that. 

[Applause.] 

Dr. BENISHEK. With that, I would like to recognize Ranking 

Member Brownley for any opening statement she may have. 

Ms. Brownley. 

Ms. BROWNLEY. Thank you, Mr. Chairman. I appreciate that. 

And thank you for calling this hearing today. I am always pleased 

to visit Michigan, particularly at this time of the year. So, thank 

you for that. Thank you for the invitation. 

And thank you all for being here. This is an important hearing 

and issue, access to quality healthcare in rural areas. The veterans 

who choose to reside in rural areas face big challenges in accessing 

appropriate healthcare. Rural veterans are older, typically older, 

sicker than their urban counterparts. They experience primary and 

specialist shortages, hospitals closing due to financial instability, 

inadequate broadband coverage, and geographic distance barriers. 


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In my district in California, we have rural areas as well, bordered by small towns. Veterans in these areas continue to have 

problems getting appropriate healthcare. So I think I am familiar 

with some of the issues certainly here in Michigan. 

I am pleased by what I have heard about the VA’s telehealth program. I think by all accounts the VA is leading the way, and I 

think telehealth can play an important role, particularly in rural 

areas, but it is not the only solution to the problem. There is much 

more that we have to do. 

So, I am extremely pleased to be here. It is a tremendous honor 

for me to serve on the VA Committee in Washington, DC. My 

brother was 20 years in the Navy, a pilot in the Navy. My dad was 

a Marine. I had two uncles, one in the U.S. Army and one in the 

Coast Guard. So at least I understand what the impacts are on veterans and veterans’ families. This was the committee that I wanted 

to serve on when I arrived in Washington, and I am extremely, extremely honored to be on this committee and to be able to serve 

veterans, not only in my home district but across the country. 

So thank you all very, very much for your service and your continued service. It is greatly, greatly appreciated. Thank you. 

Dr. BENISHEK. Thank you, Ms. Brownley. 

We are going to begin today’s hearing with our first panel of witnesses who are already seated at the table here. As this is a formal 

hearing, this is a real congressional hearing just like we have in 

Washington. It is not a town hall. We have invited witnesses to the 

table to speak, although I look forward to speaking with other audience members after the hearing is concluded. 

Before I introduce our panelists, I need to remind all of today’s 

witnesses to be mindful of the 5-minute time limit on your oral testimony, and then a question-and-answer period will follow. The 

light here is green, and then it turns yellow when there is a minute 

left, and then it turns red when your 5-minutes is up. We try to 

do that even in Washington, especially for Members of Congress, 

just to make sure we get through all the testimony and have plenty 

of time for questions and answers. Thanks in advance for your consideration. 

With us on the first panel this morning is Chairperson Aaron 

Payment, Sault Ste. Marie Tribe of Chippewa Indians; Anthony 

Harrington, a veteran who lives right here in Sault Ste. Marie; 

David Pearce, an Army veteran and Commander of VFW Post 

3676; Don Howard, Director and Commander of American Legion 

Post 3; and Jacqueline Haske, the Chippewa County Veteran Service Officer. 

I am grateful to each of you for doing this, for your willingness 

to be here and to speak candidly about the issues of importance to 

our veterans and our community. I am honored to have you all 

here with us this morning. 

The CHAIRMAN. Payment, you are recognized for 5 minutes. 

STATEMENT OF AARON A. PAYMENT 

Mr. PAYMENT. [Speaking native language.] My name is Aaron 

Payment, and I am the chairperson of the Sault Ste. Marie Tribe 

of Chippewa Indians, the largest tribe east of the Mississippi. I 

want to thank you both for bringing this hearing to Sault Ste. 


VACREP0180 with DISTILLER
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Marie. I also want to recognize one of our council members who is 

a veteran who is with us here in the audience, Denny McKelvey, 

Vince McKelvey, who is our treasurer. He is very critical of the VA, 

and so I am here to represent some of those criticisms and some 

members that I saw yesterday that gave me some input. 

While 1.4 percent of the U.S. population is American Indian, the 

military population that is represented from our people is 1.7 percent. So we represent more than our population in military service. 

I commend the Department of Veterans Affairs’ efforts to ensure 

that community-based outpatient clinics in rural areas are properly 

staffed and rural veterans are able to access care in the community 

where appropriate and necessary. However, additional changes are 

critically needed. 

The current system creates multiple barriers to treatment for our 

Native veterans living in rural areas. In the Eastern Upper Peninsula of Michigan, my tribe has partnered with the American Legion 

to provide two additional service officers in Michigan’s 1st Congressional District. This effort extends outreach activities to veterans 

who utilize our health facilities across the UP. We provide space 

and offset costs associated with additional service officers. Additionally, we are establishing baseline data collection aimed at more 

accurately reflecting the number of American Indian veterans 

across the UP. 

In 2010, our health division worked with the Iron Mountain VA 

to establish an agreement with the tribe’s optical department in 

Manistique. Under this agreement, the tribe is able to provide optical services to tribal and non-tribal veterans alike. 

The Sioux Tribe has also established a VA workgroup to access 

additional services for our veterans; partnered with a veteran’s 

service organization, again the American Legion, to provide benefits and service officers at tribal clinic sites to assist with issues 

and questions about navigating the VA bureaucracy; worked to 

identify tribal veterans as they visit our clinics in order to plan 

services for them; worked to incorporate both behavioral health and 

traditional medicine programs to develop veteran-specific services 

to include PTSD and emotional trauma; planned awareness outreach to get out the word on tribal and VA services including tribal 

elder meetings, the tribal newspaper, our website and video tag 

line information; and worked with the Iron Mountain VA to establish an MOA with the tribe for full reimbursement for providing 

clinical services to tribal veterans eligible for VA services. 

Our recommendations. 

Freedom of choice. Our veterans should be free to choose their 

care based on where they can secure the highest quality services. 

Veterans who choose to utilize tribal health centers and our providers as their primary care sites are not able to access their VA 

benefits. Currently, the VA Choice Card does not list tribal clinics 

as reimbursable entities for providing the care as a referral from 

the VA. 

MOAs should be entered into immediately. We recommend that 

the tribal healthcare programs be reimbursed for both direct service and referred care when veterans find tribal health programs 

more accessible and more accommodating to their needs. I urge 

Congress to instruct the VA to set up a process that allows reimVerDate Aug 31 2005 13:58 Oct 18, 2016 Jkt 000000 PO 00000 Frm 00008 Fmt 6633 Sfmt 6633 Y:\98-690.TXT PAT

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bursement for eligible services provided by tribes. We would love 

to be part of that solution, including our transportation. 

My tribe has identified a lack of consistent and reliable transportation to access many services that directly impact quality of life, 

including health, education, and employment. Available transportation across the Upper Peninsula is only provided at night. You 

have to leave at 12:30 a.m. to get there at 8:00 a.m., and that is 

not very good for them having a clinic visit the next day. 

We recommend that the VA reimburse tribal governments providing Native veterans transportation to primary and specialty 

clinics and follow-up care. Most American Indian veterans live in 

remote areas of the United States, and the cost of transportation 

to and from veterans’ healthcare facilities causes substantial hardship on these veterans seeking care. 

Throughout the history of the United States, Native Americans 

have fought greatly and sacrificed for this country. This proud tradition continues to this day with 24,000 active-duty American Indians. The 2010 U.S. Census identified at least 152,000 Native American men and women who have served this country in the Armed 

Forces. All veterans, including our Indian warriors, gave their best. 

Some gave all. In turn, they deserve our best, the best this country 

can offer. 

Again, we stand ready to be part of the solution. Thank you. 

[THE PREPARED STATEMENT OF AARON A. PAYMENT APPEARS IN

THE APPENDIX] 

Dr. BENISHEK. Thank you. 

Mr. Harrington, you are recognized for 5 minutes. 

STATEMENT OF ANTHONY HARRINGTON 

Mr. HARRINGTON. Chairman Benishek, Ranking Member 

Brownley, thank you for giving me the chance to testify today. I am 

a disabled veteran and I live here in Sault Ste. Marie. 

As you both know, there is a VA clinic here. The clinic has been 

here for many years, but more than two years ago the attending 

physician retired. In the interim, part-time doctors have been trying to pick up the slack, and a nurse practitioner has been brought 

in to replace the retired physician. 

I truly and deeply believe that our veterans should be entitled 

to proper healthcare. This specific VA clinic serves the entire Eastern Upper Peninsula. They are a very busy facility with many patients from across the region. I found out that just in Chippewa 

County alone, there are over 3,000 veterans, just in this county 

alone. The facility is having trouble keeping up with the number 

of patients, and its quality of care is suffering as well. The nurse 

practitioner, although very good at her job, can only do so much 

within the guidelines of her job description and abilities. 

Currently as it stands, the nurse practitioner can only see a maximum of six patients a day—if that has changed, I don’t know— 

and is limited as far as what she is allowed to diagnose and treat. 

The facility is in desperate need of a full-time attending physician 

as well as the current nurse practitioner to adequately care for the 

entire region and its patients. 

Recently they hired a physician’s assistant here. While that is a 

good step, it is really not a replacement for a full-time doctor. And 


VACREP0180 with DISTILLER
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the people from Iron Mountain at the last meeting said that their 

hands were tied, they couldn’t hire anybody else, they couldn’t hire 

a doctor. They were only allowed through the VA a nurse practitioner. Then they turn around now and they hired this physician’s 

assistant, but they can’t get a doctor. 

I just want to know why they were able to bring a PA if it wasn’t 

possible for them to bring a doctor. I have been told by Iron Mountain VA officials that they were only authorized to hire a nurse 

practitioner, and then all of a sudden the PA shows up. That 

doesn’t make sense to me. 

Prior to the hiring of the nurse practitioner I was seeing a doctor 

by the name of Lisa Vanhevel at the Bay Mills Indian Clinic. The 

reason I turned to the Indian clinic instead of the VA clinic was 

due to the lack of an attending physician at the facility. While 

under Dr. Vanhevel’s care we talked quite extensively about the 

need of a full-time doctor at the VA clinic. She told me that her 

contract with Bay Mills was coming to an end and made her intentions clear that she was interested in interviewing for the position 

at the VA clinic. 

Upon following the proper channels she was then granted an 

interview at the VA clinic in Iron Mountain, Michigan. Sometime 

later I happened to run into Dr. Vanhevel at Wal-Mart and she informed me that her interview went well and she was offered a position at the Sault Clinic, as well as the Iron Mountain clinic. She 

stated that she was only offered two days a week through our facility or a full-time position in Iron Mountain. She explained that she 

had to decline both positions because she didn’t want to move to 

Iron Mountain or commute 295 miles away for work. She also 

didn’t want to take a position for only two days a week. 

Dr. Benishek, Ms. Brownley, I am sure you can sympathize with 

her. Who in their right mind would want to take a position for two 

days a week following a contract where they had a full-time position? This was very concerning to me considering the dire need for 

a full-time attending physician here. 

In addition, Dr. Benishek’s staff has told me that prior to the hiring of the PA, Benishek’s office was told by the VA that they were 

going to try to hire a doctor. However, despite what Benishek’s office was told, we have seen no evidence that an ad was ever placed 

on usajobs.com, or that any ads were placed in UP newspapers. I 

would like to know what exactly was done to try to get a doctor 

here. 

I am glad that Congress is finally investigating this issue. I have 

yet to have someone explain to me why it is that the veterans in 

this area are not entitled to a VA facility with a full-time doctor 

and quality healthcare. 

Thank you again for having me here today. I truly hope that you 

will take the time to look into this matter and serve justice to our 

vets as we have selflessly served you and this country. It is my 

hope that you will confer with the new director of the VA and that 

you can come to an agreement to resolve this. 

Thank you very much. 

[THE PREPARED STATEMENT OF ANTHONY HARRINGTON APPEARS IN

THE APPENDIX] 

Dr. BENISHEK. Thank you very much for your testimony. 


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Commander Pearce, you are now recognized for 5 minutes. 

STATEMENT OF DAVID W. PEARCE 

Mr. PEARCE. Congressman Benishek, Congresswoman Brownley, 

committee staff, and fellow panelists, thank you for the opportunity 

to appear before you today on behalf of the members of Veterans 

of Foreign Wars Post 3676 and approximately 58,000 Upper Peninsula of Michigan veterans, one of this great state’s most valuable 

resources. I feel qualified to provide input, within my scope, as I 

am a retired service member, disabled veteran that uses the VA 

healthcare system and the commander of the Welsh-McKenna VFW 

post here in the Sault. I served this great nation of ours for over 

20 years as an active duty soldier in the United States Army. I was 

also born and raised in the Eastern Upper Peninsula and returned 

home to Sault Ste. Marie upon the completion of my military career. 

First, I would like to commend the Veterans Administration for 

recognizing a problem in the care of our veterans that live in rural 

areas. Speaking from my personal experience with the VA 

healthcare system, I believe the VA is moving in the right direction. There is still much more room for improvement. 

Improvements have been gained in the last several years with 

my access to care. When I started to use the VA healthcare system, 

it was not uncommon to drive all the way to the Iron Mountain VA 

hospital for an appointment or test. The Oscar G. Johnson VA 

Medical Center in Iron Mountain, Michigan is the closest facility. 

Some of those appointments were a simple 15- to 20-minute doctor 

visit that would require a four-hour drive one way, or an entire day 

off work. Most recently, the VA has scheduled appointments for me 

at the local hospital or sent me an authorization to seek care locally. I am satisfied with the improved choice options; however, 

there are bugs to be worked out. 

One is with billing. As a retired service member, I also use 

Tricare for medical insurance. Several times when I received care 

locally, my healthcare insurance was billed and not the VA. The response time is very slow when trying to get the medical bills routed 

in the right direction. 

I also feel that local access to healthcare for our aging veterans 

should be a priority. I am still relatively young. It is not as much 

of a burden for me as it is for some of our older veterans to receive 

care. In our community here in the Sault, there are several assisted-living facilities and nursing homes with elderly veterans that 

do not have the physical capability to travel great distances to receive care from the VA. Improved choice could help with that issue. 

I would like to comment that for me personally, the My 

HealtheVet website is a great asset to access care, re-fill prescriptions, and communicate with the local community-based outpatient 

clinic through secure messaging. That was a great idea for those 

of us who are computer literate. However, it is not such a great 

choice for those that are not familiar with using a computer or do 

not have access. Many of our older veterans do not use a computer. 

Another issue with improved choice that should be addressed is 

the lack of specialized care and women veterans’ healthcare access 

in a rural environment. I am not sure how to address these topics 


VACREP0180 with DISTILLER
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specifically, but they definitely need to be looked into and more options for care need to be available for all veterans. 

Appropriate staffing is a concern. Soon after my retirement from 

active duty I started using the VA community-based outpatient 

clinic located in Kincheloe, Michigan. The clinic was relocated to 

Sault Ste. Marie a few years later. I personally think the staff at 

the Sault Ste. Marie CBOC is absolutely wonderful. I interact with 

the staff at the local clinic several times every month for my own 

appointments. They are always helpful and friendly. The only concern I have is there is not a permanently assigned medical doctor 

at the clinic. The physician’s assistant does a great job, but I feel 

there should be a full-time M.D. assigned to the clinic also. 

When the doctor that was assigned to the clinic retired, the position was filled several times temporarily until the physician’s assistant was hired. That created a lack of continuity in care. I feel 

due to this lack of continuity, mistakes were made and treatment 

was not appropriate. 

During that time I also had an appointment with a physician located in Iron Mountain through video chat. I felt that appointment 

was very impersonal and not effective at all. On another occasion, 

I drove to Iron Mountain for a video conference with a doctor located in Milwaukee and some online testing. That, I feel, could 

have been accomplished at the clinic in Sault Ste. Marie. Now put 

yourself in a World War II veteran’s shoes. Imagine how overwhelming and confusing the video conference could be to them. 

Again, it is a great honor to have the opportunity to participate 

in this valuable discussion regarding the care of our veterans. This 

concludes my testimony. I am prepared to take any questions. 

Thank you. 

[THE PREPARED STATEMENT OF DAVID W. PEARCE APPEARS IN THE

APPENDIX] 

Dr. BENISHEK. Thank you very much, Commander Pearce. 

Commander Howard, you are recognized for 5 minutes. 

STATEMENT OF DON HOWARD 

Mr. HOWARD. Actually, it is Don Howard, Chairman of the Veterans Affairs American Legion, State of Michigan. Thank you for 

having me today. 

Aaron Payment stole my—I paid for it, he copied it. It was funny, 

we were standing out there talking and were exactly saying. 

Over a year ago, I had the opportunity to come up and visit with 

Aaron’s staff—Bonnie Kaufa, Tony Abramson, Mark Willis, and 

Tom Tefnel—and we learned when I came up the first time, first 

meeting with them, that their staff was not aware of the fact that 

many of their veterans were entitled to pensions, aid and attendance benefits, disability and such. So we took it on to start training 

their nurses. Since then it has really, really picked up. 

Since then we moved our service offices into their clinics, which 

has proven to be a major asset and it is really, really going strong. 

What we have learned in the State of Maine, the State of Washington, the VA uses MOUs with the tribal health systems, IHS I 

believe. Am I correct? The IHS systems. And again, the Sioux Tribe 

has volunteered to see every veteran, every veteran, whether it be 

Indian or not. They are willing to work with Iron Mountain. 


VACREP0180 with DISTILLER
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We have tried for the last year-and-a-half to work with Iron 

Mountain. They are dragging their feet, non-cooperative. We don’t 

know where to go from here. I did have a discussion with Danny 

Pummill, the Under Secretary of the VA in Washington, DC., and 

his staff indicated that that is the direction. I met him actually in 

Washington, DC. His father actually lives south or just north of Escanaba, the VA Secretary. 

What we would like to see is have you guys encourage a roundtable with all concerned—the tribes, the seven tribes in the UP, 

Iron Mountain, Danny Pummill’s staff out of Washington, DC, and 

yourselves to oversee it, just like the UAW and Ford Motor Company negotiations. We could hold this right here in Manistique, 

plenty of room, and if it takes 4 to 40 hours, get this fixed, make 

the UP the model for the rest of the state. These veterans deserve 

better up here. 

My family is from Singleton. I spend my summers up here. I live 

south of Detroit now. I think this can be done. I know we have the 

willingness between the tribes, and that is all we need is some help 

from you, both of you and the VA, and to bring this and put this 

together and work it out. 

That is all I have to say. Thank you. 

[THE PREPARED STATEMENT OF DON HOWARD APPEARS IN THE APPENDIX] 

Dr. BENISHEK. Thank you, Mr. Howard. 

Is it Ms. Haske or Haske. 

Ms. HASKE. It is Haske. 

Ms. Haske, you are recognized for 5 minutes. 

Ms. HASKE. I would like to decline at this time. I am too scared. 

Dr. BENISHEK. You don’t have to be scared. Just tell us any issue 

that you are having with the VA. 

STATEMENT OF JACQUELINE HASKE 

Ms. HASKE. I am Jacqueline Haske, the Chippewa County Veterans Affairs Officer. Mine is piggybacking on everybody else. 

My main concern is having a doctor in the community. One of 

the issues we have is if a veteran comes to the community as a new 

veteran, they are unable to be seen by a doctor if they have the 

Choice Card because several of the doctors are not receiving new 

patients at this time. So our concern is not just because of the need 

for a doctor in the area, but the doctors with the Choice Card are 

refusing, and that is all. 

[THE PREPARED STATEMENT OF JACQUELINE HASKE APPEARS IN

THE APPENDIX] 

Dr. BENISHEK. Is there anything else you would like to tell us? 

Ms. HASKE. No, sir. 

Dr. BENISHEK. All right. That was just fine. 

In that case, I will recognize myself for 5 minutes to ask a few 

questions. 

Chairperson Payment, tell me about this Memorandum of Understanding to get the tribal healthcare to be provided through the 

VA. Has the VA talked to you? Have there been any negotiations 

with them? Where are you at with that? 


VACREP0180 with DISTILLER
10 

Mr. PAYMENT. Well, first let me say what the young lady said 

was very impactful even though it was few words, because that is 

another issue. The Choice Card alone doesn’t get it done. You have 

to have doctors who are willing to see you. We do have doctors who 

will see Medicaid patients or welfare patients, and in this case it 

is kind of sickening to me that they wouldn’t see a veteran who has 

the ability to pay for the care. 

So we stand ready to be able to see veterans in our clinic, and 

we also pledge that—sometimes it is hard to get into our clinics 

too, but if we come to an agreement with an MOA, we would be 

willing to designate a physician that would primarily see veterans 

and then can do overflow for others. 

Dr. BENISHEK. Why don’t they have that agreement already? 

What is the story? 

Mr. PAYMENT. I think we have. We do have it with dental. So we 

have seen that the model can work. I think the bureaucracy and 

the weight of the bureaucracy and the fear of dismantling the existing bureaucracy is probably a threat. 

So I would say what Congress should do is you should direct 

them. You should give them a timeline, and we can work it out. 

I like the idea of 4 hours or 40 hours to iron it out. We have proven 

we can do it. We do it with our dental services right now. And we 

have clinics in Manistique, and I think they would probably be 

willing to extend their services as well. 

So I think if you order it and you give them a timeline by which 

they have to do it, it will get done. 

Dr. BENISHEK. How long have you been in negotiations with 

them? A year-and-a-half? 

Mr. PAYMENT. Yes, about a year-and-a-half. 

Dr. BENISHEK. Mr. Pearce, you mentioned the fact that the billing is a problem sometimes if you see somebody outside the VA. 

Can you elaborate on that a little bit more? 

Mr. PEARCE. Congressman, I think that is primarily issues due 

to hospital billing, not necessarily the VA. I will get co-pays that 

I end up with because they bill Tricare instead of the VA. A lot of 

times it doesn’t matter if I actually take the consent form with me 

and turn it in at the hospital. For some reason it gets billed to my 

primary health insurance instead of the VA. 

Dr. BENISHEK. Are there any problems that you are aware of 

with your record when you go to an off-site facility, any of you or 

Ms. Haske? Do you know of a situation where a patient’s record of 

the care they had received outside the VA, is that getting back to 

the VA so they are keeping track of what care you had and where? 

Mr. PEARCE. Yes, it does, Congressman. You have to make sure 

that happens. I do personally take care of that myself to make sure 

it gets in my VA record also. 

Dr. BENISHEK. Ms. Haske, are you familiar with any problems in 

that regard? 

Ms. HASKE. With the records? 

Dr. BENISHEK. The records, making sure that the veteran has a 

continuous record of his care outside. Is that happening that you 

are aware of? 

Ms. HASKE. Yes. 

Dr. BENISHEK. All right. Great. 


VACREP0180 with DISTILLER
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Our second panel of VA witnesses are going to testify that the 

VA provides patient-centered care to approximately 15,000 of the 

30,000 veterans that reside in the Upper Peninsula. Do any of you 

want to comment? Do you think that the VA is providing patientcentered care in the Upper Peninsula? Anyone want to comment on 

that? 

Mr. Howard, do you have any comment on that? 

Mr. HOWARD. I really don’t. 

Dr. BENISHEK. Do any of you know if it is because—— 

Mr. HOWARD. From input from one of my veterans, he faced the 

same issue with having to travel across the Upper Peninsula to get 

to a visit and then leaving that visit, coming back to the Sault, and 

then getting a phone call once he gets back that, oh, we have an 

opening for you tomorrow. It seems like that should be able to be 

addressed while you are there so he didn’t have to drive three 

hours and then drive all the way back, and then drive all the way 

back. That is not patient centered. That is getting weighted down 

by the weight of bureaucracy and not taking a moment to do continuity of care and say, okay, what is next for this patient. That 

didn’t happen. So I would say that is not patient centered. 

Dr. BENISHEK. No, I can definitely agree with you there. And 

frankly, that kind of stuff happens all the time, where patients 

have to drive, here in the Sault, a good four hours, and just that 

drive, as many of you have related, eight hours to get there and 

back for a 20-minute appointment, does seem a little bit on the ridiculous side. 

I already have followed up on many of the issues that you have 

brought up here today with the VA panel that is coming up next, 

so I really appreciate bringing up all this stuff, and I am going to 

yield to Ms. Brownley for her 5 minutes of questioning. We may 

have another round of questions as well. 

Ms. Brownley. 

Ms. BROWNLEY. Thank you very much. My staff helped me to 

prepare some questions for you, and the first question was what is 

the number-one barrier in terms of receiving access to VA 

healthcare? And it sounds to me—tell me if I am wrong—that it 

is access to a physician, a medical doctor. Would everybody agree 

that that is probably the number-one barrier? 

So I guess the question that I would ask is if the Choice program 

was working perfectly, which it is not, and we are well aware of 

that, but if it was working perfectly, are there doctors in your communities, primary physicians and specialty care physicians in the 

community that you could access? Because sometimes that is a 

problem outside of the VA in rural areas. The doctors aren’t there 

either. So I am just curious to know whether you have a sense 

within your own communities whether the doctors are there. 

Mr. HOWARD. Well, the Sioux tribes, all their clinics are pretty 

much centrally located throughout the UP, and access to their clinics are a reasonable distance. To give you an example, there is a 

gentleman out here, sitting right behind me out here, that drives 

from here to Escanaba. We have patients that are on oxygen. Well, 

they are not allowed to ride that bus because the oxygen is dangerous. So they have to find other means to get all the way over 

to Iron Mountain for a C&P exam because Iron Mountain says we 


VACREP0180 with DISTILLER
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have no doctors that are qualified on the outside to do C&P exams. 

This individual may have cancer, diabetes, whatever, and he has 

to find his own way. In many cases these people haven’t been working, so they don’t have the funds to get there. 

Why we cannot train doctors from the tribes to do C&P exams 

to keep these people from traveling across icy roads 300 miles I 

think is insane, absolutely insane. Plus, we are paying 56 cents a 

mile. We are wasting Federal tax dollars when we can do it locally. 

It just doesn’t make sense. We have everybody on board to work 

together. We need the help to push the VA ahead. Thank you. 

Ms. BROWNLEY. That is very good. Well, I would just like to comment that particularly the Choice program, the new program provided by the VA, the Choice program was designed for areas particularly like the areas here, and we have got to figure out how to 

make that work. I know in my own district I had—I don’t know 

who the provider is here. In my district for the Choice program, the 

health plan is TriWest. I don’t know what it is in—it is Health Net 

in Michigan. 

So I had the TriWest folks come out to my district to meet both 

with veterans to help them understand the program because it 

hasn’t been very clear, and we made amendments back in Washington that have passed to make the Choice program work better. 

But the main barrier, at least in my district, is there are no doctors 

to access through the Choice program because the doctors have to 

be part of—what’s the program?—Health Net. The doctors have to 

be part of Health Net. 

So we had a meeting in our district, and I tried to invite all the 

healthcare providers in our region to help them to understand how 

the program works to try to recruit more doctors into the program. 

But I will just make the comment that we have to make sure— 

I mean, this is the perfect place to ensure this Choice program is 

working, because it was designed for you and for the veterans 

across this region because you are so rural and have less access to 

healthcare than veterans do in other parts of the country. So somehow we have to figure that out and we have to provide more providers that are in the program and simplify it so that veterans 

know that they have access to local doctors, and with Choice, a doctor cannot provide—I can’t remember who talked about the doctors 

not being available in the Choice program, but the doctors have to 

be part of the program, and the VA has to approve that appointment before the veteran can utilize it. 

But I think the biggest barrier for the Choice program to work 

is actually having the providers in the program to do that. So we 

have to figure that one out. 

Dr. BENISHEK. Thank you, Ms. Brownley. 

Ms. BROWNLEY. I yield back. 

Dr. BENISHEK. I am going to ask a few more questions while we 

have you here, because once we get the VA up there, then I am 

not going to have the opportunity to do that. 

I just want to mention, Mr. Pearce, you talked about this telehealth appointment not being very effective or being very personal. 

So I would like you to expand on that a little bit, because the comments that I have heard about the telehealth from the VA and 


VACREP0180 with DISTILLER
13 

from some other people have been positive. So can you kind of relate more about your experience with that? 

Mr. PEARCE. Yes, Congressman. I believe it is impersonal because I am more of a face-to-face type of person. I don’t like talking 

to a camera, basically. You can see the picture of the person on the 

camera, but you don’t see body language, you don’t see—I am not 

a real well-versed person, so I rely on other senses in a personal 

setting. 

Dr. BENISHEK. Did you relay those sentiments to the staff? 

Mr. PEARCE. Yes, I did. 

Dr. BENISHEK. And did they appreciate your input? 

Mr. PEARCE. Oh, yes. They definitely appreciated my input. 

Dr. BENISHEK. But is there any way to improve that? Was it a 

really small picture? Was—you didn’t understand the person? I am 

just trying to—— 

Mr. PEARCE. There wasn’t a language barrier or anything, but I 

just felt it was impersonal, talking to a camera instead of an actual 

person. 

Dr. BENISHEK. Mr. Harrington, do you have a thought on that? 

Mr. HARRINGTON. Well, I have done this before at the VA. It was 

not personal. Somebody said on the camera or screen, you don’t get 

a rapport going like you can with a doctor. Eventually you go see 

the doctor and they understand your health because you can relate 

that to them and they know you. But to talk to somebody that is 

on a camera, it is like ‘‘Hi, how are you?’’ I mean, it would be like 

talking on the telephone here in Washington. You are here now, I 

can look at you, you understand where I am coming from, I understand what you are trying to do. 

So to me, it is just not a personal thing. I like to be in front of 

a doctor and talk to a doctor. If I have an ache or a pain, I can 

explain it to the doctor and then go from there. But how do you 

do that with somebody who is 300 miles away? 

Dr. BENISHEK. Chairperson Payment, I understand your tribe is 

making an effort to collect more accurate information about the 

number of American Indian veterans that live in the Eastern UP. 

Do you have that data that you can share with our office to help 

us identify those veterans? We are trying to make sure we have accurate numbers as well. Can you elaborate on that a little bit? 

Mr. PAYMENT. We have a commitment to our veterans because 

it is a continuation of our rural society, and for a number of years 

we have been reaching out. We have our veterans wall over at our 

ceremonial grounds. But the challenge that we found out was we 

don’t have any registry of who our veterans are. We don’t have that 

as part of the membership. We have reached out through communications in our newspapers with them, but because of various reasons and because of different times when people have served, people aren’t always willing to volunteer that information. 

So now what we are doing is we have a dedicated person who 

works with our veterans. We are doing a little bit now. I think we 

should be doing a lot more. So we are identifying our veterans 

when they come in so we can record that so we can then try to 

bring access to them. We have done a census. Our last census we 

collected aggregated data without names. So we don’t have the 


VACREP0180 with DISTILLER
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names of them, but we do have numbers of how many veterans 

that we have. 

But we need to do more of that. We need to find a way to make 

them feel comfortable with identifying themselves as veterans. We 

have some veterans who are very good at that because they are trying to reach out and advocate for other veterans. But we do have 

some still who don’t bring that to the forefront. So we need to do 

whatever we can to bring the services to them rather than wait for 

them to come to us, because already when they are rejected by either the VA or whatever services, that is just salt in the wound. 

So we need to find a different way to reach out to them. 

Dr. BENISHEK. Is there anything else that any of you would like 

to say to me now while you have the opportunity? 

Mr. Harrington. 

Mr. HARRINGTON. Yes, sir. To give you an example of the waste, 

I went to the doctor that was in the Sault district for a little while, 

and they wanted to reevaluate my ears. I go all the way to Iron 

Mountain. I did the whole hearing test, everything. I come back 

home and I didn’t hear anything because it was for a compensation 

thing. 

A month later I get a call, ‘‘You have to come back to Iron Mountain.’’ I said what for? ‘‘You have to have this hearing test done all 

over again.’’ I said why? I just had it done. ‘‘Well, this doctor has 

to do it, okay?’’ So I drive all the way to Iron Mountain. That doctor 

did the exact same test that I had done. And while I was in there, 

one of my hearing aids was not working right. So I asked the doctor, I said could you possibly adjust this? ‘‘Oh, I can’t do that.’’ 

Well, is there somebody else? ‘‘No, they are not here. You have to 

make an appointment to come back up here to get your hearing aid 

adjustment.’’ 

[Laughter.] 

Mr. HARRINGTON. So I finally was able to send it to them, and 

they thought they fixed it, and it still isn’t fully fixed. So that is 

just a waste, a waste of time. 

And one more point. I went up to this VA clinic and I talked to 

the lady at the front desk, and I was trying to get some information, not personal information, just trying to get some information 

about how many vets were registered there. She acted like she was 

appalled that I was trying to get a doctor. ‘‘We don’t have room for 

a doctor. We have a nurse practitioner, and now we are getting a 

physician’s assistant.’’ I said, well, you had room for a doctor before. She said everything is fine, we are not having any problems. 

I left there, went to have a coffee where vets go, and I run into— 

I have the guy’s name. I won’t mention it, but I do have it. This 

man waited five weeks for an appointment here so he could go in 

there and they could refer him to the clinic of the Sioux Tribe to 

get x-rays—five weeks. This just happened, and I have his name 

here. 

I also have Dr. Vanhevel’s contact information if you would like 

me to share that with you folks. She is the doctor who actually 

interviewed with them. They say it wasn’t an interview, and I still 

can’t believe that a person would drive 295 miles just to have a 

chat, and she was honest. 

Dr. BENISHEK. Thank you, Mr. Harrington. 


VACREP0180 with DISTILLER
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I am going to yield to my friend here, Ms. Brownley from California, once again. 

Ms. BROWNLEY. Thank you, Mr. Chairman. 

I just wanted to ask very quickly, for the CBOCs, the community 

health clinics that you have here, are they VA-run or are they subcontracted out? They are all VA-run? Okay, very good. I know in 

my district it is subcontracted out, and that presents another big 

problem, because if you go up to the front desk of my CBOC, they 

can’t answer questions related to the VA because they are subcontracted out. That becomes a very frustrating element. 

Mr. HOWARD. In Manistique, Michigan, they have a CBOC, and 

some of the veterans refer to it as a band-aid clinic. They go in 

there for chest colds or whatever. That is what Iron Mountain— 

chest x-rays. Four miles down is a brand new Sioux Tribe facility— 

eyeglasses, hearing aids, dental, x-rays. You name it, they do it 

right there. Instead of sending them 4 miles, we are going to send 

them 170 miles. 

Ms. BROWNLEY. That is crazy. 

Mr. HOWARD. It is insane. When these people are going out of 

their way saying we are going to help you, you are kicking the can 

down the road. They are afraid that they may take some of their 

work away and maybe their VA will have to lay off a few people. 

Exactly. That is a problem. But is it fair to send a veteran 170 

miles across the ice? No. A major problem. 

Ms. BROWNLEY. And I would just say that—and I don’t know if 

anyone can handle this question, but to try to understand in terms 

of hiring doctors, is the VA not hiring the doctors because the physician hasn’t been approved, or are they trying to hire doctors and 

can’t find the doctors to fill the positions but will wait for the 

next—— 

Mr. HOWARD. The reason they aren’t hiring the doctors, the point 

here in the UP is the traffic. 

Ms. BROWNLEY. Right. No, no, no, I get your point completely, 

and I think the whole MOU and trying to figure that out, it certainly sounds—based on what I am hearing, it sounds like that is 

the right path to travel to resolve a lot of these issues. I think probably the Choice program and an MOU and putting it all together 

would really go a long ways in terms of access to quality healthcare 

and not having to travel for it. 

Mr. HOWARD. Please keep this in mind: 4 hours or 40 hours, we 

don’t care. 

Ms. BROWNLEY. Yes, I hear you. I hear you on that. 

And I just wanted to comment on the telehealth that I understand in terms of both of you saying it is an impersonal experience, 

and I hear that a lot from veterans as well. I think we have to continue to keep working on that. I do think if you are in a CBOC and, 

as you said, it is a band-aid clinic, but at least if you can have the 

nurse practitioner or whoever is there sitting with you, if you approve of that, because you would have to approve that, but sitting 

with you, because the reason you are going to telehealth is typically because you need to talk to another specialist of some sort 

and those services aren’t provided, to figure out a way in which we 

could make it a more personal experience. 


VACREP0180 with DISTILLER
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I know in my district, telehealth works for some people. Some 

people like that. And I have found, I have heard from at least my 

veterans, particularly around mental health, that they like the 

telehealth process because they can do it in the privacy of their 

own homes, they don’t have to go to a clinic. Sometimes people are 

embarrassed about reaching out for mental health services, so they 

don’t have to be seen within their community, it can be very private. 

So I do think that telehealth is a pathway here. It is not a panacea or the ultimate solution, and I think it works for some and 

it doesn’t work for others. And we have got to be able—the VA has 

to be nimble enough to be able to utilize it and make it happen. 

But ultimately, we are not doing a good job unless the client, the 

patient, the veteran is satisfied with their healthcare. 

So, thank you, Mr. Chairman. 

Dr. BENISHEK. Thank you, Ms. Brownley. 

Well, thank you for being part of our hearing this morning. You 

are excused. 

We are going to ask the second panel to come up and give their 

testimony. 

We certainly appreciate your participation. 

[Pause.] 

Dr. BENISHEK. We will welcome our second and final panel of 

witnesses to the table. Joining us this morning from the Department of Veterans Affairs is Gina Capra, the Director of the Office 

of Rural Health. Ms. Capra is accompanied by James Rice, the Acting Director for VISN 12 and the Director of Iron Mountain VA; 

and by Dr. Gail McNutt, who is the Chief of Staff of the Oscar G. 

Johnson VA Medical Center in Iron Mountain. 

Thank you all for being here this morning. 

Ms. Capra, you can proceed with your testimony when you are 

ready. You are recognized for 5 minutes. 

STATEMENTS OF GINA CAPRA, DIRECTOR, OFFICE OF RURAL 

HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY 

JAMES RICE, ACTING NETWORK DIRECTOR, VETERANS INTEGRATED SERVICE NETWORK 12, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 

AND GAIL MCNUTT, M.D., CHIEF OF STAFF, OSCAR G. JOHNSON VAMC, IRON MOUNTAIN, MI, VETERANS INTEGRATED 

SERVICE NETWORK 12, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS 

STATEMENT OF GINA CAPRA 

Ms. CAPRA. Thank you, sir. Good morning, Chairman Benishek 

and Ranking Member Brownley. Thank you for the opportunity to 

be here at the National Guard Armory in Sault Ste. Marie to discuss rural health and staffing concerns. I am accompanied today by 

Mr. James Rice, Acting Network Director for Veterans Integrated 

Service Network 12; and Dr. Gail McNutt, Chief of Staff for the 

Iron Mountain VA Medical Center. Dr. McNutt is also the co-chairperson of the National Patient Aligned Care Consultant Team. 


VACREP0180 with DISTILLER
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Individuals living in rural areas have traditionally been underserved with regard to healthcare access. The reasons for this are 

multiple, but they stem from long travel distances to reach 

healthcare facilities; lack of health insurance; and an inadequate 

number of healthcare providers, particularly specialists working in 

rural areas. 

Currently, 3 million rural veterans are enrolled in the VA 

healthcare system. They account for approximately one-third of all 

VA enrolled users. 

The Veterans Health Administration’s Office of Rural Health envisions an America where veterans thrive in rural communities. 

Our mission is to improve the health and well-being of rural veterans by increasing access to care and services. We accomplish this 

mission through collaborations with other VA program offices, Federal and state partners, and local communities. 

Accessible and quality healthcare for rural veterans is possible 

through a combination of VA community-based clinic expansion, increased partnership with rural community providers, the use of 

telemedicine and health information technology, and new efforts to 

recruit and retain healthcare providers to rural areas. 

At VA, we are continuously working to increase access to care for 

rural veterans through innovative programs. Here are several examples. 

A mental health case management program called the Extended 

Rural Access Network for Growth Enhancement or E–RANGE program provides severely mentally ill veterans with intensive support 

services to improve their quality of life. It increases independent 

community living, and it connects veterans with available local resources for support and care. The Iron Mountain VA Medical Center has successfully implemented and sustained this program. 

Another example is the Rural Veterans Transportation Program 

which supplies vehicles and drivers that transport veterans to and 

from their VA medical appointments. This program saves veterans 

personal driving time and reduces missed appointments. The Iron 

Mountain VA Medical Center is a successful participant of this program as well. 

A final example highlights the importance of health information 

exchange and its intent to increase care coordination between veterans, their VA providers, and the community providers who care 

for them. This effort is facilitated by a cadre of rural health community coordinators and increases the utilization of the virtual lifetime electronic record, also known as VLER. These coordinators 

work to ensure that each veteran’s community provider is among 

the trusted partners with whom VA will share health information. 

Again, the Iron Mountain VA Medical Center is a current participant in this program. 

In the area of workforce recruitment and staffing, VHA is expanding efforts and strategies to fill vacancies for positions that are 

critical to our mission. VHA’s Workforce Management and Consulting Office, in collaboration with the Office of Rural Health, is 

working to determine where and what types of providers are in 

short supply at rural healthcare facilities; to explore and promote 

the use of VA financial incentives and other innovative solutions to 

recruit providers to rural VA facilities; to determine best practices 


VACREP0180 with DISTILLER
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in rural provider recruitment and retention; and to develop, expand, and support clinical training opportunities for rural 

healthcare practitioners so we can retain them in rural areas. 

In addition, VHA employs a national advertising campaign aimed 

at recruiting clinicians for rural patients. This recruitment is possible through VHA’s partnership with the National Rural Recruitment and Retention Network, or RRRNet. As a result, VHA has access to a robust database of candidates interested in serving veterans in VA’s rural sites of care. 

In conclusion, VA is committed to providing high-quality, safe 

and accessible care for our veterans. We continue to focus on improving veterans’ access to care. While rural locations present 

unique access challenges, VA’s rural health programs are robust 

and will continue to serve veterans in rural areas. 

We sincerely appreciate the assistance we have received from 

your committee in particular and Congress as a whole, our partners at the local veterans’ service organizations, Native American 

tribes, and key non-profit stakeholder groups. We would not be 

able to provide the necessary care to our rural veterans without the 

support and dedication of our partners. 

Mr. Chairman, this concludes my testimony. My colleagues and 

I are prepared to answer any questions you or Congresswoman 

Brownley may have. Thank you. 

[THE PREPARED STATEMENT OF GINA CAPRA APPEARS IN THE AP- PENDIX] 

Dr. BENISHEK. Thank you, Ms. Capra. 

Frankly, I am a little disappointed with your testimony. I mean, 

it sounds like you are doing everything just wonderful from that 

testimony. But as you heard from the first panel, there are a lot 

of problems. What you have heard here today is only an example 

of what is going on I think, across the country. You said all great 

stuff there in your testimony, but let’s talk about some of the 

things that are actually going on. 

One of the things I want to start out with is could you provide 

my office with the recruitment documentation of the recruitment 

efforts that have occurred to fill the position of a physician here in 

Sault Ste. Marie? Could you provide that to us in maybe the next 

30 days? 

Ms. CAPRA. Yes. I would also like to ask Dr. McNutt or Mr. Rice 

if they could address that situation as well. 

Dr. BENISHEK. Can you say yes to that question? 

Ms. CAPRA. Yes. 

Dr. BENISHEK. Great. 

So what is the story, Mr. Rice or Dr. McNutt? Do you know what 

the story is here? We have heard some contradictory things here. 

I think we are trying to get a physician here, and yet we don’t have 

one. And then some people testified that they are not trying to get 

a physician here, or only a part-time. So I don’t know what the real 

story is. What has been going on, and when are we going to get 

a doctor here? 

Mr. RICE. Okay. So Dr. Solomon retired in 2013 and we started 

our recruitment for a full-time physician. The job was advertised 

multiple times on usajobs, however, if a physician approached us, 

we can hire them without the job being advertised. So one of the 


VACREP0180 with DISTILLER
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things I did, I sent an email message to the CEO War Memorial 

to see if he could help us in our recruitment efforts, and all that 

he could provide at that time was mid-levels. So then I reached out 

and got a listing of all the providers in Chippewa County and I personally sent them a note asking if they were interested in coming 

over to the VA. I had one physician who was thinking about shutting down his practice, but it would be two to three years. 

The number of times the position has been advertised in the 

newspaper was 25 times prior to us hiring the NP and 19 times 

since. We made the decision, or I made the decision as the Director 

that after recruiting for the position for over a year, it was in the 

best interest of our veterans to hire a mid-level, so I take full responsibility for that. We felt a clinic with a provider was better 

than not having a provider at all. 

The panel size at the clinic was 1,187. A full-time provider who 

could handle 1,200 patients—mid-level, 900. During that time we 

were approached by an NP from the Battle Creek VA. They grew 

up in the UP and wanted to relocate. So we hired that individual, 

and then she ended up retiring, and then just this past month we 

hired an additional PA. So we can cover a panel of about 1,500 patients. 

One of the things, I know not everybody is satisfied with telehealth, but telehealth is the way we conduct for patients that are 

more complex, back to the medical center where they direct care 

from a physician. 

Dr. McNutt can add to that. 

Dr. MCNUTT. Congressman Benishek, I would like to add two 

things, actually. The first is in reference to the physician that was 

brought up during the first panel. I personally worked hand in 

hand with HR to recruit for all of our CBOCs at Iron Mountain. 

The day that that physician’s name was handed to me as somebody 

who might potentially be interested, I was on the phone to her that 

night. 

She indeed did interview with me twice. She was offered a fulltime position and declined. 

Dr. BENISHEK. I understand that that was here in the Sault. 

Dr. MCNUTT. Yes. I offered her either the Sault or Iron Mountain. 

Dr. BENISHEK. Oh, I see. 

Dr. MCNUTT. And she declined the position. 

I agree with Mr. Rice’s testimony that we often advertise a position—— 

Dr. BENISHEK. Is there a particular problem with physician recruitment? I mean, what is the basic problem, Mr. Rice? Is it they 

are not accepting the salary, or it is just hard to get somebody up 

here? I mean, you have the same problem at Iron Mountain too, 

as I understand it. 

Mr. RICE. Right now, the first time since I have been the Director at Iron Mountain, we are practically fully staffed and we have 

three provider vacancies. We are really trying to focus on recruiting 

physicians who like the rural environment, the lifestyle. We have 

made a concentrated effort to approach it that way, do more home 

grown approach. I don’t think it has been a thorny issue. I think 

we have been able to meet most every demand from a physician 


VACREP0180 with DISTILLER
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that we recently hired, like the anesthesiologist, podiatrist, some 

psychiatrists. We have been able to meet their financial demands. 

Dr. MCNUTT. Congressman Benishek, I think you probably recognize this is not just a VA issue. Congresswoman Brownley brought 

up there is a dearth of physicians to hire. We quite often get no 

replies from physicians when we are recruiting. 

Dr. BENISHEK. All right. Thanks. 

I will yield now 5 minutes to my colleague. 

Ms. BROWNLEY. Thank you, Mr. Chairman. 

So I think it was Mr. Harrington who testified earlier who talked 

about a promise to hire a doctor, but then a nurse practitioner or 

a physician assistant was hired in lieu of that. So I am just trying 

to get to the bottom of whether that was what was really, truly assigned by the VA, that we were going to hire a nurse practitioner 

and not a doctor, or it was because you could not hire a doctor is 

the reason for that? 

Mr. RICE. Yes, that is correct. We try to staff with physicians. 

Ms. BROWNLEY. Okay. Very, very good. 

So I guess just a broad question to all of you. I notice that a couple of you are wearing your ‘‘We Care, I Care’’ VA buttons. Those 

buttons are symbolic of something, and in my mind what it is symbolic of is the VA’s commitment, certainly the Secretary of the VA, 

his commitment to make sure that the VA is working in a way to 

satisfy all veterans across our country, every single one. 

I had the opportunity to visit with a few veterans here today who 

assured me that they are getting absolutely great care. They are 

extremely satisfied with their care. But we all know that we still 

have more work to do to make sure that we are providing highquality care for all of our veterans and that we want the VA to be 

nimble enough and flexible enough so that we are what we call 

back in Washington veteran-centric—it is a veteran-centric VA, 

that our purpose in life is to serve veterans and to make sure that 

veterans have great satisfaction, in our case in healthcare delivery. 

So having said that, based on what you have heard today from 

our veterans, and we want to listen to our veterans and learn from 

our veterans and hopefully create programs around some of their 

issues and concerns, I guess I would just ask the question, what 

is your take-away from this morning’s testimony from the veterans 

here? 

Ms. CAPRA. Thank you, Congresswoman Brownley. What speaks 

to me most is the implementation of the Choice program and those 

significant challenges that we have implementing that successfully, 

not just here in Sault Ste. Marie but, as I have made my way 

around to other rural parts of the country, I do hear the same concerns over and over about community providers either not knowing 

about the opportunity to be part of the Veterans Choice program 

or not being willing to participate for a variety of reasons, whether 

it is reimbursement or they are a little concerned about what the 

experience will be like to work with the VA. 

So I think while the Veterans Choice program presents a great 

opportunity to bring care closer to home through community providers, if the community providers aren’t there or aren’t willing to 

participate, that diminishes the intent of it. 


VACREP0180 with DISTILLER
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I would say here in Michigan, I was fortunate on July 15th to 

do a training to the Michigan Primary Care Association to inform 

the Federally-qualified health centers of the opportunity. We did 

this along with Health Net, the third-party administrator implementing in Michigan, and thus far we have 19 Federally-qualified 

health center sites signed up in Michigan. We have a long road to 

go to continue with that. 

We are doing some national provider outreach efforts with the 

National Rural Health Association and the National Association of 

Community Health Centers to try to reach those community providers, and many of them are already seeing veterans or veterans 

and their families. So we would like to bring them in, but there are 

challenges associated with that. I heard that today. 

Ms. BROWNLEY. And what about the MOU that everyone was 

talking about in terms of trying to integrate services here with the 

tribes and the capacities that they have for healthcare delivery? 

Ms. CAPRA. My office has been talking—we talk very regularly 

with the Indian Health Service. We actually did a recent training 

to encourage tribal health programs to sign up as Choice providers, 

and that is distinct and different from the Memorandum of Understanding, which allows tribal health programs to get reimbursed 

for the care they provide to Native veterans. So we would like to 

see both of those mechanisms activated more fully. 

I understand here in Michigan that there are two tribes who 

have signed the reimbursement agreement and are getting reimbursed for the services they provide. We would love to see that 

grow and can offer technical assistance on that. But those are two 

distinct and very specific ways to get involved. 

Ms. BROWNLEY. Thank you. I yield back. 

Dr. BENISHEK. I have a few more questions, a follow-up on that. 

Mr. Rice, have you been working with the Sioux Tribe? That was 

one of the main points of Mr. Payment’s testimony, that they have 

been unable to secure a relationship with the VA to allow their 

clinics. What is going on there? 

Mr. RICE. So, a little history. We first started out with Waters. 

Waters signed up, and we have an agreement with them, as well 

as they are signing up to be a Choice provider. Then we moved on 

to Hannahville. Hannahville doesn’t have the capacity to be a 

Choice provider, but they want to be reimbursed. So we are finalizing an agreement with them. 

Dr. BENISHEK. What was the deal there? They have a different 

reimbursement plan? Is that what you are saying? 

Mr. RICE. No, like Gina said, Ms. Capra, to sign them up as either a Choice provider or an agreement to take care of Native 

American veterans. 

Dr. BENISHEK. Do they have to be a part of this Health Net in 

order to be a Choice provider? Is that basically the—— 

Ms. CAPRA. Yes. 

Dr. BENISHEK. Okay. So if they don’t want to be a part of this 

Health Net, then they cannot be a Choice provider. 

Mr. RICE. Correct. 

Dr. BENISHEK. But they can still do care within the VA outside 

the Choice program, right? 

Mr. RICE. Yes. The can get an authorization—— 


VACREP0180 with DISTILLER
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Dr. BENISHEK. Where are we here with the Sioux? 

Mr. RICE. So we met with their representative actually since 

2014, and we are working with CBO to get the agreement finalized 

so they can be reimbursed for the time they take care of Native 

Americans. We are encouraging them to sign up to be a Choice provider, but that is their choice, and they would have to work with 

Health Net. We try to provide them information so they can make 

that next step. 

Dr. BENISHEK. They are not Choice providers at this time? 

Mr. RICE. No, they are not yet. But we do have a successful 

agreement over in Manistique where they take care of our optometry patients in the Manistique area. So we have been successful 

with the Sioux Tribe with setting up an agreement. 

Dr. BENISHEK. What about this Memorandum of Understanding 

for their tribal members? What is the problem there? That is separate from the Choice, right? 

Mr. RICE. Correct, and that is to reimburse for—we are trying to 

set up these agreements so we can provide reimbursement any 

time they take care of a Native American veteran. I think the 

MOUs want to focus on taking care of all veterans at their clinic, 

and that is why we are encouraging to go the Choice route, because 

then we can reimburse through Choice. 

Dr. BENISHEK. I see. So what about just a fee-for-service or another thing outside the Choice program? 

Mr. RICE. Prior to the Choice program, we did have Waters, for 

example, the health clinic in Waters sign up, and they could be reimbursed for care in the community or the old NBCC program as 

a fee provider. We can’t direct patients—so if we wanted to have 

all our patients go to that clinic, we would have to have a contract, 

and the contract would have to go out for bid. So we thought it was 

quicker if we had them sign up as a Choice provider or a fee provider, because then they are already signed up. 

Dr. BENISHEK. It seems like this has been going on for a while. 

Mr. RICE. Actually, we have had three meetings over here, educational sessions with all the tribal clinics, the Lower Peninsula 

and the Upper Peninsula and VISN 11. We meet once a year to try 

to provide education. So, yes, we have been discussing this—— 

Dr. BENISHEK. Some of the issues from Mr. Payment is that they 

are willing and eager to make this happen. I don’t know where the 

problem is, but I would think there is real opportunity to find a 

local provider who is willing to be a provider in the community. So 

I am just trying to facilitate that by having this hearing here 

today. 

One of the other things that was brought up was the transportation issue and that there is difficulty providing rural transportation. Can you address that a little bit as well? 

Mr. RICE. Yes. 

Dr. BENISHEK. Ms. Capra talked about nationwide providing 

transportation, it is already happening, but there still seem to be 

some problems. Can you update us on what is going on as far as 

you are concerned? 

Mr. RICE. For VTS, we do have a local program. The routes are 

based on Iron Mountain. We go 60 to 90 miles from Iron Mountain. 

The transportation from the Sault to Iron Mountain, as previously 


VACREP0180 with DISTILLER
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mentioned, is by vans. There are some restrictions because they 

cannot take patients who are on oxygen, so that does create a challenge. But with the recent Choice program now, the services provided at the Sault, we have been authorizing care in the community so the veterans don’t have to travel over to Iron Mountain, and 

that is improving every day. We have work to do, but that is our 

goal, to provide the care here, to get it closer to home for our veterans. 

Dr. BENISHEK. Apparently, since 2009, there has been $14 million that has gone from the Office of Rural Health to the Iron 

Mountain VA Medical Center. Can you tell me how that $14 million has been spent? 

Mr. RICE. Sure. We have been real fortunate, actually. It has allowed us to start programs this past year. For example, this is the 

first time we are offering PT at one of our outpatient clinics 

through a rural health grant. We were able to remodel some space 

at the Rhinelander clinic in Wisconsin, hire a physical therapist, as 

well as a PTA. That has allowed us to establish three E–RANGE 

teams across the UP, one in Manistique, one in Hancock, and one 

in Rhinelander. It has enabled us to start some surgeon programs 

back at the main campus. 

So we have been real lucky that this program exists. We were 

able to bring services that we wouldn’t have been able to bring to 

our community otherwise. 

Dr. BENISHEK. Ms. Brownley. 

Ms. BROWNLEY. Thank you, Mr. Chairman. 

I am just going to go back to the Choice program for a minute. 

I know it has been confusing. It has been confusing I think across 

the country, and as everyone knows here, there are several community-based programs that the VA has, the Choice being the third 

of a family of programs. They are all run differently. Their reimbursement rates are different, et cetera. I, for one, feel like we 

should combine all of those programs into one and have one reimbursement program and simplify it, but we are not there yet. 

But on the Choice program, it has been my experience, at least 

in my own community, that once doctors begin to understand, the 

local doctors, once they understand how the program operates and 

they understand that the reimbursement rate is the Medicare rate, 

that they are more willing to actually want to be a part of that program, but it does take time. As you are doing recruitment for physicians to work within the VA, that same effort has to be established to make sure that the doctors in our communities are aware 

of the program, and in this case getting them connected with 

Health Net. 

I would hope that Health Net is helping you in this process, but 

I think we have made some changes and adjustments. I know one 

of the issues that I worked on was the continuity of care issue because under the Choice program, if you had cancer and needed 

treatment, the continuity of care was only—I think it was 60 days 

or something, and who wants to be treated for cancer and at the 

end of 60 days say you have to now go to a different doctor? 

So that has been fixed in the Choice program. So there have 

been—I think we have made some improvements. 


VACREP0180 with DISTILLER
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I wanted to ask, and probably this question is not under any of 

your jurisdictions necessarily, but how do we make Iron Mountain 

more flexible to veterans who have to travel there for their services? I mean, I heard several in their testimony say that they went 

to Iron Mountain for X service, did the traveling all day to get 

there, all the way home, and then get a call the next day saying 

you need to come back because we need to make that adjustment 

on your hearing aid, or we didn’t do this test. 

How can we make the Iron Mountain folks more flexible so that 

when our veterans travel there, if they need a hearing aid adjustment, they need to get their eyes checked, and they need a chest 

x-ray, that that can all be managed in one day as opposed to three 

separate trips? How do we make that happen? 

Ms. CAPRA. I would just say nationally, Congresswoman 

Brownley, that this is an issue across the board for rural veterans 

traveling into facilities. I have been to facilities where they accommodate the veteran and his or her family overnight if it is going 

to require that sort of long day. That is really not a reasonable request to make of a veteran. 

I think also the earlier conversation around technology. If some 

veterans are uncomfortable with telehealth or a phone-based call 

with a nurse, then for them that is not the right fit. But we really 

try to use technology in a way to bridge that distance so they don’t 

have to go as far for certain services. 

I will ask Mr. Rice to comment on Iron Mountain. 

Mr. RICE. I would just say the same, that what we are trying to 

do is really educate our clerks that every time they make an appointment, that they really discuss with the veteran any future appointments. 

But one of the goals, as I said for the medical center this year, 

is prior to any veteran leaving the clinic, for example if they need 

a specialty clinic, that they have that appointment before they 

leave the medical center so we can be more veteran-centric. 

One of the things we also spend a lot of time on, I have a slide 

that I use when I go out and do the town halls, really that we want 

our staff to recognize that our main goal is to make sure veterans 

get the care at the right time and at the right place, and sometimes 

that right place isn’t Iron Mountain VA, it is here in the community. 

So it is really changing the mindset of how we approach care to 

our veterans, that it is okay if we give care in the community, 

changing the mindset. Everybody always thought it had to be behind our four walls, but really we have to put the veteran first and 

make sure we address his or her needs. 

Ms. BROWNLEY. Thank you. 

I yield back. 

Dr. BENISHEK. I have a few more questions. 

In following up with what Ms. Brownley was asking, the gentleman testified about coming and then going back three days, having to go back for more—— 

Mr. RICE. That is unacceptable. 

Dr. BENISHEK. Really, is there some inquiry to the patient prior 

to his arrival saying what are the issues you are going to be talking to us about, is there anything else we can take care of while 


VACREP0180 with DISTILLER
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you are at Iron Mountain that day? Do they have that type of discussion with the patient prior to their showing up? Because I 

haven’t heard that. 

Mr. RICE. They are supposed to. We try to do it. Because of when 

Phoenix occurred, what we do now is leadership. Myself, Dr. 

McNutt, we meet with our clerks every Friday and we go over the 

hot topics and scheduling. We discuss this topic a lot because some 

of the complaints I hear from the veterans when they call me directly is the same that we heard today, that I had an appointment 

today and they made me come all the way back. So really educating our schedulers to make sure they have that discussion with 

the veterans so we understand what their future appointments are 

so we can try to batch them all on the same day. 

Dr. BENISHEK. It just seems to me that knowing that he is going 

to go for a hearing evaluation, that the tech should be there that 

same day so that those kind of issues can be dealt with. The travel 

time is just horrible. 

Mr. RICE. We did have some positive comments about telehealth, 

but we do have over 37 clinical telehealth programs now, and one 

of those programs, for example, is we have tele-audiology where we 

can actually fit the hearing aid via tele to prevent veterans from 

traveling far distances to get adjustments to their hearing aids, 

and that is a new program we started last year. 

Dr. BENISHEK. I wanted to ask another question about the medical record because I have heard also in other testimony that when 

people get outside care in the community, their medical record is 

not updated at the VA maybe in a timely fashion. 

Does that kind of communication happen electronically? Does the 

patient in the community have access to the patient’s records in 

the VA? I mean, when I was taking care of some patients at Iron 

Mountain, I was able to get into the VA’s computer record in my 

office. It was sort of an ordeal to get in, but we always had that. 

Is that a routine now? Does the patient seen in the community 

have access to the patient’s record? 

Mr. RICE. Iron Mountain is one of 13 pilot sites across the country where we are sharing records electronically with the private 

sector hospital. Where we have been successful so far is with the 

state home. In Marquette, any time they have a new admission, we 

share the records electronically. Then we are also working with 

Dickinson, Marquette General, and I think St. Francis. It is in the 

early stages, but our goal is that relatively soon we will be able to 

share records. 

Ms. CAPRA. And I would add, under the Choice program currently, although it is still very clunky, there is the transfer of information between VA and the referred community provider. That is 

a part of the process in order for the provider to get paid on the 

community side. 

Dr. BENISHEK. I think one more question and follow-up on a previous line of testimony. I can’t remember if you actually said—are 

you going to continue to try to get a physician here in Sault Ste. 

Marie, or is that pretty much by the wayside? We went through the 

numbers game there for a minute. I don’t know if you did that because you are not going to recruit a physician anymore? I am just 

trying to get what is the final answer because that is the main 


VACREP0180 with DISTILLER
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question that people have. They want a physician at this facility, 

and I don’t think you answered the question. 

Mr. RICE. Currently right now we are not recruiting for a physician, but one of the things we have been real successful this past 

year—like, for example, Marquette, with some changes that went 

on with Marquette General, that we have encouraged all physicians, if they are interested in working for us, we have been able 

to work out arrangements where we can take on additional providers, be it via tele or other means of providing care. 

Dr. BENISHEK. And you have been unable to recruit somebody to 

the Sault Ste. Marie facility to provide part-time physician coverage? Is that correct? 

Mr. RICE. Since 2013 we haven’t had any. 

Dr. MCNUTT. We have not had a single applicant other than the 

one we discussed earlier. 

Dr. BENISHEK. Well, you are no longer recruiting for the job at 

this point in time. 

Dr. MCNUTT. I wouldn’t say that. I encourage, and I am sure 

that you being part of this medical community you know this, that 

we often talk among ourselves, and my cell phone is out everywhere. I encourage anyone who is interested to call me personally. 

I keep an ongoing file of anyone who might have interest in working for us. So I would say that as a leadership group, Mr. Rice has 

been very receptive to increasing FTE when we have a qualified 

candidate. 

Dr. BENISHEK. How much is the scope of care limited by not having a physician here on site? 

Dr. MCNUTT. I would comment on two things there, Congressman Benishek. Number one is that we provide guarantees, and our 

NPs and PAs are highly qualified for what they do. They also have 

instant access to a physician. They all have a collaborating physician. One of our very useful pieces of technology is instant messaging. While sitting in an exam room, one of those providers can 

instant message the chief of primary care, me, their collaborator, 

saying they have a clinical question. 

Dr. BENISHEK. Does that occur here? 

Dr. MCNUTT. It occurs all the time, not just in Sault Ste. Marie 

but all of our CBOCs. They also all have my cell phone, and they 

will text me saying can you give me a quick phone, which we do. 

The chief of primary care and I, since this is a small community, 

are extremely receptive to mentoring and serving as the M.D. when 

they need one. 

Ms. BROWNLEY. So what is an example of when they need one? 

What does that mean? 

Dr. MCNUTT. So, for example, when you are hiring a new provider, let’s say you hire an NP for a site, and they will start out 

with a limited number of patients while they learn to use the computer system and try to understand our record. So they may send 

me an instant message saying I have a patient here who has a 

question about a referral. Where do I send this patient? How do I 

enter this consult? Or they may send me a question saying do you 

know who the pulmonologist is in Milwaukee? Questions that are 

usually related to systems, though on occasion they do ask a medVerDate Aug 31 2005 13:58 Oct 18, 2016 Jkt 000000 PO 00000 Frm 00030 Fmt 6633 Sfmt 6633 Y:\98-690.TXT PAT

VACREP0180 with DISTILLER
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ical question also. But they have almost literally instant access to 

a physician. 

Ms. BROWNLEY. But it is more logistical than it is—— 

Dr. MCNUTT. It has been more logistical than it has been medical. Our NPs and PAs are extremely well trained for the majority 

of chronic care that they deliver. 

Ms. BROWNLEY. I was just going to follow up to say I think I suggested that if you have a nurse practitioner who is seeing a patient 

and the patient needs more than he or she can provide in terms 

of setting up a telehealth meeting, a consult with the doctor, with 

the nurse practitioner, with the patient all together, is that possible to happen, or is it—— 

Dr. MCNUTT. For all of our mid-level providers—NPs, PAs—they 

always have the option if they feel the patient’s medical situation 

is too complex for them to provide for care, they always have the 

option of referring that patient to an M.D. 

Ms. BROWNLEY. I totally get that. They can refer them to an 

M.D., and then they go and travel into Iron Mountain. I am trying 

to find other solutions to limit the amount of traveling. In some 

sense we have to get the VA thinking in terms of people that have 

to travel the farthest need to be handled with kid gloves. It is just 

so much easier when you are close by, but these patients have 

issues just like everybody else, and then they have the trauma, if 

you will, of having to do the traveling and the frustration that goes 

with setting that up and having to experience going, coming back, 

and then getting a call saying I need you to come back again, like 

it is just right around the corner. 

Dr. MCNUTT. We do provide primary care. We have two physicians who provide primary care by tele. As he commented, not everyone is fond of tele, but we have many patients who come in and 

they do like telehealth. I do have the option to assign patients to 

a tele-practice where the primary care doctor is not located here 

but is the assigned physician of record for a patient. 

Ms. BROWNLEY. Right. But if the patient has a relationship with 

the nurse practitioner, all I am asking is, is it possible for a doctor 

to be, via telehealth, and the nurse practitioner, and the patient all 

be together? 

Dr. MCNUTT. Yes, it is possible. 

Ms. BROWNLEY. Thank you. 

Ms. CAPRA. Congresswoman Brownley, I would just add that nationally we are seeing that rural communities, not just VA service 

to communities, face this issue of a lack of physicians. So the midlevel team that Dr. McNutt described is so common. I talk frequently with my counterparts at the Department of Health and 

Human Services, their rural health office, and they are equally 

challenged by this issue of how to support rural communities so 

that individuals don’t have to travel hours and hours to see specialists. 

One of the things that is very unique, I have found, in the VA 

is the home-based primary care program. It is a limited program. 

It is something the Office of Rural Health has funded to a limited 

degree, but it allows the team to go to a veteran’s home, those that 

are eligible, and I think that is really a fantastic model. It is resource intensive, but it really gets to the veteran where he or she 


VACREP0180 with DISTILLER
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is. So I think that is a place where the VA does a little better, actually, than those of us that get our care outside of the VA. 

Dr. BENISHEK. Well, while I have you here and while we have 

the time, I just want to touch again on this transportation issue. 

You mentioned that the DAV is providing the transportation. How 

is that really working? Because Mr. Payment was saying it doesn’t 

seem to be working that well from his perspective. I know that we 

have a problem with capacity because the volunteers are paging 

and it is not maybe as reliable a system as it once was. 

Can you talk about that? Is there another option for veterans 

here? Are you willing to work with Mr. Payment to try to—— 

Dr. MCNUTT. Yes, we can do that. 

Dr. BENISHEK. Can you move a little more in his direction? 

Mr. RICE. The DAV driver from the Sault I think is very, 

very—— 

Dr. BENISHEK. I don’t know the specifics, but I know this has 

been a problem in the past. 

Mr. RICE. In the past year we have driven 1,000 miles for the 

VA. We transported almost 2,700 veterans who were served by the 

DAV. But I would be willing to discuss with him those issues. Recently I worked with some veteran groups, but not—we try to get 

to the Hancock clinic, to our main campus. So we would be willing 

to sit down and talk about that. 

Dr. BENISHEK. Do you have any more questions, Ms. Brownley? 

Ms. BROWNLEY. No. 

Dr. BENISHEK. I know that we haven’t answered all the questions 

that came up from our veteran panel, but I appreciate you coming 

in here today with Mr. Rice and Dr. McNutt, Ms. Capra. Thank 

you. 

I still think there are a lot of concerns about our rural veterans. 

Some of the things have been addressed, the traveling back and 

forth, back and forth three times in the same week, that sort of 

thing. These are problems that really need to be solved, and I think 

better communication with the veteran prior to the visit. I think 

you mentioned that it is very important to be sure the veterans are 

informed as to the options and having more options available when 

they go to Iron Mountain so they don’t face too many trips. 

I know that we probably aren’t trying to solve every problem at 

the rural VA, but I hope that maybe some people here who have 

a relationship with the providers here in the Sault will continue to 

improve going forward. I didn’t want to say myself, having worked 

at the VA, I worked with Mr. Rice. He is a keeper, and that means 

a lot. He is not somebody that is coming through the VA every two 

years and moving on to his next site. He is committed to being at 

Iron Mountain. So there is a lot of improvement there, and I know 

that he is working sincerely. 

My frustration, frankly, is with upper management, making sure 

that he has the tools he needs to provide the care that we need in 

Michigan. I am happy to see that he came here. 

Ms. Capra, like I said, I was a little disappointed in your standard testimony, how you are doing things, but the specifics matter 

here, and making sure that Mr. Rice has the tools that he needs 

to provide care. Somebody on the first panel said his hands are 

tied. I would like to see a physician here in the Sault. I know that 


VACREP0180 with DISTILLER
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people here in the Sault want to see that, and I continue to encourage the VA to hire a physician here in the Sault, and I am going 

to continue to work on those efforts. 

So if you don’t have any further questions, I want to thank you 

for being here today, and I will hereby adjourn the hearing. Thank 

you very much. 

[Whereupon, at 11:40 a.m., the subcommittee was adjourned.] 

f 

APPENDIX 

PREPARED STATEMENT OF CHAIRMAN DAN BENISHEK M.D. 

The Subcommittee will come to order. 

Good morning and thank you all for joining us today. 

As you may know, I am Dr. Dan Benishek and it is my honor to be both your 

Congressman and the Chairman of the Subcommittee on Health for the Committee 

on Veterans’ Affairs of the United States House of Representatives. 

Before I was elected to Congress, I was privileged to serve for twenty-years as a 

physician at the Oscar G. Johnson VA Medical Center in Iron Mountain, which 

oversees the VA community based outpatient clinic here in Sault Ste. Marie. 

During my time there, veteran patients would tell me every day about the challenges and the frustrations they faced when attempting to get care through VA— 

the VA which is, by the way, our government’s second largest bureaucracy with a 

budget and staff that trails only the Department of Defense in size. 

Let me be clear: Our veterans fought for our freedom—they shouldn’t have to 

fight government bureaucrats too. 

And the Subcommittee Members and our staff work hard every day to break down 

the barriers between the VA bureaucracy and the veterans that this bureaucracy 

should be serving here in the U.P. and across the country. 

I am joined here today by Congresswoman Julia Brownley, the Ranking Member 

of the Subcommittee on Health and the Representative from the 26th District of 

California, just north of Los Angeles. 

Needless to say, she has traveled quite a distance to be here with us today and 

I am grateful to her for her willingness to join me in Sault Ste. Marie this morning 

and for being such a strong and effective voice on the Subcommittee. 

The purpose of today’s hearing is to make sure that the care and services that 

you and your fellow veterans receive in the Eastern U.P. is timely, accessible, and 

high-quality. 

Unfortunately, we all know that—at times—VA has failed to meet those measures 

and, in doing so, has fallen far short of providing the treatment that our veterans 

earned and deserve. 

An example of how VA has fallen short here in Sault Ste. Marie can be seen in 

VA’s inability for the past two years to recruit a physician to staff the VA community-based outpatient clinic here. 

The veterans that I have spoken to—some of whom you will be hearing from this 

morning—are understandably concerned about the lack of a physician at this facility 

and the impact that VA’s failed recruitment efforts have had on the quality of the 

care at the clinic. 

I share those concerns and, today, I want answers. 

During this morning’s hearing, we will discuss efforts that VA has taken in this 

community and around the country to ensure that rural clinics like the one here 

in Sault Ste. Marie are properly staffed and that rural veterans are able to access 

care in the community or through tribal health centers where VA is unable to provide the care that our veterans need or when our veterans would prefer to receive 

care elsewhere. 

We will hear testimony from VA and from local tribal leaders and veterans, whose 

input, expertise, and advice is critical to the work that we do in Washington. 

I am grateful to all of our witnesses for being here and I look forward to their 

testimony. 

Before that, however, I would like to take a moment to recognize the men and 

women that we are here today to serve. 

Would the veterans in our audience right now please stand—if you are able—or 

raise your hand and be recognized? 


VACREP0180 with DISTILLER
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Thank you so much for your service to our country and for being here with us 

this morning. 

I would also like to take a moment to recognize and thank the Armory staff for 

allowing us to use their facility this morning and for their assistance in helping us 

to prepare and set up for this hearing today. 

Thank you very much. 

With that, I now recognize Ranking Member Brownley (Julia) for any opening 

statement she may have. 

Thank you. 

We will begin today’s hearing with our first panel of witnesses, who are already 

seated at the witness table. 

As this is a formal hearing and not a town hall, only invited witnesses will be 

able to speak though I do look forward to greeting and speaking with our audience 

members more informally after the hearing has concluded. 

Before I introduce our panelists, I want to gently remind all of today’s witnesses 

to please be mindful of the five-minute time-limit for your oral testimony and the 

question-and-answer period that will follow. 

The light that has been placed in front of me and in front of you will change from 

green to yellow when there is one minute left and from yellow to red when time 

has expired. 

We are going to try to stay as closely within the five-minute time-limit as possible 

so that we can be sure that everyone has a chance to be heard in a timely manner. 

Thank you in advance for your consideration. 

With us on our first panel this morning is Chairperson Aaron Payment of the 

Sault Ste. Marie Tribe of Chippewa Indians; Anthony Harrington, a veteran who 

lives right here in Sault Ste. Marie, Michigan; David W. Pearce, an Army veteran 

and the Commander of the VFW Post 3676; and, Don Howard, a veteran and Commander of the American Legion Post 3. 

I am so grateful to each of you for your willingness to be here this morning and 

to speak candidly about issues of such importance to our veterans and our community. 

I am honored to have you here. 

We will begin with you, Chairperson Payment. 

You are now recognized for five minutes. 

Thank you. 

Mr. Harrington, you are now recognized for five minutes. 

Thank you. 

Commander Pearce, you are now recognized for five minutes. 

Thank you. 

Commander Howard, you are now recognized for five minutes. 

Thank you. 

I will now yield myself five minutes for questions. 

If there are no further questions, the panel is now excused. 

Thank you all very much. 

I now welcome our second and final panel to the witness table. 

Joining us from the Department of Veterans Affairs is Gina Capra, the Director 

of the Office of Rural Health. 

Ms. Capra is accompanied by James Rice, the Acting Network Director for Veterans Integrated Service Network 12, and by Dr. Gail McNutt, the Chief of Staff 

of the Oscar G. Johnson VA Medical Center in Iron Mountain, Michigan. 

Thank you all for being here. 

Ms. Capra, please proceed with your testimony. 

You are recognized for five minutes. 

Thank you. 

I will now yield myself five minutes for questions. 

If there are no further questions, the panel is now excused. 

Once again, I thank all of our witnesses and audience members for joining in today’s conversation. 

It has been a pleasure for me to spend the morning here with all of you. 

With that, I ask unanimous consent that all Members have five legislative days 

to revise and extend their remarks and include extraneous material. 

Without objection, so ordered. 

This hearing is now adjourned. 


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PREPARED STATEMENT OF AARON PAYMENT

My name is Aaron Payment, and I am the chairperson of the Sault Ste. Marie 

Tribe of Chippewa Indians. As a member and leader of the tribe, I am speaking on 

behalf of the tribe. As always, my tribe and I want to work in partnership with you. 

Throughout the history of the United States, Native Americans have fought 

bravely and sacrificed for this country. This proud tradition continues today with 

24,000 active duty American Indian service members. 

The 2010 U.S. Census identified over 152,000 Native men and women who have 

served this country in its, Armed Forces. While the U.S. population recorded nearly 

1.4 percent American Indian, the military population was 1.7 percent Native, making it the highest per-capita commitment of any ethnic population to defend the 

United States. 

I commend the Department of Veterans Affairs’ efforts to ensure that communitybased outpatient clinics in rural areas are properly staffed and rural veterans are 

able to access care in the community, where appropriate and necessary. However, 

additional changes are critically needed to meet the needs of American Indian veterans. The current system creates multiple barriers to treatment for American Indian veterans living in rural areas, which is where most reside. 

In the Eastern Upper Peninsula of Michigan, where there exists a shortage of 

service officers and service office open hours, Sault Tribe has partnered with the 

American Legion to provide two additional service officers in congressional District 

1. These added service officers provide outreach activities to veterans who utilize 

Sault Tribe’s Indian Health facilities across the EUP. The tribe provides the space 

to offset costs associated with the additional service officers. Additionally, the tribe 

has begun baseline data collection efforts aimed at more accurately reflecting the 

number of American Indian veterans across the U.P. 

Veterans’ Services Within the Sault Ste. Marie Tribe of Chippewa Indians 

Health Division 

In 2010, the Health Division worked with the Iron Mountain VA to establish an 

agreement with the tribe’s optical department in Manistique. Under this agreement, 

the tribe is able to provide optical services to tribal and non-tribal veterans. 

The tribe has also: 

• Established a VA workgroup to access additional services for its tribal veterans. 

• Partnered with a veteran’s service organization, American Legion, to provide 

benefits. Service officers at tribal clinic sites to assist veterans with issues and 

questions about navigating the VA bureaucracy. 

• Worked to identify tribal veterans as they come into tribal clinics as also 

being a veteran in order to plan services. 

• Worked to incorporate both behavioral health and traditional medicine programs to develop veteran specific services to include PTSD, emotional trauma, 

etc. 

• Planned awareness outreach to get out the word on tribal and VA services 

including tribal elders meetings, tribal newspaper, website and video tag line 

information. 

• Worked with the Iron Mountain VA to establish a Memorandum of Agreement with the tribe for full reimbursement for providing clinical services to tribal veterans eligible for VA services. 

Challenges to Choice 

Veterans who choose to utilize their Tribal Health centers and tribal providers as 

their primary care sites do not use their VA benefits. The VA cannot reimburse 

Sault Tribe until there is an MOA in place. The VA Choice Card Program does not 

list tribal clinics as reimbursable entities for providing the care as a referral from 

the VA. The tribe would need to become PC3 and Choice Provider under Health Net. 

The tribe is awaiting contact information from the VA about these programs. 

If veterans are unable to get an appointment at the Iron Mountain VA in 30 days, 

they can receive a Choice Care card and referral. They would then need to see if 

they could be seen at War Memorial Hospital (Sault Ste. Marie, Mich.), which is 

the preferred referral location in this area. Lastly, if WMH could not see veterans 

in 30 days, they would need to go back to the VA to receive another referral to use 

the Choice Card at Sault Tribe’s health center, and then the tribe would be reimbursed. 

The frustration for tribal veterans is to drive three to five hours to Iron Mountain 

and not receive an appointment resolving their issue, then receive referral to clinics 

in Wisconsin rather than Michigan, thus making the travel time even longer for follow-up and specialty care appointments. 


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Barriers to access care involve transportation to and from Iron Mountain because 

of distance and frequency. Community-based outpatient clinics are staffed with midlevel providers, not physicians, so veterans using CBOCs are not able to obtain the 

primary evaluations necessary to access their VA benefits. 

Recommendations 

• Freedom of choice. American Indian veterans should be free to choose their 

care based on where they can secure the highest quality health services. Veterans who choose to utilize tribal health centers and tribal providers as their 

primary care sites are not able to access their VA benefits. Currently, the VA 

Choice Card program does not list tribal clinics as reimbursable entities for providing the care as a referral from the VA. 

• Reimbursement to tribes. Tribal healthcare programs should be reimbursed 

for both direct service and referred care when Veterans find tribal health programs more accessible or more accommodating to their needs. I urge Congress 

to require the VA set up a process that allows reimbursement for eligible services provided by Tribes, including tribes such as the Sault Ste. Marie Tribe of 

Chippewa Indians, which is a self-governance tribe. 

• Improve public transportation. The tribe has identified a lack of consistent 

and reliable transportation to access many services that directly impact quality 

of life, including health, education and employment. The 2015 Sault Tribe Transit Implementation Plan showed transportation for making trips across the 

Upper Peninsula is provided only at night (12:15 a.m.–8:35 a.m.), which is of 

limited use for medical trips. The tribe also found a lack of evening and weekend service, another barrier limiting members’ ability to access critical health 

services. 

• Reimbursement to tribes. The Department of Veterans Affairs should reimburse tribal governments providing Native veterans transportation to primary 

and specialty clinics, and follow-up care. Most American Indian veterans live in 

remote areas of the United States and the cost for transportation to and from 

Veterans healthcare facilities cause substantial hardships on these veterans 

seeking service. 

I am available to answer any questions you might have. Thank you. 

f 

PREPARED STATEMENT OF ANTHONY HARRINGTON

Chairman Benishek, Ranking Member Brownley, thank you for giving me the 

chance to testify today. 

I am a disabled veteran and I live here in Sault Ste. Marie. 

As you both know, there is a VA clinic here. The clinic has been here for many 

years but more than 2 years ago the attending physician retired. In the interim, 

part-time doctors have been trying to pick up the slack, and a Nurse Practitioner 

has been brought in to replace the retired physician. 

I truly and deeply believe that our veterans should be entitled to proper 

healthcare. This specific VA clinic serves the entire Eastern Upper Peninsula. They 

are a very busy facility with many patients from across the region. The facility is 

having trouble keeping up with the number of patients and its quality of care is 

suffering as well. The NP, although very good at her job, can only do so much within 

the guidelines of her job description and abilities. 

Currently, as it stands the NP can only see a maximum of six patients a day and 

is limited as far as what she is allowed to diagnose and treat. The facility is in desperate need of a full-time attending physician as well as the current NP to adequately care of the entire region and its patients. 

Recently they hired a Physician’s Assistant here. While that’s a good first step, 

it’s really not a replacement for a full time doctor. I just want to know why they 

were able to bring a PA if it wasn’t possible for them to bring a doctor? I have been 

told by Iron Mountain VA officials that they were only authorized to hire a nurse 

practioner, and then all of a sudden the PA shows up. That doesn’t make sense to 

me. 

Prior to the hiring of the NP I was seeing a doctor by the name of Lisa Vanhevel 

at the Bay Mills Indian Clinic. The reason I turned to the Indian clinic instead of 

the VA clinic was due to the lack of an attending physician at the facility. While 

under Dr. Vanhevel’s care we talked quite extensively about the need of a full time 

doctor at the VA clinic. She told me that her contract with Bay Mills was coming 

to an end and made her intentions clear that she was interested in interviewing for 

the position at the VA clinic. 


VACREP0180 with DISTILLER
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Upon following the proper channels she was then granted an interview at the VA 

clinic in Iron Mountain, Michigan. Sometime later I happened to run into Dr. 

Vanhevel at Wal-Mart and she informed me that her interview went well and she 

was offered a position at the Sault Clinic as well as the Iron Mountain clinic. She 

stated that she was only offered two days a week through our facility or a full time 

position in Iron Mountain. She explained that she had to decline both positions because she didn’t want to move to Iron Mountain or commute 295 miles away for 

work. She also didn’t want to take a position for only two days a week. 

Dr. Benishek, Ms. Brownley, I’m sure you can sympathize with her. Who in their 

right mind would want to take a position for 2 days a week following a contract 

where they had a full time position? This was very concerning to me considering 

the dire need for a full time attending physician here. 

In addition, Dr. Benishek’s staff has told me that prior to the hiring of the PA, 

Benishek’s office was told by the VA that they were going to try to hire a doctor. 

However, despite what Benishek’s office was told, we’ve seen no evidence that an 

ad was ever placed on usajobs.com, or that any ads were placed in UP newspapers. 

I’d like to know what exactly was done to try to get a doctor here. 

I’m glad that Congress is finally investigating this issue. I have yet to have someone explain to me why it is that the veterans in this area are not entitled to a VA 

facility with a full time doctor and quality healthcare. 

Thank you again for having me here today. I truly hope that you will take the 

time to look into this matter and serve justice to our vets as we have selflessly 

served you and this country. It is my hope that you will confer with the new director 

of the VA and that you can come to an agreement to resolve this. 

I’m happy to answer any questions you may have. 

Thank you. 

f 

PREPARED STATEMENT OF DAVID W. PEARCE

Congressman Benishek, Committee Members, Committee Staff, and Fellow Panelists, 

Thank you for the opportunity to appear before you today on behalf of the members of Veterans of Foreign Wars Post 3676 and approximately 58,000 Upper Peninsula of Michigan Veterans—one of this great state’s most valuable resources. I feel 

qualified to provide some input, within my scope, as I am a retired service-member, 

disabled veteran that uses the VA healthcare system and the Commander of the 

Welsh-McKenna VFW post here in the Sault. I served this great nation of ours for 

over 20 years as an Active Duty Soldier in the United States Army. I was also born 

and raised here in the Eastern Upper Peninsula and returned home to Sault Sainte 

Marie upon the completion of my military career. 

First, I would like to commend the Veteran’s Administration for recognizing a 

problem in the care of our Veterans that live in rural areas. Speaking from my personal experience with the VA healthcare system, I believe the VA is moving in the 

right direction, there is still much more room for improvement. Improvements have 

been gained in the last several years with my access to care. When I started to use 

the VA healthcare system, it was not uncommon to drive all the way to the Iron 

Mountain VA hospital for an appointment or test. The Oscar G. Johnson VA Medical Center in Iron Mountain, Michigan is the closest facility. Some of those appointments were a simple 15 to 20 minute doctor visit that would require a 4 hour drive, 

one way, and an entire day off work. More recently, the VA has scheduled appointments for me at the local hospital or sent me an authorization to seek care locally. 

I am satisfied with the improved choice options; however there are bugs to be 

worked out. One is with billing. As a retired service member, I also use Tricare for 

medical insurance. Several times when I received care locally, my healthcare insurance was billed and not the VA. The response time is very slow when trying to get 

the medical bills routed in the right direction. 

I also feel that local access to healthcare for our aging veteran’s should be a priority. I’m still relatively young. It is not as much of a burden for me as it is for 

some of our older veterans to receive care. In our community here in the Sault, 

there are several assisted living facilities and nursing homes with elderly veterans 

that do not have the physical capability to travel great distances to receive care 

from the VA. Improved choice could help with that issue. I would also like to comment that for me personally, the MyHealtheVet website is a great asset to access 

care, re-fill prescriptions, and communicate with the local Community Based Outpatient Clinic thru secure messaging. That was a great idea for those of us that are 

computer literate. However, it is not such a great choice for those that are not familVerDate Aug 31 2005 13:58 Oct 18, 2016 Jkt 000000 PO 00000 Frm 00037 Fmt 6633 Sfmt 6621 Y:\98-690.TXT PAT

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iar with using a computer or do not have access. Many of our older Veterans do 

not use a computer. Another issue with improved choice that should be addressed 

is the lack of specialized care and Women Veterans’ healthcare access in our rural 

environment. I’m not sure how to address these topics specifically, but they definitely need to be looked into and more options for care need to be available for all 

Veterans. 

Appropriate staffing is a concern. Soon after my retirement from active duty I 

started using the VA Community Based Outpatient Clinic located in Kincheloe, 

Michigan. The clinic was relocated to Sault Sainte Marie a few years later. I personally think the staff at the SSM CBOC is absolutely wonderful. I interact with the 

staff at the local clinic several times every month for my own appointments. They 

are always helpful and friendly. The only concern I have is there is not a permanently assigned Medical Doctor at the clinic. The Physician’s Assistant does a great 

job, but I feel there should be a full time MD assigned to the clinic also. When the 

Doctor that was assigned to the clinic retired the position was filled several times 

temporarily until the Physician’s Assistant was hired. This created a lack of continuity in care. I feel due to this lack of continuity, mistakes were made and treatment was not appropriate. During that time I also had an appointment with a physician located in Iron Mountain thru video chat. I felt that appointment was very 

impersonal and not effective at all. On another occasion, I drove to Iron Mountain 

for a video conference with a Doctor located in Milwaukee and some on-line testing. 

That, I feel, could have been accomplished at the clinic in Sault Sainte Marie. Now 

put yourself in a World War II Veterans shoes. Imagine how overwhelming and confusing the video conference could be to them. 

Again, it is a great honor to have the opportunity to participate in this valuable 

discussion regarding the care of our Veterans. This concludes my testimony. I am 

prepared to take any questions you or the committee members may have regarding 

my personal experiences with Appropriate Staffing and Improved Choice. Thank 

you. 

Pursuant to Rule X12(g)(4) of the House of Representatives, I have not received 

any federal grants in Fiscal Year 2015, nor have I received any federal grants in 

the two previous Fiscal Years. 

I have not received payments or contracts from any foreign governments in the 

current year or preceding two calendar years. 

f 

PREPARED STATEMENT OF JACQUELINE A HASKE

Chippewa County Department of Veterans Affairs, 319 Court St, 3rd Floor, Sault 

Ste. Marie, MI 49783, (906) 635–6370/Fax (906) 635–6867, 

veteran@chippewacountymi.gov. 

September 15, 2016 

To whom it may concern, 

My name is Jacqueline A Haske. I am with the Chippewa County Department of 

Veteran Affairs Office. My office is designed to assist and support Veterans. File 

claims with the VA, apply for assistance with the Michigan Veterans Trust Fund, 

and seek further resources in the community and more. My concern is with the 

growing population of veterans in the Eastern Upper Peninsula, is the ability to provide healthcare to the veterans. We have been told about receiving a Doctor at the 

War Memorial VA Clinic and still have not received one. Several veterans have expressed their concern about getting a Doctor at this local facility. 

Jacqueline A Haske, Veterans’ Counselor 

f 

PREPARED STATEMENT OF MS. GINA CAPRA

Good morning, Chairman Benishek and Ranking Member Brownley. Thank you 

for the opportunity to discuss staffing and rural health concerns nationally and in 

the state of Michigan. I am accompanied today by Mr. James Rice, Acting Veterans 

Integrated Service Network (VISN) 12 Network Director and Dr. Gail McNutt, Chief 

of Staff Iron Mountain Veterans Affairs (VA) Medical Center and Co-Chairperson 

of the National Patient Aligned Care Team (PACT) Consultant Team. 

OVERVIEW


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The employees of VISN 11 proudly provide patient-centered care to approximately 

399,825 Veterans living in portions of Michigan, Ohio, Indiana, and Illinois. Of the 

nearly 400,000 Veterans being treated, 82,798 are classified as living in either rural 

or highly-rural areas. VISN 11 consists of 32 Community-Based Outpatient Clinics 

(CBOC) and 7 healthcare systems with main campuses located in: Ann Arbor, Battle 

Creek, Detroit, and Saginaw in Michigan; Indianapolis and Ft. Wayne in Indiana, 

and Danville, Illinois. For fiscal year (FY) 2015, VISN 11 is operating on a budget 

exceeding $2.2 billion providing our Nation’s heroes with high-quality care through 

traditional and innovative methods. VISN 11 also has a collaborative relationship 

with Vet Centers located throughout the catchment area. 

VISN 12 provides patient-centered care to approximately 15,000 of the 30,000 Veterans residing in Michigan’s Upper Peninsula. These services are provided primarily 

through the Oscar G. Johnson VA Medical Center (OGJVAMC) in Iron Mountain, 

Michigan. The medical center operates six CBOCs in Michigan (Ironwood, Hancock, 

Marquette, Menominee, Manistique, and Sault Ste. Marie) and one in Rhinelander, 

Wisconsin. 

OGJVAMC is a complexity level III care facility with 17 medical/surgical beds. It 

also has a Community Living Center with 40 beds. OGJVAMC provides urgent care 

and acute inpatient care in a geographically rural area and collaborates with larger 

healthcare facilities in VISN 12 and community facilities to provide higher level 

emergency and specialty services. It employs state-of-the-art telehealth technologies 

and is a leader in the delivery of healthcare to rural Veterans. 

The facility has 686 employees and an FY 2015 operating budget of $126 million. 

This includes $26 million for care provided by community providers. In FY 2014, 

there were 12,477 Veterans authorized to receive care in the community. Since the 

passage of the Veterans Access, Choice, and Accountability Act of 2014 (Choice), 

OGJVAMC has authorized over 4,226 Veterans to receive care for those waiting 

greater than 30 days, primarily for psychiatry, optometry, and physical therapy appointments. In addition, OGJVAMC serves 2,484 Veterans that live greater than 40 

miles away and are eligible for Choice; however, only 450 of these Veterans have 

elected to use their Choice option. 

OGJVAMC ranks 18/140 in overall efficiency and 15/140 in clinical efficiency according to the latest efficiency analysis by the Office of Productivity, Efficiency, and 

Staffing. For each VA medical center, clinical and administrative cost efficiency is 

measured by using stochastic frontier analysis (SFA). SFA is a well-validated approach in assessing operational efficiency with quality of care taken into account. 

Additionally, the medical center has done well on national level employee surveys. 

For example on the Federal Employee Viewpoint Survey, the medical center had a 

greater percentage of positive responses to the summary satisfaction questions than 

VA, the Veterans Health Administration (VHA), and VISN 12. The Employee Engagement score for the facility was also higher than VA, VHA, and VISN 12. In fact, 

the facility’s score of 66.5 was higher than the Government-wide score of 63. On the 

All Employee Survey Best Places to Work Index 2014 results, the facility ranked 

27 out of 142 facilities—in the top 20 percent. On the 2014 Integrated Ethics Staff 

Survey, the facility’s overall rating as an ethical organization was the 8th highest 

in the country for all VAMCs. 

OGJVAMC patients are satisfied with the quality of care they receive as evidenced by the medical center’s patient experience data, which exceeds the VA’s national score for both inpatient and outpatient care. As evidenced, over 80 percent 

of Veterans would recommend OGJVAMC to their friends and family. Facility leadership holds regular staff meetings with all schedulers, to include CBOCs, and the 

Director personally conducted mandated clinic observation interviews with all 

schedulers including CBOCs. The facility monitors access with internal stakeholders 

by reviewing and addressing data from the VHA Support Service Center (VSSC), 

New Patient Wait Times Exception Summary Report, and Access Glide Path data. 

To quickly identify opportunities to improve Veteran access, the Director reviews 

data during the daily morning report, such as the New Enrollee Appointment Request (NEAR), the Electronic Wait List, the Provider Workload, the local access data 

list, and the number of new patients seen in Urgent Care Clinic with no primary 

care provider assigned. 

Expanded mental health programs include the following: Operation Enduring 

Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) case outreach, Enhanced Rural Access Network for Growth Enhancement (E–RANGE) program for rural Veterans diagnosed with serious mental illness, Mental Health Intensive Case Management (MHICM), Posttraumatic Stress Disorder (PTSD) Clinical 

Care, Home-Based Primary Care (HBPC) psychology services, Compensated Work 

Therapy (CWT), recovery-based programs, suicide prevention, outpatient substance 


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abuse programs, evidenced-based therapies, VA Caregiver Support, and the Homeless Veterans Program including Veterans Justice Outreach. 

VA Rural Healthcare Program—State of Michigan 

There are approximately 660,800 Veterans in the state of Michigan, of which an 

estimated 230,000 (35 percent) are enrolled in the VA healthcare system. Additionally, 207,000 or 31 percent of all Michigan Veterans live in rural areas. Forty-one 

percent or approximately 95,000 of enrolled Veterans live in rural areas. 

In addition to funding allocated to VISN 11 through the Veterans Equitable Resource Allocation (VERA) system for Veterans’ healthcare, in FY 2014, VISNs 11 

and 12, together, received $8 million from the Office of Rural Health (ORH) to support 21 projects and programs to increase access to care for Michigan’s rural Veterans. The programs specific to Michigan include a Mobile Prosthetics Van, which 

brings prosthetic services typically found only at the main campus to the CBOCs; 

clinical training opportunities for providers in rural locations; enhanced rural access 

to mental healthcare services; Veterans transportation programs in the Upper and 

Lower Peninsulas; telehealth; and Home-Based Primary Care. 

Increasing access to VA-provided care for Tribal Veterans is addressed with a VA 

ORH-funded project for Battle Creek VAMC. This project supports a Native American Indian Veteran that has been trained as the Tribal Veteran Outreach Worker 

(TVOW). The focus of this project is to bring access to mental health services at the 

Battle Creek VAMC by utilizing telehealth technology. The project has also provided 

a liaison for Tribal Veterans that has assisted them within navigating VA for all 

their healthcare needs. The TVOW has served as the VA representative to several 

Tribal Events related to the collaborative relationship building that has occurred. 

These include Pow Wows, the Potowattomi Gathering in 2014, Tribal Veteran Council meetings, and Tribal Veterans Days events to name a few. 

VA continues to seek opportunities to expand our care via telehealth technology. 

VHA is in the early stages of developing a collaborative effort with community providers to be able to exchange health information, and OGJVAMC is one of the 14 

pilot sites. We now have the capability to provide CVT in the home, which will improve access to care for rural Veterans and mitigate the need for travel to a VHA 

site of care. Additional mental health services via telehealth to Veterans at the Patriot House in Gaylord in 2014 are also being established. Since October 1, 2009, OGJVAMC has received approximately $14.2 million dollars from ORH to implement and sustain programs. Recent grants include 

sustainment for the E–RANGE program, an outpatient mental health program that 

provides intensive, supportive services to Veterans living in rural areas who have 

a primary mental health diagnosis that is classified as severe, our Veteran Transportation Service, implementation of Physical Therapy at the Rhinelander CBOC, 

and a VA–Coordinated Transitional Care (C–TRAC) Program. 

Recruitment & Staffing 

Nationally, VHA employs an aggressive marketing and advertising campaign 

aimed at patient care providers for rural locations through its partnership with the 

National Rural Recruitment & Retention Network (3RNet), a national network of 

non-profit organizations devoted to healthcare recruitment and retention for underserved and rural locations. Through this partnership, VHA has access to a robust 

database of candidates especially interested in its rural vacancies. National recruiters routinely post VHA practice opportunities on 3RNet’s career page. In addition, 

3RNet annually dedicates the month of November to Veteran healthcare awareness 

by making VHA its featured employer for the month. 

VHA also strives to relocate physicians from urban areas to rural VAMCs and 

outpatient clinics. The increase in the rural Veteran population calls for a strong 

recruitment, marketing, and advertising campaign that directs qualified prospects 

to rural VA centers struggling to open their doors. The rural relocation marketing 

campaign targets urban physicians in transit during their daily commutes with a 

compelling recruitment marketing and advertising campaign to persuade them to 

explore options for relocation to the nearest rural VAMC. This extensive campaign 

targets geographic regions and specialties with the highest need, online, and in a 

wide range of professional healthcare publications. 

In addition to internal robust recruitment efforts by facility level human resources 

offices, VISN 11 partners with VHA’s Workforce Management and Consulting 

(WMC) Office for increased recruitment and staffing support. The National Recruitment Program (NRP), a sub-division within WMC’s Healthcare Recruitment and Retention Office, provides a centralized in-house team of skilled professional recruiters 

employing private sector best practices to fill the agency’s most critical clinical and 

executive positions. The national recruiters, all of whom are Veterans, collaborate 

with executives, clinical leaders, and local human resources departments in the deVerDate Aug 31 2005 13:58 Oct 18, 2016 Jkt 000000 PO 00000 Frm 00040 Fmt 6633 Sfmt 6621 Y:\98-690.TXT PAT

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velopment of comprehensive, client-centered recruitment strategies that address 

both current and future critical needs. In FY 2014, the NRP recruited 25 clinical 

providers for VISN 11 vacancies of which 16 were for hospitals and clinics in Michigan. For FY 2015, to date 11 of the 15 Medical Officers recruited by the NRP currently provide care to Veterans at Michigan VAMCs and outpatient clinics. As of 

July 31, 2015, VISN 11 has 921 physicians onboard and 136 active recruitments for 

physicians. In addition, WMC, ORH, other VA partners, and non-VA Federal partners are collaboratively exploring to: 

• Determine where and what types of providers are in short supply at rural 

healthcare facilities providing care for rural Veterans; 

• Solicit the voice of Veterans to better understand rural Veterans’ preferences 

and decisions regarding healthcare providers; 

• Determine best practices in rural provider recruitment and retention; 

• Explore and promote the use of VA financial incentives and other innovative 

solutions to recruit providers to rural VA facilities; 

• Develop and/or expand and support clinical training opportunities for rural 

health practitioners providing care to rural Veterans to help retain them in 

rural areas; 

• Promote and support rural health educational and rural health clinical training experiences for medical residents, nursing, and other health professions students to help recruit future healthcare providers to rural practice; and 

• Expand opportunities for training rural primary care providers in specialty 

areas that address the unique medical needs of rural Veteran demographic 

groups. 

OGJVAMC has actively recruited and retained staff while simultaneously improving relationships with community healthcare providers in the Upper Peninsula of 

Michigan and Northern Wisconsin to broaden the continuum of care available to 

Veterans. In a rural, sparsely populated area, few facilities are able to offer the full 

range of services normally available in larger metropolitan areas. Strong collaborations with multiple healthcare providers, both public and private, are essential in 

meeting the needs of patients. OGJVAMC has grown from 604 Full Time Employees 

(FTE) in FY 2012 to 648 FTE at the end of June 2015, an increase of 44 positions. 

OGJVAMC’s proactive recruitment of providers is ongoing. Since 2014, the facility 

has filled the following critical positions: Chief of Surgery, Chief of Behavioral 

Health, Associate Chiefs of Staff for Geriatrics and Primary Care, Chief of Medicine, 

and Chief of Staff. Furthermore, OGJVAMC recruited and hired an Anesthesiologist/Pain Medicine, Podiatrist, Certified Registered Nurse Anesthetist, and an Optometrist in FY 2015. In addition, since FY 2014, the facility has hired eight primary care providers and is fully staffed at all locations. To enhance CBOC services, 

mid-level providers are utilized to supplement primary care vacancies. Since April 

2014, the on-board total of critical clinical care positions (physicians, physician assistants, nurse practitioners, nurses, and other select critical occupations) has increased by 20—representing an 8 percent increase. The medical center increased interim staffing to fill short term vacancies and mitigate disruption to scheduled appointments. To address short-term primary care and mental health vacancies, telemedicine clinics were expanded to provide interim coverage. 

Rural Provider Education 

In FY 2012, ORH and the Office of Academic Affiliations (OAA) launched a collaborative three-year workforce program called the Rural Health Education and 

Training Initiative (RHTI) to increase healthcare workforce recruitment to rural 

areas. Seven sites in Maine, New York, Virginia, Nebraska, North Carolina, Alabama, and the Pacific Islands were awarded $250,000 per year for three years. By 

the end of FY 2014, 690 trainees in 23 separate medical, dental, and mental health 

disciplines had been trained at rural VA sites of care. 

Telehealth 

In FY 2014, more than 717,000 Veterans (12 percent of Veterans receiving VHA 

care) accessed VA care through Telehealth during more than 2.1 million encounters. 

Forty-five percent (45 percent) of these Veterans lived in rural areas, and may 

otherwise have had limited access to VA healthcare. The number of Veterans receiving care via VA’s Telehealth Services grew approximately 18 percent in FY 2014. 

Veterans in Michigan are served primarily by two VISNs. VISN 11 includes medical centers providing telehealth services in and around Ann Arbor, Battle Creek, 

Detroit and Saginaw, MI. Veterans in Michigan’s Upper Peninsula use telehealth 

to access services from VISN 12’s Iron Mountain, MI, VAMC and its affiliated VA 

CBOCs in Marquette, Menominee, Hancock, Ironwood, Manistique and Sault Ste. 

Marie, MI. 


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In FY 2015, Year to Date, more than 25,700 Veterans accessed VA care through 

Telehealth during more than 60,600 episodes in VISN 11. During this same period 

in VISN 12, about 23,000 Veterans accessed VA care through Telehealth during 

more than 109,900 encounters. Fifty-four percent of the VISN 11 Veterans as well 

as 54 percent of VISN 12 Veterans lived in rural areas. 

In FY 2014, within VISNs 11 and 12, 16,230 Veterans in Michigan accessed VA 

care during 32,971 clinic-based telehealth encounters. More than two-thirds of these 

Veterans (22,024) lived in rural Michigan. The types of care Michigan Veterans 

were accessing through telehealth included the following: mental health, the MOVE! 

program, primary care, diabetes, Cardiology, Dermatology, and other services. Currently in August 2015, approximately 2,560 Veterans in Michigan are enrolled in 

VHA’s Home Telehealth service to help them manage chronic conditions such as diabetes, chronic obstructive pulmonary disease, and congestive heart failure. 

Conclusion 

In conclusion, VA is committed to providing high-quality, safe, and accessible care 

for our Veterans and will continue to focus on improving Veterans’ access to care. 

While the location presents unique challenges with regard to distance, culture, and 

constrained healthcare markets, VA’s rural health programs are robust, and we will 

continue to strive to serve Veterans in rural areas. 

Mr. Chairman, this concludes my testimony. My colleagues and I are prepared to 

answer any questions you, Ranking Member Brownley, or other members of the 

Committee may have. 

f 

STATEMENT FOR THE RECORD BY BENJAMIN BALKUM, PRESIDENT, AFGE LOCAL 2280 

OSCAR G. JOHNSON VA MEDICAL CENTER IRON MOUNTAIN, MICHIGAN, THE AMER- ICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL–CIO BEFORE THE HEALTH

SUBCOMMITTEE OF THE COMMITTEE ON VETERANS’ AFFAIRS UNITED STATES HOUSE

OF REPRESENTATIVES REALIZING QUALITY RURAL CARE THROUGH APPROPRIATE

STAFFING AND IMPROVED CHOICE

September 1, 2015, 

Chairman Benishek, Ranking Member Brownley and Members of the Subcommittee: 

Thank you for the opportunity to provide a statement on behalf of Local 2280 of 

the American Federation of Government Employees, AFL–CIO and its National Veterans Affairs Council (AFGE). 

AFGE represents over 220,000 employees of the Department of Veterans Affairs 

(VA). AFGE Local 2280 represents all the healthcare professionals and support personnel at the Oscar G. Johnson VA Medical Center, including the Sault Ste. Marie 

CBOC, other outpatient facilities and our community living center. 

I have served as Local President of Local 2280 for almost 30 years and I have 

worked at the Iron Mountain VA since 1984. As a Vietnam-era combat veteran, I 

also receive healthcare services from the VA. 

At our facility, management practices have adversely impacted staffing levels, recruitment and retention of healthcare personnel, and most important, the ability of 

veterans in this very rural area to access quality, timely care. 

My statement focuses on the following problem areas: 

• Cuts in critical healthcare services; 

• Hostile and unreasonable work environment; 

• Adverse impact of ‘‘firing’’ bills on recruitment, retention and accountability. 

• Cumbersome hiring processes 

Cuts in Critical Services 

Over the past year, management at Oscar G. Johnson VA Medical Center has 

downgraded its emergency room (ER) into an urgent care facility so it no longer provides 24-hour emergency care. As a result, the facility is unable to accept ambulances, veterans with chest pains or veterans presenting other acute conditions. 

Management also recently closed our intensive care unit (ICU); we are now unable 

to perform general surgeries or intubate patients. If a patient codes, he or she must 

be sent to a very small community hospital or to a full capacity VA facility that is 

over 100 miles away in Green Bay. 

Millions of taxpayer dollars were spent to build a state of the art surgery suite 

in 2014. As soon as the doors opened earlier this year, management lowered the 

complexity of our surgery program to a basic ambulatory standard of care, requiring 

veterans to travel great distances to other VA medical centers for all general surgeries and emergency surgeries. This brand new surgical suite is now being used 


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only for ‘‘lumps and bumps’’ surgery that could just as easily be performed on an 

outpatient basis. 

Just prior to the opening of the new surgical suite, we were finally able to recruit 

and competitively pay an anesthesiologist to come to Iron Mountain. As a result of 

these cutbacks, the VA has had to pay for him to receive additional credentials in 

acupuncture in order to supervise our pain clinic instead. 

These cutbacks in essential medical services are life threatening to veterans with 

serious medical conditions. They also put veterans at risk by devastating the medical center’s ability to recruit and retain surgeons, hospitalists and other clinicians 

who will no longer be able to maintain their skills and credentials if they stay at 

Iron Mountain. 

Iron Mountain’s cutbacks are very drastic but not unique. A spring 2015 AFGE 

survey of our locals at VA medical centers found that 62% of respondents reported 

similar cutbacks at their facilities, especially closings of ERs, ICUs and inpatient 

beds. 

Hostile and Unreasonable Work Environment 

A number of providers have already left Iron Mountain for positions in the private 

sector due to our facility’s toxic workplace and difficult working conditions. Because 

of increased turnover rates, many veterans at Iron Mountain never see the same 

doctor twice for clinic care. Chronic turnover is also significantly undermining the 

effectiveness of our PACT teams; many PACT team clinicians are being reassigned 

to fill vacancies in the CBOCs. We recently lost three highly qualified physicians 

(two emergency doctors and a long time hospitalist.) 

The dedicated healthcare personnel represented by Local 2280 are very concerned 

that the closing of our ICU and downgrading of our Emergency Department and 

surgical unit are seriously impacting the services to veterans who reside throughout 

the rural areas of the Upper Peninsula, Northern Lower Peninsula, and North Eastern Wisconsin. 

Attrition is also worsening because of management’s overreach into providers’ 

clinical decisions and because of their use of sham peer reviews and other performance evaluations to intimidate and harass providers. False allegations of poor performance can irreparably damage a VA provider’s future employment opportunities 

both within and outside the VA. 

Varying panel sizes and double booking (in direct violation of VA policy) have 

forced Iron Mountain providers to work long extended hours on a regular basis 

without additional pay or time off. Initially, our physicians were promised an hour 

of administrative time every day to enable them to promptly respond to hundreds 

of daily computer alerts, review lab results and follow up on care provided by other 

VA and non-VA providers. However, due to constant overbooking by management, 

providers were not actually able to use these one-hour daily slots to handle their 

other major responsibilities. Management’s quick fix was to block off four hours one 

day a week instead, but even that limited set aside time continues to be swallowed 

up by enormous panel sizes, walk-ins and unassigned patients. 

Adverse Impact of ‘‘Firing’’ Bills on Recruitment, Retention and Accountability 

The counterproductive and fear-driven work environment at Iron Mountain is deteriorating further in the face of legislative proposals such as H.R. 1994 that assault 

basic workplace rights. At-will employment is simply not an accountability tool. 

Taking away our physicians’ rights to defend their professional reputation and positions prior to termination is not a path to accountability either. We must ask ourselves: How many VA healthcare professionals will come forward to Congress or will 

even want to work at the VA if they know they can be fired on the spot or falsely 

accused of poor patient care without recourse? 

That is why AFGE Local 2280 urges lawmakers to support the true accountability 

fixes in H.R. 2999. This bill preserves due process—which is critical for protecting 

the front line employees who are the VA’s most valuable watchdog against mismanagement—while addressing workplace safety, improper management-contractor 

relationships and abuse of paid administrative leave. If we truly want bureaucrats 

out of the examining room and the operating room, we cannot give VA managers 

more power to interfere with patient care through whistleblower retaliation, antiveteran animus, nepotism, politics and other prohibited personnel practices. 

To further increase accountability and the voice of the front-line provider, AFGE 

Local 2280 urges passage of H.R. 2193 to restore equal collective bargaining rights 

to the ‘‘full Title 38’’ VA providers—VA physicians, dentists, registered nurses, physician assistants, optometrists, chiropractors and podiatrists—who have been unfairly singled out and silenced by current VA Title 38 policy. It hurts VA accountability and recruitment to deny a VA physician the basic bargaining rights afforded 


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to a DoD physician or to every Hybrid Title 38 VA healthcare employee. This unfair 

VA practice is another example of nonmedical personnel (managers and human resources) interfering with clinical decisions. 

Finally, to improve recruitment and retention, AFGE Local 2280 urges reintroduction of legislation to make sure every veteran working as a VA Title 38 healthcare 

professional has equal veterans’ preference rights. An unintended loophole in the 

Veterans Employment Opportunities Act allows VA hiring officials to pass over veterans with preference points to hire non-veterans for Title 38 healthcare positions. 

Former combat medics and corpsmen will not want to bring their valuable experience to the VA instead of DoD or the private sector if they cannot enforce their veterans’ preference rights at the VA. 

Cumbersome Hiring Processes 

I would like to close by focusing on hiring instead of firing. The providers represented by AFGE offer the following suggestions for strengthening the VA 

healthcare workforce and we urge the Subcommittee to conduct VA provider 

roundtables on Capitol Hill and in the field to further explore these and other reforms to the hiring process: 

• Establish a more formal and permanent applicant pool that can be quickly 

accessed when vacancies occur (and even earlier when providers give notice that 

they are leaving). 

• Shorten the credentialing process by requiring less information and reducing 

duplication by reducing requests for older information already collected by state 

medical boards. 

• Eliminate the requirement that VA providers transferring within the VA 

healthcare system repeat the full credentialing process. 

• Conduct oversight to curb ‘‘bait and switch’’ practices by human resources 

personnel who fail to deliver on promises made to new hires. healthcare professionals regularly share this type of information with colleagues who are considering VA employment. 

• Conduct oversight to ensure that job openings are always posted and posted 

in a timely manner (e.g. 48 hours). This will greatly assist in recruitment and 

also curb ‘‘off the grid’’ hiring that bypasses job postings and has resulted in 

a growing problem of cronyism where hiring and promotion is based on who you 

know rather than skills and experience. 

I want to thank the Subcommittee for the opportunity to share AFGE Local 2280’s 

views on these critical issues. Over the past 30 years, I have personally witnessed 

the transformation of the VA healthcare system into a national leader in patient 

care, research and training and the nation’s most exemplary provider of veterancentric medical and behavioral healthcare. 

I am extremely proud of the care that our employees deliver and that I personally 

receive at the Iron Mountain VA. We should not let the rhetoric of privatizers and 

opponents of employee rights obscure the truth that this is a healthcare system very 

much worth saving and fixing and that veterans consistently prefer to receive their 

care inside the VA. But we must stop starving Iron Mountain and other medical 

centers of the very clinicians who consistently receive high marks from veterans. 

The critical ingredients for improved access to rural healthcare for Oscar G. Johnson 

Medical Center veterans are a professional, supportive work environment, an end 

to politically driven assaults on due process and the restoration of critical surgical, 

ER and ICU services. Thank you. 

Benjamin F. Balkum. 

f 

AMERICAN OSTEOPATHIC ASSOCIATION

Chairman Benishek, Ranking Member Brownley, and members of the Committee 

On behalf of the American Osteopathic Association (AOA) and the more than 

110,000 osteopathic physicians and osteopathic medical students we represent, including more than 7,500 in Michigan, thank you for your continued focus on efforts 

to improve choice and access to healthcare for our nation’s veterans, especially for 

those in rural areas. I appreciate the opportunity to provide the perspective of the 

osteopathic medical profession as the committee examines ways to ensure the delivery of high-quality care for rural veterans, and to reiterate our commitment to working with you to address the health needs of all veterans. 

The AOA strongly supports the mission of the U.S. Department of Veterans Affairs (VA) and the Veterans Health Administration (VHA) in delivering care tailored 

to those who have served our country. There is little doubt the VA is uniquely posiVerDate Aug 31 2005 13:58 Oct 18, 2016 Jkt 000000 PO 00000 Frm 00044 Fmt 6633 Sfmt 6621 Y:\98-690.TXT PAT

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tioned to address the comprehensive health needs of its veteran population, as well 

as the specific areas of traumatic brain injury, post-traumatic stress disorder, prosthetics, and other injuries and conditions associated with the battlefield. The philosophy and practice of osteopathic medicine is grounded in a ‘‘whole person’’ approach 

to care, which aligns well with the diverse needs of the veteran population. 

We also believe that community care providers serve an important role in this 

mission—not only to help relieve some of the existing strain upon VA personnel and 

resources, but also to improve access to high-quality care for veterans living in rural 

areas. Osteopathic physicians in particular tend to practice in rural and underserved communities, and more than sixty percent of our members enter primary 

care fields. Guided by a patient-centered, holistic approach to care, osteopathic physicians are well-equipped to help meet the healthcare needs of veterans, whether in 

the VA or in the communities in which they reside. 

The Veterans Choice Program (VCP) is an essential tool in achieving our shared 

goal of improving veterans’ access to care. While implementation of the VCP has not 

been without challenges, the AOA appreciates the Committee’s efforts to identify 

these issues and work with the VA to effect positive changes. We are encouraged 

by successful recent legislative efforts, spearheaded by the House Committee on Veterans’ Affairs, which will streamline existing VA community care programs under 

a unified ‘‘Veterans Choice Program,’’ ensuring that the system will be easier to 

navigate for veterans and healthcare providers alike. 

We must also continue our efforts to ensure that a highly-skilled physician workforce is trained and ready to meet the needs of veterans with complex health conditions, as well as the specific health needs of new generations of veterans who will 

be entering the VA system. The AOA strongly supports efforts to increase graduate 

medical education (GME) residency positions, such as the 1,500 new positions created under the Veterans Access, Choice, and Accountability Act (‘‘Choice Act,’’ P.L. 

113–146). Especially as the majority of these new residencies are in primary care 

fields, we believe this is a critically important step toward ensuring an adequate 

supply of physicians to care for these deserving patients. Further, as a majority of 

physicians tend to practice where they complete their residencies, the value of a robust graduate medical education system with sufficient rural training track opportunities cannot be understated. 

The AOA looks forward to today’s discussion, and we are eager to work together 

with Committee members, the VA, and veterans to ensure that those who have 

served our country receive the care they have earned and deserve through a system 

that is equipped and responsive to their needs. Thank you for the opportunity to 

share the perspective of the osteopathic medical profession, and for your continued 

attention to the healthcare needs of rural veterans. 

Æ 


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